An exploration of sexual behaviour and self-definition in a cohort of men who have sex with men.
Key words: Bisexuality MSM Sexuality Drug use Trading sex IDU HIV
Growing concern that bisexual men might be bridging HIV infection from the gay community to the larger heterosexual population drew the attention of HIV researchers who realized that the risk factors and prevention needs of this group of men who have sex with men (MSM) may be distinct (Rust, 2000). The magnitude of the risk of HIV transmission by bisexual men to the heterosexual population has since been questioned (Kennedy & Doll, 2001; Worth, 2003). Nevertheless, for well over a decade now, bisexual men have been investigated separately from homosexual or gay men in studies on the psychosocial and behavioural determinants of HIV infection. Collectively, this research has reinforced the observation that male bisexuality and, by extension, homosexual activity, encompasses an extremely diverse class of experiences.
Although the patterns and contexts of bisexual men's sexual expression are varied, within the context of the HIV literature a few specific interrelated typologies of bisexually active or non-gay identified MSM have been described. Doll & Beeker (1996) identified four contexts of bisexual behaviour associated with increased vulnerability to infection: male prostitution, injection drug use, sexual identity exploration among youth and communities of color. A qualitative study by Goldbaum, Perdue & Higgins (1996) yielded six overlapping categories of men: hustlers or men who have sex with men for economic reasons; closeted men or men who are coming out; new age men or experimenters; incarcerated or formerly incarcerated men; people of colour or cultural groups; and heterosexually identified men, including married men. Emphasizing the fluidity of sexual behaviour and orientation, and echoing aspects of Goldbaum et al.'s (1996) classification, Stokes, Miller & Mundhenk (1998) proposed a four group typology: men in transition (e.g., bisexual men on their way to becoming gay-identified); experimenters (e.g., gay-identified men who, on occasion, will have sex with a woman); opportunity driven men (e.g., men who have sex with men when women are not available) and men with dual involvement (e.g., men whose involvement with men and women is both emotional and sexual).
As suggested by the above typologies, consideration of bisexuality in the context of HIV studies has placed renewed emphasis on the incongruity that can exist between sexual practices and sexual identity. Behaviourally bisexual men do not invariably describe themselves as bisexual. In HIV research, depending on the sample, the proportion of bisexual identified men can range from approximately 30% (35%, Bennett, Chapman & Bray, 1989; 29%, Lever, Kanouse, Rogers, Carson & Hertz, 1992) to 60% (56%, Boulton, Hart & Fitzpatrick, 1992; 59%, McKirnan, Stokes, Doll & Burzette, 1995; 59%, Montgomery, Mokotoff, Gentry & Blair, 2003; 61%, Wood, Krueger, Pearlman & Goldbaum, 1993). A more recent study examining the sexual self-identification of an international sample of bisexual men and women suggests that if given free reign to describe themselves, most (60%) will opt for more than one identity term (e.g., bisexual, straight, gay, queer) and over a tenth will prefer not to label themselves at all (Rust, 2001).
Several factors have limited the success of HIV research in elucidating the specificities and associated HIV risk contexts linked to male bisexuality. Notably, in this work, bisexuality is commonly reduced to a one-dimensional phenomenon, in contrast with the complexity of sexual orientation models designed to accommodate bisexuality. For example, the Klein Sexual Orientation Grid (Klein, Sepekoff & Wolf, 1985), which is arguably the best known adaptation of the Kinsey continuum, measures sexual orientation with seven variables rated on a seven-point scale (1 = heterosexual/other sex to 7 = homosexual/same-sex). These variables refer to sexual attraction, sexual behaviour, sexual fantasies, emotional preference, social network, lifestyle and self-identification. In total, this model contains 21 items as each variable receives a present, past and ideal rating, allowing sexual orientation to fluctuate over time. Conversely, in public health studies, the operational definition of bisexuality has generally been based either on an isolated measure of sexual behaviour (e.g., Heckman, Kelly, Sikkema et al., 1995; Diaz, Chu, Frederick et al., 1993; Stokes, Vanable & McKirnan, 1997) or of identity (e.g., Doll, Petersen, White, Johnson, Ward & the Blood Donor Study Group, 1992; Evans, Bond & MacRae, 1998; Stokes, McKirnan & Burzette, 1993).
