Role versatility among men who have sex with men in urban Peru.
Role versatility refers to the practice in which individual men who have sex with men Men who have sex with men (MSM) is a term used mostly in the United States to classify men who engage in sex with other men, regardless of whether they self-identify as gay, bisexual, or heterosexual. (MSM MSM - Micronetics Standard MUMPS ) play both insertive and receptive sexual roles over time. Versatility has been thought to be relatively uncommon among Latin American MSM but possibly is rising. Versatility also has been shown to be a potentially large population-level risk factor for HIV HIV (Human Immunodeficiency Virus), either of two closely related retroviruses that invade T-helper lymphocytes and are responsible for AIDS. There are two types of HIV: HIV-1 and HIV-2. HIV-1 is responsible for the vast majority of AIDS in the United States. infection. In this study we examine the correlates of versatile behavior and identity among 2,655 MSM in 6 Peruvian cities. Versatile behavior with recent male partners was found in 9% of men, and versatile (moderno) identity was reported by 16%. Significant predictors included high education, white-collar occupation, sex work, and residence in Lima. Age was not significant in any analysis. Since sex work is correlated negatively with other predictors, versatile men appear to comprise two distinct subpopulations. Insertive-only men appear to play a strong role in bridging the HIV epidemic between MSM and women.
Homosexual sex is largely distinguished from heterosexual in that either partner may play either role (insertive or receptive) during a single type of sexual act. This simple fact allows for two distinct patterns of sexual role to emerge among homosexuals: those of role segregation (individuals only engaging in one of the two roles over time) and role versatility (individuals engaging in both). Although this distinction can in fact be drawn for some sexual acts for any couple--whether same-sex or opposite--research largely has focused on anal sex Noun 1. anal sex - intercourse via the anus, committed by a man with a man or woman
anal intercourse, buggery, sodomy
sexual perversion, perversion - an aberrant sexual practice; between men, given its central role in the spread of HIV and other sexually transmitted infections (STIs). The prominence of role segregation among MSM in Latin America Latin America, the Spanish-speaking, Portuguese-speaking, and French-speaking countries (except Canada) of North America, South America, Central America, and the West Indies. has been well documented, although role versatility also clearly has been present as long as investigators have been exploring the topic (Arboleda, 1995; Caceres & Jimenez, 1999; Carrier, 1976, 1989, 1995; Carrillo, 2002; Gutmann, 2003; Murray, 1995; Parker, 1999). Role-segregated behavior often is accompanied by role-segregated identities, marked by the terms activo (insertive, "top") and pasivo (receptive, "bottom"). Terms indicating a versatile role identity (e.g., moderno in Peru, internacional in Mexico) also have been present since at least the 1960s (Carrier, 1976). These terms suggest that the identity (and corresponding behavior) is viewed as less traditional, and perhaps is conceived of as a diffusion of gay-identified sexual norms A sexual norm can refer to a personal or a social norm. Most cultures have social norms regarding sexuality, and define normal sexuality to consist only of certain legal sex acts between individuals who meet specific criteria of age, relatedness or social role and status. from the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. and Western Europe Western Europe
The countries of western Europe, especially those that are allied with the United States and Canada in the North Atlantic Treaty Organization (established 1949 and usually known as NATO). , although the extent to which this reflects its true origin is debated (e.g., Carrillo, 2002; Gutmann, 2003; Murray & Arboleda, 1995; Parker, 1989). Anecdotal evidence anecdotal evidence,
n information obtained from personal accounts, examples, and observations. Usually not considered scientifically valid but may indicate areas for further investigation and research. from urban Peru points to a rise in moderno identity, which suggests that versatile behavior also may be increasing, although this is not automatically true--it may simply represent more behaviorally versatile men choosing to identify thus.
