Introduction

HIV rates among African American men who have sex with men (AAMSM) continue to be among the highest across populations. According to recent data from the Centers for Disease Control and Prevention (CDC), AAMSM represent 63 % of new infections among all African American men, and 35 % among all MSM. The situation for African American young men who have sex with men (AAYMSM) in particular is especially grave, as nearly two-thirds (63 %) of all YMSM aged 13–24 years with HIV infection in 2008 were AAYMSM [1]. In a HIV/AIDS trend analysis, AAYMSM displayed the greatest increase in the number of HIV/AIDS diagnoses, representing a 42 % increase between 2005 and 2008 [2].

In spite of the high prevalence of HIV/AIDS within the African American communities, there is limited research to better understand HIV risk and protective behaviors among populations of AAMSM and AAYMSM. As a result, there is only one evidence-based HIV prevention intervention for AAMSM (as designated by the Centers for Disease Control and Prevention) and none designed specifically for AAYMSM [3]. Further complicating the effective development of interventions with AAYMSM is lack of acknowledgement that AAYMSM are not a homogenous group. Indeed, subgroups exist that may require different methods and/or theoretical approaches to be effective. The House and Ball communities, which have been identified as potential high-risk populations, represent one such subgroup [4].

House and Ball Communities

In general, the House and Ball communities work in tandem to develop and support a community involving African American and Latino individuals of diverse sexual and gender identities, primarily AAYMSM and transgender women. Balls and Houses function as different entities, yet work together in forming the vibrant community often known as the Ballroom scene or community. Houses are different groups of individuals that compete against each other during Balls—underground events that reward individuals who win competitions focused around dance, athletics, and gender expression. The roots of the House and Ball communities originate from 1920s Harlem. Annual Harlem Balls of the 1920s involved working-class, mostly African American men under the age of 30 performing in elaborate and ostentatious female attire as a popular form of entertainment [5]. Although Balls originated as a safe space for “female impersonators” to compete amongst one another, this community has become more inclusive of AAYMSM of different sexual and gender identities as well as Latino and Asian YMSM. House and Ball communities are currently present in major cities across the United States including Los Angeles, Oakland, Atlanta, Chicago, Philadelphia, Baltimore, and Washington, DC [6]. Although Balls in their current form have occurred in other parts of the United States since the 1970s, it was not until 1998 that the first Ball occurred in Los Angeles.

The limited research with these communities suggests that HIV is a major public health concern among this population. From 1998 to 2000, research on an outbreak of tuberculosis among House members in Baltimore and New York City found that 16 of the 26 (62 %) House and Ball participants were HIV positive [7]. This study highlights the importance of HIV research within these communities as well as the closely connected nature of its members, which has epidemiological implications for the spread and transmission of disease. In a more recent study (N = 504) of the New York City House and Ball scene, Murrill et al. [4] found a seroprevalence rate of 20 %, with 73 % of those testing positive for HIV unaware of their HIV status.

A recent qualitative study describes the House and Ball communities in the San Francisco and Detroit areas as communities that are accepting of AAYMSM, as well as African Americans of other gender and sexual identities [6]. Houses are identified as having a sense of family, friendship, and support. Sanchez et al. [8] also suggest that support is an integral component of the House and Ball communities that assuages the negative effects of stigma and life stress on risk-taking behaviors. For young men who have experienced instances of discrimination based on race/ethnicity and/or sexual identity, this sense of support may be highly valued and difficult to find outside of a community such as the Ballroom scene.

Discrimination: Racism, Homophobia and Related Risk

Research examining the relationship between forms of discrimination and HIV risk behaviors is still in its infancy, especially for AAYMSM. While the connection between the two is still unclear, it is evident that African American (AA) youth continue to experience various forms of discrimination in their daily lives [9–11]. Most specifically related to this manuscript are experiences AA youth endure that revolve around exclusion and being perceived as incompetent or lacking the ability to succeed. The research suggests these forms of discrimination occur frequently among AA youth [9–12].

LGBT youth, in general, experience higher rates of victimization and discrimination than their non-LGBT identified counterparts. These experiences occur in employment, housing, school and other venues [14–16]. Limited research has been conducted with AAYMSM and discrimination, although it is clear that AAYMSM encounter discrimination in the forms of heterosexism and racism. For instance, in one study of 526 ethnically diverse YMSM, African American respondents were significantly more likely than Latino and White respondents to report experiences of racism in sexual relationships and/or gay social settings or institutional racism. AAYMSM who reported social/sexual racism were at a significantly greater risk for drug use than those not reporting social/sexual racism [13]. In terms of homophobia experienced by youth of color, qualitative research suggests that young African American men encounter homophobia within various facets of their lives including church, family, and societal settings [14, 15]. Research with adult AAMSM also illustrates challenges revolving around racism and heterosexism [16–18]. For example, Choi et al. [17] discuss coping strategies (e.g., stress management, confrontation) used by AAMSM who encounter racism in mostly White gay spaces and heterosexism in African American communities.

Resilience and Social Support

These experiences of homophobia, and other types of minority stress (e.g., prejudice, stigma), can result in psychological distress which can be related to suicidality, anxiety, guilt, and sexual problems [19]. Similarly, it has been found that social support, and seeking social support if one is ostracized or excluded from other social outlets, can be a source of resilience or protection from the negative outcomes related to stigma and discrimination [20]. One model to explain the protective roles of social support on stress is known as the stress-buffering effect and supposes that adequate social support will offset or moderate the impact of stress on health [21, 22].

While there is no agreement on how to define or operationalize resilience or even what specifically constitutes resiliency within individuals, currently, one of the most common definitions of resilience is: positive adaptation despite adversity [23]. Luthar has called resilience a construct with two distinct dimensions: significant adversity and positive adaptation. From this perspective, resilience is never directly measured but is indirectly inferred from evidence of these dimensions. It can be agreed that what is considered to be resilience should be studied within the context of the risk being studied and the index population. Specifically, if a particular condition (e.g., discrimination, stigma) confers high-risk for some outcomes (e.g., mental health, HIV risk) within certain populations (e.g., AAYMSM, MSM) then focusing on those aspects of resiliency that address those conditions and risks should be prioritized over other aspects of resiliency[24]. In this context, social support would therefore be considered essential given its ability to offset the negative outcomes of discrimination and stigma.

