Sexual practices of gay, bisexual, and other nonidentified MSM
Research on gay sexual practices, bisexual practices:
Introduction
HIV infection continues to be a public health challenge in the United States among gay, bisexual, and other nonidentified men-who have sex with men (MSM). The Centers for Disease Control and Prevention (CDC) report that in the period between 2001 and 2004, MSM accounted for seven out of 10 new HIV infections (CDC, 2006). Explanations for the disproportionate rates of HIV infection in this segment of the population have focused on the role of risky sexual behaviors, primarily unprotected anal intercourse (UAI). Among gay, 
bisexual, and other MSM, several studies have indicated risky sexual behavior is still prevalent, with some documenting a steady increase over the last several years (Crawford et al., 2006; Fernandez et al., 2005; Semple, Patterson, & Grant, 2003; Williamson, Dodds, Mercey, Johnson, & Hart, 2006; Xia et al., 2006).
Behavioral studies of gay, bisexual, and other MSM consistently have found the risk-taking behavior of UAI to be relatively common. In a recent study, Xia et al. (2006) found that among 398 men interviewed via a population-based survey in California, 29% reported having five or more male partners over the past 12 months; furthermore, 15% reported UAI with two or more men. This pattern of potentially dangerous behavior, however, is not an isolated one. Prestage and colleagues (2005) determined that in a cohort of 1,148 HIV-negative men who were part of a clinical study cohort, 30.7% had reported UAI with a casual partner within the past 6 months. Similarly, Crawford and colleagues (2006) reported rates of UAI of 36% among men recruited at gay social venues in the community. Additionally, Martin, Pryce, & Leeper (2005) found that 43% of gay and bisexual participants from a variety of different venues reported having engaged in UAI during the preceding 6 months. In a street outreach study in Hollywood, California, Reback & Grella (1999) found that only 22.7% of gay and bisexual men report using condoms “always,” whereas 69.8% report their use of condoms as “sometimes.”
More recently, studies of the sexual practices of gay, bisexual, and other MSM have focused on communicating one’s HIV status and have lead to the documented phenomenon of strategic positioning. This is a practice in which partners position themselves (as either insertive or receptive) during anal sex in a manner that they believe prevents the transmission of HIV (Elford, 2006; Siconolfi & Moeller, 2007). HIV-positive gay and bisexual men who position themselves as the receptive partner during UAI when having sex with HIV-negative primary and causal partners believe that this behavior can reduce the probability of HIV transmission (Prestage et al., 2005). This phenomenon has been well documented in a longitudinal cohort of men in Sydney, Australia (Van de Ven, Rawstorne, Crawford, & Kippax, 2002).
In addition to strategic positioning, some gay and bisexual men have adapted serosorting behaviors by which they select their sexual partners based on perceived HIV serostatus (Siconolfi & Moeller, 2007). Xia and colleagues (2006) report that 60% of known HIV-positive men and 40% of known HIV-negative men rely on serosorting in selecting their sexual partners. In a longitudinal study of MSM in San Francisco, assessed between 1997 and 2002, Osmond, Pollack, Paul, & Catania (2007) discovered that serosorting was adopted more frequently than condom use by young MSM. Furthermore, in a London cohort the phenomenon also was documented, though the reliance on this strategy has not seemed to increase over time (Elford, Bolding, Sherr, & Hart, 2007).
Confounding the phenomena of strategic positioning and serosorting is the fact that decisions often are made based on assumptions about HIV serostatus. In fact, many gay and bisexual men frequently engage in UAI without discussing actual HIV serostatus (Chen, Gibson, Weide, & McFarland, 2003; Denning & Campsmith, 2005). Duru et al. (2006) have found that in the context of nonexclusive sexual relationships, 42% of gay and bisexual men reported having UAI without disclosure of HIV status. Moreover, rates of disclosure do not seem to have changed significantly over time. Ekstrand, Stall, Paul, Osmond, & Coates (1999) reported findings from a 1996-1997 study that showed that almost half of all men who reported UAI indicated that it occurred with a partner of unknown or discordant HIV status. More recently, Parsons and colleagues (2006) reported 76% of HIV-positive participants reported multiple unknown serostatus partners, with a mean of 9.54 (SD = 20.22) unknown status partners in the previous 3 months. Thus, while strategic positioning and serosorting hold the potential to reduce incidents of HIV transmission, the effectiveness of both are built on accurately knowing one’s HIV status and disclosing one’s HIV status to sexual partners. This strategy may be less effective for men who believe they are HIV negative but who are, in fact, HIV positive, either because of mythological understandings of their serostatus (Halkitis, Zade, Shrem, & Marmor, 2004) or because they are in the acute infection stage of HIV disease (Brenner et al., 2007; Halstead, 2006; Wawer et al., 2005). Despite the fact that some have labeled both strategic positioning and serosorting as harm-reduction strategies (Grov et al., 2007), the effectiveness of such behaviors is highly questionable when considered in light of the sustained and slightly increasing rates of new HIV infection among gay, bisexual, and other MSM (CDC, 2006).
In the end, risky sexual behavior among gay, bisexual, and other MSM continues to be associated with HIV serostatus, with HIV-positive men more likely than their HIV-negative peers to engage in high-risk sexual behaviors (Choi, Operario, Gregorich, & Han, 2003; Poppen, Reisen, Zea, Bianchi, & Echeverry, 2005). Specifically, HIV-positive men report having more sexual partners, engaging in more UAI with a secondary partner, and having more serodiscordant UAI than their HIV-negative peers (Xia et al., 2006). Other variables that predict high-risk sexual behavior among all MSM are substance use (Theodore, Duran, Antoni, & Fernandez, 2004), educational attainment (Xia et al., 2006), and mental health (Perdue, Hagan, Thiede, & Valleroy, 2003).
It should be noted that behavioral research examining the sexual partnerings of gay, bisexual, and other MSM primarily has been derived from samples recruited at social venues such as clubs and bars (Crawford et al., 2003; Harawa et al., 2004; Nardone et al., 2001; Williamson et al., 2006), sex clubs and parks (Fernandez et al., 2005; Frankis & Flowers, 2006; Van de Ven, Mao, & Prestage, 2004), STI clinics (Crepaz & Marks, 2003; Van de Ven et al., 2005), and street outreach (Reback & Grella, 1999). Thus, these previous samples may be skewed toward risk-taking rather than health-promoting men, and these data hold the potential for over-representing sexual risks among gay, bisexual, and other MSM. In addition, while the role of context has been considered theoretically (McKirnan, Ostrow, & Hope, 1996), a recent study suggests that context may not be a factor in explaining UAI (Grov, Parsons, & Bimbi, 2007).
Building and expanding upon work conducted in the United Kingdom (Elford, Bolding, & Sherr, 2001; 2002), a cross-sectional study of the sexual behaviors of gay, bisexual, and other nonidentified MSM who attended gym facilities in New York City was undertaken. The aims of the analysis were to (1) document the primary and casual sexual partnerings of gay, bisexual, and other MSM recruited from New York City gyms; (2) consider differential rates of sexual risk taking in relation to key demographic states, including age, race, and HIV status; and (3) delineate contexts in which these men meet their sexual partners.
Authors: Halkitis, Perry N.; Moeller, Robert W.; Pollock, James A.
Read the full paper here “Sexual practices of gay, bisexual, and other nonidentified MSM attending New York City gyms: patterns of serosorting, strategic positioning, and context selection.”