The Threeness: A Black, Gay Man in America

By: Dr. Derek Dangerfield

When I visit the doctor’s office, it’s hard to decide if I should be “Derek” the patient seeking health care services or “Dr. Dangerfield” the sexual health scholar. Most of the time I try to be the “regular patient,” but it’s one of the most uncomfortable experiences for me.

Here’s what usually happens:

I enter the room as “Derek” the patient and there’s an older white male physician who has little experience with the multiple contexts of my life as a black, gay man, but he provides “great care.” I sit anxiously, answer health history questions, and prepare myself for screening. I have to report sexual partners and practices and get swabbed everywhere for everything. While I’m doing that, I’m assessing the doctor’s ability to ask the right questions and not make me feel stigmatized or ashamed. If that happens, I will have to find another provider.

Despite the doctor’s ability to provide proper screening, I have to make a conscious effort to disregard his inability to connect with me and overcome my feelings of shame and fear about discovering any positive HIV or STI test results. Next, he takes my sexual and health history and starts to talk about “risk” for Black men. He tells me, “You should be using PrEP. Your probability of getting HIV is high.” PrEP is a once-daily pill used to prevent HIV infection. Tragically, black men who have sex with men have an estimated 50% lifetime risk of HIV despite reporting greater levels of all prevention behaviors compared to other groups of men who have sex with men.

That’s when I switch to my identity as “Dr. Dangerfield.” Dr. Dangerfield can rationalize clinical visits, meet my health care needs, and is certainly not vulnerable to feelings of shame, guilt, and discomfort. Dr. Dangerfield helps me unpack whether the visit is uncomfortable because of my own internalized stigma or if the provider’s lack of cultural competency is impacting the session.

Like many black, sexual minority men, I often delay health care visits because the experience is so uncomfortable. Most of the time, “Derek” enters the room but “Dr. Dangerfield” ends up leaving, whether I tell the provider or not.

We need better clinical care and engagement for black sexual minority men. Men in this community often feel shame and guilt, and understandably fear that HIV infection is inevitable. Other issues, such as violence and stigma (at being both a black man and a gay man), are also salient for many black, sexual minority men and they impact health care engagement and health outcomes. Larger social issues such as internalized homonegativity, medical mistrust, and socioeconomic status impact health care engagement for many black, gay men as well.

We need more diverse providers who can connect with patients at the different contexts of their lives. To better understand this, W.E.B. Dubois described the “twoness,” a double consciousness that many African-Americans experience as they operate as black in America. Black sexual minority men experience a “threeness,” an added identity as gay or bisexual, which complicates their personal identity and impacts their capacity to navigate through society and maintain their health. This is evident in the disparities observed for many health issues including HIV and HIV treatment adherence.

Fortunately, I can call upon “Dr. Dangerfield” to keep at bay the shame, stigma, and distress that could impact my health, but many men do not have a protective identity like that. We need to work to ensure that black, sexual minority men do not experience stigma, shame, or distress in society. Ultimately, that work will improve the health of black men.

This blog is a part of the “Dialogues in Health Equity” series by the Health Equity Faculty Interest Group. They are committed to decreasing health disparities experienced by local and global communities by promoting social justice and health equity through nursing practice, research, education, and service.

Dialogues in Health Equity

Dr. Derek Dangerfield is a postdoctoral fellow at the Johns Hopkins School of Nursing. His primary research promotes sexual health and targets ways to reduce HIV and STIs for men who have sex with men (MSM) in the U.S. and abroad. His research has been supported by the U.S. Department of State, the National Science Foundation, and the Johns Hopkins Center for AIDS Research. Currently, Dr. Dangerfield is exploring the feasibility of mailing HIV and STI self-testing materials to MSM in Baltimore who use HIV PrEP to reduce the need for in-person clinical follow-up visits.