Bisexual and homosexual behavior and HIV risk among Chinese-, Filipino-, and Korean-American men.

Little is known about cultural patterns of sexual behavior among Asian-Americans that might affect HIV transmission or about attitudes that might have an impact on educational efforts with this population. Even less is known about bisexual and homosexual behavior among Asian-Americans. Although the number of AIDS cases among Asian-Americans is increasing more rapidly than in the nation as a whole (Centers for Disease Control and Prevention, 1990, 1996), HIV/AIDS has tended to remain a hidden phenomenon in the Asian community (Yep, 1993). Earlier in the epidemic there was evidence that persons of Hispanic or Asian backgrounds were less likely than their White cohorts to have heard about AIDS (Albrecht, Levy, Sugure, Prohaska, & Ostrow, 1989). Asian-American youth had less accurate knowledge about HIV/AIDS than their non-Asian cohorts (DiClemente, 1987; Strunin, 1991), especially regarding knowledge of how to prevent transmission (Horan & DiClemente, 1993). Asian cultural restraints may inhibit direct discussion of sexual activities (Horan & DiClemente, 1993; Moore & Erickson, 1985).

There is a risk of overgeneralizing among Asian cultures. The stereotype that Asian-American youth are less sexually active than their non-Asian cohorts may be true of Chinese-American high school students but may not apply to other Asian-American groups, such as Filipino youth (Horan & DiClemente, 1993) and may be limited to behaviors concerned with initiating sexual activity (Cochran, Mays, & Leung, 1991). After sexual activity was initiated among Asian-American youth, the heterosexual practices in which they engaged and their inconsistent use of condoms were similar to those of their Non-Asian counterparts (Cochran et al., 1991).

As HIV infection continued to rise among heterosexuals, in particular heterosexual women, interest grew in bisexual behavior as one of the possible paths of transmission (Anderson & May, 1992; Crawford et al., 1992; Doll & Beeker, 1996; Doll, Peterson, Magana, & Carrier, 1991). There is some evidence that bisexual behavior is more common in non-White cultures (Kumar & Ross, 1991) and non-White subcultures in the U.S. (Chu, Peterman, Doll, Buehler, & Curran, 1992; Diaz et al., 1992; Harry, 1990). Empirical data for Asian-Americans are lacking, but the value placed on fulfilling family roles (Atkinson, Morten, & Sue, 1993) and the expectation that the son will marry and continue the family name and progeny suggest that in Asian-American culture homosexuality may more likely be expressed in bisexual lifestyles than in exclusively homosexual behavior. "Most Asian cultures are neither asexual nor extremely repressed" (Chan, 1992, p. 9), but sexuality is only expressed within the private sphere. This privacy makes it possible for homosexual behavior to go unnoticed. Engaging in homosexual behavior may not produce "guilt" or be viewed as "taboo" if the normal roles and expectations are met and the homosexual behavior occurs privately.

In general, Asian cultures value putting the family first, respecting and obeying elders, formalized personal relationships, and male dominance. In contrast, the emphasis in dominant American culture is on putting the individual first, informal personal relationships, equality of genders (at least in theory), and a youth-centered and future-directed orientation (Locke, 1992). Western gay culture's emphasis on making homosexuality part of one's public identity may directly violate Asian norms and "shame" the family. The reliance on the family identity and family esteem rather than the individual identity and self-esteem (Roland, 1988) has implications for the study of sexual behaviors.

The concepts of same-gender versus other-gender attraction and the labels gay, bi, and straight are recent Western constructions (Katz, 1995). In East Asian societies, as well as in much of earlier Western society, the crucial distinction concerning sexual behavior has been who penetrates whom--the insertive/receptive distinction (Ross, 1991). Being the one who penetrates (the "insertive partner") defined "manhood"; the receptive partner, the one who is penetrated, was viewed as "female or female like," regardless of gender. Anthropologists refer to this as "Latin homosexuality."

The Filipino culture has a gender/ homosexual construction, termed bakla in the Tagalog language, applied to biological men who play a somewhat stylized "womanly" role in dress, mannerisms, and often occupation and who engage in receptive homosexual behavior. Historically, the term was used only for the orally or anally receptive male partner and did not apply to a man who took the insertor role. The slang phrase for anal intercourse in parts of the Philippines is Chinese kick, and some early Spanish writers on the Philippines claimed that anal intercourse was introduced to the Filipinos by the Chinese (Hart, 1968, see p. 231). In classical Chinese society, in both art and literature, there was an accepted pattern of what contemporary Western society calls homosexual relations. Nineteenth century Chinese culture based sexual categories on the insertive/receptive distinction (Kapac, 1992). Anal intercourse appears to have been common then but does not appear so in Chinese populations currently (Kapac, 1992, see p. 261). Many Asian-American immigrants am not aware of these Asian traditions; they believe that homosexual behavior is a "Western" pattern and assume that it does not exist among their ethnic group (Hinsch, 1990, see p. 165; Ruan, 1991, see p. 132).

Homosexuality and HIV Risk among Asian-Americans

To my knowledge, only five studies exist of homosexual behavior among Asian-Americans; only three include data on behaviors related to the risk of contracting HIV No previous study has been focused on Asian American men who have sex with both men and women.

In a small study of 13 Japanese-American gay males, Wooden, Kawasake, and Mayeda (1983) noted that the respondents were very private about their sexual involvements. The authors attributed this to the respondents' fears of non-acceptance in the Japanese-American community. The difficulty of combining an Asian and a gay or lesbian identity, attested to in this study, was further explored by Chan (1989). She used a questionnaire to study the Conflict in identities experienced by 34 Asian-American lesbians and gay men. These participants perceived the Asian-American community as denying the existence of Asian-American gays and lesbian. Only in meetings of an Asian-American gay and lesbian club did they experience integration of both components of their identities.