With the advent of HIV, the phenomena of role segregation and versatility have taken on additional public health significance. Mathematical modeling
That can be transmitted: transmissible signals.
trans·mis for insertive and receptive anal sex, such men are capable of both becoming infected efficiently while receptive and then transmitting efficiently while insertive. Role segregation, in contrast, should create bottlenecks to the efficient transmission of HIV through long chains of people, providing protection to the entire population. The population-level impact of versatility may be in operation even when versatility does not act as an individual risk factor--that is, versatile men are fueling a larger overall epidemic for everyone, while still remaining at lower individual risk than receptive-only men. Mathematical models exploring this phenomenon initially incorporated the assumption of no transmission from receptive to insertive partner (Van Druten, Van Griensven, & Hendriks, 1992; Wiley & Herschkorn, 1989). Subsequent evidence showed, however that unprotected insertive anal intercourse Noun 1. anal intercourse - intercourse via the anus, committed by a man with a man or woman
anal sex, buggery, sodomy
sexual perversion, perversion - an aberrant sexual practice; (UIAI) poses a non-negligible risk of infection for the insertive partner (Tovanabutra et al., 2002; Vittinghoff et al., 1999). More recent modeling work has shown that the effect of versatility remains large even when there is considerable risk from UIAI, as long as it is less than that for unprotected receptive anal intercourse (URAI URAI International Conference on Ubiquitous Robots and Ambient Intelligence ; Goodreau, Goicochea, & Sanchez, 2005).
Role segregation and versatility represent a continually shifting framework around which male homosexual relations in Latin America are structured. Given the strong relevance of versatility to the epidemic vulnerability of MSM populations, we sought to identify the characteristics that distinguish versatile men from nonversatile men among one set of MSM communities in Latin America--those of urban Peru.
We collected data on sexual behavior sexual behavior A person's sexual practices–ie, whether he/she engages in heterosexual or homosexual activity. See Sex life, Sexual life. from MSM in 6 larger cities in Peru This is a list of cities in Peru.
or coitus or copulation
Act in which the male reproductive organ enters the female reproductive tract (see reproductive system). with at least one man during the previous year. Piura and Sullana are twin cities and were combined for the purposes of analysis.
[FIGURE 1 OMITTED]
Subjects were recruited by trained recruiters and peer educators using outreach work and snowball snowball: see honeysuckle. techniques over a 3-month period in each city. Recruitment occurred at venues known to be frequented by MSM (saunas, pornographic movie theaters and arcades, prostitution areas, discotheques, bars, beauty parlors, transvestite trans·ves·tite
One who practices transvestism.
transvestite Sexology A person with a compulsion to dress as a member of the other sex, which may be essential to maintaining an erection and achieving orgasm. See Transsexual. houses, and sport courts). Methods used to contact potential participants and to refer them to study clinics included posters, flyers, and informational meetings. The reliance on convenience sampling was unavoidable given the marginalized nature of homosexuality in Peru.
Sexually transmitted disease sexually transmitted disease (STD) or venereal disease, term for infections acquired mainly through sexual contact. Five diseases were traditionally known as venereal diseases: gonorrhea, syphilis, and the less common granuloma inguinale, (STD (Subscriber Trunk Dialing) Long distance dialing outside of the U.S. that does not require operator intervention. STD prefix codes are required and billing is based on call units, which are a fixed amount of money in the currency of that country. ) clinics from the Ministry of Health and from private nongovernmental organizations Transnational organizations of private citizens that maintain a consultative status with the Economic and Social Council of the United Nations. Nongovernmental organizations may be professional associations, foundations, multinational businesses, or simply groups with a common interest in served as sentinel sites during the study period. At each site, one counselor explained the objectives of the study to potential participants and obtained informed consent for their participation in the questionnaire and blood testing. Those men who agreed and provided written informed consent underwent a structured interview using Computer-Assisted Self-Interviewing (CASI CASI Campaign Against Sanctions on Iraq (UK)
CASI Center for Aerospace Information
CASI Council on Accreditation and School Improvement
CASI Canadian Aeronautics and Space Institute
CASI Canadian Association of Snowboard Instructors ) to collect information about demographics The attributes of people in a particular geographic area. Used for marketing purposes, population, ethnic origins, religion, spoken language, income and age range are examples of demographic data. , sexual risk behavior, sexual identity, and HIV testing HIV test Various tests have been used to detect HIV and production of antibodies thereto; some HTs shown below are no longer actively used, but are listed for completeness and context. See HIV, Immunoblot. and diagnosis. The characteristics of the three most recent sexual partners were described individually as were sexual practices with each partner. Counselors assisted participants in cases of illiteracy illiteracy, inability to meet a certain minimum criterion of reading and writing skill. Definition of Illiteracy
The exact nature of the criterion varies, so that illiteracy must be defined in each case before the term can be used in a meaningful or lack of familiarity or comfort with computers. Physicians obtained a medical history and conducted a targeted physical examination for STIs. Peripheral venous blood venous blood
n. Abbr. v
Blood that has passed through the capillaries of various tissues other than the lungs, is found in the veins, in the right chambers of the heart, and in pulmonary arteries, and is usually dark red as a result of a samples were obtained for detection of HIV antibodies HIV antibody A self antibody specifically directed against one or more proteins or antigens on the surface of HIV, which may be minimally protective against HIV by ELISA ELISA (e-li´sah) Enzyme-Linked Immuno-Sorbent Assay; any enzyme immunoassay using an enzyme-labeled immunoreactant and an immunosorbent.
