CTCA Assessment Form Approved:
OMB No. 0920-
Expiration Date:
Critical Thinking and Cultural Affirmation (CTCA): Evaluation of a Locally Developed HIV Prevention Intervention
Attachment 6
Baseline Assessment
Public reporting burden of this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)
CTCA ASSESSMENT
TABLE OF CONTENTS
Sexually Transmitted Diseases 9
HIV Testing (Includes perceived risk) 10
Sexual Assessment (Includes perceived risk) 12
Contemplation Ladder – Condoms During Anal Sex (M/F versions) Use 37
Decisional Balance for Condom Use 39
HIV Stigma for Positive Men – Negative Self Esteem Subscale 46
HIV Stigma for Negative Men – Disclosure Concerns Subscale 49
Adverse Childhood Event Scale 61
Partner Violence Questionnaire (M/F versions) 63
Everyday Discrimination – Sexual Orientation 66
Everyday Discrimination – Race 68
Black Identity (items from the Multidimensional Inventory of Black Identity/MIBI) 70
Identification and Involvement with the Gay Community Scale 73
Study Site: [LUCBMX]
Participant ID: [SUBJECT]
Staff ID: [STAFF]
Assessment Point: [ASSESS] [Baseline, 3-Month, 6-Month]
Date: [TODAY] –
The following may be considered as CORE if surveys are administered in QDS (or any program used for ACASI)
Version of Questionnaire: [VERSION] – Programmed as automatic variables in QDS
Starting Time: [STIME] – Programmed as automatic variable in QDS
Ending Time: [ETIME] – Programmed as automatic variable in QDS
Module A: DEM -Demographics
DEM1. Date of Birth
In what month and year were you born? MM/YYYY
98 Refuse to Answer
DEM2. Gender
Are you…
01 Male – SKIP TO DEM 4
02 Transgender/Transsexual SKIP TO DEM 3
98 Refuse to Answer – SKIP TO DEM 4
DEM3. Transgender Identity
Are you…
01 Male to Female Transgender/Transsexual
02 Female to Male Transgender/Transsexual
98 Refused to Answer
DEM4. Hispanic or Latino
Do you consider yourself to be Hispanic or Latino?
01 Yes
02 No
98 Refuse to Answer
DEM5. Race
For this question you may select more than one option.
Do you consider yourself?
01 White
02 Black or African American -
03 Asian
04 American Indian or Alaska Native
05 Native Hawaiian or Pacific Islander
98 Refuse to Answer
DEM6. Education Level
What is the highest level of education you have completed? (Choose One)
01 < Grade 8
02 Grades 9 through 11
03 Grades 12 or GED
04 Some college, Associate’s Degree, or Technical Degree
05 Bachelor’s Degree
06 Any post graduate studies
98 Refuse to Answer
DEM7. Employment Status
What best describes your current employment status? (Choose One)
01 Employed full-time
02 Employed part-time
03 Unemployed but looking for work
04 Unemployed, am a student, not currently seeking employment
05 Unemployed, not a student, not currently seeking employment
98 Refuse to Answer
DEM8. Income Level
What was your household income last year from all sources before taxes? Household income refers to the total amount of money from all people living in the household. (Choose One)
01 less than $10,000
02 $10,000 -19,999
03 $20,000 –29,999
04 $30,000 –39,999
05 $40,000 –49,999
06 $50,000 –59,999
07 $60,000 –69,999
08 $70,000 –79,999
09 $80,000 or more
97 Don’t Know
98 Refuse to Answer
DEM9. Dependents
Including you, how many people depend on this income?
# of People
98 Refuse to Answer
DEM10. Children
How many children do you have? _____
98 Refuse to Answer
DEM11. Finance
During the past 12 months, how many times did you run out of money for your basic necessities like rent or food? (Choose one)
01 Never
02 Once
03 Twice
04 Three times or more
98 Refuse to Answer
DEM13. Incarceration
Have you ever spent at least one night in jail or prison? (Choose One)
01 Yes
02 No - SKIP TO DEM 15
98 Refuse to Answer
DEM14. Incarceration Time
Was this in the past 3 months?
01 Yes
02 No
98 Refuse to Answer
DEM15. Homelessness
In the past 3 months, were you homeless at any time? That is, you slept in a shelter for homeless people, on the streets, or another place not intended for sleeping.
01 Yes
00 No
98 Refuse to Answer
DEM16. Housing
In the past 3 months, have you experienced unstable housing at any time? That is, you lived with other persons or moved constantly because you did not have a place of your own.
01 Yes
02 No
98 Refuse to Answer
DEM17. Class Background
What do you consider your parents' class background?
01 Upper Middle Class
02 Middle Class
03 Working Class
04 Poor
98 Refuse to Answer
DEM18. Relationship Status
How do you define your CURRENT relationship status?
01 I am legally married OR My partner and I had a commitment ceremony
02 I have a partner or a lover
03 I have a boyfriend or a girlfriend
04 I have a boyfriend and a girlfriend
05 I am single
98 Refuse to Answer
DEM19. Population
Which type of area did you grow up in?
01 Large central city (population over 250,000)
02 Medium size city (population 50,000-250,000)
03 Suburb of a large or medium size city
04 Small city (population 10,000-50,000)
05 Town/village or unincorporated area
98 Refuse to Answer
DEM20. Did you grow up in the Chicago area?
01 Yes - Skip to DEM23
02 No
98 Refuse to Answer
DEM21 How old were you when you moved to the Chicago area?
Enter Age
98 Refuse to Answer
DEM22 Is Chicago the first large central city you have lived in?
01 Yes
02 No
98 Refuse to Answer
DEM23. Financial History
How stressed were you about money growing up?
01 Not at all
02 Slightly
03 Somewhat
A good deal
05 Extremely
98 Refuse to Answer
DEM24. Sexuality
Do you think of yourself as (Choose one)
01 Heterosexual or "Straight"
02 Homosexual, Gay, or Same gender loving
03 Bisexual
04 Other
98 Refuse to Answer
DEM25. Identity
Do you identify with any of the following terms? (Check all that apply)
01 Queer
02 Same gender loving
03 Bisexual
04 In the life
05 On the down low
06 Other –Go to DEM26
07 None
98 Refuse to Answer
DEM26. Identity Specify “other.”_______________
DEM 27. Participation in Community Based Services
In the past 3 months have you participated in any of the following community based or community organized activities?
Yes
No
98 Refuse to Answer
Enter a Yes or No for each of the following.
Howard Brown HIV services
Chicago Public Health Department HIV Testing
Chicago BMX/Black Men’s Xchange
South Side Help Center
Brothers Health Collective
Center on Halstead
Broadway Youth Center
Taskforce Prevention & Community Services
Beyond Care
Module B: GH - Physical and Mental Health
GH1. In general, what do you consider your health to be? (Choose one)
01 Poor
02 Fair
03 Good
04 Excellent
98 Refuse to Answer
GH2. Do you have a regular doctor or health care provider?
01 Yes
02 No
98 Refuse to Answer
GH3. What kind of health insurance or medical coverage do you currently have?
(Choose one)
01 No medical coverage
02 Medicaid (government insurance for people with low incomes)
03 Medicare (government insurance for the elderly and disabled)
04 Tricare, formerly known as CHAMPUS (e.g., Government insurance for military personnel)
05 Veterans Administration coverage
06 Private health insurance (e.g., HMO, Blue Cross, other employer-based health plan)
98 Refuse to Answer
GH4. In the last 3 months, approximately how many days did you feel sad or depressed for most of the day?
01 Never
02 a couple of days
03 less than a week
04 for a couple of weeks
05 for about a month
06 more than a month
98 Refuse to Answer
GH5. Have you ever been told by a doctor or psychiatrist that you have a mental illness?
01 Yes
02 No – SKIP TO STD 1
98 Refuse to Answer
GH5a. What was the diagnosis? (Check all that apply)
01 Major Depression
02 Anxiety disorder
03 Bipolar disorder
04 Schizophrenia
05 Other specify
98 Refuse to Answer
GH6. Have you ever been hospitalized because of your mental illness?
01 Yes
02 No
98 Refuse to Answer
GH7. Has a doctor prescribed you medication to treat this mental illness?
01 Yes
02 No – SKIP TO STD 1
98 Refuse to Answer
GH8. Are you currently taking the medication as the doctor prescribed?
01 Yes
02 No
98 Refuse to Answer
Module C: STD - Sexually Transmitted Diseases
Please answer the following questions as best as you can.
STD1. Have you ever had a sexually transmitted disease (STD)?
01 Yes
02 No - Skip to STD5.
98 Refuse to Answer
STD2. In your lifetime, have you ever been told by a health-care provider that you had a sexually transmitted disease (STD) such as gonorrhea (GC, clap), syphilis, Chlamydia, genital warts, herpes, or hepatitis B?
01 Yes
02 No - Skip to STD5.
98 Refuse to Answer
STD3. Which STDs has a health care provider told you that you had?
(Check all that apply)
01 Gonorrhea (GC, Clap)
02 Chlamydia
03 Syphilis ("Bad blood")
04 Genital Warts (anal, penile) (Human Papilloma Virus)
05 Genital Herpes (anal, penile) (Herpes Simplex Virus)
06 Hepatitis B
07 Hepatitis C
08 Other
09 Don't Know
98 Refuse to Answer
STD4. When was the last time that a health care provider told you that you had a STD?
01 Less than 1 year ago
02 1 – 2 years ago
03 3 – or more years ago
98 Refuse to Answer
The next question will help us understand more about your risk of getting an STD.
STD5. Is your penis circumcised or cut?
01 Yes
02 No
98 Refuse to Answer
Module D: HT-HIV Testing
We are interested in knowing about your HIV testing history.
HT1. Have you ever been tested for HIV?
01 Yes
02 No - Skip to HT6.
98 Refuse to Answer
HT2. How many times in your life have you been tested for HIV?