These first studies of Asian-Americans who engaged in homosexual behavior were limited to samples drawn from gay-identified settings and thus may have included only the more "Westernized" Asian-Americans. Kitanes (1988) highly educated, highly motivated, gay-identified sample were well informed and rarely reported engaging in high risk sexual behaviors. She reported Filipino respondents engaged in significantly more risk behaviors than the Chinese respondents. Based on a very small number of interviews in Canada (as well as Singapore and Hong Kong), Kapac (1992) observed that anal intercourse was rather uncommon among his Chinese sample. Anal intercourse also appeared to be rare among Vietnamese homosexuals, as reported by immigrant respondents as part of a field study of a Vietnamese community in California (Carrier, Nguyen, & Su, 1992). Themes included a general denial of the existence of homosexuality among Vietnamese-Americans at the community level, the issue of family shame, and the "feminine male" stereotype of homosexual men.

In my study, recruitment was first concentrated on men who had sex with both men and women, later a comparison group of Asian-American men who had sex only with men was added. Extensive recruitment efforts were made to reach men who had sex with men but were not gay identified.

I focused on three questions: How does acculturation to three subcultures--Asian, mainstream American, and gay--have an impact on bisexual or gay behavior? What variables are associated with sexual behavior that may put Asian-American men and/or their partners at risk for contracting HIV? Are there differences in risk behavior among the three Asian Amen can ethnic groups studied?

Methods

Participants

This study was an exploratory component of a larger quantitative study in a large Midwestern city. Large samples of White and Black men between ages 18 and 30, who reported that during the previous three years they had had sex with both men and women, participated in structured interviews averaging an hour. I will refer to that portion of the study as the Interview Study of Bisexually Behaving Men (ISBBM) (McKirnan, Stokes, Doll, & Burzette, 1995).

As in the ISBBM study, respondents were chosen in terms of behavior; my use of bisexual and gay does not imply self-identification. Recruitment strategies were designed to obtain samples that were more representative of a hidden, stigmatized population than the usual convenience samples. Field staff placed posters in most of the city's gay bars and business establishments, and print ads were run in mainstream, gay, and ethnic newspapers. These announcements provided a phone contact and stated that respondents fitting the criterion would be paid. These strategies were successful for all ethnic groups. In addition, graduate student men on the field staff approached men in sexual pick-up areas (gay bars, parks, forest preserves), presented calling cards to them, and explained the study. Although Black and White respondents were reached through all pick-up venues, Asian-Americans were successfully recruited only at gay bars. Respondents were offered additional payment for referring others.

Respondents who phoned were screened to see if they fit the criteria and given a choice of meeting places for the interview. Because of expected difficulty in recruiting a large enough Asian-American sample, I eliminated inclusion criterion concerning the upper limit on age and how recently bisexual behavior had occurred. Given that penetrative sex between men may not be common in some Asian countries, that criterion was dropped as well. The men who fit these broader criteria were included in descriptions of the qualitative and ethnic data. The quantitative data on sex risk, however, were limited to that portion of the Asian-American sample who fit the three-year criterion and engaged in penetrative sex, in order to make comparisons to the data from the ISBBM. Surprisingly, this still included 80% of the men from the 3 ethnic groups. Early participation included respondents of any self-reported Asian ethnicity. It soon became clear that only three ethnic groups were responding in sufficient numbers, and further recruitment was limited to those three.

Asian-Americans are generally reluctant to talk about their homosexual activities with others of Asian descent. Discussions with leaders of two Asian gay groups and a focus group of Filipino gay men led to the decision that I, as a White bisexual, would conduct the interviews. Lack of previous research on Asian American bisexual behavior and acculturation required extending the interview time to three hours. Face-to-face interviews allowed comparison with the ISBBM Black and White samples, anonymous cash payment for participation, and greater rapport and honesty and discouraged participation by persons who might falsify being Asian-American to receive payment.

Recruitment resulted in 43 interviews with Asian-American men who had had sex with both men and women, with 58% recruited from mainstream print ads, 31% from "gay" sources. 7% from ads and articles in Asian print media, 4% from the referral of new respondents by previous respondents. and none through contacts with Asian gay organizations. (See Matteson & MacQueen, 1992.) Of the 43 bisexual respondents interviewed, 37 self-reported being of Chinese, Filipino, and Korean descent.

A cohort of 27 additional men whose lifetime sexual experience was only with men were recruited. I also conducted six "informant" interviews, primarily with White men who regularly sought Asian men as their sexual partners (see Table 1). In total, 94 men called for appointments; 13 were eliminated for not fitting the criteria, 5 did not show and did not reschedule; thus, 76 interviews were completed. Statistical analyses focused on the 58 men who were of Chinese, Korean, or Filipino descent, 31 of whom had had both male and female partners in the previous 3 years, and 27 of whom had had only male partners.

Table 1

Sample Size: Bisexual-Behaving and Homosexual-Behaving
Asian-American Men

                                Chinese-   Filipino-   Korean-
                                American   American    American

Bisexual Behavior in Previous
  3 Years                          10         13           8
Lifetime But Not Current
  Bisexual Behavior                 2          2           2
Only Homosexual Behavior           11         11           5
Totals by Ethnicity                23         26          15

                                   Other Asian-   Totals by
                                   American       Behavior

Bisexual Behavior in Previous
  3 Years                             6              37
Lifetime But Not Current
  Bisexual Behavior                   6
Only Homosexual Behavior             27
Totals by Ethnicity                   6              70

Note: Total Asian-Americans = 70 plus 6 White informants, T = 76

Measures

The interview. The three-hour structured interview consisted primarily of open, qualitative questions concerning acculturation to American, Asian, and gay subcultures; the emerging recognition of one's sexual orientation; social networks; family interactions; heterosexual (where appropriate) and homosexual partners; and sexual behaviors, including types of behavior (e.g., anal, oral; receptive or insertive), types of partners (committed, previously known, or casual), and the meaning of those behaviors for the respondent. (Copies of the structured interview and the rating scales may be obtained from the author.)

Quantitative scales within the interview. Respondents were asked to list the 10 persons to whom they felt closest (referred to as social network), and information was systematically obtained on the gender, race/ethnicity, sexual orientation, and whether the person had been told about the respondent's attraction to men. Items from scales of internalized homophobia, depression, and self esteem (based on Stokes, McKirnan, & Burzette 1993), and gay identity (McKirnan, Stokes, Doll, & Burzette, 1992) were also imbedded in the interview.