n. with confirmation by Western Blot Western blot
A technique developed in 1979 that is used to confirm ELISA results. HIV antigen is purified by electrophoresis and attached by blotting to a nylon or nitrocellulose filter. .
All participants received risk reduction counseling, condoms, and lubricants lubricants
preparations for the lubrication of passages to reduce frictional injury, e.g. oily preparations, including petroleum jelly, lanolin or water-soluble preparations such as methyl cellulose. . Participants with diagnoses of HIV or STI STI systolic time intervals. received postdiagnosis counseling and education. Syndromic treatment was provided to those with curable cur·a·ble
Capable of being cured or healed. STI, while HIV-infected men were referred for standard care, which in Peru at the time (2002) did not include antiretroviral antiretroviral /an·ti·ret·ro·vi·ral/ (-ret´ro-vi?ral) effective against retroviruses, or an agent with this quality.
Definitions of Versatility
We use three definitions of role versatility. The first is self-identified moderno role. This stems from participants' response to the question, "What is your role in the bedroom?" (activo, pasivo, moderno): The question purposefully pur·pose·ful
1. Having a purpose; intentional: a purposeful musician.
2. Having or manifesting purpose; determined: entered the room with a purposeful look. excluded a specific time frame to allow participants to report their overall self-perception. The second definition involves role reported during anal sex with men in the last 3 months. We refer to this as AAI AAI American Association of Immunologists. role ("any anal intercourse"). The third definition is similar to the second, but is limited to acts not involving a condom--the UAI UAI Unprotected Anal Intercourse
UAI University Admissions Index (NSW/ACT, index needed by HS Graduating students in order to enter university)
UAI Union Académique Internationale
UAI Use As Is
UAI Universal Armament Interface ("unprotected anal intercourse") definition. The UAI definition is the most epidemiologically relevant one, since UAI is the behavior in which HIV is most readily spread. The AAI definition also is useful for understanding versatility generally, however and for delimiting a set of men who may be likely to practice unprotected role versatility with unreported or future partners.
These definitions rely on reports of behavior with sexual partners in the last 3 months. For the sake of brevity Brevity
of short life. [Br. Lit.: I Henry IV]
symbolic of transitoriness of life. [Art: Hall, 54]
cherry orchards where fruit was briefly sold; symbolic of transience. and recall accuracy, however respondents were asked to provide detailed sexual behavior with only their last three partners in this time period. Those who had more than 3 partners in the last 3 months (48.6%) thus did not provide complete behavioral information for the last 3 months. In addition, some reported partners were female. Together this means that some men who were versatile among all recent male partners would appear to be role segregated. The analyses involving the AAI or UAI definitions of versatility were conducted separately for men reporting on 1, 2, and 3 male partners to avoid confounding confounding
when the effects of two, or more, processes on results cannot be separated, the results are said to be confounded, a cause of bias in disease studies.
confounding factor the tendency toward versatility with the tendency for many or exclusively male partners.
Descriptive Statistics descriptive statistics
The study enrolled 2,703 men. Of these, 2,655 are included for analysis; 43 (1.6%) did not complete the survey, and an additional 5 did not respond to questions on the sex of their partners. An unknown number of men were screened out at the many informal outreach venues.
Table 1 provides basic demographic and behavioral information on the sample. Although the majority of respondents declared their sexual identity as homosexual or bisexual bisexual /bi·sex·u·al/ (-sek´shoo-al)
1. pertaining to or characterized by bisexuality.
2. an individual exhibiting bisexuality.
3. pertaining to or characterized by hermaphroditism.
4. , 10.3% declared themselves heterosexual. Self-described current sexual role was evenly divided between activo (41.8%) and pasivo (40.6%); only 16% declared themselves to be moderno (versatile). Moderno identity ranged from a high in Lima (56.5%) to a low in Piura/Sullana (7.2%). Behavioral bisexuality bisexuality /bi·sex·u·al·i·ty/ (-sek?shoo-al´i-te)
1. sexual attraction to persons of both sexes; exhibition of both homosexual and heterosexual behavior.