Subcultures

Subcultures are generally defined as a group of people with a culture (whether distinct or hidden) which differentiates them from the larger culture to which they belong. Hebdige [25] argued that subcultures bring together like-minded individuals who feel neglected by societal standards and allow them to develop a sense of identity. Research among youth who feel marginalized from more mainstream society indicates that these youth may form or join a subculture to provide them support and identity [26]. For instance, Wilkins writes that White youth who do not excel in traditional avenues of success (e.g., academics or athletics) may participate in Goth subculture in order to claim membership to a community, develop intimate relationships, and gain social visibility; thus, resulting in validation and desirability. Other groups participate in subcultures for sociality, bonding, or and/or status, including rave, circuit party, youth street gang, and gamer subcultures [27–32]. The House and Ball communities may represent another subculture that provides support and a positive identity to its members.

This ability for marginalized youth to seek out their own support networks suggests a quality of resiliency, specifically that labeled by Herrick et al. [33] as “social creativity” which allows its members to identify new or “alternative” venues for social support. Social creativity counters or addresses the sense of loneliness and lack of social support for individuals who, for a myriad of reasons, may not be fully accepted into mainstream society. We believe that the House and Ball communities offer its members this sense of social creativity through its family networks and other organizational structures.

The limited research with these communities suggests that the House and Ball scene is both a community at high-risk for HIV and other infectious diseases, and, conversely, a place that may offer its members support and acceptance. It is this sense of support and acceptance that the present study seeks to investigate. Following the call of recent researchers [33] to investigate the resiliency of young gay men rather than taking a deficit approach (which has been the standard for HIV research to date), this study seeks to identify the sources of resilience and strength that exist within the House and Ball communities. Through identifying the benefits and positive motivating factors that exist within these communities, researchers and interventionists will be better prepared to design community-level prevention interventions that build on the resiliency of Ballroom community members.

This manuscript seeks to identify aspects of resiliency within the House and Ball communities in order to identify supportive mechanisms that can be leveraged for intervention development. Building on the work of Herrick et al. [33], we have identified sources of resiliency within the House and Ball communities and through the qualitative data (and validation of quantitative data) begin to build a grounded theory approach to studying resiliency within this population. This will in turn be used as a guide for developing and/or adapting HIV prevention interventions for this vulnerable community.

Methods

The present study utilized a number of different methods including a survey administered at House and Ball events, focus groups with House members and semi-structured qualitative interviews with young men who attend Balls but are not House members. The study was a collaborative effort between the research team and the House and Ball communities. As such, the House and Ball community members were involved in the study design and methods development through participation in a community advisory board. All study procedures were presented to local House leaders in order to ensure that the methods were not intrusive to the community’s activities and that they were appropriate for the target population.

Quantitative Data Collection and Measures

We conducted a confidential survey to better understand the HIV risk and protective behaviors among persons involved in the Los Angeles House and Ball communities. Individuals were recruited regardless of gender, sexual identity or behavior in order to represent the entire community of individuals attending Balls in Los Angeles. Between February 2009 and January 2010, 263 unduplicated surveys were completed at 12 survey events. House and Ball community members were eligible to participate if they attended an event during the study time period and had not previously participated in the research survey.

Sampling procedures were modeled after the Healthy Young Men’s Study, with venue selection and participant recruitment adapted for the target community [34]. Recruitment venues were categorized into three types: Balls, House meetings, and community events. Events and venues included in the sampling frame had at least a 2-hour time period with an expected yield of at least four House and Ball community members. Private survey areas were created at Balls and other events through the use of portable “voting booths” designed for the project. Sampling periods typically occurred during late-night or early-morning hours.

Study staff approached persons who entered the designated venue to administer screening questions to assess eligibility of each person. A total of 296 people were found eligible to take the survey; 287 (97 %) completed the survey and a total of 263 (89 %) unduplicated surveys were completed (24 surveys were deemed duplicates through reviewing demographic and other survey data). Eligible persons were escorted to the private survey booths to complete the data collection activity. Respondents completed a 30–45 min interviewer administered survey on site; a portion of the survey relating to substance use and sexual behavior was self-administered with audio computer-assisted self-interview (ACASI) technology. All respondents provided written informed consent. For persons younger than 18, a waiver of parental permission was obtained. Participants received a $40 incentive for completing this survey.

The survey questions assessed social and demographic characteristics, sexual identity and attraction, experiences of racism and homophobia, participation in the House and Ball communities and connection to communities (e.g., racial/ethnic, religious, school, work, House, Ball), as well as motivations for joining Houses and/or walking in Balls.

Demographic Variables

Participants were asked to report their: gender; age; race/ethnicity; residence; employment status; sexual identity; and sexual attraction.

House and Ball Scene Involvement

A dichotomous variable was created to measure involvement in the House and Ball community. This variable was comprised of a measure indicating House membership and another indicating having recently walked in a Ball. Those who were House members and/or had recently walked in a Ball were scored as 1; all others were scored as 0. We believe that this as an appropriate proxy for House and Ball involvement as, based on observations and discussions with community leaders, we have found that those in Houses or who have walked are the most involved. This measure also captures those who may be highly involved in the scene but are “in between Houses” (aka “free agent” or “007”).