While evidence suggests that discrepancies between self-identified sexual orientation and sexual behaviour are associated with greater (e.g., Earl, 1990; Seibt, McAlister, Freeman et al., 1991) or lesser HIV risk (McKirnan et al., 1995), these two dimensions have only infrequently been considered together in the classification of MSM for HIV research. Studies that have considered both sexual self-identification and sexual behaviour to compare subgroups of MSM are to be commended although such research has generally done so unsystematically (e.g., Boulton et al., 1992; Fitzpatrick, Hart, Boulton, McLean, & Dawson, 1989) or has classified exclusively bisexually active men (e.g., Lever et al., 1992; Taywaditep & Stokes, 1998) and not broader samples of MSM.
The study by Fitzpatrick et al. (1989) is an example of the unsystematic use of identity as a classification criterion in that their sample of men who reported sex with a man was divided into three groups: exclusively (behavioural) homosexual men (n=309), self-ascribed bisexuals (n=31) and men who were behaviourally bisexual but did not identify as bisexual (n=16). Highlights of the results include the finding that a similar proportion of each group reported active anal sex with a man in the previous year while fewer men who were bisexual in identification or behaviour had had passive anal sex. Behaviourally bisexual men, however, reported more male partners in the last year compared with the other groups.
Boulton et al. (1992) provide an additional illustration of this research strategy. They organized their groupings of behavioural bisexuals (n=60) in terms of the participants' social context, whether homosexual, bisexual or heterosexual. A heterosexual context was indicated by being married, living with a female partner or identifying as heterosexual (n=29), a homosexual context, by being significantly involved in the organized gay community (n= 15) and a bisexual context, by participating in organized bisexual groups (n=13). These researchers found that the largest proportion of behavioural bisexual men living in a heterosexual context engaged only in unprotected penetrative sex with a woman (41%) while among those living in a gay context the largest proportion had only unprotected sex with a man (40%) in the previous year. Men living in a bisexual context had only unprotected sex with women.
In contrast, the systematic consideration of both behavioural and self-identification measures appears more common in research with samples restricted to bisexually active men. For example, Stokes et al. (1993) compared self-identified bisexual men who met a six-month behavioural criterion for bisexuality (n = 55) with self-identified bisexual men who did not (n = 50). While the men did not differ in their degree of involvement in the gay community nor in their disclosure of their bisexual attraction, the behaviourally bisexual men reported higher self-esteem and scored lower on a scale of depression. On measures of substance use, however, they were more likely to consume a greater amount of drinks per sitting and to use marijuana "at least occasionally". Behaviourally bisexual men also engaged in significantly more unprotected oral sex to ejaculation in the past six months but the proportion of men in each group reporting unprotected anal sex did not differ.
Perhaps the most detailed classification of behaviourally bisexual men for HIV research was carried out by Taywaditep and Stokes (1998). These investigators considered 12 variables along three dimensions in the grouping of their respondents (n=443): a) sexual orientation self-identity, a forced choice between bisexual, gay or straight; b) the orientation of their erotic fantasies and; c) their sexual experience and relationship history. Eight clusters of bisexually active men were formed. Two of these groups identified as straight (10%), four as bisexual (59%) and two as gay (31%). The two groups with the greatest frequencies of unprotected anal sex with men (one of which was gay-identified, the other, bisexual-identified) differed dramatically. The gay-identified group (n=115), reported fewer male partners (M=2.8 in the past 6 months), the highest levels of education, gay-identification, "outness" and self-esteem, and the lowest levels of psychological distress and drug-related problems. The bisexual identified group (n=14), by comparison, reported a much larger number of male partners (M = 31.5 in the past 6 months), were among those with the lowest levels of education and self-esteem, as well as those with the highest levels of psychological distress and drug-related problems.
