An exploration of sexual behaviour and self-definition in a cohort of men who have sex with men.

ABSTRACT: A measure of sexual activity (homosexual vs. bisexual) and a measure of sexual identification (homosexual/gay vs. bisexual) were combined to classify men who have sex with men (MSM) for HIV research. Using polytomous logistic regression analyses, gay-defined homosexually active men (GDHA; n=994) were compared with three groups: bisexually defined bisexually active (BDBA; n=83), bisexually defined homosexually active men (BDHA; n=47), and gay-defined bisexually active men (GDBA; n=25). Over an 18-month period, differences were observed between the bisexual groups and the GDHA in some socio-demographic characteristics, sexual practices, partners, venues used for sex, and in trading sex. The bisexually defined groups also showed increased odds of injection drug use. These exploratory analyses identified a constellation of practices that distinguished each group from the GDHA and are suggestive of distinct risk contexts. Future research should examine in greater detail the intersections between male bisexuality, trading sex and drug use as well as the role of discrepancies between identity and behaviour in HIV risk.

Key words: Bisexuality MSM Sexuality Drug use Trading sex IDU HIV

INTRODUCTION

Growing concern that bisexual men might be bridging HIV infection from the gay community to the larger heterosexual population drew the attention of HIV researchers who realized that the risk factors and prevention needs of this group of men who have sex with men (MSM) may be distinct (Rust, 2000). The magnitude of the risk of HIV transmission by bisexual men to the heterosexual population has since been questioned (Kennedy & Doll, 2001; Worth, 2003). Nevertheless, for well over a decade now, bisexual men have been investigated separately from homosexual or gay men in studies on the psychosocial and behavioural determinants of HIV infection. Collectively, this research has reinforced the observation that male bisexuality and, by extension, homosexual activity, encompasses an extremely diverse class of experiences.

Although the patterns and contexts of bisexual men's sexual expression are varied, within the context of the HIV literature a few specific interrelated typologies of bisexually active or non-gay identified MSM have been described. Doll & Beeker (1996) identified four contexts of bisexual behaviour associated with increased vulnerability to infection: male prostitution, injection drug use, sexual identity exploration among youth and communities of color. A qualitative study by Goldbaum, Perdue & Higgins (1996) yielded six overlapping categories of men: hustlers or men who have sex with men for economic reasons; closeted men or men who are coming out; new age men or experimenters; incarcerated or formerly incarcerated men; people of colour or cultural groups; and heterosexually identified men, including married men. Emphasizing the fluidity of sexual behaviour and orientation, and echoing aspects of Goldbaum et al.'s (1996) classification, Stokes, Miller & Mundhenk (1998) proposed a four group typology: men in transition (e.g., bisexual men on their way to becoming gay-identified); experimenters (e.g., gay-identified men who, on occasion, will have sex with a woman); opportunity driven men (e.g., men who have sex with men when women are not available) and men with dual involvement (e.g., men whose involvement with men and women is both emotional and sexual).

As suggested by the above typologies, consideration of bisexuality in the context of HIV studies has placed renewed emphasis on the incongruity that can exist between sexual practices and sexual identity. Behaviourally bisexual men do not invariably describe themselves as bisexual. In HIV research, depending on the sample, the proportion of bisexual identified men can range from approximately 30% (35%, Bennett, Chapman & Bray, 1989; 29%, Lever, Kanouse, Rogers, Carson & Hertz, 1992) to 60% (56%, Boulton, Hart & Fitzpatrick, 1992; 59%, McKirnan, Stokes, Doll & Burzette, 1995; 59%, Montgomery, Mokotoff, Gentry & Blair, 2003; 61%, Wood, Krueger, Pearlman & Goldbaum, 1993). A more recent study examining the sexual self-identification of an international sample of bisexual men and women suggests that if given free reign to describe themselves, most (60%) will opt for more than one identity term (e.g., bisexual, straight, gay, queer) and over a tenth will prefer not to label themselves at all (Rust, 2001).

Several factors have limited the success of HIV research in elucidating the specificities and associated HIV risk contexts linked to male bisexuality. Notably, in this work, bisexuality is commonly reduced to a one-dimensional phenomenon, in contrast with the complexity of sexual orientation models designed to accommodate bisexuality. For example, the Klein Sexual Orientation Grid (Klein, Sepekoff & Wolf, 1985), which is arguably the best known adaptation of the Kinsey continuum, measures sexual orientation with seven variables rated on a seven-point scale (1 = heterosexual/other sex to 7 = homosexual/same-sex). These variables refer to sexual attraction, sexual behaviour, sexual fantasies, emotional preference, social network, lifestyle and self-identification. In total, this model contains 21 items as each variable receives a present, past and ideal rating, allowing sexual orientation to fluctuate over time. Conversely, in public health studies, the operational definition of bisexuality has generally been based either on an isolated measure of sexual behaviour (e.g., Heckman, Kelly, Sikkema et al., 1995; Diaz, Chu, Frederick et al., 1993; Stokes, Vanable & McKirnan, 1997) or of identity (e.g., Doll, Petersen, White, Johnson, Ward & the Blood Donor Study Group, 1992; Evans, Bond & MacRae, 1998; Stokes, McKirnan & Burzette, 1993).