Motivations for Attending Balls

Using a scale developed in partnership with House leaders, questions were developed to assess motivations for attending Balls. Participants were asked how much of a reason various motivations (e.g., feel supported, feel accepted, feel like part of a group, find friends, access drugs, meet sexual partners, feel validated, entertainment, walk in) are for their participation. Items were scored on a five-point scale (1 = Not a reason, 2 = A little bit of a reason, 3 = Somewhat of a reason, 4 = A lot of the reason, 5 = One of the main reasons). Based on factor analyses conducted with this scale, a composite scale for attending Balls to receive social support was created using the first four items named above (α = 0.84). Other motivations were treated as single item measures.

Experiences of Rejection and Discrimination

Experiences of lifetime homophobia and racism experienced while growing up were measured using scales developed by Díaz et al. [35]. To measure experiences of homophobia, we used a subset of items measuring verbal harassment and physical assaults in relation to both perceived sexual orientation and gender nonconformity (α = 0.90). To measure racism, we chose general items measuring institutional forms of racism, physical assault due to race, and items that focused on experiences of racism in gay social settings and/or sexual relationships. All items used a 4-item response format (1 = Never, 2 = Once or twice, 3 = A few times, 4 = Many times). Alphas calculated for these racism scales were 0.70 and 0.84, respectively. Internalized homophobia was measured using a shortened version of Ross and Simon-Rosser’s internalized homophobia scale [36] which uses a 4-point scale to measure elements of internalized homophobia (e.g., guilt, stress/conflict, dislike for self).

Connectedness to Community

Items developed for a prior study [37] were used to assess participants’ feelings of connection to the various communities in which they interact. Items included the community in which they grew up, as well as the gay, ethnic, school, work, spiritual/religious, club/party, Ball, and House communities. All items used a 4-item response format (1 = Not at all, 2 = Not very, 3 = Somewhat, 4 = A lot) and were treated as individual items in this analysis.

Qualitative Data Collection and Measures

Between July 2008 and December 2009, 45 respondents were identified and recruited to participate in eight semi-structured focus group discussions. Through our community engagement activities and participant observations, we identified and approached each of the local leaders and their Houses to participate in this portion of the data collection. Specifically, research team members attended House meetings and other events to explain the focus groups and obtain contact information from those interested in participating. Once this information was collected, a date and time was set and follow-up calls and emails were sent. Participants included members from seven different Houses in Los Angeles. The focus group discussion guide was designed to gather in-depth information on the structural, social and cultural characteristics of the Houses; challenges members experience in the House and Ball scene; perceived benefits of participation; House rules, activities, and communication; relationships within and outside the House; values, norms and expectations related to HIV/STI risk behaviors; and receptiveness to interventions. Each focus group lasted 1.5–2.5 h and was digitally recorded and professionally transcribed. All focus groups were conducted in the project offices. Respondents were provided a $25 incentive for completing the focus group.

In order to better understand the experiences of young men who attend the Balls but choose not to be a House member, we completed semi-structured qualitative interviews with Ball spectators. Participants were recruited based on responses to key survey items. When completing the quantitative survey, if a respondent reported that he was: (1) male; (2) lived in Los Angeles County; and (3) had never been a House member, a programmed message appeared on the computer screen explaining that he was eligible for an additional part of the study. A total of 72 survey respondents met this eligibility, and we interviewed a third of those eligible (n = 24). Project team members explained this additional portion and, if the respondent was interested, contact information was obtained in order to schedule the subsequent qualitative interview. The interview discussion guide was designed to obtain in-depth data on topics such as: first experiences in the Ball scene; role in scene; social and sexual networks; extent individuals serve as a bridge to other social networks/communities; knowledge/attitudes and perceptions of STIs/HIV/AIDS and health; and perceptions of sexuality. Each interview lasted 1 to 1 1/2 hours and was digitally recorded and professionally transcribed. All interviews were conducted in the project offices or a location convenient to the respondent (e.g., café, park). Respondents were provided a $45 incentive for completing the interview. All study procedures were approved by the Institutional Review Board at Children’s Hospital Los Angeles.

Analysis

Bivariate analyses were conducted to identify variables associated with House membership and having recently walked in a Ball. Associations between these two outcomes and continuous variables were established using independent sample t-tests; associations between categorical variables and these two outcomes were established using Chi-square or Fisher’s exact tests. An a priori alpha level of 0.05 was used to determine statistical significance; however due to the exploratory nature of this study, marginally significant results (p < 0.10) are also reported. Due to the large number of tests that were conducted, we employed the false discovery rate controlling procedure described by Benjamini and Hochberg [38], which is a more powerful alternative to overly conservative adjustment measures.

The qualitative analysis for this manuscript utilized a “constant comparative” approach, an aspect of grounded theory that entails the simultaneous process of data collection, analysis and description. In this process, data are analyzed for patterns and themes to discover the most salient categories, as well as any emergent theoretical implications. As the data are collected, they are immediately analyzed for patterns and themes, with a primary objective of discovering theory implicit in the data. Interview and focus group transcripts were included in the analysis. Atlas.ti was used for coding and analysis of relationships between and within text segments.

Members of the research team reviewed an initial sample of interviews to identify key themes, which formed the basis of the project codebook. Codes focusing on a range of topics were identified and defined based on the key constructs included in the discussion guide. The codebook was modified as needed, and once finalized, three members of the research team were responsible for coding the interviews. To establish the coding system, 15 % of the transcripts were double-coded. Differences in coding were discussed and resolved by the team. The open coding process included refining codes based on the data. Codes related to House activities, benefits, reasons for participation and discrimination were included in the current analysis. This process led to the structure of the present study which: (1) provides an overview of instances of discrimination experienced by respondents; and (2) using a mixed methods approach, describes the benefits and motivations for participating in the House and Ball communities.

Results

Demographics

As summarized in Table 1, a total of 263 participants completed the quantitative survey, including 7 (3 %) American Indian/Native American, 3 (1 %) Asian/Asian American/Pacific Islander, 218 (83 %) Black/African American, 17 (7 %) Latino/Hispanic, 2 (1 %) White/Caucasian, and 16 (6 %) identifying as some other ethnicity; nearly one-third of the sample identified with more than one ethnicity. The average age was 23.74 years, with 50 % of the sample being 21–25 years old. A majority of the respondents reported living either in their own place/apartment (49 %) or with family (37 %). While the majority (60 %) reported being employed or both in school and employed, nearly a quarter (21 %) also reported being neither in school nor employed.