2. true hermaphroditism.
3. androgyny (1). is common among these men; 35.0% reported a female partner among their most recent 3 partners in the last 3 months.
Predictors of Moderno Identity
In Table 2, we consider the predictors of moderno identity for the entire study population using multiple logistic regression In statistics, logistic regression is a regression model for binomially distributed response/dependent variables. It is useful for modeling the probability of an event occurring as a function of other factors. . Thirteen additional men who did not answer all relevant questions are excluded from this and subsequent analyses. We see a significant and consistent increase in moderno identity with increasing education. An independent effect is seen for higher-status occupations (professional, employee [empleado], university student) versus lower-status ones (worker [obrero], taxi driver taxi driver n → taxista m/f
taxi driver taxi n → chauffeur m de taxi
taxi driver taxi n → , hairdresser). Engaging in sex work also increases the odds of being moderno. Travel abroad and to other regions domestically were included in the analysis, given the belief that moderno identity in Latin America represents cultural diffusion In anthropology, cultural diffusion refers to the spread of ideas, inventions, or patterns of behavior to different societies (Wintrop 1991:82)
Since cultures have never been completely isolated from each other, diffusion has happened throughout history, and continues on from the north. Nevertheless, these predictors were not significant, perhaps partly because they correlate highly with education and occupation.
Surprisingly, age (reclassified into five categories) shows no significant effect on moderno status. We can examine the issue further with a simple graph of all three role identities by age (Figure 2). Although moderno status remains relatively constant across all ages, the two types of segregated role identities (activo and pasivo) reverse, with activo being more common among younger men and pasivo among older men. This suggests that the set of men who are moderno at each age may differ from one another; at younger ages, they are selecting moderno identity largely in contrast to activo, while in older ages it represents men who choose moderno identity in contrast to pasivo. Because of this pattern, we repeated the analysis of moderno predictors from above for each of the five age classes separately (not shown). The qualitative results do not change; the same predictors appear, although some lose significance among the smaller age categories.
[FIGURE 2 OMITTED]
Predictors of Versatile Behavior
We run the same model using AAI and UAI as outcomes instead of moderno identity. Because of the confounding with reported partner numbers discussed above, these analyses are stratified stratified /strat·i·fied/ (strat´i-fid) formed or arranged in layers.
Arranged in the form of layers or strata. by number of male reported partners. The qualitative results are again the same as for moderno identity, so Table 3 lists only the significant predictors and the magnitude of the effect for these analyses. Overall, the predictors among these different subsets remain generally the same as those for moderno identity; higher education higher education
Study beyond the level of secondary education. Institutions of higher education include not only colleges and universities but also professional schools in such fields as law, theology, medicine, business, music, and art. , higher-status occupation, and residence in Lima are positive predictors of role versatility. When the factors are limited to unprotected sexual behavior, differences in education remain significant, despite the fact that one might expect increased versatility to be offset by increased condom 1. condom - The protective plastic bag that accompanies 3.5-inch microfloppy diskettes. Rarely, also used of (paper) disk envelopes. Unlike the write protect tab, the condom (when left on) not only impedes the practice of SEX but has also been shown to have a high failure use among this population. Having a serious male partner is either significant or close to significant in most analyses, suggesting that men may be more inclined to be versatile with their serious partners than with others.
Sex Work, Transvestites, and Versatility
Some of the predictors of versatility were themselves negatively correlated: sex work and high status as marked through education and occupation. This suggests that the set of men who are versatile may be a heterogeneous group, with men following two different paths to versatility: one opportunistic opportunistic /op·por·tu·nis·tic/ (op?er-tldbomacn-is´tik)
1. denoting a microorganism which does not ordinarily cause disease but becomes pathogenic under certain circumstances.
2. (sex work) and one reflecting a cosmopolitan or international perspective of educated, affluent men. To explore this, we rerun re·run
The act or an instance of rebroadcasting a recorded movie or a recorded television performance.
tr.v. re·ran , re·run, re·run·ning, re·runs
To present a rerun of. the analyses separately for sex workers and nonsex workers. We add an additional predictor for transvestite status, as this divides the world of sex work into two distinct types, widely assumed to relate to the client's desired sexual role (specifically insertive with transvestite sex workers). For the 10% of respondents who consider themselves sex workers, only residence in Lima is significant (OR 4.17); transvestite status was in fact not. For nonsex workers, the effect of education becomes even stronger than in the initial analysis--for instance, college-educated men are now 6.3 times more likely to be moderno than low-educated men, as opposed to only 4.4.
