Childhood sexual abuse (CSA) is nearly five times greater among men who have sex with men (MSM) than in the general male population [1], with prevalence as high as 27% according to findings from a meta-analysis [2]. Yet, society has scarcely recognized sexual abuse among boys outside of institutional settings [3-5]. MSM with CSA history are more likely to be black or Latino [6-10], or less likely to be white [11]. Although men who engage in same-sex encounters and have a history of CSA tend to be behaviorally bisexual or less likely to identify as gay [9-11], it is unclear whether and how the formative sexual experiences of men who have sex with men and women (MSMW) differ from those of MSM only. CSA is associated with adverse consequences among MSM and MSMW including substance use [2,8,9,12-14], poor mental health [8,9,11,13-19], high-risk sexual behavior [11,13,14,19-23], and revictimization [11,15,24]. Yet, investigating these histories is often confounded by underreporting [22,25-27] and varied definitions of abuse [2,27-31]. Moreover, large scale quantitative studies that confront participants with questions about unwanted or coercive sexual encounters during childhood are not likely to account for experiences perceived as consensual or normative that would otherwise meet criteria for abuse—that is, unrecognized by the victim [27,32-34]. Recognizing men’s own appraisals and interpretations of their childhood sexual experiences (hereafter referred to as CSE) may lead to a better understanding and assessment of abuse and its consequences [12,32,35-37].

Appraisals of CSE (eg, desired, unwanted, coercive, abusive) are influenced by social environmental factors including gender and culture. Men may be less likely than women to define certain CSE as abusive because their socialization into masculine gender roles leads them to fear that they will be perceived as homosexual or as victims [25,38,39]. Black and Latino MSM and MSMW may be under additional pressure to deny unwanted CSE as abusive or to appraise abusive experiences as consensual, including those with female perpetrators, as black and Latino cultures stress the most traditional forms of masculinity [29,32,40,41]. Indeed, these cultural forces may also pressure black and Latino men to conceal same-sex behavior [29,42-45] and to not identify themselves as gay or homosexual [29,46-48]. For these men, CSE with an older male and/or same-sex behavior may be sources of shame and social isolation [44,46,47,49-51]. Furthermore, research suggests that men with histories of sexual abuse are less comfortable with their same-sex attraction than men without such histories [13], and several studies have found that some black and Latino men who were sexually abused as children experience sexual identity confusion [41,52] or establish a link between their abusive experiences and current same-sex desire [32,50,52].

This study recognizes female perpetrators in the early sexual experiences of MSM and MSMW. To our knowledge, this is the first study to investigate formative sexual experiences of black and Latino MSM/W involving older female partners relative to their sexual identity development, adult sexual relationships, masculine and cultural norms, and psychosocial health outcomes. The majority of CSA research with men, specifically gay and bisexual men, would suggest that perpetrators are typically male. Female perpetrators are rarely accounted for in either research designs or analyses. Indeed, several studies have failed to report the gender or sex of perpetrators [8,12,17,21,29,33,53]. Others have omitted female perpetrators from their analysis and discussion [11,20,22,23]. In most of these studies, participants were asked to report incidents they perceived as abusive. If some men normalize early sexual experiences with older female partners, including those where conditions were coercive or there was an obvious age difference between the child/adolescent and partner, they are less likely to appraise—let alone report—such experiences as abusive [27]. Thus these studies will fail to detect situations of abuse that may have affected men’s sexual identity development, mental health, substance abuse, and adult sexual relationships.

However, there are a few exceptions [9,32,35]. In a recent study of MSM with a history of CSA, 42% reported at least one incident of abuse by an older female [9]. Another study found that 20 cases (out of 43) involved a female perpetrator, out of which only 4 men initially defined their experiences as abusive [35]. By recruiting and interviewing adult men who experienced their first sexual encounter(s) as a child or adolescent (with an older male, female, or both), the proposed study will overcome this limitation of prior research by increasing knowledge about female perpetrators, particularly, the way men consider these experiences as being influential to their sexual development, psychological and emotional functioning, and current risk-taking behaviors. Moreover, it responds to recent calls for research with black and Latino MSM/W to explore differences in appraisal and meanings of sexual abuse by perpetrator gender [29,52].