Table 1 Demographics of House and Ball participants (N = 263)
Full size table

Eighty-nine percent identified their gender as male, with 66 % identifying as gay or some other same-sex sexual identity. Interestingly, although only 25 % of males identified as bisexual, nearly double (44 %) reported an attraction to both men and women, a proportion nearly similar to those reporting an attraction to men exclusively (50 %).

Bivariate Associations of Motivations for Participation

As presented in Table 2, there were a number of bivariate associations between motivations to attend Balls, experiences of rejection and discrimination, connection to community and being a House member and/or having walked in a Ball. Statistically significant relationships emerged between Ball involvement and seeking to “receive social support” (p < 0.001), seeking “to feel validated” (p < 0.05), and seeking to “walk in Ball categories” (p < 0.001). In addition, those who were more involved in the House/Ball community reported higher experiences of homophobia (p < 0.01), feeling more a part of the gay community (p < 0.05), and trended toward feeling more a part of their school community (p < 0.10).

Table 2 Bivariate associations between motivations for attending Balls, experiences of discrimination, and connection to community and involvement in the House and Ball Scene (N = 263)
Full size table

Experiences of Homophobia

Family

Interviews with members of the Ballroom scene support the idea that experiences of rejection, racism and homophobia are common experiences for AAYMSM. When asked to describe what brought them to the scene or what attracted them to the scene, typical responses focused on feelings of acceptance and lack of judgment. Young men in this sample reported experiencing judgment from family, friends and their communities based on their sexual identity. Young men generally described sensing they were “this way” or gay at a young age, but felt the need to suppress that part of themselves in order to maintain family ties.

Well, the thing is I actually found out I was this way when I was around 10 years old.

I: This way… okay.

R: [whispering] Gay. And I never did come out. I didn’t come out until 12th grade. So throughout the years in which I kind of figured out who I was, which is gay, I kind of hid in the darkness because my grandma would always say, ‘Don’t be like this, you might be neglected, rejected. You just might be put aside’. I never, especially when it comes to family, I would never wanna know that kind of feeling from them.

For some young men, the fear of rejection from family and friends was related to cultural values. For example, Brian is a young man with a Haitian background. He related that his mother and father maintained their traditional views toward homosexuality and this was in direct contrast to his own beliefs, which he felt the need to hide from his family.

I come from a Caribbean background and homosexuality coming from a Caribbean background, it just doesn’t mesh well. It’s oil and water. So when you’re dealing with proud, Caribbean people who love their culture and bring parts of their culture to America where they’re trying to instill that into their children and that coupled with the fact that American culture being as progressive as we think we are, it’s not a good mix.

These experiences were described by respondents as making them feel badly about themselves, contributing to what were alternatively described as inferiority complexes, low self-confidence or a negative self-image.

My self-confidence is very low, even though a lot of my friends and people I never knew before, they’re always tryin’ to make me higher but it kills me because if I’m not accepted by my family, it’s like I’m not accepted by nobody.

In addition to contributing to respondents’ negative emotions, young men also reported that their parents at times made comments about changing their behavior to become heterosexual. “Dad says ‘stop’ and we all know what stop means. What are you doing? Stop.” While respondents seemed to believe that this advice was given to them in order to protect them from discrimination from the “outside world”, the fact that these messages came from family often led young men to feel a lack of support at home, compelling them to seek support in other places.

Some members of the Ballroom scene reported taking on the role as “mentors” for the young men who arrived in the community without a support system in place. These were typically young men who had been forced to leave their homes once their family learned of their sexual identity.

There was you can say flack in the gay community. A lot of the children that came up gay, their parents had put them out, stuff like that. They had left their home… Runaways and all that stuff and they came to me and they stayed with me. So that’s when I help them as far as food and shelter and all that type of stuff. So, as they were doing that they were looking and getting into the scene, the Ball scene.

Although many participants felt a lack of support from family because of their sexual orientation, others spoke about finding acceptance within their families. One House member begins to explain that he is more comfortable around the female members of his family but adds that his larger family is also comfortable with his sexual orientation.

I feel more comfortable around the girls and the women in my family. I can talk to them about really anything. And they were the first persons I came out to. Like I was never really scared to tell anybody in my family. And they’re all like, my whole family is comfortable with it. Nobody discourages it, nobody said anything, bad things. Like I could bring friends around my whole entire family, like to family events and all that.

Community

This sense of possible rejection from friends and families seemed to also contribute to respondents’ awareness of how individuals present themselves to others. For example, one young man described members of the Ballroom community as “gayer” than other communities, a perception that seemed to minimize his contact with Ballroom members outside of typical Ballroom venues (e.g., Balls, House meetings). Another respondent, when asked to define Ballroom terms such as “femme queen” or “butch queen”, felt that “butch queens” (e.g., gay men who generally present as more masculine or “butch” at Ball events) were the preferred illusion, because it would lessen homophobic responses from those outside the scene.

Butch queens are cool…okay, well femme queens are guys who are kind of gay and they don’t really care, they don’t try and hide it, they’re just free. And butch queens are guys who do everything that femme queens do, but they act straight, they talk straight, they dress real straight and you would be able to be undetectable… I think they have it a lot easier. I’m not saying they’re not conflicted but if you can’t tell someone’s a certain way right away, you just kind of embrace them…

This respondent further elaborated that performing as a butch queen would be easier, and may be the preference for some young men because they are better able to “blend into” the larger gay community and society. Several felt that the larger gay community was also prejudiced against African Americans, so the need to be discreet was important, especially because there were limited “Black crowds”, or spaces open to African Americans, within the gay community.

