Public health approaches to sexual health for Black sexual minority men (SMM) have been overwhelmingly HIV-focused, treating sexuality primarily as a source of pathology and disease transmission. Although this focus has been informative for addressing community health, it has also narrowed the scope of scientific inquiry regarding Black SMM, leaving broader psychological, developmental, and cultural dynamics of sexual decision-making and health across the lifespan generally underexplored. Importantly, this reductive framing of sexuality is not confined to the United States. Across sub-Saharan Africa, the Caribbean, and Latin America, Black SMM are similarly reduced to HIV outcomes with little recognition of their agency, mental health, or cultural contexts. Sexual epidemiology is an emerging field that examines the distribution, determinants, and consequences of sex and related health outcomes. For example, sexual roles such as “top,” “bottom,” and “versatile” function as cultural scripts tied to social meanings, behaviors, and health outcomes. However, few studies have examined how age-related and developmental factors influences the sexual life course. Generational differences in HIV epidemiology, social tolerance for LGBTQ + groups, and medical/policy advances further underscore the importance of focusing on age and developmental trajectories for this population. This chapter applies a Life Course perspective to examine the sexual epidemiology of Black SMM and reorient sexual health promotion toward a more holistic approach that recognizes agency, culture, and linked lives across time and place.