01 ______ - if 0 Skip to HT6
98 Refuse to Answer
HT3. When did you have your first HIV test? (Please take your best guess at the month, if you do not remember the exact month)
MM/YYYY
98 Refuse to Answer (Year)
HT4. When did you have your most recent HIV test? (Please take your best guess at the month, if you do not remember the exact month)
MM/YYYY
98 Refuse to Answer (Year)
If HT4 is less than HT3 then The date you entered as your most recent HIV test came before the date of your first HIV test. Please check your responses." Skip to instruction before HT4.
HT5. What was the result of your most recent HIV test? (Choose one)
01 Negative - Skip to HT8.
02 Positive - Skip to HT7.
03 Did not get the result of the last test - Skip to HT8.
04 Indeterminate (neither positive or negative) - Skip to HT8.
98 Refuse to Answer - Skip to HT8.
HT6. What are the reasons why you have not taken an HIV test? (Check all that apply)
01 I'm afraid I might be HIV positive
02 I'm afraid my result will be reported to the government
03 I'm afraid people might suspect that I'm gay or homosexual
04 I'm afraid people might treat me differently
05 I don't have the time
06 I can't afford it
07 I can't get to test site
08 I have been practicing safe sex
09 I know my partners don't have HIV
10 I am not at risk for HIV
11 It is not important
12 I don't know where to get tested
13 My doctor never recommended I get an HIV test
14 Other
98 Refuse to Answer
HT7. When did you first test positive for HIV?
MM/YYYY
98 Refuse to Answer (Year)
If HT7 is less than HT3 and HT2 is equal to 1 or HT7 is less than HT3 and HT2 is greater than 1 or HT7 is greater than HT4 then The date you entered as the first time you tested positive for HIV happened either before your first HIV test date or after your most recent test date. Please check your responses.”
HT8. How likely is it that you are infected with HIV now? (Click on a number)
01 Extremely unlikely
02
03
04
05
06
07
08
09
10 Extremely likely
98 Refuse to Answer
HT9. How likely do you think it is that you will become infected with HIV in your lifetime? (Click on a number)
01 Extremely unlikely
02
03
04
05
06
07
08
09
10 Extremely likely
98 Refuse to Answer
Module E: SA - SEXUAL ASSESSMENT
The next items are about sexual relationships you have had and/or are having and views you have about sexual relationships.
SA1. How old were you when you first had anal sex (giving or receiving) with a male? (Choose one)
01 Never had anal sex with a man
02 Less than 13 years old
03 13 to 15 years old
04 16 to 18 years old
05 19 to 21 years old
06 22 to 25 years old
07 Older than 25 years old
98 Refuse to Answer
SA2. How old were you when you first had vaginal sex with a female? (Choose one)
01 Never had vaginal sex with a female
02 Less than 13 years old
03 13 to 15 years old
03 16 to 18 years old
04 19 to 21 years old
05 22 to 25 years old
06 Older than 25 years old
98 Refuse to Answer
SA3. How old were you when you first had anal sex with a female? (Choose one)
01 Never had anal sex with a female
02 Less than 13 years old
03 13 to 15 years old
04 16 to 18 years old
05 19 to 21 years old
06 22 to 25 years old
07 Older than 25 years old
98 Refuse to Answer
SA4. How old were you when you first had anal or vaginal sex with a Male-to-female Transgender? (Choose one)
01 Never had anal sex with a Male-to-female Transgender
02 Less than 13 years old
03 13 to 15 years old
04 16 to 18 years old
05 19 to 21 years old
06 22 to 25 years old
07 Older than 25 years old
98 Refuse to Answer
SA5. How important would your close male friends say it is to use a condom when having anal sex with a man? (Choose one)
01 Very important
02 Somewhat important
03 A little important
04 Not at all important
05 They do not have anal sex with men
98 Refuse to Answer
SA6. How important would your close male friends say it is to use a condom when having vaginal sex with a woman? (Choose one)
01 Very important
02 Somewhat important
03 A little important
04 Not at all important
05 They do not have vaginal sex with women
98 Refuse to Answer
SA7. How important would your close male friends say it is to use a condom when having anal sex with a woman? (Choose one)
01 Very important
02 Somewhat important
03 A little important
04 Not at all important
05 They do not have anal sex with women
98 Refuse to Answer
SA8. How important would your close male friends say it is to use a condom when having anal sex with a male-to-female transgender woman? (Choose one)
01 Very important
02 Somewhat important
03 A little important
04 Not at all important
05 They do not have anal or vaginal sex with male-to-female transgender women
98 Refuse to Answer
SA9. In the past 3 months how many male sexual partners have you had?
(Actual Number)
98 Refuse to Answer
SA10. In general my male sexual partners tend to be:
01 1 to 5 years younger
02 6 to 10 years younger
03 More than 10 years younger
04 The same age
03 1 to 5 years older
04 6 to 10 years older
05 More than 10 years older
98 Refuse to Answer
SA11. In the past 3 months how many female sexual partners have you had?
(Actual Number)
98 Refuse to Answer
SA12. In general my female sexual partners tend to be:
01 1 to 5 years younger
02 6 to 10 years younger
03 More than 10 years younger
04 The same age
03 1 to 5 years older
04 6 to 10 years older
05 More than 10 years older
98 Refuse to Answer
SA13. In the past 3 months how many Male-to-Female Transgender sexual partners have you had?
(Actual Number)
98 Refuse to Answer
SA14. In general my Male-to-Females sexual partners tend to be:
01 1 to 5 years younger
02 6 to 10 years younger
03 More than 10 years younger
04 The same age
03 1 to 5 years older
04 6 to 10 years older
05 More than 10 years older
98 Refuse to Answer
SA15. How would you describe your relationship with your most recent male sexual partner? (select one)
01 Boyfriend, Primary Partner or lover
02 Casual partner (friend, fuck buddy, pick-up, acquaintance, one-night stand)
03 Other
98 Refuse to answer
B. The next items are about your PRIMARY male sex partner.
Now we are going to ask you about your Primary sexual partners and sexual behavior. By Primary Sexual Partner we mean someone you consider to be a lover, boyfriend, etc. The next questions are about things you have done in the last 3 months. That is since [insert calculated date]. Please do not count Transgender partners that are men who have used hormones to help them become women or had surgery to give them breasts or a vagina.
SA16. At any time during the past three months, have you been in a committed relationship with another man (this could be a lover or boyfriend or a primary partner)? (Choose one)
01 Yes
02 No - Skip to Section C: Non-Primary Partner.
98 Refuse to Answer
SA17. At any time during the past three months, with how many men have you been in a committed relationship?
(Actual Number)
98 Refuse to Answer
SA18. Are you currently in a committed relationship with a man? (Choose one)
01 Yes
02 No
98 Refuse to Answer
SA19. How many men have you had a committed relationship with in the last 3 months?
(Actual Number)
98 Refuse to Answer
If SA18 = 1: When answering the questions below, think about this current male partner when answering the questions below.
If SA18> or equal to 1 and SA16= 2: When answering the questions below, think about your male ex-partner when answering the questions below.
SA20. How long were you in or had you been in this relationship? (Choose one)
01 Less than 6 months
02 6-11 months
03 1-2 years
04 3-4 years
05 5 or more years
98 Refuse to Answer
SA21. Where did you first meet this partner? Check only one
01 Online hook-up or dating sites or Internet chat rooms
02 A telephone chat line
03 A personal ad in a newspaper or magazine
04 A gay/homosexual bar or club
05 A straight/heterosexual bar or club
06 At a party (not a sex party)
07 At a sex party
08 At a bath house
09 At a bookstore
10 At a public park or restroom
11 On the street
12 Someplace else
13 Other _________ See SA22
98 Refuse to Answer
SA22. Other meeting place specified.
(Actual Place)
SA23. Which racial/ethnic group or groups best describes him? (Check all that apply)
01 Asian
02 American Indian or Alaskan Native
03 Black or African American
04 Latino or Hispanic
05 Native Hawaiian or Pacific Islander
06 White
98 Refuse to Answer
SA24. In the past 3 months, did you live together at any time?
01 Yes
02 No
98 Refuse to Answer
SA25. In the past 3 months, did he help pay for any of your bills, food, or other expenses? (Choose one)
01 He didn't pay for any of the expenses
02 Less than half of the expenses
03 About half of the expenses
04 More than half of the expenses
05 He paid for all of the expenses
98 Refuse to Answer
SA26. In the past 3 months, did you help pay for any of his bills, food, or other expenses? (Choose one)
01 He didn't pay for any of the expenses
02 Less than half of the expenses
03 About half of the expenses
04 More than half of the expenses
05 He paid for all of the expenses
98 Refuse to Answer
The next questions are about anal sex with this primary sex partner.
SA27. In the past 3 months, how many times did you put your penis in his butt?
(Actual Number)
98 Refuse to answer
IF SA27 is equal to 0, then skip to SA29.
SA28. Of the [response to SA27] times you put your penis in his butt in the past 3 months, how many times was a condom used?
(Actual Number)
98 Refuse to answer
SA29. In the past 3 months, how many times did he put his penis in your butt?
(Actual Number)
98 Refuse to answer
IF SA29 is equal to 0, then skip to SA31.
SA30. Of the [response to SA29] times he put his penis in your butt in the past 3 months, how many times was a condom used?
(Actual Number)
98 Refuse to answer
SA31. What is his current HIV status? (Choose one)
01 He has HIV
02 He does not have HIV
03 Don't know/unsure
98 Refuse to Answer
SA32. Did you ask him about his HIV status?
01 Yes
02 No
98 Refuse to Answer
IF SA 31 equals 1 or 2 Skip SA33
SA33. Could you tell me what you think his HIV status is? (Choose one)
01 He has HIV
02 He does not have HIV
98 Refuse to Answer
IF SA33 equal to 98 Skip to SA35
SA34. How did you learn about his HIV status? (Check all that apply)
01 He told me
02 I asked him
03 I guessed based on other things he has talked about
04 I guessed based on things I had seen in his home
05 Someone else told me
06 His physical appearance
07 We got tested together
08 I saw his test results
09 I went with him to get his test results
10 Other
98 Refuse to Answer
SA35. Does he know your HIV status? (Choose one)
01 Yes
02 No
03 Don't know/unsure
98 Refuse to Answer
IF SA35 > 1 Skip SA36 go to Section C
SA36. How did he learn your HIV status? (Check all that apply)
01 I told him
02 He asked me
03 Someone else told him
04 We got tested together
05 He saw my test results
06 He went with me to get my test results
07 Other
98 Refuse to Answer
C. The next items are about CASUAL MALE SEX PARTNERS
SA36a.C. The next items are about CASUAL MALE SEX PARTNERS you may have had in the past 3 months. CASUAL PARTNERS are men you’ve had sex with, but you are NOT in a committed relationship with them. Casual partners could be friends, fuck buddies, pick-ups, acquaintances, one-night stands, or any other man who was not a committed partner. When answering these questions please do not count any boyfriends or main partners you have just told me about.