To date, limited Canadian data are available on the distinguishing characteristics of subgroups of MSM based on either sexual behaviour (with men and/or women) or self-identification. An exception is the work of Myers, Allman, Jackson and Orr (1995), who developed a formulation of sexual orientation that considered not only current sexual behaviour (past year) but also the respondents' sexual history in order to obtain data on differences in risk-taking between bisexual and homosexual Canadian men. Men were classified as lifetime-gay (n = 308), gay-previously heterosexual (n = 226) and currently bisexual (n = 83). In this study, gay-previously heterosexual men were significantly more likely than the other groups to be in a relationship with a man, to know a person living with AIDS and to have had at least one episode of unprotected anal sex in the previous year.
The disparate operational definitions and reductive strategies to subject classification evident in much HIV research on male bisexuality are not new features of published studies concerned with sexual orientation and identity (Cass, 1984; Sell, 1997; Shively, Jones & De Cecco, 1984). These varied classification strategies predate the HIV epidemic and challenge our ability to draw comparisons between studies. The Western concept of bisexuality as an identity or even a valid sexual orientation is of very recent origin (Rust, 2000). In sex research, much remains to be learned about the relationship between the various measures used to qualify it (Kennedy & Doll, 2001). While a consideration of too many measures may be impractical (Sell, 1997) and risk paralysing analyses (Weinrich & Klein, 2002), the merit of systematically combining the two main strategies used for defining bisexuality in HIV research (self-identification and sexual behaviour), needs to be further assessed. Such a strategy would have the added benefit of integrating "a 'psychological' component and a 'behavioural' component," the two components that generally define sexual orientation (Sell, 1997, p.646).
The pertinence of considering identity, particularly a bisexual self-identification, in the creation of subgroups of MSM for analysis is reinforced by evidence that men who are lost to attrition in AIDS intervention programs are more likely to label themselves as bisexual (Roffman, Downey, Beadnell, Gordon, Craver & Stephens, 1997). According to Roffman et al. (1997), in the three months prior to enrolment in the program, self-labelled bisexual men were less likely to have a college education, had smaller social support networks and were more likely to have engaged in unprotected oral and anal sex. This lends support to the belief among HIV/AIDS prevention workers that non-gay identified MSM lack the social structure, whether close friends, family or a gay social network, to help foster and maintain risk reduction (Goldbaum et al., 1996). In Canada, HIV and public health researchers acknowledge the need for prevention, interventions and services tailored to bisexual men (Dobinson, MacDonnell, Hampson, Clipsham & Chow, 2005; Huber & Kleinplatz, 2002; Myers, Calzavara, Millson, Graydon, Leblanc & Major, 1998). A call for more research in this area has also been made. Specifically, studies that account "for bisexual MSM as a unique segment of the MSM population" (Huber & Kleinplatz, 2002, p. 12) and that investigate the distinctions between gays and bisexuals (Dobinson et al., 2005) have been requested.
To address these needs and the frequently simplistic approach to subject classification in HIV studies on bisexuality with samples of MSM, the present study proposes a four-category classification based on sexual behaviour (homosexual or bisexual) over a period of 18 months, and sexual orientation self-definition (gay/homosexual or bisexual). Its main objectives are to compare groups of men with bisexual characteristics (i.e. bisexual identity, behaviour or both) with exclusively gay/homosexual men (in behaviour and identification) on a selection of socio-sexual and drug-related practices in order to examine the performance of this classification in differentiating between the groups, and in characterizing each bisexual group in relation to exclusively gay men.
The Omega Cohort Study, which actively recruited from October 1996 to July 2003, was a longitudinal study on the incidence and psychosocial determinants of HIV infection in MSM residing in the Montreal area of Quebec, Canada. The study population was MSM aged 16 years or older who were HIV-negative or did not know their HIV status. A man was eligible to participate if he reported having had sex with a man in the previous year. Recruitment was conducted via community associations, the local gay print or electronic media, snowball sampling and clinical settings. Participation was voluntary and interested persons called the study office to make an appointment (see Dufour, Alary, Otis, Remis, Masse, Turmel et al., 2000, for more details on the study's methodology).