I think what a lot of the butch queens have told me, that I’ve met, it’s kind of like I’m already Black, I mean and to have the gay thing, it’s like “Fuck, I don’t want that shit”. It’s just another reason for people to hate on me…Cause the gay community doesn’t just say “Come on in everybody, let’s all just hug, Kumbaya”. It’s not fuckin’ like that. I mean television and maybe movies and magazines are all this big rainbow. All lots of love. It’s not always like that. You know, a lot of shadiness and maybe unfriendliness.

This sense of being able to “pass” in the larger community was important for some respondents, as they felt that the larger African American community tended to “look down upon gays”. For some, this led to them feeling the need to be discreet in their appearance and behavior so that they were not further stigmatized in their communities. This also seemed to contribute to the perception that some AAYMSM may describe themselves as “bisexual” or on the “down low” in order to fit into the larger society more easily. One older respondent who had been a part of the Ballroom scene off and on for many years stated:

You’ll find that a lot of young Black men, who are not gay in appearance, will identify themselves as bisexual, because they don’t want to say they’re gay. But I realize that there are a lot of problems in their lives for young gay males. Problems with their family, rejection, stuff like that.

While this perception seemed to be relatively common among respondents, several also described a sense of disdain for the term and idea of being “on the down low”.

You don’t want people knowing about you. You are really down low. Your family doesn’t really know about you. I think this is really silly not even so much stupid, just silly…Because it’s just, I don’t know, it’s like you are lying to yourself. You don’t want people to know and I understand some people are not comfortable with people knowing about them but at the same time it’s kind of like you are only lying to yourself.

Benefits and Motivations for Participation

Social Creativity: Seeking Family and Support

Respondents shared their first encounters with the Ballroom scene and what initially attracted them to it. They also described their first meetings with their House parents and how this first impression of a House parent helped them to decide the “right” House for them. They needed to “click” with the parent and also generally needed to see the Houses in action at the Balls before making a decision. When observing Houses, they mentioned looking for things such as “togetherness” (“That’s what I went to the Balls to see was the House of Cayenne because I always was on the other side. Their togetherness made me say, ‘Okay, there is something to look to.”) and “unity” (she [House Mother] explained to me what she meant by the unity and so I said, ‘Okay, if this is a support group thing I was down’).

For some respondents, the organizational structure of the Houses, with a Mother and/or Father, was identified as the primary benefit of being a part of the Ballroom scene. As described above, some respondents experienced discrimination based on their sexuality from friends and family; some even were forced to leave home because of this. Thus, the family structure of the Houses provided an alternative family, complete with brothers and sisters.

Honestly I don’t really have any support as far as I never had family, never and I am just now getting… my mom just doesn’t understand. I just got into it with her about this today. So, basically support, family, somebody to be there because I don’t have that.

One respondent described this as “morale”, indicating a sense of support through this family structure.

Yeah, there is a lot of morale I think that happens in the House, good morale because we take it literal. I think when we say mothers and fathers and brothers, I think we take that literal to a certain extent because we would treat these people like our regular brothers and sisters.

This family structure differed across Houses, with some Houses seen as more competitive or “trying to make a name”. With this competitiveness also came issues and more fighting; this was not necessarily the ideal structure for everyone, as one respondent explained:

A lot of the Houses claim to be brother and sister but there is so much issues between them. They all are used to going out always trying to fight or trying to make a name for themselves and she [my House mother] didn’t want the House to be like that. She wanted it to be more of a unity, actually like a fraternity or whatever. So, just like a brotherhood or sisterhood or whatever. So, and I was like, “Okay, I like that because of the unity,” and came off like actually a mother, like genuinely like a mother figure.

Seeking Social Support through Houses

The focus groups and interviews clearly identified two different types of Houses, those that were more family oriented and those that were organized more around the competitions at Balls. It seemed that for most focus group participants, greater benefits were recognized through the family-like structure, a place where members could simply “hang out and we won’t talk about the Ball at all. We will just hang out and talk about problems we are all having, how we feel about these problems. So, it’s almost—it’s literally like a family”. This support seemed to be viewed as bidirectional, providing the member not only with individuals to care for him but also a venue for members to care for others, giving them a chance to help others as well: “to be a part of something bigger. More than Ball scenes. It’s like somebody to actually care for and care for me as well.”

While the benefits of the support provided by the family structure seemed to be of primary importance, the competitions themselves—and their competitive nature—were also seen as being a place where respondents could reap the benefits of the support of their House family. Respondents described the preparations for a Ball as a time of “anticipation”, a time for their House family to work together creating costumes and illusions for the upcoming Ball. The competitions also provided a time for the House family to show their support, “There is nothing like having your House behind you chanting and loud for you”.

One respondent was able to bridge both of these features of the House by pointing out aspects of the togetherness and “positive” nature of the House, while also indicating that it was important to be in a winning organization:

I wanted something that was more family oriented because when I first started out it was so much negativity, drugs and things like that and I didn’t want to be a part of that. So I wanted to go towards something that was a little more positive. So, just being organized, together, and making sure that they had the hottest, hottest people in the House so that we can all do our thing together.

Safe Place: Formation of a Subculture

Related to the feeling of support provided by the House family, respondents also spoke at length about having their own space that allowed them to freely express themselves. For some, the first time they came to a Ball was also the first time they were exposed to any gay community. Given that 75 % of participants were 20 years old or younger (16 % under 17) at the time of their first Ball, this is not that surprising. One young man described his first impression of a Ball as: “It was like, ‘Oh, my God, there are more gay people than I thought.’ Before I thought it was just everybody was just in the closet. So I just, oh my goodness. It was just—it was a heart shocker”. This first exposure to a “gay scene” gave many of the participants a sense of comfort and solace in realizing there were other gay young men like themselves: “The positive thing was it was just– it felt kind of good to be around people like you”.