There is a need for qualitative research on CSE of black and Latino MSM/W. An in-depth qualitative exploration can yield a better understanding of the meanings that individuals assign to CSE [32,33] and the impact they believe those experiences have on their lives, particularly later substance use, mental health, and sexual behavior. As discussed above, much of the research on sexual abuse among MSM has been quantitative. Moreover, although several of these studies included sizable samples of black and Latino men [9,20,21,29,35,54], most included small percentages of MSMW.

Few studies have explored CSE with MSMW beyond quantitative assessment [10,32,37,50,52,55]. The findings from these qualitative studies are promising, suggesting that men perceive connections between abuse and their current same-sex behavior [32,37,50,52], including high-risk exploration of their sexuality [37], that abusive experiences may result in negative mental health consequences and coping strategies [10,32,50], and that being coerced into same-sex encounters by older men led to intense internal debate about their sexual identity and coming to terms with the combined pain and pleasure they derived from these experiences [55]. Nevertheless, these studies are limited; they had small sample sizes (Ns=13-33), some of which focused exclusively on black men, the original study aims were broader than childhood sexual experiences, and/or only a few included in-depth interviews. Therefore, it is critical to further explore through in-depth interviews how black and Latino MSM and MSMW perceive connections between their formative sexual experiences, cultural attitudes and masculinity norms, same-sex and opposite-sex attractions, and adult health and risk behavior. This study will also be critical in addressing shame, internalized homophobia, and fear of provider insensitivity, all of which may impact the disclosure of CSE (and potential detection of CSA by competent providers) and same-sex behavior and can reduce men’s willingness to seek substance abuse treatment and other health services [56-59].

Service providers, including substance use counselors and HIV outreach workers, may not be adequately prepared to recognize or safely address CSA with male clients. Male survivors of CSA, often overlooked as health care consumers, have unique clinical and psychological needs that warrant critical scientific inquiry [60]. Knowing that CSA history among gay and bisexual men is associated with negative outcomes (eg, revictimization, substance use, mental health, high-risk sexual behavior), researchers have called for interventions to incorporate CSA history into health services used by these men [2,29,37,50,56,61]. Recent evidence suggests that doing so can achieve reductions in psychological symptoms and sexual risk taking [62]. Yet, there is reason to believe that black and Latino MSM/W may be reluctant to access health services and substance abuse treatment due to fears of being stigmatized, potential exposure of their same-sex behavior, general provider mistrust, and perceptions that providers lack training in sexuality [56,63,57,64]. Furthermore, service providers may not be equipped to recognize the need for safe trauma-informed care, particularly as it relates to sexual abuse [65-70]. Currently, the inclusion of CSA in treatment and health-related service settings is nonexistent or hindered by assessments that use language assuming an experience is appraised as abusive, inadequate provider training, or lack of provider preparedness [65-70] that potentially places clients at risk of retraumatization. Thus, we need to understand attitudes and expectations of the providers and their potential clients regarding the inclusion of sexual histories in treatment and other health care settings, and how this should be done. We also need to account for the perceived level of preparedness among providers to address issues of abuse and sexuality among racial and ethnic minority men.

To our knowledge, very few studies focus specifically on understanding formative sexual histories, particularly those experiences occurring before the age of 16 years (ie, CSE), of black and Latino MSM and MSMW. We are conducting mixed-methods interviews with 80 black and Latino men (40 MSM and 40 MSMW) in New York City (NYC), exploring appraisals of their formative sexual experiences, including those described as consensual but meeting criteria for abuse (Multimedia Appendix 1). We are also interviewing 30 local service providers representing substance abuse treatment, mental health care, and HIV/sexually transmitted infection (STI) prevention and outreach.