Approximately every 6 months, participants visited the study office situated in downtown Montreal to provide a blood sample for HIV and syphilis testing and to complete two questionnaires. One contained psychosocial measures and was administered by an interviewer. Sensitive behavioural information was gathered with a self-administered questionnaire. The content of questionnaires varied from one observation period to the next. The variables presented in this article were constructed to maximize the time frame considered, using data from as many observation periods as were available from baseline to the second follow-up. This explains why variables could be measured over 6, 12 or 18 months.
Sexual orientation self-definition. Irrespective of sexual behavior, subjects were categorized as bisexual defined (BD) if at baseline ([T.sub.0]) or their second follow-up visit ([T.sub.2]) they described themselves as bisexual in response to the open-ended question "At this time, how do you define yourself with respect to your sexual orientation?" Participants were categorized as gay defined (GD) if at both [T.sub.0] and [T.sub.2] they defined themselves as gay or homosexual. As will be evident in the results, eliminating bisexual identified men who were fluid in their self-definition to create a category more comparable to that of gay defined men, given their great number (49.2%), would have potentially removed an important feature of male bisexuality in this sample.
Homosexual or bisexual activity. Bisexual and gay defined men were classified among the homosexually active (HA) if they reported no sexual activity with a woman in the 6-month periods prior to completing the [T.sub.0], [T.sub.1] and [T.sub.2] questionnaires (18 months of observation). Men were considered bisexually active (BA) if they reported oral, vaginal or anal sex with a woman at least once over this period, independent of their sexual activity with men.
Socio-demographic variables. Age was coded at [T.sub.2] as a dichotomous variable distinguishing between men aged less than 30 years and those aged 30 years or more. Education was coded at baseline with 2 levels (a high school degree or less and more than a high school degree), as was income which was coded at [T.sub.2] (annual income of less than $20,000 or $20,000 CND or greater) and ethnicity, coded at [T.sub.0]. This last variable, a decidedly rough measure of ethnic identity, distinguishes between individuals identifying as a member of a visible ethnic minority (e.g., African, Haitian, Arab, Native, Latino) from individuals labelling themselves as Canadian (French or English), Quebecois or European.
Sexual practices, partners and sex venues. All of the variables grouped under this heading concern sexual activity and relationships between men. The internal consistency of the scales composed of three or more items was verified by calculating the Cronbach Alpha. Pearson product-moment correlations are provided for measures composed of only two items. Among the sexual practices considered were kissing (1 item); masturbation (2 items, r = .85) which combined receiving and performing masturbation with a partner; soft anal practices (4 items, [alpha] = .81) which grouped together receiving and performing anal fingering and rimming; toys (2 items, r = .55) which combined using an object for anal penetration and sharing an object for anal penetration without cleaning it between uses; and fisting (2 items, r = .56) which combined receiving and performing manual penetration of the anus. For each of the individual activities, participants indicated with what proportion of their male sexual partners in the past six months, ranging from 1 (none) to 5 (all), they engaged in the particular activity. The individual item scores belonging to each of the six variables were averaged over [T.sub.1] and [T.sub.2] to produce the final score used in the analyses.
Oral sex refers to the proportion of respondents reporting oral sex in the course of at least one time period from [T.sub.1] to [T.sub.2] by partner type (whether regular or casual).
Anal sex refers to the proportion of respondents reporting anal sex in the course of at least one time period from [T.sub.1] to [T.sub.2] by partner type (whether regular or casual).
Unprotected anal sex (UAS) was measured separately for casual and regular partners as the proportion of respondents reporting a minimum of one episode of unprotected anal sex in the course of at least one 6-month time period from [T.sub.0] to [T.sub.2].
Partner types (i.e. couple, regular or casual partners) were measured separately as the proportion of participants who reported a male partner of this type over a year and a half of observation ([T.sub.0], [T.sub.1], [T.sub.2]).