Rating and scaling the interview transcripts. All interviews were transcribed verbatim. I trained four graduate research assistants to rate interview transcripts using each acculturation scale described later. Portions of interview transcripts concerning acculturation were rated independently by each rater and then discussed with me. Training continued on each scale until each assistant's ratings reached at least 80% agreement with mine; typically this was achieved after rating 4 to 6 interviews. The portions of the transcripts pertaining to the respondent's acculturation to mainstream and Asian society included questions on the language used in specific situations, magazines and newspapers read, music listened to, social functions attended, reference groups, and attitudes and criticisms of the ethnic and mainstream cultures. These segments were rated for American acculturation using anchored statements that formed a scale running from 1 point (dysfunctional) to 5 points (fluent functioning). The same process was repeated for functioning in the respondents particular Asian-American society (Ethnic acculturation) and in the gay subculture (Gay acculturation). The assessment of Gay acculturation included responses to questions about both the more visible aspects of gay culture--gay or bisexual media, gay bars, and sex clubs--and the interest groups, service organizations, and political groups. A respondent was not considered fluent in gay culture if he had experienced only the more visible and publicized aspects. Each cultural sphere (American. Ethnic, and Gay) was rated independently. Dichotomous scales of acculturation falsely assume a zero-sum relationship: that high levels of competence in the dominant culture are inversely related to high levels of involvement in the ethnic or subculture. (See Kim, 1988.)

Acculturation to or fluency in a culture does not necessarily reflect a respondent's current involvement in that culture. For example, a person who has lived some years in an Asian culture may have become fluent but may no longer be involved or interested. Therefore, separate rating scales were developed to measure each respondent's current investment in mainstream, Asian, and gay subcultures. Although impressionistic, the ratings were based on respondents' descriptions of their attempts to learn about and participate in each cultural sphere, their critique or defense of each sphere, and the time and energy the narrative suggested they put into each sphere.

The sexual behavior pattern of some Asian-Americans approximated Latin homosexuality, in contrast to the Western conception based on same- or other-gender attraction. My criterion for Latin homosexuality was almost exclusively receptive or almost exclusively insertive anal or oral intercourse rooted in a view of each behavioral role as gender based. Similar behavior because of aesthetic taste or inexperience was not labeled Latin. Examples of Latin homosexuality included viewing oneself as "sissy" and limiting oneself to receptive sex, or viewing oneself as "macho" and seeking receptive partners whose personality was dependent or submissive.

Responses to a question concerning the respondents' current "religious affiliation, either formal or personal," were tabulated into five categories: no affiliation, Protestant, Catholic, Eastern religions, and others.

Two factors weighed heavily in our rating of sexual risk: a need to condense the complex data so as to avoid the statistical error of numerous tests of significance on a small sample and the concern that much research on sexual risk for HIV is based solely on specific behaviors (e.g., unprotected anal intercourse) without considering the context in which that risk was taken. Recent evidence suggests many committed couples in this time of AIDS do remain monogamous (Laumann, Gagnon, Michael, & Michaels, 1994), and many men in steady homosexual or bisexual relationships use a strategy of consistently protected sex in casual relationships but engage in unprotected sex with their primary or steady partner (Hospers & Kok 1995; Stokes, McKirnan, Doll, & Burzette, 1996). Gaies, Sacco, and Becker (1995) argued that perceived HIV antibody status of partners should be considered when investigating variables related to AIDS-relevant condom use. Kippax, Crawford, Davis, Rodden, and Dowsett (1993) argued against measurements of relapse that include behaviors of unprotected sex negotiated safely within regular partnerships of concordant sero status. We chose a contextual categorizing of risk that included the type of relationship with the partner and whether the partner claimed to have been tested. Table 2 describes the scale in detail.

Table 2

Levels of Sexual Risk Behavior among Bisexual Chinese-,
Filipino-, and Korean-American Men

                                                      Number of
                                                      Participants

Reasonably Safe                                            15

1. Has never had unprotected anal intercourse with
men. Has not had unprotected vaginal or anal
intercourse with women in previous six months.
There may have been unprotected oral intercourse.     7

2. No unprotected anal or vaginal intercourse in
the past six months, although it did occur
previously.                                           8

Some Risk                                                  10
3. He and his primary partner have both tested
negative and claim to have been monogamous.           1

4. He and his primary partner have both tested
negative. His vaginal or anal intercourse outside
this relationship has always been protected.          5

5. Has engaged in unprotected vaginal intercourse
with one woman, and at least one of them has not
been tested. If he previously engaged in
unprotected anal intercourse with men, he tested
negative.                                             4

Risky                                                      6
6. a Risk with women. He has not had unprotected
anal intercourse with men since tested negative,
but has had more than one woman partner and engaged
in unprotected vaginal intercourse.                   2

6. b Risk with men.

1. No longer active with women, but has had
unprotected anal intercourse with one or more
untested men.                                         2

2. Has resumed unprotected anal
intercourse with a lover who, during a break up,
was active. Lover has not been tested since the
break up.                                             1

6. c Risk with both: Had unprotected
anal intercourse with men in the past and has not
been tested. Has had unprotected vaginal
intercourse with two women since.

Totals =                                                   31

                                                       %

Reasonably Safe                                       48

1. Has never had unprotected anal intercourse with
men. Has not had unprotected vaginal or anal
intercourse with women in previous six months.
There may have been unprotected oral intercourse.

2. No unprotected anal or vaginal intercourse in
the past six months, although it did occur
previously.

Some Risk                                             32
3. He and his primary partner have both tested
negative and claim to have been monogamous.

4. He and his primary partner have both tested
negative. His vaginal or anal intercourse outside
this relationship has always been protected.

5. Has engaged in unprotected vaginal intercourse
with one woman, and at least one of them has not
been tested. If he previously engaged in
unprotected anal intercourse with men, he tested
negative.