To address the need for better recognition of CSA at multiple levels, we will do the following: (1) investigate appraisals of CSE among black and Latino MSM and MSMW and evaluate these experiences using established criteria for defining sexual abuse; (2) examine appraisals of CSE relative to sexual identity formation, adult sexual relationships and behaviors, concealment of same-sex behavior, alcohol and drug use, psychological and emotional functioning, and cultural ideologies of masculinity among black and Latino MSM and MSMW; and (3) examine perspectives of black and Latino MSM and MSMW and relevant service providers to understand the role of, and the need to include, sexual history in treatment and counseling settings and to determine service providers’ preparedness to address CSE in treatment and counseling settings.

This study employs an intersectionality framework to examine appraisal and interpretation of CSE. Multiple social identities (eg, race, ethnicity, gender, sexual orientation) “intersect at the micro level of individual experience to reflect interlocking systems of privilege and oppression at the macro level” [71-73]. This framework holds that no one social identity is more important than others, and is ideally suited to qualitative or mixed-methods research as it is not intended to predict behaviors, health, or mental processes. It was included as a conceptual perspective for advancing lesbian, gay, bisexual, and transgender (LGBT) research in the Institute of Medicine Committee on LGBT Health report [74].

Through an intersectionality lens, and relying on an indirect approach to assessing CSE, this study will use mixed methods to consider how current appraisals of first sexual experiences are shaped by intersecting social identities (Multimedia Appendix 2). These include gender and perceptions of masculinity, black or Hispanic racial or ethnic identification, level of cultural estrangement, and sexual orientation. Measuring cultural estrangement and masculinity norms will help to specify racial and ethnic identity factors that may have particular salience for men’s appraisals of their CSE. Examining these factors using mixed methods permits data triangulation, enabling us to assess their reliability and validity. We further conceptualize that one’s appraisal of a childhood sexual encounter (or multiple encounters), together with these social identities, influences adult sexual relationships (including disclosure or concealment of same-sex behaviors), current and past use of alcohol or drugs, current psychological distress and emotional functioning, and whether or not an individual perceives a need for (or has attempted to access) substance use, mental health, or other health services. As has been suggested [75], attention will be paid to within- and between-group differences and similarities.

This cross-sectional study will include in-person interviews with 80 black and Latino men (40 MSM and 40 MSMW) with a history of CSE, and interviews with 30 service providers about their preparedness to address issues of abuse with clients.

We will employ “Best Practices” for mixed methods research [111] to integrate quantitative and qualitative data. Quantitative data will be used to identify subgroups to compare emergent qualitative themes. For example, cases of problematic substance use will be identified before reviewing the qualitative data pertaining to IG9 (coping with CSE) and IG10 (alcohol or drug initiation). Quantitative and qualitative data will be used to assess multiple social identities expected to influence appraisal (Multimedia Appendix 2). Thus, we will be able to examine, for example, how black MSM who identify themselves as gay understand their CSE with an older male compared with heterosexually-identified black MSMW who actively conceal same-sex behavior. We will also analyze potential cultural similarities in CSE appraisal and interpretation—for example, Latino and black MSMW with low levels of cultural estrangement and high identification with traditional masculine norms. Attention will be paid to similarity and diversity within and between groups throughout the analysis [75]. Finally, employing both qualitative and quantitative analyses can enhance the validity of study findings [110,111].

We recognize that this formative study will not have sufficient resources to recruit a truly representative sample. For example, nonspeakers of English will not be included. Moreover, recruitment methods favor those with internet access, but this may be somewhat offset by recruitment from community-based organizations. Much of the data will be retrospective and despite measures that we have incorporated to minimize recall bias, the possibility remains that some accounts may suffer from memory suppression.

Findings will inform an R01 proposal to develop and test an alternative CSA instrument accompanied by a training curriculum for use in health services and research settings. Specifically, data from black and Latino MSM/W will be translated into a preliminary set of testable questions to indirectly detect sexual abuse perpetrated against male participants or clients. Study findings from service providers will offer insight into how qualitative assessments of sexual history can be used in conjunction with substance use measures and mental health screenings to better understand the impact of abuse; inform strategies to improve linkage to care; elucidate the degree of acceptability, preparedness, and potential discomfort among service providers in taking childhood sexual histories; and inform training in the use of this alternative instrument.