Intro S367a is for respondents who have primary partner and answered questions in the previous section.
SA36b.C. The next items are about CASUAL MALE SEX PARTNERS you may have had in the past 3 months. CASUAL PARTNERS are men you’ve had sex with, but you are NOT in a committed relationship with them. Casual partners could be friends, fuck buddies, pick-ups, acquaintances, one-night stands, or any other man who was not a committed partner. When answering these questions please do not count any boyfriends or main partners.
SA37. In the last 3 months how many casual male sex partners have you had?
(Actual Number)
98 Refuse to Answer
If SA37 equals 0 Skip to SA45
SA38. In the past 3 months how many causal male sex partners put their penis in your butt without using a condom?
(Actual Number)
98 Refuse to Answer
SA39. In the past 3 months how many different casual male sex partners did you have where you put your penis in their butt without using a condom?
(Actual Number)
98 Refuse to Answer
SA40. In the past three months, how many times did you have anal sex with any casual male sex partners because he gave you drugs, money, a place to stay, or other things you needed?
(Actual Number)
98 Refuse to Answer
SA41. In the past three months, how many casual male partners did you give drugs, money, a place to stay, or other things he needed so he would have sex with you?
(Actual Number)
98 Refuse to Answer
SA42. How many casual male sex partners (with whom you later had anal sex without using a condom) did you meet in the following places? [Actual number for each]
01 Online hook-up or dating sites or Internet chat rooms
02 A telephone chat line
03 A personal ad in a newspaper or magazine
04 A gay/homosexual bar or club
05 A straight/heterosexual bar or club
06 At a party (not a sex party)
07. At a sex party
08. At a bath house
09. At a bookstore
10. At a public park or restroom
11. On the street
12 Other place See SA43
98 Refuse to Answer
SA43. Specify other places
(Actual Answer)
SA44. Which racial/ethnic group or groups best describes any of the casual partners you just described? How many were…. (choose all that apply) [Actual numbers]
01 Asian
02 American Indian or Alaskan Native
03 Black or African American
04 Latino or Hispanic
05 Native Hawaiian or Pacific Islander
06 White
98 Refuse to Answer
Intro is for respondents who answered SA37 equals 0.
SA45. You indicated you have not had a casual male sex partner in the past 3 months. When was the last time you had a casual male sex partner?
01 More than 3 months but not more than 6 months
02 More than 6 months but less than 1 year
03 More than 1 year
04 I have never had a casual male sex partner
98 Refuse to answer
IF SA45 > 1 Skip to Section F.
The next questions are about your most recent encounter with a causal male sex partner –
SA46. During this encounter did you put your penis in his butt?
01 Yes
02 No – (SKIP to SA48)
98 Refuse to Answer
SA47. Did you wear a condom?
01 Yes (Skip to SA49)
02 No
98 Refuse to Answer
SA48. Was a condom available to be used during the encounter?
01 Yes
02 No
03 Don't Know
98 Refuse to Answer
SA49. During this encounter did he put his penis in your butt?
01 Yes
02 No (SKIP to SA51)
98 Refuse to Answer
SA50. Did he wear a condom?
01 Yes (SKIP to SA52)
02 No
98 Refuse to Answer
SA51. Was a condom available to be used during the encounter?
01 Yes
02 No
03 Don't Know
98 Refuse to Answer
SA52. In this sexual encounter, did he give you things you needed (drugs, money, food, etc)?
01 Yes
02 No
98 Refuse to Answer
SA53. In this sexual encounter did you give him things he needed (drugs, money, food, etc)?
01 Yes
02 No
98 Refuse to Answer
SA54. Did you use alcohol or drugs before or during this sexual encounter?
01 Yes
02 No (Skip to SA61)
98 Refuse to Answer
SA55. Were you drunk or buzzed on alcohol during this encounter?
01 Yes
02 No
98 Refuse to Answer
SA56. Did you use marijuana (pot, hash) before or during the encounter?
01 Yes
02 No
98 Refuse to Answer
SA57. Did you snort or smoke cocaine/crack before or during the encounter?
01 Yes
02 No
98 Refuse to Answer
SA58. Did you use club drugs (for example, crystal meth, ecstasy, GHB, special K) before or during the encounter?
01 Yes
02 No
98 Refuse to Answer
SA59. Did you use Viagra, Levitra, or Cialis before or during the encounter?
01 Yes
02 No
98 Refuse to Answer
SA60. Did you use poppers before or during the encounter?
01 Yes
02 No
98 Refuse to Answer
SA61. To the best of your knowledge, did the person you had sex with use any alcohol before or during the encounter?
01 Yes
02 No
98 Refuse to Answer
SA62. To the best of your knowledge, did the person you had sex with use drugs before or during the encounter?
01 Yes
02 No
98 Refuse to Answer
IF SA46 and SA49 equals 2 Skip to SA65
SA63. Did you tell him your HIV status before you had anal sex with him in this encounter?
01 Yes
02 No
98 Refuse to Answer
SA64. Did he tell you his HIV status before you had anal sex with him in this encounter?
01 Yes
02 No (Skip to SA65)
98 Refuse to Answer
SA65. What did he say about his HIV status? (Choose one)
01 He had HIV
02 He did not have HIV
03 He did not know his HIV status
98 Refuse to Answer
IF SA65 equals 1, 2 or 3 Skip to SA67
SA66. Did you ask him about his HIV status? (Choose one)
01 Yes
02 No
98 Refuse to Answer
SA67. At the time of the encounter did you think.....? (Choose one)
01 He had HIV
02 He did not have HIV
03 I was unsure of his HIV status
98 Refuse to Answer
F. The next questions ask you about any sexual activity you may have had with MALE-TO-FEMALE TRANSGENDER PERSONS.
By transgender we mean men who have used hormones to help them become women or had surgery to give them breasts or a vagina.
SA68. Have you had anal or vaginal intercourse with a male-to-female transgender in the past 3 months?
01 Yes
02 No
98 Refuse to Answer
IF SA68 is equal to 2, then skip to SA72
SA69. In the past 3 months, with how many transgender persons did you put your penis in their butt without using a condom?
Actual Number
98 Refuse to Answer
SA70. In the past 3 months, how many transgender persons put their penis in your butt without using a condom?
Actual Number
98 Refuse to Answer
SA71. In the past 3 months, with how many transgender persons did you put your penis in their vagina without using a condom?
Actual Number
98 Refuse to Answer
G. The next questions ask you about sexual activity you have had with any FEMALE PARTNER(S).
SA72. Have you ever had a female sex partner?
01 Yes
02 No – Skip to KHIVTS1.
98 Refuse to Answer
SA73. When did you most recently have sex with a female?
01 Within the past week
02 Within the past month
03 Within the past 3 months
04 Within the past 6 months
05 Within the past year
06 Within the past 5 years
07 More than 5 years ago
98 Refuse to Answer
SA74. Were you in a committed relationship (girlfriend, lover, or primary partner) with this most recent female sexual partner? (Choose one)
01 Yes
02 No
98 Refuse to Answer
SA75. Are you currently in a committed relationship with this female? (Choose one)
01 Yes
02 No
98 Refuse to Answer
IF SA75 equals 2 Skip to SA77
SA76. How long were you in or have been in this relationship? (Choose one)
01 Less than 6 months
02 6-11 months
03 1-2 years
04 3-4 years
05 5 or more years
98 Refuse to Answer
The following items ask you about your most recent female sexual relationship.
SA77. Which racial/ethnic group or groups best describes her? (Check all that apply)
01 Asian
02 American Indian or Alaskan Native
03 Black or African American
04 Latino or Hispanic
05 Native Hawaiian or Pacific Islander
06 White
98 Refuse to Answer
SA78. In the past 3 months, did you live together at any time?
01 Yes
02 No
98 Refuse to Answer
SA79. In the past 3 months, did she help pay for any of your bills, food, or other expenses? (Choose one)
01 She didn't pay for any of the expenses
02 Less than half of the expenses
03 About half of the expenses
04 More than half of the expenses
05 She paid for all of the expenses
98 Refuse to Answer
SA80. In the past 3 months how many times did you have vaginal sex with her (or put your penis in her vagina)?
Actual Number
98 Refuse to Answer
If SA80 is equal to 0, then skip to SA82.
SA81. Of those [response to SA80] times you had vaginal sex with her, how many times did you use a condom from start to finish?
(Actual Number)
98 Refuse to Answer
SA82. How many times did you have anal sex with her (or put your penis in her butt)?
(Actual Number)
98 Refuse to Answer
IF SA82 is equal to 0, then skip to SA84.
SA83. Of those [response to SA82] times you had anal sex with her, how many times did you use a condom from start to finish?
(Actual Number)
98 Refuse to Answer
SA84. Did you ask her about her HIV status?
01 Yes
02 No
98 Refuse to Answer
SA85. What is her current HIV status? (Choose one)
01 She has HIV
02 She does not have HIV
03 Don't know/unsure
98 Refuse to Answer
IF S85 is equal to 1 or 2, then skip to SA87.
SA86. Could you tell me what you think her HIV status is? (Choose one)
01 She has HIV
02 She does not have HIV
98 Refuse to Answer
SA87. How did you learn about her HIV status? (Check all that apply)
01 She told me
02 I asked
03 I guessed based on other things she has talked about
04 I guessed based on things I had seen in her home
05 Someone else told me
06 Her physical appearance
07 We got tested together
08 I saw her test results
09 I went with her to get her test results
10 Other
98 Refuse to Answer
SA88. Does she know your HIV status?