Versatility, Female Partners, and HIV Bridging
In this population, men who are exclusively receptive during UAI with male partners have a higher prevalence of HIV infection (16.6%) than either versatile (12.9%) or insertive (6.5%) men. As demonstrated by Goodreau and colleagues (2005), this pattern, where versatility is not an individual risk factor, is to be expected under some circumstances even though versatility is placing the population as a whole at greater risk. We also find that the number of female partner(s) reported on is largest for insertive-only men, intermediate for versatile men, and smallest for receptive men. Together, these points mean that it is not immediately clear who presents the greatest risk of bridging the HIV epidemic to females: insertive men (who have many female partners but low HIV), receptive men (who have few female partners but high HIV), or versatile men (who are intermediate on both). Table 4 shows a simple analysis in which we consider the question: On average how many women might a typical man in each role category be exposing? We simply assume the two effects (female partnering and HIV status, given role) are independent and take their product. Note that by doing this we are implicitly assuming that the men obtained HIV from their male partners such that their female partners are in turn at risk from them, which we suspect is most often the case among behaviourally bisexual men in this population.
We find that an individual man who is always insertive during UAI with other men is potentially exposing more women to HIV than is a man who is either receptive only or versatile; the lower HIV prevalence among insertive-only men is more than counteracted by their higher rates of female partnering. Insertive-only men comprise roughly one third of our sample, and this is likely a considerable underestimate of their true fraction in the MSM population, since our sampling venues disproportionately exclude married, heterosexually identified men. It appears, then, that a considerable fraction of the bridging of HIV from MSM to females occurs through men who are strictly insertive, although putting an exact number on this attributable risk attributable risk Epidemiology Any factor which ↑ the risk of suffering a particular condition. See Relative risk, Risk factor. Cf Nonattributable risk Statistics The rate of a disorder in exposed subjects that is attributable to the exposure derived from is difficult given our sampling scheme.
This study considered the predictors of versatile behavior among MSM in urban Peruvians. The versatile population appears to consist largely of two different subpopulations: one is educated, white-collar men of all ages and in all cities, although highest in Lima; the other is sex workers across the board, but, again, especially in Lima. Education and occupation remained as predictors when limiting the question to unprotected anal sex only; the higher levels of condom use that might be expected with higher education did not offset the high level of versatility among these men.
Previous work has identified the disproportionate impact on the HIV epidemic that versatile men can have, even under the counterintuitive coun·ter·in·tu·i·tive
Contrary to what intuition or common sense would indicate: "Scientists made clear what may at first seem counterintuitive, that the capacity to be pleasant toward a fellow creature is ... scenario where they have relatively low HIV prevalence themselves (Goodreau et al., 2005). Changing the behavior of such men should thus have relatively large indirect effects for reducing HIV transmission overall. We believe that efforts to reduce versatility itself would be inappropriate and ineffective, however; this is the case regardless of the source and strength of role preferences, but it seems especially unhelpful in cases where versatility emerges from increasingly egalitarian e·gal·i·tar·i·an
Affirming, promoting, or characterized by belief in equal political, economic, social, and civil rights for all people. norms about same-sex relations. Furthermore, the risk created by versatility is less to oneself than to one's potential future partners, who may not even be known yet; changing one's own behavior from versatile to exclusively receptive may in fact increase one's own immediate risk of infection. Rather, we propose that further behavioral interventions behavioral intervention Behavior modification, behavior 'mod', behavioral therapy, behaviorism Psychiatry The use of operant conditioning models, ie positive and negative reinforcement, to modify undesired behaviors–eg, anxiety. promoting higher condom use, lower rates of partner exchange, or both be targeted to subpopulations in which versatility is high. This work has demonstrated the existence of two such communities. Although numerous HIV interventions are already targeted at sex workers in Lima, relatively little focus has been placed on the well-off and highly educated, under the assumption that they already generally have received the message and are relatively safe. The fact that these sociodemographic characteristics remain as strong predictors for unprotected versatile anal sex indicates that this assumption is not correct. Interventions that are targeted specifically to the bars and discos that cater to such men may be especially helpful in lowering HIV rates for everyone given the disproportionate role that versatile men may play in sustaining an HIV epidemic.
