Objectives. We sought to determine whether there were differences in sexual risk among behaviorally and self-identified bisexual men, men who reported having sex with both men and women without reporting a bisexual identity and men who self-identified as bisexual but reported only recent homosexual behavior over the past 6 months.

Methods.secondary data analysis, we conducted stepwise linear regression equation modeling to determine which factors were significant predictors of sexual risk among various subgroups of bisexual Latino men.

Results. Having sex with women, regardless of sexual identity, increased the likelihood of insertive unprotected anal intercourse with men. Bisexual identity was not statistically associated with unprotected anal intercourse with men.

Conclusions. Future studies should begin to examine differences within groups rather than focusing on group comparisons that yield limited insights into sexual risk predictors for homosexually and bisexually active men. Further research that explores risk and protective factors in the sexual lives of Latino bisexual men is also needed.

Relationships between men’s bisexuality (sexual interactions with both sexes) and HIV and sexually transmitted infection (STI) risk continue to be poorly understood.14 In most previous studies, bisexual men have been combined with behaviorally and self-identified homosexual men under the rubric of gay men or men who have sex with men without being examined separately in terms of their risk and prevention needs. Simultaneously, a body of literature has emerged that explicitly identifies male bisexuality as a significant psychosocial risk factor for HIV/STI infection.114 Researchers have recently suggested that behaviorally bisexual men of color and their partners are at particularly high risk for HIV transmission. For example, Brooks et al.15 found that among African American and Latino men, the odds of being infected with HIV were significantly greater for men who have sex with both men and women than for men who have sex exclusively with men (MSM) and men who have sex exclusively with women (MSW).15

Since the onset of the AIDS pandemic, men who have sex with both men and women were considered the bridge between MSM—in whom the HIV/AIDS epidemic was concentrated—and the “general” population. In 1997, Kahn et al. published a national study of the role of bisexuality and HIV infections, analyzing the annual incidence of HIV infections, and found that among the 40 000 infections studied, bisexual transmission accounted for only 3%.12 Kahn et al. concluded that bisexual men played a minimal role in the overall epidemic. However, in a recent study, Prabhu et al. used a series of cross-sectional samples in San Francisco that included more than 17 000 participants from 1998 to 2003 and found that unprotected anal intercourse between HIV-serodiscordant partners had significantly decreased among MSM but remained stable among men who have sex with both men and women.16 They also found that rates of vaginal intercourse between HIV-serodiscordant partners peaked in 2001 among men who have sex with both men and women but decreased in recent years. Prabhu et al. concluded that African American and Latino men who have sex with both men and women were at particularly high risk of HIV infection and transmission. Furthermore, from the mid-1980s to the present, the literature has produced one consistent key finding: Latino MSM are at high risk of HIV infection.14,15,17,18 Although rates of HIV infection have decreased among White MSM over the past 2 decades, the rates among African American and Latino MSM have constantly increased over time.22 Latino bisexual men are part of this larger group. Therefore, Latino bisexual risk behavior must be considered a central focus for addressing the HIV/AIDS epidemic among Latino communities in the United States.

Overall, “bisexual” individuals are an exceptionally diverse population. A voluminous literature has shown that substantial numbers of men and women report numerous forms of bisexuality across cultures and throughout the life course.3,4,1628 Diversity is particularly evident among bisexual individuals. Bisexual is a commonly used sociocultural and sexual identity label,29 although it has received notably less scientific attention than homosexuality in sexuality and HIV/STI research.30 Laumann et al.31 estimated that the percentage of men in the general US population who self-identify as bisexual is approximately 1%. Although there is often overlap, bisexual behavior is more frequently reported than bisexual identity. Interpretation of data on the general prevalence of behavioral bisexuality is complex. Differences exist across studies in terms of the time frame in which the bisexual behavior was measured (i.e., lifetime, past 12 months) and because many individuals who engage in bisexuality hide their behavior. In large-scale empirical studies, bisexual men have been found to be between 0.7% and 5.8% of the general US population31 and between 0.4% and 3.9% of 10 European nations,32 depending on the time period in which the behavior took place. In addition, African American and Latino men have been found to be consistently more likely to report bisexuality than have their White counterparts in the United States.510

Although bisexual men have generally been noted as being at particularly high risk for HIV and STIs, previous research has not yet explored what elements within bisexuality contribute to or protect them from, risk behavior. This is a major limitation given the diversity of men often subsumed under the category of bisexual. We sought to determine whether there were differences in sexual risk, among men who were behaviorally bisexual (i.e., men who have sex with both men and women) and men who self-identified as bisexual over the past 6 months.