Risky                                                 19
6. a Risk with women. He has not had unprotected
anal intercourse with men since tested negative,
but has had more than one woman partner and engaged
in unprotected vaginal intercourse.

6. b Risk with men.

1. No longer active with women, but has had
unprotected anal intercourse with one or more
untested men.

2. Has resumed unprotected anal
intercourse with a lover who, during a break up,
was active. Lover has not been tested since the
break up.

6. c Risk with both: Had unprotected
anal intercourse with men in the past and has not
been tested. Has had unprotected vaginal
intercourse with two women since.

Totals =                                              100

Tally sheets were used to count venues of meeting male partners, ethnicity of partners, and types of relationships. Finally, qualitative data concerning the development of the respondent's sexual fantasies, behavior, and relationships were summarized using post-hoe categories of bisexuality (Table 3).

Table 3
Patterns of Bisexuality among Bisexual Chinese-,
Filipino-, and Korean-American Men

                                                      Number of
                                                      Participants
                                                      Subcategories

1. Congruent Bisexual: Currently sexually attracted
to both men and women.                                        19

a. Fantasies and experience have been bisexual as
long as respondent remembers them.                      9

b. Same-sex fantasies and experience developed
later (after social inhibitions declined).              5

c. Same-sex fantasies or experience predominated,
but later an interest in sex with women emerged.        1

d. Subtype unclear or other.                            4

2. Recently acknowledging homosexual
desires/behavior. Respondent's experience is too
limited to distinguish between pattern #1 or #3.
Current behavior is bisexual.                           3     3

3. Transitional bisexuality: Same-sex feelings
and fantasies developed early, but respondent tried
to look and act straight.
Currently he seems                                            6

a. Interested only in male partners.                    4

b. Interested mainly in men, but sees women to keep
up appearances for others.

c. Interested mainly in men, but sees women to keep
up appearances for others and for his own need to
am self as bisexual.                                    1

d. Unspecified subtype.                                 1

4. Marriage important, but has same-sex activities
on the side: Can admit to self he is more sexually
aroused by men, but doesn't want to give up the
marriage.                                               1    1

Totals =                                               29    29

                                                         %
                                                       Levels

1. Congruent Bisexual: Currently sexually attracted
to both men and women.                                 66

a. Fantasies and experience have been bisexual as
long as respondent remembers them.

b. Same-sex fantasies and experience developed
later (after social inhibitions declined).

c. Same-sex fantasies or experience predominated,
but later an interest in sex with women emerged.

d. Subtype unclear or other.

2. Recently acknowledging homosexual
desires/behavior. Respondent's experience is too
limited to distinguish between pattern #1 or #3.
Current behavior is bisexual.                          11

3. Transitional bisexuality: Same-sex feelings
and fantasies developed early, but respondent tried
to look and act straight.
Currently he seems                                     21

a. Interested only in male partners.

b. Interested mainly in men, but sees women to keep
up appearances for others.

c. Interested mainly in men, but sees women to keep
up appearances for others and for his own need to
am self as bisexual.

d. Unspecified subtype.

4. Marriage important, but has same-sex activities
on the side: Can admit to self he is more sexually
aroused by men, but doesn't want to give up the
marriage.                                               3

Totals=                                               100

Note: For 2 of the 31 respondents, there were insufficient data.

Results

Statistical measures. The statistical analyses in this report use three levels of risk. The use of levels of risk avoids treating unprotected intercourse in the context of a steady relationship in which both couples tested seronegative as the game as unprotected intercourse with a casual partner. In testing significance, I checked first whether the variable predicted highest risk level, and if that was significant, reported it as "highest risk." On variables where "highest risk" alone failed to predict for this small sample, middle and highest levels were combined and results reported as "risky groups." Tests of significance were determined using a Fisher non-parametric test.

For the bisexual respondents, demographic information, quantitative data from the psycho-social scales, and information about whether the respondent had engaged in risky sexual behavior were compared to data from the White and Black bisexuals from the ISBBM, using one-way analysis of variance.

Results from the bisexual sample are reported first, with both quantitative results and the ethnographic findings of that portion of the exploratory study. The reasons for adding a homosexual cohort and the data analysis from the combined samples are presented (refer to Table 1).

Part 1: Bisexual Sample

Comparisons between Asian-American and other American bisexuals. The Asian-American bisexuals (n = 31) were significantly better educated than either the White (n = 254) or Black (n = 281) sample (McKirnan et al., 1995), the majority having completed a college degree. Given almost identical methods of recruitment, this difference most likely reflects a higher educational level among Asian-Americans. Contrary to the expectation, the Asian-Americans showed no higher percentages of marriage (only 15% had ever married) than their Black and White cohorts, perhaps because many were still engaged in or had only recently finished their education; education is considered an even higher priority than marriage in many Asian cultures (Carrier, 1994). The Asian-Americans had a higher mean income level than the larger sample (significant in relation to Blacks). Asian-American respondents waited until significantly older to engage in their first sexual intercourse with a woman, congruent with cultural expectations and previous data (Moore & Erickson, 1985). In my sample this experience came an average 2-1/2 years later (at about 18-1/2 years of age) than for the ISBBM White and Black sample.

Levels of sexual risk among Asian-American bisexuals. Although 57% of the sample had engaged in unprotected anal intercourse with another man at least once in their lifetime, only 17% had engaged in unprotected anal intercourse in the previous 6 months. Both of these measures were lower than the rates for the other American bisexual men in the ISBBM. [Aggregate White and Black rates for anal intercourse were 68% lifetime and 31% previous 6 months (McKirnan et al., 1995, and personal correspondence).] Of the Asian-American respondents currently having unprotected anal intercourse, two thirds had both receptive and insertive; the other third had only had receptive. None was engaging only in unprotected insertive anal intercourse. The rate of unprotected vaginal sex in the Asian-American sample in the previous 6 months was 37%. A high portion of the participants (78%) reported having been tested for HIV antibodies at least once. Only one reported a positive test result.

