Bisexual men have many unmet public health needs, which leave them vulnerable to sexually transmitted infections (STIs) and other health problems. This new study from the Centers for Disease Control and Prevention (CDC) illuminates the behavioral, interpersonal, and social realities of men who have sex with men and women (MSMW), and it explores possible interventions to better serve their needs. The findings are published today in the American Journal of Preventive Medicine.
MSMW represent a small portion of the population, with about 2% of sexually active males reporting sex with both men and women. Although low in numbers, the bisexual male population is disproportionally affected by HIV and STIs. According to study author William L. Jeffries IV, PhD, MPH, MA, factors that may affect the sexual health of MSMW include sex without condoms, early sexual debut, forced sexual encounters, increased numbers of sexual partners, substance use, exchange sex, risk behaviors of their male and female partners, and attitudes toward pregnancy. These factors shape MSMW’s vulnerability to HIV and STIs in ways that distinguish bisexual men from gay and heterosexual men. Negative attitudes toward bisexual individuals, economic barriers, masculinity norms, and the meanings associated with their sexual identities are among the social factors that may negatively influence their sexual partnerships and risks for HIV/STIs.
While HIV prevalence among MSMW is lower than among gay men, MSMW are more likely than heterosexual men to become infected with HIV. Also, MSMW are less likely than gay men to be tested for HIV, which can lead to undiagnosed HIV and transmission to partners. Along with HIV, other STIs are common among MSMW, with 21% of these men reporting STI treatment in the past year, compared to 12% for gay men and 2.3% of heterosexual men.
“MSMW’s increased likelihood of insertive sex without a condom, as well as commonly occurring oral sex with men and women, likely increase MSMW’s vulnerability to STIs readily acquired via penile-insertive and oral sex,” writes Dr. Jeffries. “Moreover, receptive and insertive sex without a condom with men (no matter how common) makes MSMW more vulnerable to HIV than men who only have sex with women because HIV is more prevalent among men than women in the United States.”
Dr. Jeffries also identifies other behavioral factors that may increase chances of acquiring HIV and STIs among MSMW, including early sexual experiences, multiple partners, illicit drug use, and attitudes towards pregnancy.
HIV Among Men Who Have Sex With Men and Women (MSMW): Prevalence Estimates, Acquisition and Transmission Risks, and Implications for Interventions
Men who have sex with men and women (MSMW) have unique HIV-related health disparities when compared with men who have sex with men only (MSMO) and men who have sex with women exclusively (MSWE) in the United States. This dissertation characterizes these disparities, first by conducting a literature review, which contextualizes disparities found among MSMW across the domains of childhood adversities, psychosocial health conditions, and HIV risk behaviors; this review also reports estimates of the population percentage of MSMW. A meta-analysis of HIV prevalence in men was conducted: findings show that MSMW are significantly less likely to be HIV positive than MSMO but significantly more likely to be HIV positive than MSWE. Trajectory analyses of biomedical, psychosocial, and behavioral health conditions were then estimated using longitudinal data from a prospective cohort of sexually active MSM. Results indicated that MSMW are more likely to be depressed; and, among HIV positive men, more likely to have higher viral load levels unresolved over time, but also unlikely to transmit HIV to main female partners. A secondary data analysis was conducted among substance-using MSMO and MSMW; results demonstrated that MSMW were more likely to engage in transactional sex and have anal sex with men while high. Taken together, findings show that MSMW are subject to profound HIV-related health disparities that deserve theoretical attention and public health intervention design and delivery attuned to their specific needs.
Friedman, Mackey (2013) HIV Among Men Who Have Sex With Men and Women (MSMW): Prevalence Estimates, Acquisition and Transmission Risks, and Implications for Interventions. Doctoral Dissertation, University of Pittsburgh.
“MSMW’s attitudes toward pregnancy influence their sexual health. Qualitative data from black men suggest that desires to prevent pregnancy may prompt some MSMW to consistently use condoms with women,” Dr. Jeffries explains in the paper. “Yet, MSMW may avoid condom use when their female partners use other contraceptives or when female partners perceive condom use as a sign of relationship infidelity. Further, MSMW’s desires to produce offspring biologically may prompt sex without a condom with female partners. In this regard, desires for fatherhood may indirectly increase these men’s vulnerability to HIV/STIs and transmission of these infections within their sexual networks.”
In the current social climate, MSMW face several sociocultural obstacles including biphobia, or negative attitudes towards bisexuals.
“Biphobia can manifest in erroneous beliefs that MSMW are gay men who have not disclosed their sexual orientation and, particularly for black men, responsible for HIV transmission to women,” Dr. Jeffries adds. “Experiencing these sentiments can contribute to MSMW’s social isolation and psychological distress, which in turn may promote HIV/STI risk through substance use, sexual risk behaviors, and the avoidance of prevention services.”
This new research not only describes an understudied population, but also recommends interventions to better serve bisexual men. Dr. Jeffries suggests that some strategies for comprehensively promoting MSMW’s sexual health may be to: • Launch social marketing campaigns that use affirmative images of sexual minority men to counteract the biphobia and homophobia that MSMW experience • Develop comprehensive sexuality education programs that provide invaluable HIV/STI prevention education to MSMW, including promoting school safety for MSMW • Encourage social spaces that cultivate a sense of community to provide opportunities for social support and candid discussion of sexual health concerns • Engage medical and health professionals in sensitivity trainings to lessen any hostility encountered by MSMW when they seek information about sexual health or HIV/STI testing
HIV Risk Among Men Who Have Sex with Men Only (MSMO) and Men Who Have Sex with Men and Women (MSMW) in Baltimore
Men who have sex with men and women (MSMW) are at high risk for HIV. However, the majority of research on populations of men who have sex with men (MSM) combines MSMW and men who have sex with men only (MSMO) samples, which limits our understanding of HIV risk behaviors and factors associated with HIV risk among MSMW populations. We used the BESURE-MSM2, a venue-based cross-sectional study of HIV risk behaviors among MSM in Baltimore, MD, to examine HIV risk among MSMW. MSMW were less likely to report unprotected receptive anal intercourse than MSMO (6.8% vs. 19.6%, p = .0024). Among MSMW, 43.0% reported unprotected sex with a woman in the past year, but only 19.4% reported unprotected sex with both men and women, representing only 5.0% of the total MSM sample. In multivariate analyses, we found that among MSMW having unprotected sex with women in the past year, disclosing same sex behavior and having a main female partner were associated with unprotected anal intercourse with male partners. HIV prevention programs for MSMW are needed that address the complex partnerships of MSMW and the social contextual factors within which relationships and behaviors are embedded.
While more research and outreach is needed to better understand the particular health and other needs of bisexual men, this study sheds new light on the current situation.
“Sexual health promotion for MSMW should not be limited to HIV/STI prevention alone,” concludes Dr. Jeffries. “Recognition of MSMW’s unique sexual and social experiences can lay the foundation necessary for ensuring that these men have healthy and fulfilling sexual experiences. Purposefully designed and tailored efforts for MSMW are indispensable for improving the sexual health of this vulnerable population.”
Angela J. Beck
Elsevier Health Sciences