We conducted a secondary data analysis of the 2002 self-administered Urban Latino Men’s Health Survey conducted by Gay Men’s Health Crisis. The original research project focused on the impact of knowledge of HIV antiretroviral medications and viral load on sexual risk behavior among Latino MSM in New York City (for details on the research design, see reference 33). The men in the sample represented 15 Latin American and Caribbeans countries.

The majority of the sample was employed, bilingual, older than 25 years, HIV negative, single, and had a moderate level of education (high school or general equivalency diploma; Table 1). Most were long-term immigrants (more than 3 years in the United States) and did not live alone at the time of data collection. Because this was an exploratory analysis, we used stepwise linear regression equation modeling to determine which factors were significant predictors of sexual risk within this sample. Because we conducted multiple regressions, we set the α level at 0.05 and used the Bonferroni correction method to reduce the probability of type I error.34

Bisexual Latino men (n = 68), encapsulating both those who reported bisexual behavior and those who identified themselves as bisexual, whether practicing or not, presented an overall larger proportion of sexual risk than the nonbisexual men (men who had sex exclusively with men or men who identified as gay). Specifically, 60.3% of the bisexual men reported having at least 1 sexual risk encounter (defined as unprotected insertive anal intercourse) with a man over the past 6 months in comparison with 36.3% of non-bisexual men (χ2 = 13.46, P = .001). Bisexual men did not differ from nonbisexual men with regard to receptive unprotected anal intercourse (39.7% vs 33.5%, respectively). This evidence is in line with other research findings that have cited bisexual men as being at relatively high behavioral risk for HIV/STI transmission and infection compared with exclusively homosexual men.1,2,6,8

However, it was not clear whether bisexual identity or bisexual behaviors were associated with the higher levels of sexual risk. Thus, in the next level of analysis, we regressed having insertive unprotected anal intercourse with other men onto bisexual behavior (having sex with both men and women over the past 6 months), bisexual identity, and both bisexual behavior and bisexual identity. Although bisexual identity was independently associated with levels of sexual risk, once the variable of having sex with women was introduced into the equation, bisexual identity was no longer related to sexual risk. We found that having sex with women (regardless of the men’s professed sexual identity) increased the slope of the number of men with whom they had insertive unprotected anal intercourse (t = 5.61, P= .001).

Next, we regressed the number of partners with whom respondents had receptive unprotected anal intercourse onto the same predictors as in the prior equation. Reporting having sex with women (regardless of the men’s professed sexual identity) increased the slope of the number of partners who engaged in receptive unprotected anal intercourse over the prior 6 months (t = 2.08, P= .039).

The third level of analysis was to examine if the associations between having sex with women and sexual risk with men still existed after adjustment for age differences. After control for age, the effects of having sex with women on sexual risk became slightly stronger; for insertive unprotected anal intercourse, the slope increased (t = 5.66, P= .001), and for receptive unprotected anal intercourse, the slope increased (t = 2.18, P= .030). Having sex with women was a statistically stronger predictor of insertive unprotected anal intercourse (R = 0.329, F = 16.96, P= .001) than a predictor of receptive unprotected anal intercourse (R = 0.149, F = 3.10, P= .046).