Cultural and lifestyle issues. The men in my sample had in common that they dealt with two forms of oppression: as ethnic minorities and sexual minorities. Although the places where gay men (mostly White) gather were familiar to many members of the sample, they did not congregate there as Asians. The metropolitan area has two social organizations for Asian gays, but only a minority of the bisexual men had attended these, and when they did so they usually were not open about being bisexual--they gathered as Asian gays. Asian-American bisexuals struggled with living between two ethnic cultures and two sexual cultures; they did not comprise a "community" of their own.

Most of the Asian-American bisexual sample attempted, at first, to fit in with the heterosexual norm of their adolescent group. Behaviorally, they explored heterosexually first although concurrently they had become aware of fantasies regarding men's bodies and later explored their homosexual attractions. Two thirds of the bisexual Asian-Americans had been attracted to both men and women since early adolescence and continued to be so; they fit the "congruent bisexual" category (see Table 3).

The next largest category of bisexuals (21%) consisted of those who appeared to be in transition. At the time of the interviews, most transitional bisexuals had stopped having sexual relationships with women and were only attracted to male sexual partners. These Asian-American bisexuals who shift in 3 years compare to a 40% shift in attractions in a 1-year follow-up study (Stokes et al., 1993). When I compared behavior (rather than attraction), more than half the Asian-American men were no longer having sex with women. In addition, four men had given up having sex with other men, three of whom claimed to desire an asexual lifestyle. Only 11 of the 31 men (35%) who were bisexually active in the previous three years continued to be so--a remarkable attrition.

Similar changes in behavior have been reported in a study spanning five years (Ekstrand et al., 1994). Factors that Asian-Americans mentioned for this move away from a bisexual lifestyle included the emotional complexity of managing multiple relationships, the fear of AIDS, the moral belief that a committed relationship should be monogamous, and the lack of support for bisexuality in either the gay or heterosexual culture. These reasons suggest that the move of some bisexuals to solely heterosexual or solely homosexual relationships was not necessarily an indication that bisexuality was not "real" for these men, but that social supports and personal resources to handle the complexity were lacking. A bisexual lifestyle increased these men's experience of being multiply oppressed--as an ethnic minority, non-heterosexual in the mainstream culture, and bisexual in the gay community. Their reports Of strong conflict around whether to disclose their sexual orientation to parents suggested that many of these men no longer accepted the Asian privatization of sex and the option of marriage with a hidden bisexual life was very uncomfortable for them. At least behaviorally, most shifted away from a bisexual lifestyle.

Acculturation to American society and the gay subculture. Almost half of this sample of Asian-American men were born in the U.S.; most grew up in settings where the majority of their playmates and classmates were White. Their parents made great efforts to be sure that they became well acculturated to American society; many parents had raised their children speaking only English. As soon as it was financially possible, they moved their families out of Asian-American ghettos or extended family homes to White suburbs. The high value they placed on education may have motivated their emphasis on learning English and moving to the suburbs, where the schools were considered better. Thus, it is not surprising that 87% of the men were rated "5" (fluent functioning) on the American Acculturation scale. Fewer than a thud of the sample had lived in Asia since age five. Of the 13% who were scored from 1 to 4 (less than "fluent"), half had not moved to North America until late adolescence or adulthood. The great majority of the sample appeared better adapted to the dominant culture than to Asian-American culture.

Almost half of the sample rated at least "4" on both the American Acculturation and the Ethnic Cultural Competence scales. However, only one quarter of the sample were rated "5" ("fluent") on Ethnic Cultural Competence, whereas 87% reached fluency in American Acculturation. Nearly half of the participants were rated "3" or below on Ethnic Cultural Competence, although only one respondent was scored that low on American Acculturation.

Westernization of the families of our respondents began before their immigration. This is made obvious by the fact that involvement in Eastern religious heritages (Buddhist, Taoist, and Confucian traditions) was limited to about half the Chinese families, and very few respondents practiced these religions. More than half of the respondents came from Catholic or Protestant Christian traditions, and about half still identified as such. A surprising finding was that bisexual respondents who identified as Protestants were significantly more likely (p = .02) to engage in medium- or high-risk sexual behavior. Although there was no significant difference among the three Asian-American ethnic groups on this small sample, there is a possibility that religious identifications and ethnicity are confounded, because a greater proportion of Korean-Americans were Protestant (see Table 4).

Table 4 Ethnicity and Religious Identification of Bisexuals: Frequency Distribution

                         Religious Identification

Ethnicity           Protestant   Catholic   Eastern   Other   T =

Chinese-American     (0)0        (1)3       (0)1      (3)6   (4)10
Filipino-American    (2)2        (2)6       (0)0      (2)5   (6)13
Korean-American      (3)3        (0)1       (0)0      (3)4   (6) 8
T =                  (5)5        (3)10      (0)1      (8)15  (16)31

Note: (Respondents with higher risk) Total respondents in that cell

Although the Asian-Americans were considerably less competent in gay culture than in either American or ethnic cultures, the ratings showed the respondents' current investment was highest in the gay subculture--almost twice as high as in Asian culture. They were somewhat more likely to choose friends/acquaintances who were gay or bisexual than friends/acquaintances who were Asian. The finding that gay/lesbian identity tends to take priority over Asian identity was consistent with Chan's (1989) results and was especially noteworthy given that the sampling methods of the study reported here overcame the limitations of Chan's convenience sample.

The concept of homosexuality versus heterosexuality. I showed bisexual respondents the Kinsey, Pomeroy, and Martin (1948) scale and asked them what point best described their current sexual orientation. Their answers ranged from "completely homosexual" to "primarily heterosexual," centering at "more homosexual than heterosexual." Only a minority of the Asian-American bisexual or gay respondents were conscious of the homosexual aspects of their Asian heritage; their lack of conscious awareness does not indicate that they were not influenced by this heritage, however. Most Filipino men were aware of the term bakla, although many thought of it as synonymous, with gay. Yet three Filipino men fit the bakla pattern rather closely, usually limiting themselves to receptive sex and thinking of themselves as feminine. Another Filipino man fit the "macho" complement of the bakla role. Two Chinese and one Korean respondent restricted their sexual role with men to receptive intercourse, although their self-concepts did not fit the feminized pattern. None of these Asian-Americans was aware that his behavior fit a cultural pattern.