01 Yes
02 No
03 Don't Know
98 Refuse to Answer
IF SA88 is equal to 2 or 3 than skip to SA90
SA89. How did she learn your HIV status? (Check all that apply)
01 I told her
02 She asked
03 Someone else told her
04 We got tested together
05 She saw my test results
06 She went with me to get my test results
07 Other
98 Refuse to Answer
SA90. Have you told her that you have had sex with a man?
01 Yes
02 No
98 Refuse to Answer
Module F: SBD - Sexual Behavior Disclosure
SBD1. At the present time, how close do you feel to your mother or the woman who raised you? (Choose one)
01 Very Close
02 Somewhat Close
03 Not Close
04 At the present time I do not have this type of person in my life
05 She passed away
98 Refuse to Answer
SBD2. At the present time, how close do you feel to your father or the man who raised you? (Choose one)
01 Very Close
02 Somewhat Close
03 Not Close
At the present time I do not have this type of person in my life
05 He passed away
98 Refuse to Answer
SBD3. At the present time, how close do you feel to your brother(s)? (If you have more than one brother, answer by thinking of the one you feel closest to) (Choose one)
01 Very Close
02 Somewhat Close
03 Not Close
04 At the present time I do not have this type of person in my life
98 Refuse to Answer
SBD4. At the present time, how close do you feel to your sister(s)? (If you have more than one sister, answer by thinking of the one you feel closest to) (Choose one)
01 Very Close
02 Somewhat Close
03 Not Close
04 At the present time I do not have this type of person in my life
98 Refuse to Answer
SBD5. At the present time, how close do you feel to your minister or priest?
(Choose one)
01 Very Close
02 Somewhat Close
03 Not Close
04 I don't have this type of person in my life
98 Refuse to Answer
SBD6. At the present time, how close do you feel to your straight friends? (Choose one)
01 Very Close
02 Somewhat Close
03 Not Close
04 I don't have this type of person in my life
98 Refuse to Answer
SBD7. At the present time, how close do you feel to your homosexual friends? (Choose one)
01 Very Close
02 Somewhat Close
03 Not Close
04 I don't have this type of person in my life
98 Refuse to Answer
SBD8. At the present time, how close do you feel to your doctor? (Choose one)
01 Very Close
02 Somewhat Close
03 Not Close
04 I don't have this type of person in my life
98 Refuse to Answer
SBD9. Have you told at least one person that you have sex with men?
01 Yes
02 No – Skip to SBD12
98 Refuse to Answer
SBD10. Who have you told that you have sex with men? (Check all that apply) (Check all that apply)
01 My mother or the woman who raised me
02 My father or the man who raised me
03 My brother(s)
04 My sister(s)
05 My minister or priest
06 My straight/heterosexual friends
07 My gay/homosexual friends
08 My doctor (or other health or mental health provider)
98 Refuse to Answer
SBD11. About how many of your friends know that you have sex with men?
(Choose one)
01 All
02 More than half
03 About half
04 Less than half
05 None
98 Refuse to Answer
SBD12. How important is it for you that people who are close to you know that you have sex with men? (Choose one)
01 Very important
02 Somewhat important
03 A little important
04 Not at all important
98 Refuse to Answer
SBD13. Generally, how important is it for you to keep your sexual relationships with men secret? (Choose one)
01 Very important
02 Somewhat important
03 A little important
04 Not at all important
98 Refuse to Answer
Module G: KHIVTS - Knowledge of HIV Treatment Scale
KHIVTS1. People with HIV who take HIV medications are less likely to infect their sex partners during unsafe sex.
01. Strongly Disagree
02. Disagree
03. Agree
04. Strongly Agree
98. Refuse to Answer
KHIVTS2. HIV treatment makes it easier to relax about unsafe sex
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
KHIVTS3. It is safe to have sex without a condom when a person’s viral load is undetectable.
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
KHIVTS4. HIV treatments take the worry out of sex.
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
KHIVTS5. People with an undetectable viral load don’t need to worry about infecting others with HIV.
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
Imagine that an HIV negative man has sex with an HIV positive man who is not being treated for his HIV infection. Please rate how risky you believe each sexual activity is for the HIV negative partner.
KHIVTS6. Anal sex with no condom when the HIV negative partner is bottom.
01Very Low Risk
02 Low Risk
03 Moderate Risk
04 High Risk
05 Very High Risk
98 Refuse to Answer
KHIVTS7. Anal sex with no condom when the HIV negative partner is top.
01 Very Low Risk
02 Low Risk
03 Moderate Risk
04 High Risk
05 Very High Risk
98 Refuse to Answer
Now imagine that an HIV negative man has sex with an HIV positive man who is being treated for his HIV infection with anti-viral medications. Rate how risky you believe each activity is for the HIV negative partner.
KHIVTS8. Anal sex with no condom when the HIV negative partner is bottom.
01 Very Low Risk
02 Low Risk
03 Moderate Risk
04 High Risk
05 Very High Risk
98 Refuse to Answer
KHIVTS9. Anal sex with no condom when the HIV negative partner is a top.
01 Very Low Risk
02 Low Risk
03 Moderate Risk
04 High Risk
05 Very High Risk
98 Refuse to Answer
Now imagine that an HIV negative man has sex with an HIV positive man who is being treated for his HIV infection with anti-viral medications and his viral load is undetectable. Rate how risky you believe each activity is for the HIV negative partner.
KHIVTS11. Anal sex with no condom when the HIV negative partner is bottom.
01 Very Low Risk
02 Low Risk
03 Moderate Risk
04 High Risk
05 Very High Risk
98 Refuse to Answer
KHIVTS12. Anal sex with no condom when the HIV negative partner is top.
01 Very Low Risk
02. Low Risk
03 Moderate Risk
04 High Risk
05 Very High Risk
98 Refuse to Answer
The next questions ask what you think your chances are of getting HIV/AIDS. Please circle the number that best describes what you think. If you have tested HIV positive, answer these questions regarding what you think your risk is for getting a sexually transmitted disease (STD).
KHIVTS13. Based on your sexual life from the last 6-months, how much do you think you are at risk for HIV/AIDS?
01 Not at Risk at all
02 Slight Risk
03 Somewhat at Risk
04 Good Deal at Risk
05 Great Deal at Risk
06 Extremely Risky
98 Refuse to Answer
KHIVTS14. How much risk do you think your friends are at for HIV/AIDS?
01 Not at Risk at all
02 Slight Risk
03 Somewhat at Risk
04 Good Deal at Risk
05 Great Deal at Risk
06 Extremely Risky
98 Refuse to Answer
KHIVTS15. Think about the number of men in your community that have HIV. For every 1,000 men in your community, how many do you think are infected with HIV? Have HIV/AIDS
01(Actual Number)
02 I don’t Know
98 Refuse to Answer
Module H: PrEP- PREP/PEP Items
If HT5 equals 2 Skip to PrEP10
HIV-Negative and Unknown Status Participants
PrEP1. Before today, have you heard about pre-exposure prophylaxis or PrEP?
01 Yes
02 No
98 Refuse to Answer
PrEP2. A recent study showed that PrEP prevents HIV infection in 44% of the people who take it. Would you be willing to take PrEP pills every day for the rest of your life (or as long as you are sexually active) to try to protect yourself from becoming infected with HIV?
01 Yes
02 No
98 Refuse to Answer
PrEP3. Have you ever used an anti-HIV medication before sex because you thought it might prevent HIV transmission between you and your sex partner?
01 Yes
02 No – Skip to PrEP7
03 Don't Know
98 Refuse to Answer
PrEP4. How many times have you done this in the past year?
01 times per year
02 Don't Know
98 Refuse to Answer
PrEP5. How long have or did you take the medication this time? (Choose one)
01. One day or less
02. 2 - 6 days
03. 1 week but less than 1 month
04. 1 month or longer
05 Don't Know
98 Refuse to Answer
PrEP6. How did you obtain the anti-HIV medication?
01 Health care provider (prescription, sample, etc
02 Sexual Partner
03 Friend
04 Internet
05 Other (Please describe) _______________________________
98 Refuse to Answer
PrEP7. Have you ever used an anti-HIV medication only after sex because you thought it might prevent HIV transmission between you and your sex partner?
01 Yes
02 No – Skip to PrEP10
03 Don't Know
98 Refuse to Answer
PrEP8. How many times have you done this in the past year?
01 times per year
02 Don't Know
98 Refuse to Answer
PrEP9. How long have or did you take the medication after having unprotected sex? (Choose one)
01. One day or less
02. 2 - 6 days
03 1 week but less than 1 month
04 1 month or longer
05. Don't Know
98 Refuse to Answer
If HT5 equals 1, 3, or 4 Skip to Module I: CUSE - Condom Use Self-Efficacy
Only HIV+ status Participants respond to PrEP10
PrEP10. Have you ever given anti-HIV medication to a sex partner before sex because you thought it might prevent HIV infection?
01 Yes
02 No - Skip to PrEP13
03 Don't Know
98 Refuse to Answer
PrEP11. How many times have you done this in the past year?
01 times per year
02 Don't Know
98 Refuse to Answer
PrEP12. At that time, how much medication did you give them? Enough for... (Choose one)
01 One day or less
02 2 - 6 days
03 1 week but less than 1 month
04 1 month or longer
05 Don't Know
98 Refuse to Answer
PrEP13. Have you ever given anti-HIV medication to a sex partner only after sex because you thought it might prevent HIV infection?
01 Yes
02 No – Skip to CS
03 Don't Know
98 Refuse to Answer
PrEP14. How many times have you done this in the past year?
01 times per year
02 Don't Know
98 Refuse to Answer
PrEP15. At that time, how much medication did you give them? Enough for... (Choose one)
01 One day or less
02 2 - 6 days
03 1 week but less than 1 month
04 1 month or longer
05 Don't Know
98 Refuse to Answer
Module I: CUSE - Condom Use Self-Efficacy
CUSE1. In general, how much of a problem would it be for you to put a condom on your hard penis prior to having sex?