After having spent some time in the Ballroom scene, respondents realized that the Ballroom community was not typical of other gay communities. One respondent clearly articulated this by explaining, “there is a gay community and then there is a Ball community. It’s like the Ball community is a subculture with the gay community”. The atypical nature of the Ballroom scene was seen as a subculture for a number of reasons including its defined structure, a membership of almost exclusively ethnic minority LGBT youth, and its underground nature. Balls are generally held after hours (starting around 3:30 in the morning) and in warehouses or other nontraditional spaces. The underground nature of the Balls seemed to be a big part of the appeal of the Balls, with one focus group explaining:

R5: I loved the undergroundness about it because people don’t– I like the discretion because a lot of people don’t know what’s going on. So it’s like our own little world.

R2: Yeah.

R5: You know what I mean, it’s like our escape to this place where you can go and just be like he said, be whoever you want to be. Yeah, I mean whatever person you want to be that night you can be that person.

The underground nature of the Ballroom scene extended to the participants themselves having what they called an “alter ego” when living in that world. Generally, House members take on a House name when they join a House. This name includes a first name (e.g., Fonzi, Snoopy) and a last name, generally the name of their House. Thus, the “alter egos” that participants spoke of included a name unique to the Ballroom scene as well as different illusions depending on the participants’ personality, desires or talents.

R4: It’s the alter ego so you get to be whatever. That’s your moment to be whoever you want to be… With us, we can’t be whoever we want to be in the regular world because then we are going to get a lot of ridicule and judgment. But, in our world I can– you can come in one day and be the boy and then the next day you can come in and you can be the girl… you aren’t being judged unless you look a mess but other than that it’s usual.

R1: I think my alter ego kind of hooked my confidence in my everyday life because I had really low self esteem at first and a lot of people wouldn’t know that but I did.

As this last participant described, the alter ego and being able to be whoever you want to be, seemed to contribute to building self confidence for some young men, particularly those who had experienced ridicule or other negative feedback when expressing themselves in the “real world”. Several of the young men spoke of this issue and the importance of finding a “safe place” for them to feel comfortable being who they wanted to be. Some felt it was still difficult to be an “open gay male”; and even within the gay communities, there was often a lack of tolerance for creative expression. The open acceptance of all types of people in the Ballroom scene contributed to many young men’s feeling it was “okay to be who you are”.

I feel like it it’s an outlet for female expression, kind of what you are talentwise or what you like to do that you are not able to do outside of that community. You can’t go to a club and just start walking runway through the club. People are going to look at you like, “What are you doing?” I mean you can feel it but you know you are not able to do that…but in a Ball scene it’s oriented around that. Then it calls for so many different categories and so many different effects to the point where you are able to kind of just try and kind of like a place to let yourself be free kind of outside of even the regular gay community but outside of the mainstream community, especially because you know a lot of times even if people who aren’t in the Ball scene just being gay, lesbian or whatnot you are shunned automatically. So it’s just an outlet for expression, just to express yourself I think.

While most of the young men in the Ballroom scene are active participants and “walk” their categories at the Ball, the community is open to everyone and does not require individuals to compete. Some House members take on different roles such as administrative duties (e.g., collecting dues, purchasing supplies) and costume designers. While these individuals may not sport different illusions or personas as a part of their Ballroom experience, they too experienced the benefits of the safe space the Ballroom offered.

I am a little bit different because I don’t walk but I get more of acceptance. I get a lot of things especially like being African American, homosexual you don’t really have too many options for acceptance and when you find a place where they accept you for who you are versus what you do or what lifestyle you live it’s actually worthwhile.

“Shamelessness”: Entertainment, Winning and Validation at the Balls

Many participants reported enjoying attending Ball events for the entertainment aspect or because they are “new and fun”. These reasons were especially common among respondents who attended Balls but did not belong to a House. Some of these participants spoke about the fun and excitement involved with attending their first Ball. One respondent recalled going to one of the first balls in Los Angeles about 10 years ago.

The first ball was really, really – it was just really exciting. It was something new. It was really new for everybody. So, it was just really new and fun.

Many respondents discussed going to Balls to see their favorite categories performed. Respondents also spoke about being impressed by particular Ball members who excel within specific categories. One participant, who had recently joined a House, listed some of his favorite performance categories.

I just do it for the entertainment. I love to see people that I know, just to look nice. I do it for the entertainment. It’s just something fun. And now that I’m actually in a House, I guess I’m gonna have to probably do a little bit more, attending Balls more often. But entertainment. I like seeing people vogue. I love vogueing. I love face kids. I love sex siren. And I just like it. It’s very interesting to me.

The competitions themselves and the sense of satisfaction individuals received from competing and winning were also mentioned among the main benefits of being a part of the Ballroom scene. When asked to describe the feelings associated with winning at a Ball, respondents reported feeling a sense of validation, importance and recognition for their efforts. These feelings seemed to be of upmost importance to the participants. Some of the more popular and competitive categories also offer monetary prizes to the winners, another benefit of the competitions.

I guess it’s like somewhat of an accomplishment because basically…when you really get into the Balls, all it is an illusion and if you can give your illusion better than the next person then you know it’s kind of like you felt like you have done, like you have accomplished something. Never mind the fact that some of the categories are worth money.

This sense of accomplishment through winning also seemed to help participants build self confidence and pride in themselves. The idea of being recognized for their efforts in front of their “family” and friends led one respondent to report that he had become “more accepting I guess of myself”. The competitive atmosphere of the Balls seemed to some, the appropriate venue to “grab your validation”, particularly when venues such as this are uncommon for most of the Ball participants. One focus group session discussed how Balls were a chance for AAYMSM and transgender individuals to “step out” and gain their recognition.

R3: [The Balls] instill confidence sometimes. Like you can do anything. You’re competing against these people that are just like you. Like “She’s just like me”, you know. “I’m competing against her and I can win”.

R4: There’s all types of things out there. You have sports…regular fashion shows and for us, this would be our own zone, or our chance to step up. It’s entertainment. It’s a chance to prove yourself to somebody and it’s a chance to step out and feel good about yourself.