Different boundaries in choosing male partners. The Filipino sense of a special, culturally defined role may have helped many Filipino parents acknowledge and respect the "identity" of their sons, even though the bakla identity results in somewhat inferior status. The sense of belonging to a distinct group of people existed for some Filipino gay and bisexual men and included a norm of exogenous mate selection, even when they did not follow the bakla role. To quote one Filipino respondent, "I never [have sex] with my [Filipino] friends ... these are my sisters, my family. To have sex with them] would be like incest."

Early in my interviewing, I discovered that many Asian-American men, in all three ethnic groups, rarely chose other Asian-American men as sexual partners. Once I recognized this exogenous pattern I began collecting data from those men who had been seeking homosexual partners for a number of years. Nearly two thirds (63%) of the 24 bisexuals on whom I have data regularly chose non-Asian partners, frequently men older than themselves. Some Asian-Americans stated that they avoided contact with other Asians in gay settings for fear of disclosure or did not choose Asian partners simply because few were available. However, by far the most common explanation was that "Asian men are not my type." Seventy-one percent of those who gave reasons for preferring White partners stated that men of their own racial group do not fit their ideal of masculine attractiveness; they usually elaborated that they preferred men who were big, were thick muscled, or possessed other physical traits less common in Asian men. This phenomenon suggests that acculturation to the dominant society has meant accepting White standards of physical attractiveness.

Because the rate of HIV infection was higher among White men than Asian-American men, I was concerned that partnerships with older White men might increase the spread of the virus into the Asian-American community. Carrier et al. (1992) noted that the more acculturated Vietnamese-Americans in their sample were more likely to engage in anal intercourse, the most risky sexual behavior. Morris, Zavisca, and Dean (1995) found, in a sample of primarily White young men, that those who chose older men as partners were at greater risk. However, the data for my Asian-American sample were not in the direction that would be predicted from this previous research. It is possible that these relationships provided the Asian-Americans with an opportunity to become better acculturated to both American society and the gay subculture. Further, if the White partner was older and more involved in the gay community, he may have taught the Asian-American the concrete details of safer sex.

The Context of Unsafe Sex

Although only 35% of the men in the bisexual cohort were currently having sex with both men and women, at least 55% continued to have sex with more than 1 partner. Only 6 sexually active bisexual men (22%) were clearly monogamous--2 were in monogamous relationships with women partners and 4 with men partners.

Reasons Asian-Americans give for risk taking. Data from open-ended questions on risk behavior suggested that some of those engaging in high-risk sex during the previous six months (see Table 2) did so because of misinformation or false assumptions. Some men had proceeded with unprotected sex with "monogamous partners" on the assumption that blood tests their partners had had included a test for HIV, although this was not routine at the time. Some Asian-Americans associated risk with homosexual behavior; they restricted themselves to safer sex with men but were not practicing safer sex with women--even though 10% regularly practiced anal intercourse with women. Boulton, Evans, Fitzpatrick, and Hart (1992) and Ekstrand et al. (1994) found in their bisexual male samples that unprotected sex was more common with women than with men, as was the case for the ISBBM Black-American sample (McKirnan et al.. 1995). A striking example of misinformation occurred with a respondent who had relied solely on television and Asian-American newspapers for his information. He had regularly engaged in unprotected anal receptive sex, believing that semen taken in anally would soon pass out of the body with food wastes through the rectum. He had avoided oral sex, believing it would be dangerous because semen would go through the stomach and into the blood stream.

In other cases the men put themselves and their partners at risk even though they seemed to understand the facts concerning transmission. This often involved accepting unprotected sex with a partner who was now monogamous but had not been re-tested since having outside partners. Some Asian Americans noted the contribution of being intoxicated, lonely, or not having had sex in a long time to past risky sexual behavior, but there were very few indications of slips like these having occurred in the previous six months.

Contracting HIV in a homosexual relationship and transmitting it in a heterosexual relationship. Nineteen percent of the sample (of men who had had sex with both men and women in the previous three years) had engaged in the previous six months in unprotected anal or vaginal sex in relationships in which there was little assurance that the partner was HIV negative. Only 35% of the sample continued to be bisexually active. Almost all the current unsafe sex involved sex with a primary partner, trusting the primary partner and himself to be negative when the data did not support such trust. All the men whose primary partners were women, and who continued to engage in unprotected sex with them, claimed to have tested negative and no longer to be having unprotected anal intercourse with men. This is similar to the pattern of current behaviors reported in the five-year study of a San Francisco population of bisexually identified men (Ekstrand et al., 1994). Thus, in the Asian-American sample, there was a very low likelihood of HIV being transmitted from homosexual relationships to a heterosexual partner.

Heterosexual contracting, then heterosexual transmission. The data suggested that some bisexual men might contract HIV from unprotected intercourse with a woman and transmit it to another woman. In all cases where risky sex occurred outside the primary partnerships. the unprotected sex occurred with women. None involved respondents who restricted female relationships to steady partners. However, of the men who had sex with women who were not steady partners, more than half engaged in high-risk behaviors. A woman who was in a steady relationship could not correctly assume she was safe unless she was sure that her male partner had restricted his relationships to steady partners.

Homosexual contracting, homosexual transmission. In the AIDS pandemic to date, almost all HIV transmission that has occurred between men because of sexual behavior has been through anal intercourse. Among the subsample of 31 Asian-American men, only 3 continued to practice unprotected anal intercourse with other men and were in relationships in which their partner was not monogamous. None of these men currently had sex with women. The persons at risk were the respondents and any new male partners they may have had.

Part 2. Cohort Data on Gay Asian-Americans

This cohort served two purposes: It allowed a contrast between the bisexual and the gay men within the Asian-American cultural context, and it expanded the size of the sample of Asian-Americans who had sex with men (and with men and women) to n = 54, allowing greater statistical power to the search for variables related to sexual risk taking.