01 None
02 Not much
03 A little
04 Some
05 A lot
98 Refuse to answer
CUSE2. How much of a problem would it be for you to unroll a condom down correctly on the first try?
01 None
02 Not much
03 A little
04 Some
05 A lot
98 Refuse to answer
CUSE3. How much of a problem would it be for you to start over using a new condom if you placed it on the wrong way prior to having sex?
01 None
02 Not much
03 A little
04 Some
05 A lot
98 Refuse to answer
CUSE4. How much of a problem would it be for you to unroll a condom fully to the base of your penis?
01 None
02 Not much
03 A little
04 Some
05 A lot
98 Refuse to answer
CUSE5. How much of a problem would it be for you to squeeze air from the tip of a condom?
01 None
02 Not much
03 A little
04 Some
05 A lot
98 Refuse to answer
CUSE6. How much of a problem would it be for you to take a condom off without spilling the semen?
01 None
02 Not much
03 A little
04 Some
05 A lot
98 Refuse to answer
CUSE7. How much of a problem would it be for you to take a condom off before you lose your erection?
01 None
02 Not much
03 A little
04 Some
05 A lot
98 Refuse to answer
CUSE8. How much of a problem would it be for you to dispose of a used condom?
01 None
02 Not much
03 A little
04 Some
05 A lot
98 Refuse to answer
CUSE9. How much of a problem would it be for you to use a spermicidal/lubricant with a condom?
01 None
02 Not much
03 A little
04 Some
05 A lot
98 Refuse to answer
Module J: Contemplation Ladder - Condoms During Anal Sex (Female partners)
CFLPFS Contemplation Ladder - Condoms During Anal Sex (Female partners) Screening item : In the past year (12 months) have you had vaginal or anal sex with a female partner other than a primary female partner?
01 – No – Skip to CFLPMS
02 - Yes
98. Refuse to Answer
CFLPFS. Each rung on this ladder represents the way a person may relate to the idea of using condoms during anal or vaginal sex with casual female partners. Select the number that best represents where you are now.
01. I have used condoms regularly and will never go back to having unprotected anal sex. |
02. I have used condoms more frequently, but I still worry about slipping back to having unprotected anal/vaginal sex. |
03. I still plan to have anal/vaginal sex without condoms, but I'll make some changes like cutting back how often I do it. |
04. I definitely plan to use condoms for anal/vaginal sex more often, and I'm almost ready to make some plans about how to do it. |
05. I definitely plan to use condoms for anal/vaginal sex more often, but I'm not ready to make any plans to do it. |
06. I often have anal/vaginal sex with condoms, but I have no plans to use them more often . |
07. I sometimes have anal/vaginal sex with condoms, but I have no plans to use them more often. |
08. I rarely have anal/vaginal sex with condoms and I have no plans to use them. |
9. I never have anal/vaginal sex with condoms and have no plans to use them. |
10. I enjoy anal/vaginal sex without condoms and have decided to never change it. I have no interest in using condoms. |
Module J: Contemplation Ladder - Condoms During Anal Sex (Male partners
CFLPMS Contemplation Ladder - Condoms During Anal Sex (Male partners) Screening item : In the past 90-days have you had anal sex with a male partner other than a primary male partner?
01 - No – Skip to Next Section DBCU1
02 – Yes
98. Refuse to Answer
CFLPMS Each rung on this ladder represents the way a person may relate to the idea of using condoms during anal sex with casual male partners. Select the number that best represents where you are now.
01. I have used condoms regularly and will never go back to having unprotected anal sex.
02. I have used condoms more frequently, but I still worry about slipping back to having unprotected anal sex.
03. I still plan to have anal sex without condoms, but I'll make some changes like cutting back how often I do it .
04. I definitely plan to use condoms for anal sex more often, and I'm almost ready to make some plans about how to do it.
05. I definitely plan to use condoms for anal sex more often, but I'm not ready to make any plans to do it.
06. I often have anal sex with condoms, but I have no plans to use them more often .
07. I sometimes have anal sex with condoms, but I have no plans to use them more often.
08. I rarely have anal sex with condoms and I have no plans to use them.
09. I never have anal sex with condoms and have no plans to use them.
10. I enjoy anal sex without condoms and have decided to never change it. I have no interest in using condoms.
Module K: DBCU - Decisional Balance for Condom Use
When you think about having sex with or without condoms, how important are any of the following statements to you, when making your decisions to use or not use condoms.
DBCU1. Sex without a condom is more spontaneous.
01 Not at all
02 Slightly
03 Moderately
04 Very
05 Extremely
98 Refuse to Answer
DBCU2. I could get infected (or) re-infected with HIV if I have sex without a condom.
01 Not at all
02 Slightly
03 Moderately
04 Very
05 Extremely
98 Refuse to Answer
DBCU3. Not using a condom with a partner shows that person I trust them.
01 Not at all
02 Slightly
03 Moderately
04 Very
05 Extremely
98 Refuse to Answer
DBCU4. It feels better to have sex without a condom.
01 Not at all
02 Slightly
03 Moderately
04 Very
05 Extremely
98 Refuse to Answer
DBCU5. Sex without a condom feels more natural.
01 Not at all
02 Slightly
03 Moderately
04 Very
05 Extremely
98 Refuse to Answer
DBCU6. I feel guilty after having sex without condom.
01 Not at all
02 Slightly
03Moderately
04 Very
05 Extremely
98 Refuse to Answer
DBCU7. It’s easier for me to cum when I have sex without a condom.
01 Not at all
02 Slightly
03 Moderately
04 Very
05 Extremely
98 Refuse to Answer
DBCU8. It’s easier to keep my hard-on/stay lubricated when I have sex without a condom.
01 Not at all.
02 Slightly
03 Moderately
04 Very
05 Extremely
98 Refuse to Answer
DBCU9. I would feel bad if my friends found out I had sex without a condom.
01 Not at all
02 Slightly
03 Moderately
04 Very
05 Extremely
98 Refuse to Answer
DBCU10. Having sex without a condom is more exciting because I’ve been told I shouldn’t do it.
01 Not at all
02 Slightly
03 Moderately
04 Very
05 Extremely
98 Refuse to Answer
DBCU11. I don’t like to have a barrier between me and my partners when we have sex.
01 Not at all
02 Slightly
03 Moderately
04 Very
05 Extremely
98 Refuse to Answer
DBCU12. Not using a condom for sex makes me feel really irresponsible.
01 Not at all
02 Slightly
03 Moderately
04 Very
05 Extremely
98 Refuse to Answer
DBCU13. When my partner doesn’t want to use a condom, I want to give that person what he/she wants.
01 Not at all
02 Slightly
03 Moderately
04 Very
05 Extremely
98 Refuse to Answer
DBCU14. Having a sex without a condom is like showing a partner I don’t care what happens to him/her.
01 Not at all
02 Slightly
03 Moderately
04 Very
05 Extremely
98 Refuse to Answer
DBCU15. It feels wrong to have sex without a condom.
01 Not at all
02 Slightly
03 Moderately
04 Very
05 Extremely
98 Refuse to Answer
DBCU16. Using condoms reminds me of HIV.
01 Not at all
02 Slightly
03 Moderately
04 Very
05 Extremely
98 Refuse to Answer
DBCU17. Just knowing that sex without a condom can be dangerous is a turn on.
01 Not at all
02 Slightly
03 Moderately
04 Very
05 Extremely
98 Refuse to Answer
Module L: SECU- Self-Efficacy Condom Use
SECOND1. How confident are you that you could avoid having sex without a condom when you really want sex?
01 Not at all confident
02 Not very confident
03 Somewhat confident
04 Very confident
05 Extremely confident
98 Refuse to Answer
SECOND2. How confident are you that you could avoid having sex without a condom when you really need affection?
01 Not at all confident
02 Not very confident
03 Somewhat confident
04 Very confident
05 Extremely confident
98 Refuse to Answer
SECOND3. How confident are you that you could avoid having sex without a condom when you are with someone who is really hot?
01 Not at all confident
02 Not very confident
03 Somewhat confident
04 Very confident
05 Extremely confident
98 Refuse to Answer
SECOND4. How confident are you that you could avoid having sex without a condom when he/she says he/she does not want to use a condom?
01 Not at all confident
02 Not very confident
03 Somewhat confident
04 Very confident
05 Extremely confident
98 Refuse to Answer
SECOND5. How confident are you that you could avoid having sex without a condom when you are angry?
01 Not at all confident
02 Not very confident
03 Somewhat confident
04 Very confident
05 Extremely confident
98 Refuse to Answer
SECOND6. How confident are you that you could avoid having sex without a condom when you think the risk of STDs is low?
01 Not at all confident
02 Not very confident
03 Somewhat confident
04 Very confident
05 Extremely confident
98 Refuse to Answer
SECOND7. How confident are you that you could avoid having sex without a condom when you think the risk for HIV (or re-infection) is low?
01 Not at all confident
02 Not very confident
03 Somewhat confident
04 Very confident
05 Extremely confident
98 Refuse to Answer
SECOND8. How confident are you that you could avoid having sex without a condom when you feel depressed?
01 Not at all confident
02 Not very confident
03 Somewhat confident
04 Very confident
05 Extremely confident
98 Refuse to Answer
SECOND9. How confident are you that you could avoid having sex without a condom when you think that he/she does not want to use condoms?
01 Not at all confident
02 Not very confident
03 Somewhat confident
04 Very confident
05 Extremely confident
98 Refuse to Answer
SECOND10. How confident are you that you could avoid having sex without a condom when you are drunk or high on drugs?
01 Not at all confident
02 Not very confident
03 Somewhat confident
04 Very confident
05 Extremely confident
98 Refuse to Answer
SECOND11. How confident are you that you could avoid having sex without a condom when you think stopping to get a condom will spoil the mood?
01 Not at all confident
02 Not very confident
03 Somewhat confident
04 Very confident
05 Extremely confident
98 Refuse to Answer
SECOND12. How confident are you that you could avoid having sex without a condom when you are really sexually aroused?