Number of partners was assessed separately for regular and casual male partners over a period of 12 months ([T.sub.1] and [T.sub.2]). These dichotomous variables distinguished between men reporting fewer than 2 regular partners and those reporting 2 or more and between men reporting fewer than 6 and those reporting 6 or more casual partners over this period.
Sex venues includes six separate situations depending on partner type (casual or regular) and whether sex occurred in a public venue (i.e., a park, public toilet, peepshow, car or alley), in private (i.e., the partner's or the respondent's residence) or at a sauna. Participants indicated with what frequency, ranging from 1 (never) to 5 (often), they had had sex in each of these contexts within the last 6 months. The Cronbach Alpha and Pearson product-moment correlations for these item groupings are as follows: sex with a casual partner in private (r = .37); sex with casual partner in public ([alpha] = .66); sex with a regular partner in private (r = .42); sex with a regular partner in public ([alpha] = .68). The final score for each of the six variables was the mean of the corresponding item ratings across all three time periods ([T.sub.0] to [T.sub.2]).
Trading sex for money, drugs, or goods/services (examined separately), combining sex and drugs or alcohol (i.e., being under the influence of drug or alcohol during sex), non-prescription drug use and injection drug use were assessed over a 12-month period of observation ([T.sub.1] and [T.sub.2]) to determine the presence or absence of the activity.
To determine which variables would be submitted to polytomous logistics regression analysis, bivariate analyses were initially conducted on all of the variables defined. For categorical variables, Chi-Square tests were performed and when 25% of the cells had expected counts of less than 5, Fisher's Exact Test was used. For continuous variables, one-way ANOVA with Tukey post-hoc comparisons were conducted. All variables significant at the level of p [less than or equal to] .05 were submitted to polytomous logistic regression analyses which controlled for significant socio-demographic variables. These analyses required that a referent group be selected against which to compare the other groups. The referent selected was the gay defined homosexually active group (GDHA) which contained a majority of participants. The BDHA, GDBA and BDBA were thus compared to the GDHA yielding odds ratios for each comparison. This article presents only the results of the polytomous logistic regression analyses (CATMOD procedure) and not the initial bivariate analyses.
BREAKDOWN OF THE SAMPLE
From October 1996 to July 2003, 1,377 participants completed the baseline, [T.sub.1] and [T.sub.2] questionnaires. A little over three-quarters (76.9%) repeatedly defined themselves as gay or homosexual at baseline and [T.sub.2] (n = 1059). Approximately 10% (n = 137)defined themselves as bisexual on at least one occasion. Excluded from the study sample were 13.1% of participants (n = 181) whose sexual orientation self-definition did not fall within these patterns. In terms of sexual activity, the majority of participants who completed the baseline to [T.sub.2] questionnaires had not had sex with a woman during the 18-month period considered (homosexually active: 90.5%; bisexually active: 9.5%; percentages do not include the 47 missing cases). By far the largest group created for analysis was the gay-defined homosexually active group (GDHA: n = 994). Together, the other groups represent 11.3% of the complete [T.sub.2] sample (BDBA: n = 83; BDHA: n = 47; GDBA: n = 25).
To gain a better understanding of the composition of the different bisexual groups, we conducted three tests. First, we examined the proportion of each bisexual defined (BD) group that consistently defined themselves as bisexual. Sixty percent of the BDBA (n=50) was stable in their self-definition over both time periods compared with 34% of the BDHA (n=16). This difference was significant ([chi square] (1) = 8.24; p = .004). A second test among the two bisexually active (BA) groups looked at the proportion of each group that recurrently reported bisexual activity. Over a quarter (26.5%) of the BDBA (n=22) reported sex with a woman at each 6-month observation period compared with 12.0% (n=3) of the GDBA, though this test was not significant ([chi square] (1) = 2.27; p = .13). A third test examined the proportion of each of the four groups that reported being married to a woman or having a common law wife at [T.sub.0], [T.sub.1] or [T.sub.2]. Over a fifth of the BDBA (22.5%), 8% of the GDBA, 1.6% of the GDHA and none of the BDHA reported having such a female partner. This test was significant ([chi square] (3) = 109.75; p < .0001).