Age was found to play surprisingly little role in predicting versatility, suggesting that versatility may not be as much on the rise as is popularly believed. An alternate (but less parsimonious par·si·mo·ni·ous
Excessively sparing or frugal.
parsi·mo ) explanation, however, is that there are two countervailing effects in play: a period effect (probability of versatility rises as one ages) and a cohort effect The term cohort effect is used in social science to describe variations in the characteristics of an area of study (such as the incidence of a characteristic or the age at onset) over time among individuals who are defined by some shared temporal experience or common life (each subsequent generation begins its sexually active life more versatile than the previous). If both of these phenomena are present in roughly equal strengths, one would see little variation in versatility by age at any single time point, yet versatility would be continuously on the rise through time. Each of these two pieces is plausible, but distinguishing this more complex scenario from the simple case of complete stasis stasis /sta·sis/ (sta´sis)
1. a stoppage or diminution of flow, as of blood or other body fluid.
2. a state of equilibrium among opposing forces. is not possible from this simple cross-sectional study cross-sectional study
See synchronic study.
n the scientific method for the analysis of data gathered from two or more samples at one point in time. . Doing so requires multiple similar studies, a longitudinal study longitudinal study
a chronological study in epidemiology which attempts to establish a relationship between an antecedent cause and a subsequent effect. See also cohort study. , or additional qualitative work. Goodreau and colleagues (2005) reported on the first wave of a longitudinal study examining sexual roles among MSM; as further waves become available, the answer to this question should become clearer.
Finally, we identified that men who are insertive only with their male partners play a major role in bridging the HIV epidemic to their female partners. The general perception among MSM in Peru is that being exclusively insertive is a way to avoid HIV infection (Caceres & Rosasco, 1997), which is strictly true relative to being receptive and when focusing only on one's own infection. At the population level, however, the greatest risk to women from MSM may in fact be from insertive-only men, although given our sampling approaches an exact number is difficult to estimate. Nevertheless, it is clear that stronger messages are called for on the high indirect risk to a man's wife, girlfriend, or other female partners when he engages in unprotected insertive anal sex with men.
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The concentration of a virus, such as HIV, in the blood.
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Asociacion Civil Impacta Salud y Educacion, Lima, Peru
Steven M. Goodreau
University of Washington
Asociacion Civil Impacta Salud y Educacion, Lima, Peru
Asociacion Civil Impacta Salud y Educacion, Lima, Peru
Asociacion Servicios Generales dela Salud y Educacion, Piura, Peru
Asociacion Civil Selva Amazonica, Iquitos, Peru
Asociacio Civil Cayetano Meredia, Pucallpa, Peru
Instituto Sur Peruano de Infectologia, Arequipa, Peru
Asociacion Civil Impacta Salud y Educacion, Lima, Peru
Jorge R. Sanchez
Asociacion Civil Impacta Salud y Educacion, Lima, Peru
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Table 1. Demographics of Study Population Number Percent Total 2655 Age-median (range 18-71) 24 City Piura/Sullana 738 27.8 Lima 908 34.2 Iquitos 304 11.5 Pucallpa 278 10.5 Arequipa 427 16.1 Self-reported sexual orientation Homosexual 1438 54.2 Bisexual 936 35.3 Heterosexual 273 10.3 NA 8 0.3 Self-described current sexual role Activo (Insertive) 1127 42.4 Pasivo (Receptive) 1095 41.2 Moderno (Both insertive & receptive) 432 16.3 NA 1 0.0 Sexual self-perception Hombre (man) 966 36.4 Gay 824 31.0 Transvestite 389 14.7 Buse (closeted, predominantly pasivo or 216 8.1 moderno man) Mostacero (closeted, predominantly activo man) 159 6.0 Other (woman, fete, none) 95 3.6 NA 6 