This sense of pride and validation members’ experienced through participating in Balls may serve to address experiences of internalized homophobia. Survey data indicate that about 30 % of male respondents reported either agreeing or disagreeing that they “sometimes dislike myself for being sexually attracted to men”; an additional 50 % reported sometimes wishing they were not sexually attracted to men, 22 % reported feeling stress of conflict over having sex with men and a third (34 %) reported sometimes feeling guilty about having sex with men.

Apart from the more intangible benefits such as support and acceptance of participating in the Ballroom scene, participants also discussed the more perceptible benefits of participation including the competitions and winning. Most of the young men who participate in the Ballroom community are competitive by nature. The organization of the House and Ball scene is such that House parents and other community leaders typically comprise the judging panel at Balls. This means that House parents are likely to vote for their own kids, and that loyalties and allegiances to other Houses may sway a judge’s vote. This political nature of the scene makes it difficult for competitors who are not a House member (aka “007” or free agent) to win. Thus for some young men who participate in the scene for the competitions, their primary motivation for joining a House was to succeed in competitions.

Like I said earlier if you are by yourself you are not going to get the votes that you deserve like you are participating in a House. So, that was one of my motives also for joining a House in the first place.

Participants choose their categories based on their interests, talents and appearance. Some mentioned participating in sports when they were younger, and commented that as they grew older and became more aware of their sexual identity, they felt that finding outlets for competition were less available to them. For those young men, the Balls were attractive as they allowed them to compete in categories that celebrate their creativity, their passion and their sense of self.

R4: That’s why I like my category because it’s just– that’s the one where you know fashion is just the whole creative part. You can be a designer for that moment.

R2: Right, like Project Runway.

The passion that participants bring to the Balls was also something that participants in the scene looked forward to. Some categories (e.g., Bizarre, European Runway, Performance) dictate that individuals spend time creating a scenario or illusion that fits the category’s description while also bringing a “wow factor” to the competition. For some members, this passion and seeing the creativity in action was a primary motivation for attending Balls.

I like the fact that these people are so passionate about something that people will look at and feel was a waste of time but these people are actually putting their all into it and really doing a good job…which makes it– which makes it entertaining because – when you put your passion in the competitive state it makes people go far beyond what you would expect sometimes and to see people bring whatever the category calls for to life it–that’s what I look for when I go to Balls, that’s one thing I like.

Discussion

The data presented in this study begin to identify the perceived benefits and motivations of participating in the House and Ball communities from the perspective of the participants. Prior research has identified that these communities may be at high-risk for HIV and other sexually transmitted infections; however, there are a number of resiliency factors within these communities that may serve to mitigate the risks [4]. Survey data found that both walking in Balls and obtaining social support were the two primary motivators for being “active” participants at the Balls. While one would expect walking in Balls (the primary form of active participation) would be a primary motivator; it is interesting to note that receiving social support was seen as equally important. One can infer that social support is an important component for these respondents and perhaps something that is not easily obtained. Qualitative data provide additional insight into this association, as young men described the sense of support they received thorough the House structure as well as the self-confidence and validation they received through participating in Ball competitions. The underground world of the Ballroom allows its members to freely express themselves and celebrate their talents in a safe and supportive environment amongst their House parents and siblings.

Many young men within the Ballroom community have experienced discrimination from friends, family and their communities due to their sexuality or appearance. This was seen both in our qualitative data which described cultural and other factors that influenced family and community perceptions as well as our survey data which showed a relationship between experiences of homophobia and involvement in the House and Ball communities. While the temporal relationship between experiences of discrimination and involvement in the communities cannot be established due to the cross-sectional nature of our results, it is clear that these young have experienced a great deal of discrimination in their lives based on both race and sexuality. It is also clear that for many, the Ballroom scene was a welcome addition to their social environment, for in it they found a place where, not only are they accepted, but also an opportunity for them to be celebrated and rewarded for their talents and creativity. While subcultures have not generally been described as a source of resiliency or a protective environment, the descriptions of the young men in this study lend support to the idea that seeking refuge in a subculture, where one becomes a part of a group or family whose membership reflects their own interests and beliefs (also an element of social creativity described below), may be a sign of resiliency.

The experiences of the participants in our study also align with recent work [33], which encouraged HIV researchers to consider elements of resiliency when designing HIV prevention interventions. According to Syndemic Theory [39], improving health across one or more psychosocial health conditions will have a positive impact on HIV risk as well as the other component epidemics that as a group comprise syndemic conditions. Stall et al. [39] argue that if syndemic conditions work together to increase vulnerability to HIV, then mitigation of one of more of these conditions should work to decrease HIV vulnerability. These aspects of resiliency such as seeking social support and social creativity, as noted in this discussion may help to mitigate stress and related mental health as one of the syndemic conditions.

The House and Ball communities offer a safe space and an alternative to the discrimination and potential social marginalization that AAYMSM face. Therefore, the Ballroom community may be an important source of resilience for AAYMSM and other LGBT youth. The overwhelming majority of both our quantitative and qualitative findings demonstrated that desire for support and acceptance are primary motivations for involvement in the House and Ball communities. Borrowing from the strengths-based correlates of HIV risk developed by Herrick et al. [9], we have identified several strengths-based HIV correlates present in the House and Ball communities. This is summarized in Table 3.

Table 3 Resiliency constructs and their manifestation in the Ballroom community
Full size table

For example, the idea of shamelessness or pride in oneself, can potentially counter the effects of homophobia, both external and internal, as well as depression and other mental health conditions. Qualitative descriptions from respondents illustrate the sense of freedom and celebration in being able to be themselves in the Ballroom scene, without fear of ridicule or ostracizing. Thus, the Ballroom scene could be described as encouraging and celebrating shamelessness, a strong contradiction to internalized homophobia which has been described as YMSM applying negative attitudes to themselves, often hiding their sexuality and/or feeling ashamed of their attractions and behaviors [19]. Conversely, respondents reported discomfort in being shameless outside of the Ballroom scene. Interventionists and service providers should consider how to encourage AAYMSM to be shameless and express their true selves and tap into this important construct. This would encourage AAYMSM and others to celebrate their uniqueness rather than feeling ashamed.