There were no significant differences between the groups in ethnicity, as revealed by Chi-Square analysis. Only a small proportion of each group (0% to 6.5%) defined themselves as other than French or English Canadian, Quebecois or European. In the polytomous logistic regression analyses (Table 1), the BDHA did not differ significantly from the referent group (GDHA) on any of the socio-demographic variables considered (i.e. income, education, age). The BDBA alone differed significantly from the comparison group in income and education, as did the GDBA in age. Compared to the GDHA referent group, the BDBA were approximately three times less likely to have had more than a high school education and two times less likely to have had an annual income of $20,000 Cdn or more. The GDBA were about three and a half times less likely to be aged 30 years or older.
SEXUAL PRACTICES, PARTNERS AND SEX VENUES
The preliminary analyses (Chi-Square, ANOVA) revealed no differences between the three bisexual groups and the referent GDHA group in the following variables not shown in Table 2: oral sex with a casual partner, anal sex with a casual partner, regular or casual partner types, number of casual partners, having had sex in private with a casual partner, and having had sex at the sauna with a casual partner.
Table 2 reports the results of the polytomous logistic regression analyses on other variables for which preliminary Chi-Square analyses indicated the possibility of group differences. Overall, the BDBA seemed to differ most from the comparison GDHA group on the measures shown. In their sexual practices, the BDBA were distinguished by lower odds of engaging in kissing, masturbation and soft anal practices (i.e., rimming, fingering) with their male partners. The BDBA group was also almost two times less likely to make each of the above activities a part of their sexual relations with men. Oral sex and anal sex with regular partners were also less likely among the BDBA.
With reference to partner types, the odds of men in the BDBA group having a male couple partner were five times lower relative to the comparison group. The BDHA shared with the BDBA a lesser likelihood of kissing their male partners, of engaging in oral sex with regular partners and of reporting a couple relationship with a man. In addition, they were characterized by significantly lower odds of having two or more regular partners relative to the comparison group. The GDBA shared only one difference with another bisexual group, the BDBA. Each of these groups distinguished themselves from the referent by their greater probability of having sex in a public venue with a regular partner. The BDBA alone showed lower odds of having sex in a private venue with a regular partner, of having had sex with a regular partner in a sauna, and of having had sex with a casual partner in a public venue. This GDBA group was also alone in differentiating from the comparison group in reports of unprotected anal sex (UAS). The GDBA were approximately three and a half times more likely to have practiced anal intercourse without a condom with a casual partner (i.e., a one-night stand compared to the referent GDHA group) (Table 2).
TRADING SEX AND DRUG USE
Among the variables concerned with trading sex and drug use, only combining sex with drug or alcohol use did not distinguish significantly between the bisexual groups and the GDHA in the preliminary Chi-Square analyses. Table 3 presents the results of the polytomous logistic regression analyses on trading sex and drug use. Trading sex for a variety of benefits was more likely among the bisexual groups. Across all categories (sex in exchange for money, drugs or goods and services), the GDBA had no less than four times greater odds of engaging in each of these activities. The BDBA were three times more likely to have traded sex for monetary gain and five and a half times more likely to have traded sex for drugs. Like the two other groups, the BDHA had over four times greater odds of trading sex for drugs. Injection drug use was significantly more likely among the bisexual defined groups. In contrast, none of the GDBA had injected drugs in the 12-month period of observation. Added to their greater odds of injection drug use, the BDBA were approximately twice as likely to have used other non-prescription drugs.
The findings of this exploratory study appear to reinforce four risk features associated with bisexual men identified by HIV researchers: injection drug use, trading sex for money, drugs or goods, lower emotional involvement with other MSM, and sexual exploration. In this section we discuss these features in relation to the literature, contextualize our results with respect to the limitations of the methodology employed, and present reasons for caution in interpretation of some of the findings. We also propose some general guidelines for intervention and offer suggestions for future research on bisexuality in the context of HIV prevention.