01 Not at all confident
02 Not very confident
03 Somewhat confident
04 Very confident
05 Extremely confident
98 Refuse to Answer
SECOND13. How confident are you that you could avoid having sex without a condom when you really want to see or be with her/him again?
01 Not at all confident
02 Not very confident
03 Somewhat confident
04 Very confident
05 Extremely confident
98 Refuse to Answer
SECOND14. How confident are you that you could avoid having sex without a condom when your partner doesn't know that you are bisexually-active?
01 Not at all confident
02 Not very confident
03 Somewhat confident
04 Very confident
05 Extremely confident
98 Refuse to Answer
Module M: HVPOSS- HIV Stigma - Negative Self-Esteem Subscale of the HIV Stigma Scale
FOR HIV-Positive Men
If HT1 is equal to 2 or HT5 is equal to 1 Skip to HNEGS1.
HPOSS1. I feel guilty because I have HIV.
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
HPOSS2. People’s attitudes about HIV make me feel worse about myself.
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
HPOSS3. I work hard to keep my HIV a secret.
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
HPOSS4. I feel I am not as good a person as others because I have HIV.
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
HPOSS5. I never feel ashamed of having HIV.
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
HPOSS6. It is easier to avoid new friendships than worry about telling someone that I have HIV.
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
HPOSS7. Having HIV makes me feel unclean.
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
HPOSS8. Since learning I have HIV, I feel set apart and isolated from the rest of the world.
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
HPOSS9. Having HIV makes me feel that I’m a bad person.
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
HPOSS10. Having HIV in my body is disgusting to me.
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
HPOSS11. As a rule, telling others that I have HIV has been a mistake.
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
HPOSS12. People who know I have HIV tend to ignore my good points.
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
HPOSS13. People seem afraid of me once they learn I have HIV.
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
If HT5 is equal to 2 Skip to DCSHSPOS1.
Module N: HNEGS- HIV Stigma - Negative Self-Esteem Subscale of the HIV Stigma Scale
FOR HIV-Negative Men
HNEGS1. I would feel guilty if I got HIV.
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
HNEGS2. People’s attitudes about HIV would make me feel worse about myself.
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
HNEGS3. I would work hard to keep my HIV a secret.
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
HNEGS4. I would feel I am not as a good a person as others because I have HIV.
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
HNEGS5. I would never feel ashamed of having HIV.
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
HNEGS6. It would be easier to avoid new friendships than worry about telling someone that I have HIV.
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
HNEGS7. Getting HIV would make me feel unclean
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
HNEGS8. Upon learning I got HIV, I would feel set apart and isolated from the rest of the world.
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
HNEGS9. Getting HIV would make me feel that I’m a bad person.
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
HNEGS10. Having HIV in my body would be disgusting to me
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
HNEGS11. Telling others that I got HIV would be a mistake.
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
HNEGS12. People who found out I got HIV would be likely to ignore my good points.
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
HNEGS13. People would act afraid if they learned I have HIV.
01 Strongly Disagree
02 Disagree
03 Agree
04 Strongly Agree
98 Refuse to Answer
Module O: SCSEP -Sexual Communication Self-Efficacy with a Partner
The next items are about ways you talk to sexual partners about sex.
SCSEP1. How hard is it for you to ask how many sex partners he has had?
01 Very hard
02 Hard
03 Easy
04 Very easy
98 Refuse to answer
SCSEP2. How hard is it for you to ask if he is having sex with you and other men?
01 Very hard
02 Hard
03 Easy
04 Very easy
98 Refuse to answer
SCSEP3. How hard is it for you to ask if he is having sex with you and other women?
01 Very hard
02 Hard
03 Easy
04 Very easy
98 Refuse to answer
SCSEP4. How hard is it for you to ask if he has an STD?
01 Very hard
02 Hard
03 Easy
04 Very easy
98 Refuse to answer
SCSEP5. How hard is it for you to ask if he could use a condom?
01 Very hard
02 Hard
03 Easy
04 Very easy
98 Refuse to answer
SCSEP6. How hard is it for you to demand that he use a condom?
01 Very hard
02 Hard
03 Easy
04 Very easy
98 Refuse to answer
SCSEP7. How hard is it for you to refuse to have sex if he won't wear a condom?
01 Very hard
02 Hard
03 Easy
04 Very easy
98 Refuse to answer
Module P: Collective Self Esteem Scale
CSES1. I am a worthy/valued member of my race/ethnic group.
01. Strongly disagree
02. Disagree
03. Disagree somewhat
04. Neutral
05. Agree somewhat
06. Agree
07. Strongly agree
98. Refuse to Answer
CSES2. I often regret that I belong to my racial/ethnic group.
01. Strongly disagree
02. Disagree
03. Disagree somewhat
04. Neutral
05. Agree somewhat
06. Agree
07. Strongly agree
98. Refuse to Answer
CSES3. Overall, my racial/ethnic group is considered good by others.
01. Strongly disagree
02. Disagree
03. Disagree somewhat
04. Neutral
05. Agree somewhat
06. Agree
07. Strongly agree
98. Refuse to Answer
CSES4. Overall, my race/ethnicity has very little to do with how I feel about myself.
01. Strongly disagree
02. Disagree
03. Disagree somewhat
04. Neutral
05. Agree somewhat
06. Agree
07. Strongly agree
98. Refuse to Answer
CSES5. I feel I don't have much to offer to my racial/ethnic group.
01. Strongly disagree
02. Disagree
03. Disagree somewhat
04. Neutral
05. Agree somewhat
06. Agree
07. Strongly agree
98. Refuse to Answer
CSES6. In general, I'm glad to be a member of my racial/ethnic group.
01. Strongly disagree
02. Disagree
03. Disagree somewhat
04. Neutral
05. Agree somewhat
06. Agree
07. Strongly agree
98. Refuse to Answer
CSES7. Most people consider my racial/ethnic group, on the average, to be more ineffective than other groups.
01. Strongly disagree
02. Disagree
03. Disagree somewhat
04. Neutral
05. Agree somewhat
06. Agree
07. Strongly agree
98. Refuse to Answer
CSES8. The racial/ethnic group I belong to is an important reflection of who I am.
01. Strongly disagree
02. Disagree
03. Disagree somewhat
04. Neutral
05. Agree somewhat
06. Agree
07. Strongly agree
98. Refuse to Answer
CSES9. I am a cooperative participant in the activities of my racial/ethnic group.
01. Strongly disagree
02. Disagree
03. Disagree somewhat
04. Neutral
05. Agree somewhat
06. Agree
07. Strongly agree
98. Refuse to Answer
CSES10. Overall, I often feel that my racial/ethnic group is not worthwhile.
01. Strongly disagree
02. Disagree
03. Disagree somewhat
04. Neutral
05. Agree somewhat
06. Agree
07. Strongly agree
98. Refuse to Answer
CSES11. In general, others respect my race/ethnicity.
01. Strongly disagree
02. Disagree
03. Disagree somewhat
04. Neutral
05. Agree somewhat
06. Agree
07. Strongly agree
98. Refuse to Answer
CSES12. My race/ethnicity is unimportant to my sense of what kind of a person I am.
01. Strongly disagree
02. Disagree
03. Disagree somewhat
04. Neutral
05. Agree somewhat
06. Agree
07. Strongly agree
98. Refuse to Answer
CSES13. I often feel I’m a useless/unvalued member of my racial/ethnic group.
01. Strongly disagree
02. Disagree
03. Disagree somewhat
04. Neutral
05. Agree somewhat
06. Agree
07. Strongly agree
98. Refuse to Answer
CSES14. I feel good about the race/ethnicity I belong to.
01. Strongly disagree
02. Disagree
03. Disagree somewhat
04. Neutral
05. Agree somewhat
06. Agree
07. Strongly agree
98. Refuse to Answer
CSES15. In general, others think my racial/ethnic group is unworthy.
01. Strongly disagree
02. Disagree
03. Disagree somewhat
04. Neutral
05. Agree somewhat
06. Agree
07. Strongly agree
98. Refuse to Answer
CSES16. In general, belonging to my race/ethnicity is an important part of my self image.
01. Strongly disagree
02. Disagree
03. Disagree somewhat
04. Neutral
05. Agree somewhat
06. Agree
07. Strongly agree
98. Refuse to Answer
Module Q: NE- Negative Experiences
NE1. In the past 12 months, how often have you been hit or beaten up because people thought or knew you were homosexual or not manly enough? (Choose one)
01 Never
02 Once
03 2 - 3 times
04 4 - 7 times
05 8 or more times
98 Refuse to Answer
NE2. In the past 12 months, how often have you been treated rudely or unfairly because people thought you were homosexual or not manly enough? (Choose one)
01 Never
02 Once
03 2 - 3 times
04 4 - 7 times
05 8 or more times
98 Refuse to Answer
NE3. In the past 12 months, how often have you been made fun of or called names because people thought you were homosexual or not manly enough? (Choose one)
01 Never
02 Once
03 2 - 3 times
04 4 - 7 times
05 8 or more times
98 Refuse to Answer
NE4. In the past 12 months, how often have you had to act more manly than usual in order to be accepted? (Choose one)
01 Never
02 Once
03 2 - 3 times
04 4 - 7 times
05 8 or more times
98 Refuse to Answer
NE5. In the past 12 months, how often have you felt uncomfortable in a crowd of straight (heterosexual) Blacks in Chicago because people thought you were homosexual or not manly enough? (Choose one)
01 Never
02 Once
03 2 - 3 times
04 4 - 7 times
05 8 or more times
98 Refuse to Answer
NE6. In the past 12 months, how often have you thought that you have been hit or beaten up because of your race or ethnicity? (Choose one)
01 Never
02 Once
03 2 - 3 times
04 4 - 7 times
05 8 or more times
98 Refuse to Answer
NE7. In the past 12 months, how often have you thought that you have been treated rudely or unfairly, or harassed, because of your race or ethnicity? (Choose one)
01 Never
02 Once
03 2 - 3 times
04 4 - 7 times
05 8 or more times
98 Refuse to Answer
NE8. In the past 12 months, how often have you felt uncomfortable in a crowd of white gay men because of your race or ethnicity? (Choose one)
01 Never
02 Once
03 2 - 3 times
04 4 - 7 times
05 8 or more times
98 Refuse to Answer
NE9. In the past 12 months, how often have you thought that you have had trouble finding a male lover or boyfriend because of your race or ethnicity? (Choose one)
01 Never
02 Once
03 2 - 3 times
04 4 - 7 times
05 8 or more times
98 Refuse to Answer
NE10. In the past 12 months, how often have you thought that men turned you down for sex because of your race or ethnicity? (Choose one)
01 Never
02 Once
03 2 - 3 times
04 4 - 7 times
05 8 or more times
98 Refuse to Answer
Module R: ACE - Adverse Childhood Event Scale
While you were growing up, during your first 18 years of life:
AC1. Did a parent or other adult in the household often or very often…
Swear at you, insult you, put you down, or humiliate you?
or
Act in a way that made you afraid that you might be physically hurt?