While currently there is not a validated measure for the construct of “shamelessness”, descriptions from the young men in this study indicate that it is more than just the reverse of internalized homophobia. Thus, from a quantitative perspective, we cannot reliably discuss how the survey supports this construct; however, we did see that sizeable proportion of respondents reported experiencing some aspects of internalized homophobia.

Shamelessness includes pride, celebration and expression of oneself. This sense of shamelessness in relation to sexuality may be similar to ethnic pride, which has been identified as a protective factor among adolescents for risk behaviors such as substance use and sexual risk [40, 41]. Future studies should consider developing and testing a measure of shamelessness that can be used to identify this important area of resilience.

Another strengths-based construct is the idea of social creativity, which can counter the risks associated with loneliness and lack of social support. Social creativity is the process whereby a group or individual changes their group status through identifying different criteria in which they have been compared [42]. For example, the Ballroom community data indicate that there are members who may have experienced a loss of support from their family of origin and that these young men in turn change the way they define or view family and develop close familial-type networks within their House structure. Survey data indicate that one of the motivations for being involved in the Ballroom community is to seek social support, indicating a desire to change or augment their current support structure. Thus, the Ballroom community is an excellent example of social creativity with its inherent structure around “Mothers” and “Fathers” and other family.

This structure is not necessarily unusual among African Americans; there is a long tradition of ethnographic research that documents the “fictive kin” networks among African Americans as a means to extend one’s social network, which can serve as additional social and economic resources to manage societal challenges including discrimination, rejection and poverty [43–45]. Similar alternative family structures or fictive kin networks have been identified among other sexual minority groups in general and AAMSM specifically [46, 47]. This support can be crucial to the health and well-being of AAYMSM who have experienced rejection or discrimination from their family, peers, the larger African American community, and society in general. This rejection and discrimination can in turn contribute to the negative health outcomes that result from heterosexism and homophobia, including psychological distress [48, 49], substance use [13] and high-risk sex [50]. Therefore, encouraging AAYMSM and others participating in HIV prevention programs to freely identify their family and not limiting them to biological or other more traditional family structures may be important for intervention development. With recent recommendations to consider family-level interventions for YMSM [51], the freedom to have some social creativity in identifying family members may be important for AAYMSM and others.

Another component of resilience is volunteerism and social activism which can counter social vulnerability such as violence, victimization and homophobia [52, 53]. While not included in this manuscript, prior analyses among the parents in the House and Ball communities indicate that many of the House parents and leaders see their role as giving back to the community [54]. Parents saw their role as a House leader as an opportunity to contribute to the development of young people in their communities. This was often seen as a chance to make a difference in a young man’s life or to pay a debt to their own House parent. Many of the current House members plan to ascend to the rank of Mother or Father in their House or someday form their own House. Thus, this sense of social activism and giving back to their community exists in the Ballroom scene and may also contribute to the resiliency of its members.

While there are a number of ways to measure volunteerism quantitatively (e.g., social activism, engagement in community activities) for this study, the closest proxy would be how connected respondents feel to the gay community. We saw that this was tending towards significance in its relationship to being actively involved in the Ballroom community. This may indicate that those who are a part of the Ballroom community are also more likely to be involved in the larger gay community; additional investigation is necessary to better understand this relationship.

A final strengths-based construct identified in this analysis is social support which can counter unhealthy social relationships, loneliness and potential negative outcomes including substance abuse, depression, and sexual risk. Our analyses—both quantitative and qualitative—demonstrate the associations between motivation to participate in the House and Ball communities and a desire for social support. Based on the present study, the House and Ball communities could best be described in two ways: a source of social support and a venue for competition and celebration. The importance of the sense of support received through the House family and the camaraderie at the Balls is an integral part of the Ballroom community. Therefore, the community lends itself well to the design of community-level HIV prevention interventions. Creating or adapting HIV prevention programs for this community should use this sense of social support as its foundation while integrating the other aspects of resiliency clearly visible within this subculture.

There are several limitations to this study. These analyses are based on perceptions from one Ballroom community and may not be generalizable to Ballroom communities in other cities. For HIV prevention efforts, future studies should include comparisons to other cities, particularly those with a longer history of the Ballroom scene, to identify other mechanisms of support or resilience within the scene. In addition, the findings rely on respondents’ self-reported behaviors, which cannot be independently verified; we expect that the use of ACASI surveys may have minimized the underreporting of these behaviors. Additionally, the data reported here are cross-sectional and therefore do not contain information about the temporal relationships of motivations and social support or risk. For example, respondents were asked about lifetime experiences of rejection/discrimination and it is therefore impossible to know whether or not these experiences occurred prior to joining the House and Ball communities. In fact, it is quite possible that these experiences may have occurred subsequent to joining these communities. We encourage other researchers to further explore these areas to better understand the temporal relationships.

However, in spite of these limitations, we feel the data presented here present ideas for providers on leveraging the support systems available in the House and Ball scene so they can develop and/or advocate for new programs designed for House and Ballroom communities. Little is known about these communities, and this study provides an important foundation for understanding the social and structural characteristics of a Ballroom community, a community whose members have previously been identified as being at-risk for HIV infection [4, 7].

We are well into the third decade of the HIV epidemic and while great strides have been made in the area of prevention, HIV rates for AAMSM and AAYMSM continue to increase—indicating that perhaps the traditional deficit-approach of HIV prevention interventions is not effective for all populations. Moving to a model of resiliency and designing HIV prevention interventions founded on the strengths-based constructs identified in this analysis (as well as others) may be an effective new avenue for HIV prevention effort.