When the gay cohort was compared to the bisexual men, the Asian-American bisexuals were significantly more likely to have engaged in risky sex (p = .003), using the low-risk group compared to the mid- and high-risk groups. A comparison of the rates of men engaged in the highest risk sexual behavior showed no difference. Among the total sample, no significant difference was found on levels of sexual risk comparing the three Asian-American groups.

Variables Related to Sexual Risk Taking in the Combined Sample

All variables that approached significance in the bisexual sample were tested in the combined bisexual and gay cohorts.

Acculturation. Acculturation to American society, although in the predicted direction, did not reach significance, nor did acculturation to the gay subculture. However, differences in the respondents' acculturation to their Asian heritage were highly predictive of safer sex. Combining the higher risk groups, low Ethnic Cultural Competence predicted higher risk at p. = .007.

Protestant identification. The religious heritages and identifications of the gay sample closely approximated those described for the bisexual sample. Perhaps because few of the gay sample were in the higher risk categories, the comparison between Protestant identification and other religious identifications fall just short of significance for the combined bisexual and gay sample (n = 58).

Other significant dependent variables. Disclosure to parents proved to be highly significant (p = .01) in predicting the highest sexual risk. The pattern of Latin homosexual roles was significant in predicting the highest sexual risk (p = .025) for the combined gay and bisexual sample.

Variables unrelated to risk taking in the combined sample. Variables that failed to predict sexual risk taking included methods of recruitment; scales of internalized homophobia, self esteem, and depression; age, place of birth (Asia or USA); whether the respondent had moved away from his parents' home; suburban versus urban address; the choice of non-Asians as sexual partners; and connection with the gay community.

Connection to the gay community deserves special mention because of previous research. Doll et al. (1991) speculated that bisexually-behaving men may be less connected than homosexuals and therefore less subject to peer norms that have emerged supporting safer sex. Studies reviewed in Boulton et al. (1992) have shown inconsistent results. I tested this hypothesis using four measures: the Gay Cultural Competence scale. the social network responses regarding gay friends, and the psycho-social scales of internalized homophobia and gay identity. None of these measures suggested that involvement with the gay community was related to lower levels of risk taking.

Discussion

How Does Acculturation to Three Subcultures--Asian, Mainstream American, and Gay--Relate to Bisexual or Gay Behavior?

There are two kinds of evidence that Asian acculturation is associated with safer sex. First, compared to the ISBBM White or Black samples, the Asian-American bisexuals were engaged in less sexual risk behavior. They also showed a very low likelihood of transmitting HIV from homosexual relationships to heterosexual partners, in contrast to other bisexual samples (Heckman et al., 1995, and McKirnan, Vanable, & Stokes, 1996). Second, within my sample, high acculturation to Asian culture was associated with high functioning in terms of safer sex. Because acculturation to American culture was also associated in the same direction, although not significantly, it may be that practicing safer sex was simply one manifestation of higher adaptability in social interactions. On the other hand, the fact that it was acculturation to Asian culture that was significantly associated with safer sex suggests that some aspects of Asian culture, such as the value placed on education and on conformity to social norms, may have led to conforming to norms even though they were the norms of a different community, e.g., the safer sex norms of the gay subculture (see Matteson, 1995). Perhaps Asian acculturation may have encouraged greater caution in sexual exploration. Neither American acculturation nor immigrant versus native-born status was related to risk.

Although Asian-American bisexuals practiced unsafe sex more than their gay cohorts, none of my measures of connection with the gay community or gay cultural competence predicted lower sexual risk. This contrasts to earlier studies but parallels the finding for the White and Blacks in the ISBBM study i McKirnan et al., 1995). Perhaps at this stage of the epidemic, contact with the gay community no longer increases knowledge of safer sex or changes behavioral norms enough to affect behavior.

What Variables are Associated with Sexual Behavior That May Put Asian-American Men and /or Their Partners at Risk for Contracting HIV?

Three additional variables were found to be significant the Latin pattern of homosexuality, disclosure to parents, and Protestant affiliation. My impressions from my interviews with the respondents who fit the Latin Pattern were that their risk taking may have had to do with poor assertiveness skills; research directly measuring assertiveness would be useful. The fact that high sexual risk was related to high disclosure rates to parents suggested the possibility of a general personality trait of risk taking.

Protestant identification was highly related to unsafe sex practices for the bisexual sample. A quotation from one Korean Protestant respondent is illustrative:

I struggled with, and still (struggle

with) ... the conflict with Christianity.

That first night, I was both

blissful and guilty Blissful about

the relationship--not just the sex

I prayed to God "How can something

that feels so good feel so bad

at the same time?" I didn't want to

read others' opinions, but I did look

to the Bible to see if it was just Old

Testament law, or was it also in the

New Testament. I was told that

Jesus didn't mention it,--but I saw

that it was condemned by Paul. I

couldn't resolve it, so I just put it

off to the side ... This (religious

conflict)--not (the conflict with)

my parents, was the real conflict.

The Protestant groups in which my Asian-Americans were members tended to be conservative denominations. which may have encouraged guilt-oriented self-control. Possibly all-or-nothing responses, which are sometimes associated with guilt, or fear-motivated behavior, accounted for their high rate of unsafe sex. Anecdotal evidence for all-or-nothing responses has emerged from HIV-prevention work: An emphasis on sexual abstinence among persons who had already been sexually active appeared to have a boomerang effect. When such persons were sexually tempted and broke some part of their vow of abstinence, a "total relapse" effect often ensued, as if they rationalized "I've already sinned; I might as well go all the way." Possibly the Protestant Christians experienced having sex with men as the breaking of a taboo, and this led to the breaking of safer sex norms as well. I am not aware of any previous research connecting religious affiliation or guilt motivation to BE[V risk and hope that this finding will encourage such research.

Impressionistic data suggested that specific socialization experiences may enhance adhering to safer sex: For example, the Asian-American's choice of a non-Asian male partner may have facilitated his initiation into receptive anal intercourse in a context that also taught him the importance of condom use (see Stokes, Variable et al., 1996). A combination of inaccurate information and unfounded trust of partners also seemed to play a role in risk behavior. All these interpretations require further investigation.