0.2 Number of sex partners (male and female, last 90 days) 0 142 5.3 1 668 25.2 2 554 20.9 3+ 1291 48.6 Gender of all sex partners * Only male 1583 59.6 Only female 211 7.9 Both male and female 719 27.1 None 142 5.3 Relationships to sexual partners * At least one male "primary" partner 1028 38.7 At least one female "primary" partner 549 20.7 At least one male "one-time" partner 1425 53.7 At least one female "one-time" partner 424 16.0 Role during unprotected anal intercourse with males ** Only receptive 697 26.3 Only insertive 496 18.7 Both insertive and receptive 116 4.4 No unprotected anal intercourse 993 37.4 with male partners No male partners 353 13.3 Role during anal intercourse with males ** Only receptive 1109 41.8 Only insertive 840 31.6 Both insertive and receptive 246 9.3 No anal intercourse with male partners 107 4.0 No male partners 353 13.3 Sexually transmitted infections Genital Herpes Reactivity (by IR > 3.5) 1207 45.5 Syphilis Reactivity (MHA-TP + & RPR +) 350 13.2 HIV (Western Blot) 329 12.4 * For up to the 3 most recent sexual partners involving contact within the last 90 days. ** For up to the 3 most recent male sexual partners involving contact within the last 90 days. Table 2. Global Predictors of Moderno Role Identity, (Total n = 2,642; # Moderno = 429) Predictor p Odds ratio 95% C.I. Age class 0.838 21-25 * 0.598 1.09 0.79-1.49 26-30 * 0.259 1.22 0.86-1.74 31-40 * 0.578 1.11 0.77-1.61 41+ * 0.954 1.02 0.60-1.71 Education 0.000 Secondary ** 0.070 1.55 0.97-2.50 Trade school ** 0.000 2.72 1.61-4.58 University ** 0.000 4.41 2.60-7.48 Occupation 0.000 High status *** 0.000 2.40 1.74-3.31 None/other *** 0.050 1.40 1.00-1.97 Sex worker 0.022 1.49 1.06-2.11 Has long-term male partner 0.005 1.39 1.10-1.74 Has long-term female partner 0.056 0.64 0.40-1.01 Any sex with women 0.006 0.57 0.38-0.85 Lima 0.000 2.57 2.04-3.24 Travel abroad 0.724 1.02 0.91-1.15 Domestic travel 0.673 0.97 0.86-1.10 Constant 0.000 0.04 0.02-0.07 * Reference category = 18-20. ** Reference category = Less than secondary. ** Reference category = Low status. Table 3. Significant Predictors for Behavioral Versatility Outcome n n versa. Significant predictors AAI w/1 1,068 71 Education (trade school) * male partner Education (university) * Lima AAI w/2 494 60 Education (university) * male partners Occupation (high status) ** Has long-term male partner Lima AAI w/3 736 115 Occupation (high status) ** male partners Lima UAI w/1 1,068 40 Education (University) * male partner Lima UAI w/2 494 24 Has long-term male partner male partners UAI w/3 736 52 Has long-term male partner male partners Travel abroad Lima Outcome Odds ratio (95'% CI) AAI w/1 12.90 (1.67-99.85) male partner 10.69 (1.33-85.78) 2.35 (1.37-4.04) AAI w/2 5.24 (1.27-21.71) male partners 2.45 (1.01-5.94) 3.19 (1.64-6.22) 2.97 (1.51-5.84) AAI w/3 2.35 (1.25-4.40) male partners 3.54 (2.19-5.72) UAI w/l 8.93 (1.07-74.25) male partner 2.18 (1.08-4.38) UAI w/2 3.33 (1.22-9.08) male partners UAI w/3 2.19 (1.09-4.39) male partners 0.27 (0.11-0.64) 2.47 (1.27-4.78) * Reference category = Less than secondary. ** Reference category = Low status. Table 4. Potential Exposure of Female Partners to HIV UAI role with all the partners--last HIV infection 90 days (Western blot positive) (a) n % Only receptive during UAI with male 116 16.6 partner(s) (n = 697) Only insertive during UAI with male 32 6.5 partner(s) (n = 496) Both insertive and receptive during UAI 15 12.9 with male partner(s) (n = 116) Avg. # of female UAI role with all the partners--last partners in 90 days last 3 mos. mean (95% C.I.) Only receptive during UAI with male 0.31 (0.15-0.47) partner(s) (n = 697) Only insertive during UAI with male 1.81 (1.56-2.05) partner(s) (n = 496) Both insertive and receptive during UAI 0.63 (0.28-0.98) with male partner(s) (n = 116) Mean no. of females a UAI role with all the partners--last man in this category is 90 days potentially exposing to HIV Only receptive during UAI with male 0.05 partner(s) (n = 697) Only insertive during UAI with male 0.12 partner(s) (n = 496) Both insertive and receptive during UAI 0.08 with male partner(s) (n = 116) (a) Chi-square test < 0.00.