We then compared the frequencies of ejaculating inside the partner and the frequencies of receiving ejaculate for those who reported bisexual behavior. We found that those who reported having sex with women were also more likely to report ejaculating inside a man at least once over the past 6 months (59.1%) than were nonbisexual men (32.6%; χ2 = 6.02, P= .01). The insertive unprotected anal intercourse adjusted age slope for having sex with women was .462 (t = 2.03, P= .044). However, having sex with women was not related to receiving ejaculate during receptive unprotected anal intercourse. Because data available on bisexual behavior and identity were limited, no further analyses were conducted.

Because prior studies have demonstrated that bisexual men are generally more likely to report sexual risk than exclusively homosexual or heterosexual men are, we originally hypothesized that there would be no differences between men who have sex with both men and women and those who self-identified as bisexual. However, we found that having sex with women (more than sexual identity or any combination of identity and behavior) increased the likelihood of sexual risk with other men.

These findings were based on a study that was, as with most HIV/STI research, not intended to measure sexual risk specifically among bisexual men. Our sample was reached through the efforts of large nonprofit organization that provides HIV/AIDS prevention and treatment services and was not a random sample of Latino bisexual men. Furthermore, all the men in the original study were recruited because they reported having sex with other men. Questions on sexual risk with women were not asked. The available data simply indicated whether or not each of the men had sex with a woman over the prior 6 months; in hindsight, this represents a limitation of the study. A second concern is that this was a cross-sectional analysis on variables that were asked about retrospectively. Thus, the nature of the causal relationship between predictors and the dependent variables could not be determined with full certainty. Therefore caution should be taken in generalizing the findings from this analysis.

Nonetheless, we found a relation between having sex with women and sexual risk with men that we believe can be explained in at least 2 ways. First, in comprehensive reviews of previous research, heterosexual men have been found to use condoms inconsistently.1,2 Thus, men who reported having sex with both men and women might also be less likely to use condoms overall, a reflection of general high-risk sexual behavior patterns found in other samples of behaviorly bisexual men. A second possible explanation is that the connection between having sex with women and sexual risk with men resides in the insertive nature of the sexual interaction. Men’s sexual relations with women are, for the most part, insertive, and our findings indicate that this was a predictor of insertive unprotected anal intercourse with men. The ensuing question then is, is it logical to infer that for bisexual men, having sex with women would lead to unprotected anal intercourse with men?

The literature on bisexuality in Latin America has consistently supported the finding that for bisexual men there is a strong relation between the type of sexual intercourse they have with women and that which they have with men. For bisexual men in multiple Latin American studies, the object of sexual desire (whether man or woman) is less important than the role performed in the sexual interactions with both types of partners.3541 From multiple studies, we know that bisexual Latino men engage in both insertive and receptive roles during sexual encounters.4245 Thus, it is possible that the Latino men who had sex with women in this study were mostly those who engaged in insertive roles during sexual intercourse with other men. Another possibility relies on the transference of the habitual form of sexual intercourse with women to sexual intercourse with men. For many men, having sex with women does not involve the use of condoms once there is trust in the relationship and other forms of contraceptives are used to avoid unintended pregnancy.46,47

Additionally, Latin American studies have shown that having sex with women is an important milestone in the development and reinforcement of manhood.4851 Thus, private symbolic interactions such as having “conquered” and penetrated a woman, or social indicators of heterosexuality such as marriage and impregnating a woman, are powerful representations of heterosexual masculinity.4849 However, it is important to highlight that, as several Latin American scholars have pointed out, the linkages between preserving a public heterosexual image are strongly related to social class and structural oppression.4853 That is, the men who are more socially excluded place higher stakes in maintaining a public image. For this reason, we cannot discount the idea that notions of maintaining power within the sexual encounters may be operating for the men in this study, facilitating engaging in unprotected sex with other men.