Are There Differences in Risk Behavior Among the Three Asian-American Ethnic Groups Studied?

No significant difference was found among these group& ImpresSionistic data showed a subculture of "sisterhood" among some Filipino respondents that was not observed in the other ethnic groups and may relate to Latin homosexuality, which has implications for risk (see Carrier. 1994)

Recommendations for Prevention

Readers interested in prevention approaches that may reach bisexuals and other men who have sex with men but do not identify or involve themselves in the visible gay community are encouraged to see Doll and Beeker, 1996; Marin and Marin, 1992; and Stokes et al., 1996. The recommendations that follow are focused on acculturation and Asian-American cultural issues.

Cognitive messages. Several Asian-Americans had been at risk for contracting HIV because of misinformation or incomplete information. Those who had limited skills in reading English often relied solely on television and Asian-American newspapers for their information. Ethnic media could do much to improve their credibility among men who have sex with men (see Aoki, Ngin, Mo, & Ja, 1988), and prevention messages on American TV (e.g., compared to many European countries) have been much too vague. Clear and explicit messages in these media are needed to understand safer sex; prevention messages that fail to distinguish the relative risks of oral, anal, and vaginal sex do a disservice. Persons entering monogamous relationships need information about the advisability of testing. Many men continue to rationalize unprotected sex with their steady female partners. It appears that even basketball star Magic Johnson's announcement that he was HIV positive failed to convince some participants of the risk of heterosexual transmission, although that event preceded our first interviews by only two months.

Types of media and settings for intervention. After rapport was established in our interviews, many participants seemed to welcome discussion. seeking clarification from this White interviewer concerning their own risk behavior. The distinction between public and private self in Asian cultures may make it more difficult to interact face to face about sexual information. Yet it is likely that interactive learning is necessary to personalize the issues. Telephone counseling (Roffman et al., 1990) and the use of interactive electronic media (computer, e-mail, or voice mail) might be particularly helpful because these interactions can take place privately and anonymously without face-to-face meetings.

Other types of intervention. More than half of the high-risk-Asian-Americans in my sample knew they were putting themselves at risk, yet they failed to insist on condom use. As is well known, cognitive knowledge alone may not change behavior. Wider use of assertiveness training and skill building is needed in prevention program. The possibility exists that guilt and negative views of sexuality may be involved in risk taking. Recent efforts to involve religious institutions in HIV prevention, such as the ADDS National Interfaith Network (Centers for Disease Control and Prevention, 1995) may be especially relevant to Asian-American Protestants. Multicultural programs in the schools need to go beyond emphasizing acceptance of different cultures to encouraging youths' attempts to sort out their unique values from the cultures that influence them. Thus, those, like our respondents, who fall between cultures and between sexual categories can feel affirmed. Interventions may encourage acceptance and positive attitudes toward Asian physical characteristics and positive affirmation of healthy homosexual behavior. Building pride and integrating ethnic and homosexual aspects of one's life may be facilitated by awareness of the tolerance of homosexual behavior that was part of much of Asian history prior to the effects of Western imperialism (see Hinsch, 1990; Lau & Ng, 1989; Matteson, 1991; and Ruan, 1991). Support groups for young gay or bisexual Asian-American men, especially groups with leadership from mature Asian-American men who can model affirmation of their gay or bisexual lifestyle, may be particularly effective.

Popular media have begun to include portrayals of Asians or Asian-Americans leading lifestyles involving homosexuality The public acknowledgment of homosexuality in much of Chinese history has been described in a readable book, Passions of the Cut Sleeve (Hinsch, 1990). Films such as My Beautiful Launderette, Farewell My Concubine, and The Wedding Banquet treat with sensitivity both the affirmation of homosexual relationships and the respect for elders and traditions. Perhaps as these issues are more frequently addressed on TV and other popular media, it will become easier for Asian American men who have sex with men to accept this in themselves without having to sever their connection with their Asian heritage and their Asian physical features.

Limitations of This Study and Suggestions for Further Research

In contrast to most researchers, I did not rely on paper-pencil responses, and recruitment of the sample included print ads in mainstream and ethnic papers as well as contacts in gay-identified settings. Given these differences, the areas in which I have replicated previous results are especially impressive and argue for some generalizability. Nonetheless, the problems of generalizing from a small and geographically limited sample are obvious.

I have emphasized that most of the population was highly acculturated to American society. Those few Asian-Americans who were recruited through ethnic papers consistently failed to fit the criterion of having had sex with another man in the previous three years. This suggests that there may be a population of bisexually-inclined men who are more identified with the ethnic community than with their identity as bisexual or gay and who, instead of moving toward increasing homosexual behavior (as is the norm for the men on whom I focused), move toward a socially and culturally approved heterosexuality.

Because the research was exploratory rather than hypothesis driven, many sets of data were examined post hoc, and only those that appeared to show a pattern were tested statistically. Thus, even statistically significant results are tentative.

The use of face-to-face interviews may have screened out those more fearful of exposure or less comfortable with English. Phone interviews might provide a valuable addition in future studies and extend the generalizability of findings, despite the problems with phone interviews already discussed. The results, based on a Midwestern sample, cannot be assumed to generalize, e.g., to coastal cities that appear to provide more social support for affirming both an Asian and a bisexual or gay identity. Differences among Asian ethnic cultures make it risky to generalize across Asian-Americans; the small numbers in the sample make it risky to generalize within any particular ethnic group. Developmental trends and changes in sexual behavior suggested in the data may be subject to biased recall; follow up on respondents over time would be necessary to confirm these.

The findings suggest that Asian-American men who had sex with men were more likely than comparison groups to comply with safer sex, acculturation to Asian society enhanced this compliance, but identification with Western Protestantism, or with traditional Latin homosexual roles, was related to higher risk behavior. The reported behavior of the men who had sex with both men and women did not substantiate fears that bisexuals were a conduit for transmitting the virus from the gay to the heterosexual community.

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