01Yes
02 No
98. Refuse to Answer
ACE2. Did a parent or other adult in the household often or very often…
Push, grab, slap, or throw something at you?
or
Ever hit you so hard that you had marks or were injured?
01Yes
02 No
98. Refuse to Answer
ACE3. Did an adult or person at least 5 years older than you ever…
Touch or fondle you or have you touch their body in a sexual way against your will?
or
Attempt or actually have oral, anal, intercourse with you against your will?
01Yes
02 No
98. Refuse to Answer
ACE4. Did you often or very often feel that …
No one in your family loved you or thought you were important or special?
or
Your family didn’t look out for each other, feel close to each other, or support each other?
01Yes
02 No
98. Refuse to Answer
ACE5. Did you often feel that …
You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you?
or
Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
01Yes
02 No
98. Refuse to Answer
ACE6. Were your parents ever separated or divorced?
01Yes
02 No
98. Refuse to Answer
ACE7. Was your mother or stepmother:
Often or very often pushed, grabbed, slapped, or had something thrown at her?
or
Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard?
or
Ever repeatedly hit at least a few minutes or threatened with a gun or knife?
01Yes
02 No
98. Refuse to Answer
ACE8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
01Yes
02 No
98. Refuse to Answer
ACE9. Was a household member depressed or mentally ill, or did a household member attempt suicide?
01Yes
02 No
98. Refuse to Answer
ACE10. Did a household member go to prison?
01Yes
02 No
98. Refuse to Answer
Module S: PVQFP - Partner Violence Questionnaire (Female Partner)
If SA72 is equal to 2, Skip to PVQMP1.
Has any of the following ever happened with a girl friend or female partner?
PVQFP1. You pushed, shoved, kicked, hit or threw something at her?
Yes
No – SKIP to PVQFP2
98. Refuse to answer
PVQFP1a. If yes, has this happened within the past 90 days?
Yes
No
98. Refuse to answer
PVQFP2. You made fun of or humiliated her in front of others?
Yes
No – SKIP to PVQFP3
98. Refuse to answer
PVQFP2a. If yes, has this happened within the past 90 days?
Yes
No
98. Refuse to answer
PVQFP3. You forced her to have sex?
Yes
No – SKIP to PVQFP4
98. Refuse to answer
PVQFP3a. If yes, has this happened within the past 90 days?
Yes
No
98. Refuse to answer
Has any of the following ever happened with a male partner?
PVQMP1. He pushed, shoved, kicked, hit or threw something at you?
Yes
No – SKIP to PVQMP2
98. Refuse to answer
PVQMP1a. If yes, has this happened within the past 90 days?
Yes
No
98. Refuse to answer
PVQMP2. He made fun of or humiliated you in front of others?
Yes
No
98. Refuse to answer
PVQMP2a. If yes, has this happened within the past 90 days?
Yes
No
98. Refuse to answer
PVQMP3. He forced you to have sex?
Yes
No
98. Refuse to answer
PVQMP3a. If yes, has this happened within the past 90 days?
Yes
No
98. Refuse to answer
PVQMV4. You pushed, shoved, kicked, hit or threw something at him?
Yes
No – SKIP to PVQMV2
98. Refuse to answer
PVQMV4a. If yes, has this happened within the past 90 days?
Yes
No
98. Refuse to answer
PVQMV5. You made fun of or humiliated him in front of others?
Yes
No
98. Refuse to answer
PVQMV5a. If yes, has this happened within the past 90 days?
Yes
No
98. Refuse to answer
PVQMV6. You forced him to have sex?
Yes
No
98. Refuse to answer
PVQMV6a. If yes, has this happened within the past 90 days?
Yes
No
98. Refuse to answer
Module T: ED-SO - Everyday Discrimination -Sexual Orientation
In your day-to-day life how often have any of the following things happened to you because of your sexual orientation?
EDSO1. You are treated with less courtesy than other people.
Almost every day
At least once a week
A few times a month
A few times a year
Less than once a year
Never
98. Refuse to Answer
EDSO2. You are treated with less respect than other people.
Almost every day
At least once a week
A few times a month
A few times a year
Less than once a year
Never
98. Refuse to Answer
EDSO3. You receive poorer service than other people at restaurants or stores.
Almost every day
At least once a week
A few times a month
A few times a year
Less than once a year
Never
98. Refuse to Answer
EDSO4. People act as if they think you are not smart.
Almost every day
At least once a week
A few times a month
A few times a year
Less than once a year
Never
98. Refuse to Answer
EDSO5. People act as if they are afraid of you.
Almost every day
At least once a week
A few times a month
A few times a year
Less than once a year
Never
98. Refuse to Answer
EDSO6. People act as if they think you are dishonest.
Almost every day
At least once a week
A few times a month
A few times a year
Less than once a year
Never
98. Refuse to Answer
EDSO7. People act as if they're better than you are.
Almost every day
At least once a week
A few times a month
A few times a year
Less than once a year
Never
98. Refuse to Answer
EDSO8. You are called names or insulted.
Almost every day
At least once a week
A few times a month
A few times a year
Less than once a year
Never
98. Refuse to Answer
EDSO9. You are threatened or harassed.
Almost every day
At least once a week
A few times a month
A few times a year
Less than once a year
Never
98. Refuse to Answer
Module U: ED-R - Everyday Discrimination Race
In your day-to-day life how often have any of the following things happened to you because of your racial/ethnic identity?
EDR1. You are treated with less courtesy than other people.
Almost every day
At least once a week
A few times a month
A few times a year
Less than once a year
Never
98. Refuse to Answer
EDR2. You are treated with less respect than other people.
Almost every day
At least once a week
A few times a month
A few times a year
Less than once a year
Never
98. Refuse to Answer
EDR3. You receive poorer service than other people at restaurants or stores.
Almost every day
At least once a week
A few times a month
A few times a year
Less than once a year
Never
98. Refuse to Answer
EDR4. People act as if they think you are not smart.
Almost every day
At least once a week
A few times a month
A few times a year
Less than once a year
Never
98. Refuse to Answer
EDR5. People act as if they are afraid of you.
Almost every day
At least once a week
A few times a month
A few times a year
Less than once a year
Never
98. Refuse to Answer
EDR6. People act as if they think you are dishonest.
Almost every day
At least once a week
A few times a month
A few times a year
Less than once a year
Never
98. Refuse to Answer
EDR6. People act as if they're better than you are.
Almost every day
At least once a week
A few times a month
A few times a year
Less than once a year
Never
98. Refuse to Answer
EDR7. You are called names or insulted.
Almost every day
At least once a week
A few times a month
A few times a year
Less than once a year
Never
98. Refuse to Answer
EDR8. You are threatened or harassed.
Almost every day
At least once a week
A few times a month
A few times a year
Less than once a year
Never
98. Refuse to Answer
Module V: MIBI-Multidimensional Inventory of Black Identity (MIBI)
MIBI1. Overall, being Black has very little to do with how I feel about myself
1. Strongly Agree
2
3
4. Neutral
5
6
7. Strongly Agree
98. Refuse to Answer
MIBI2. I feel good about Black people.
1. Strongly Agree
2
3
4. Neutral
5
6
7. Strongly Agree
98. Refuse to Answer
MIBI3. In general, being Black is an important part of my self-image.
1. Strongly Agree
2
3
4. Neutral
5
6
7. Strongly Agree
98. Refuse to Answer
MIBI4. I am happy that I am Black.
1. Strongly Agree
2
3
4. Neutral
5
6
7. Strongly Agree
98. Refuse to Answer
MIBI5. 8. I feel that Blacks have made major accomplishments and advancements.
1. Strongly Agree
2
3
4. Neutral
5
6
7. Strongly Agree
98. Refuse to Answer
MIBI6. My destiny is tied to the destiny of other Black people.
1. Strongly Agree
2
3
4. Neutral
5
6
7. Strongly Agree
98. Refuse to Answer
MIBI7. I have a strong sense of belonging to Black people.
1. Strongly Agree
2
3
4. Neutral
5
6
7. Strongly Agree
98. Refuse to Answer
MIBI8. Being an individual is more important than identifying oneself as Black.
1. Strongly Agree
2
3
4. Neutral
5
6
7. Strongly Agree
98. Refuse to Answer
MIBI9. I have a strong attachment to other Black people.
1. Strongly Agree
2
3
4. Neutral
5
6
7. Strongly Agree
98. Refuse to Answer
Module W: IGCS - Identification and Involvement with the Gay Community Scale (IGCS)
How much do you agree with the following statements?
IGCS1. It is very important to me that at least some of my friends are bisexual or homosexual.
1 Strongly disagree
2 Disagree
3 Do not agree or disagree
4 Agree
5 Strongly agree
98. Refuse to Answer
IGCS2. Identifying as gay makes me feel part of a community.
1 Strongly disagree
2 Disagree
3 Do not agree or disagree
4 Agree
5 Strongly agree
98. Refuse to Answer
IGCS3. Being attracted to men is important to my sense of who I am.
1 Strongly disagree
2 Disagree
3 Do not agree or disagree
4 Agree
5 Strongly agree
98. Refuse to Answer
IGCS4. I feel very distant from the gay community in general.