Our finding that having sex with women increased the likelihood of unprotected receptive anal intercourse reflects a different path to sexual risk than insertive sexual risk behavior. Men who have sex with men and women in our sample may seek receptive anal intercourse as a way of not having to perform the expected active role during sex. Thus, the experience of being penetrated may serve as an opportunity to transgress traditional forms of masculinity. The available data do not allow us to examine this hypothesis. However, findings from our own previous research with Latino bisexual men as well as other ethnographic research support this inference.36,4243

In this study, bisexual identity alone was not related to sexual risk. Nonetheless, it is important to highlight that little is known about self-identified bisexual men’s lives in relation to HIV/STI risk in general. Research has typically focused on increased risk among “non–homosexually identified” men. It is possible that self-identified bisexual men may experience and express their sexuality in different, and potentially less risky, ways than their nonidentified bisexual counterparts. This can only be clarified through more refined research on the relations between sexual behavior and sexual identity among bisexual men.

In summary, studies in the literature on HIV/STI risk among diverse sexual groups have generally focused on comparing “M”s and “W”s (MSMs, MSMWs, WSWs, WSWMs). These studies have examined differences between groups without first having a clear understanding of differences within groups. Latino bisexual men are among the least understood, not only in terms of sexual risk but also in other aspects of sexuality, intimacy, and social relations.4243 We recommend larger quantitative and qualitative studies that can provide more clarity to the determinants and causal relations that produce or protect from HIV/STI risk in the sexual lives of Latino bisexual men, as well as other bisexual men and women in the United States.

Table
TABLE 1— Sample Demographic and Behavioral Characteristics (n = 395): Urban Latino Men’s Health Survey, New York, NY, 2002
TABLE 1— Sample Demographic and Behavioral Characteristics (n = 395): Urban Latino Men’s Health Survey, New York, NY, 2002
CharacteristicPercentage
Age, ya
    15–2113.9
    22–3960.8
    40–5920.8
    60 and older2.0
    No answer2.5
Annual income, $
    ≤ 5,20010.1
    5,201–15,60017.7
    15,601–26,00028.4
    26,001–39,00029.9
    > 39,00013.2
    No answer0.7
Occupation
    Full time58.9
    Part time12.0
    Self-employed6.8
    Student15.9
    Unemployed5.8
    No answer0.6
Language spoken most often
    Spanish39.7
    English36.3
    Spanish and English19.7
    Portuguese2.5
    English and Portuguese1.8
Sexual self-identity
    Gay82.2
    Bisexual14.4
    Heterosexual1.7
    Transgender.25
    Transsexual.25
    Gay and Bisexual.25
    Gay and Heterosexual.25
    Other.70
Education
Some high school9.4
High school diploma19.5
Passed General Educational Development (GED) test27.6
Some college18.7
College degree21.3
Graduate school0
No answer3.5
Time in the United States, y
    < 13.3
    1–311.6
    > 347.6
    Entire life35.4
    No answer2.1
Health insurance coverage
    Private insurance50.9
    Medicaid or Medicare15.9
    None33.2
HIV Status
    Negative68.6
    Assumed negative2.3
    Positive11.9
    Assumed positive.25
    Unknown or never tested11.9
    Tested but never got results4.6
    No answer.45

aMean age 32.9 ±10.2.

This study was supported by the Institute for Gay Men’s Health at Gay Men’s Health Crisis (GMHC) and the Ford Foundation (grant 1020-148103).

We would also like to thank the reviewers for their feedback on this manuscript and Steven Pruett, of the University of Florida Department of Behavioral Sciences and Community Health, for his time and assistance with statistical issues related to this manuscript. Daniel Castellanos and Russell Westacott played key roles in the development and implementation of the study, and this study will not have been possible without the hard work of all the volunteers at the GMHC project and the technical support and advice from the Center for Gender, Sexuality and Health at the Mailman School of Public Health at Columbia University.

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Miguel Muñoz-Laboy, DrPH, and Brian Dodge, PhDMiguel Muñoz-Laboy is with the Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY. Brian Dodge is with the Department of Behavioral Science and Community Health, College of Public Health and Health Professions, University of Florida, Gainesville. “Bisexual Latino Men and HIV and Sexually Transmitted Infections Risk: An Exploratory Analysis”, American Journal of Public Health 97, no. 6 (June 1, 2007): pp. 1102-1106.

https://doi.org/10.2105/AJPH.2005.078345

PMID: 17463376