1 Strongly disagree
2 Disagree
3 Do not agree or disagree
4 Agree
5 Strongly agree
98. Refuse to Answer
IGCS5. I feel very distant from the black gay/homosexual community.
1 Strongly disagree
2 Disagree
3 Do not agree or disagree
4 Agree
5 Strongly agree
98. Refuse to Answer
For Questions 6-8, please think in terms of the last six months or so.
IGCS6. How often do you read a gay or lesbian oriented paper or magazine, such as the Advocate or other local gay/bisexual papers?
Never
Once a month or less
Several times a month
Several times a week or daily
98. Refuse to Answer
IGCS7. How often do you attend any gay or lesbian organizational activities, such as meetings, fund-raisers, political activities, etc.?
Never
Once a month or less
Several times a month
about once a week
Several times a week or daily
98. Refuse to Answer
IGCS8. How often do you go to a gay bar?
1. Never
2. Once a month or less
3. Several times a month
4. about once a week
5. Several times a week or daily
98. Refuse to Answer
IGCS9. About how many gay/homosexual-identified men would you call personal friends (as opposed to casual acquaintances)?
1. None
2. One
3. Between 2 and 5
4. Between 6 and 10
5. More than 10
98. Refuse to Answer
IGCS10. How often do you attend any gay, lesbian, or bisexual organizational activities, such as meetings, fund raisers, political activities, etc. frequented by or geared toward black people?
1. Never
2. Once a month or less
3. Several times a month
4. about once a week
5. Several times a week or daily
98. Refuse to Answer
IGCS11. About how many black gay men, homosexual, lesbian, or bisexual women would you call personal friends (as opposed to casual acquaintances)?
1. One
2. Between 2 and 5
3. Between 6 and 10
4. More than 10
5.
98. Refuse to Answer
IGCS12. How often do you attend any social functions frequented by black people?
1. Never
2. Once a month or less
3. Several times a month
4. about once a week
5. Several times a week or daily
98. Refuse to Answer
IGCS13. How often do you attend any organizations activities, such as meetings, fund raisers, political activities, etc. frequented by black people (e.g., college alumni meetings, fraternity meetings, etc.)
1. Never
2. Once a month or less
3. Several times a month
4. about once a week
5. Several times a week or daily
98. Refuse to Answer
GCS14. About how many black men and women would you call personal friends (as opposed to casual acquaintances), regardless of sexual orientation?
1. None
2. One
3. Between 2 and 5
4. Between 6 and 10
5. More than 10
98. Refuse to Answer
Module X: IHS - Internalized Homophobia Scale
IH1. I often feel it is best to avoid personal or social involvement with other homosexual or bisexual men.
1. Strongly Disagree
2. Disagree
3. Agree
4. Strongly Agree
98. Refuse to Answer
IH2. I have tried to stop being attracted to men in general.
1. Strongly Disagree
2. Disagree
3. Agree
4. Strongly Agree
98. Refuse to Answer
IH3. If someone offered me the chance to be completely heterosexual, I would accept the chance.
1. Strongly Disagree
2. Disagree
3. Agree
4. Strongly Agree
98. Refuse to Answer
IH4. I wish I weren't sexually attracted to other men.
1. Strongly Disagree
2. Disagree
3. Agree
4. Strongly Agree
98. Refuse to Answer
IH5. I feel alienated from myself because of being gay/bisexual.
1. Strongly Disagree
2. Disagree
3. Agree
4. Strongly Agree
98. Refuse to Answer
IH6. I wish that I could be more sexually attracted to women.
1. Strongly Disagree
2. Disagree
3. Agree
4. Strongly Agree 98. Refuse to Answer
IH7. I feel that being homosexual/bisexual is a personal shortcoming for me.
1. Strongly Disagree
2. Disagree
3. Agree
4. Strongly Agree
98. Refuse to Answer
IH8. I would like to get professional help in order to change my sexual orientation from homosexual/bisexual to straight/heterosexual.
1. Strongly Disagree
2. Disagree
3. Agree
4. Strongly Agree
98. Refuse to Answer
IH9. I have tried to become more sexually attracted to women.
1. Strongly Disagree
2. Disagree
3. Agree
4. Strongly Agree
98. Refuse to Answer
Module Y:Religion and Spirituality
RS1. How often have you attended a place of worship (e.g., church, temple, mosque) during the past 6 months other than for a wedding or funeral? (Choose one)
1. Never – Skip to RS4
2. Once a week
3. 2-3 times a month
4 Once a month
5 Less than once a month
98 Refuse to Answer
RS2. Approximately how many people are Black at the place you worship?
1 All
2 More than half
3 About half
4 Less than half
5 None
98 Refuse to Answer
RS3. Of the people that you know at the place you worship, approximately how many are aware that you have sex with men? (Choose one)
1 All
2 More than half
3 About half
4 Less than half
5 None
98 Refuse to Answer
RS4. I am able to be open about my sexuality in my religious community with… (Choose one)
1. Everyone
2. More than half of those attending my religious community
3. About half of those attending my religious community
4. Less than half of those attending my religious community
5. None of those attending my religious community
98. Refuse to Answer
RS5. My religious beliefs make me feel bad about having sex with other men. (Choose one)
1. Always
2. More than half the time
3. About half the time
4. Less than half the time
5. None of the time
98. Refuse to Answer
RS6. I often have to choose my religious beliefs over my desire to be with a man. (Choose one)
1. Always
2. More than half the time
3. About half the time
4. Less than half the time
5. None of the time
98. Refuse to Answer
RS7. I always seek guidance from a higher power in times of need. (Choose one)
1. Always
2. Most times
3. About half the time
4. Less than half the time
5. Never – Skip to RS 9
98. Refuse to Answer
RS8. My spiritual connection with a higher power helps me cope with negative beliefs that other people have about homosexuality. (Choose one)
1. Always
2. More than half the time
3. About half the time
4. Less than half the time
5. None of the time
98. Refuse to Answer
RS9. My spiritual beliefs encourage me to do everything that I can to stay healthy. (Choose one)
1. Always
2. More than half the time
3. About half the time
4. Less than half the time
5. None of the time
98. Refuse to Answer
Module Z: Homegrown Cross site assessment items
Items for considerations across all 3 sites
I. Demographics
CS1. How many children do you have?
1._______
98 Refuse to Answer
CS2. Have you ever been told by a doctor or psychiatrist that you have a mental illness?
1. Yes
2. NO –Skip to CS7
98 Refuse to Answer
CS3. If yes, what was the diagnosis? (check all that apply)
1. Major Depression
2. Anxiety disorder
3. Bipolar disorder
4. Schizophrenia
5. Other specify
98. Refuse to Answer
CS4. If yes, have you ever been hospitalized because of your mental illness?
1. Yes
2. No
98 Refuse to Answer
CS5. If yes, has a doctor prescribed you medication to treat this mental illness?
1. Yes
2. No
98 Refuse to Answer
CS6. Are you taking the medication as the doctor prescribed?
1. Yes
2. No
98 Refuse to Answer
II. Outcome measures
Forgoing unsafe sex/ episodic abstinence
CS7. In the past 3 months, how many times did you NOT have anal or vaginal sex because you or your partner did not have a condom?
1.___________
98 Refuse to Answer
CS8. In the past 3 months, how many times have you been in a situation where your partner wanted to have anal or vaginal sex without a condom?
98 Refuse to Answer
CS9. Of those ____ times, how many times did you have vaginal or anal sex without a condom?
1. ___________
98 Refuse to Answer
Measuring sexual health/sexual well-being
General overall sexual satisfaction
CS10. During the past 3 months, how emotionally satisfying was your sex life?
1 Not at all satisfying
2 Slightly satisfying
3 Moderately satisfying
4 Very satisfying
5 Extremely satisfying
98 Refuse to Answer
CS11. During the past 3 months, how physically pleasurable was your sex life?
1 Not at all satisfying
2 Slightly satisfying
3 Moderately satisfying
4 Very satisfying
5 Extremely satisfying
98 Refuse to Answer
III. Other
Enema use
CS12. How often do you use enemas (insert a fluid into the anus to clean it out), in preparation for anal sex?
(4) Always, (3) Often, (2) Sometimes, (1) Rarely, (0) Never
98 Refuse to Answer
CS13. Do you expect your partner to use enemas (insert a fluid into the anus to clean it out) in preparation for anal sex?
(4) Always, (3) Often, (2) Sometimes, (1) Rarely, (0) Never
98 Refuse to Answer
How you met last partner
CS14. How did you first meet partner your most recent partner? (Choose one)
Adult bookstore, sex club, bathhouse
Gay bar /nightclub
Church, political function
Grocery store ****only in UNC
Gym / health club / athletic activity
Internet (hook up, dating or social networking site)
Newspaper ads
Non-gay bar, nightclub
Private party
Social club*** only in NC
Public places including street, park, shopping mall, grocery store, l library, public transportation
School
Social organizations / volunteer service activities
Through friend(s)
Vacation / Business trip
Work
Some other way, please specify:
98 Refuse to Answer
Internet and cell phone use
The next questions are about the Internet.
CS15. How do you usually access the Internet or go online? (Choose all that apply)
Cell phone, Computer at home, Computer at work, Computer in library or Internet café, Other specify, I don’t ever access the Internet
98 Refuse to Answer
CS16. During the last 3 months, how often did you go online to connect with or find gay Black men for social and personal connections other than sex?
1. Never
2. Very rarely
3. Monthly
4. Weekly
5. Daily
98 Refuse to Answer
CS17. During the last 3 months, how often did you go online to connect with or find male sex partners?
1. Never,
2. Very rarely,
3. Monthly,
4. Weekly,
5. Daily
98 Refuse to Answer
CS18. During the past 3 months, how often did you use apps on a cell phone or mobile device to find people for sex? Grindr and Jack’d are examples of apps.
1.Never
2. Very rarely
3. Monthly
4. Weekly
5. Daily
98 Refuse to Answer
If CS 18 is equal to Never, then skip.
1. What apps did you use, please specify _______________.
98 Refuse to Answer
Version 15 2/2/2012
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