INJECTION DRUG USE AND TRADING SEX
In our study, all three bisexual groups showed greater odds of involvement in various aspects of trading sex and in the two bisexually defined groups, greater odds of injection drug use. Other research concerned with HIV/AIDS has found disproportionate levels of injection drug use and trading sex among bisexual men defined with reference either to their behaviour or to their identity. Among MSM recruited in public sex environments in four American cities, compared with gay-identified men, self-identified bisexuals (40% of the sample) were approximately twice as likely to have ever injected drugs and to have ever had sex in exchange for drugs or money (Goldbaum, Perdue, Wolitski et al., 1998). A study by Chu, Peterman, Doll, Buehler & Curran (1992), based on national surveillance data among American MSM with AIDS, found that behaviourally bisexual men were twice as likely as homosexual men to have injected drugs, independent of ethnicity (20% versus 9%). In a sample of sexually experienced American male high-school students, Goodenow, Netherland & Szalacha (2002) similarly found that bisexual activity was related to higher odds of injection drug use. Over a third (39.2%) of adolescent males with partners of both genders had ever injected drugs compared with 9.6% of males with only same-sex partners, and 1.2% of males with only female partners. Among sexually active American men with AIDS, Diaz et al. (1993) found injection drug use (12% versus 6%) and receiving sex for money (11% versus 4%) were significantly more common among behaviourally bisexual men than homosexual men.
In research with sex workers and other marginal populations, intersections between injection drug use, sex work and bisexuality are also frequent. Rekart, Chan, James, & Barnet (1989) reported, that these three practices were common among street-involved people in Vancouver and argued for HIV prevention strategies "focused on bisexual male prostitutes" given their level of sero-positivity (12.1% of bisexual male sex workers who injected drugs were HIV-positive as were 10.3% of bisexual male sex workers who did not inject drugs; as cited in Allman, 1999).
A Canadian study comparing injection drug using MSM (MSM-IDU) with other MSM, found that MSM-IDU were more likely to have had sex with a woman in the previous 12 months (69% versus 13%), to have been involved in sex work (72% versus 14%) and to have engaged in unprotected anal sex with a casual partner (O'Connell, Lampinen, Weber et al., 2004). The authors emphasized "the crucial role of sexual behavior" (p. 22) as a risk factor for HIV infection among MSM-IDU in their cohort. Among American men with AIDS who had injected drugs in the previous five years, behavioural bisexuals were more likely to have received money for sex (29%) when compared with behavioural homosexuals (13%) and heterosexuals (3%) (Diaz et al., 1993).
A New Zealand study comparing male sex workers (defined as men who had been paid money to have sex with a man in the past six months) with other MSM found that the sex workers were more likely to have had sex with women (31.4% versus 16.6% in the past six months), to have injected illegal drugs (14.9% versus 1.7% in the past six months) and to self-identify as bisexual (39.2% versus 26.7%; Weinberg, Worth & Williams, 2001). In a study of American male prostitutes, Boles, Sweat and Elifson (1989) reported that 62% of bisexuals (behaviourally defined as having had recreational sex with both men and women) had injected drugs (principally cocaine and heroin) compared with 37% of heterosexuals and 43% of homosexuals (as cited in Ross, Wodak, Gold & Miller, 1992).
Our own results pertaining to IDU, trading sex and bisexuality raise many questions about the relationships among these factors but do not provide answers. In terms of bisexual men's greater participation in trading sex, the methodological approach we adopted does not allow an in-depth examination of many of the dimensions deemed important to the study of sex work in HIV research. We know neither the intentionality, the frequency, the history nor the cultural milieu of this activity for our participants (Carballo-Diegues & Susser, 2001). Furthermore, we are unable to determine whether they freely chose to exchange sex for material or monetary gain and, because our variables do not distinguish between sexual partners and activities arising from commercial versus non-commercial pursuits, we cannot ascertain with how many partners sex was traded.
In our study, trading sex and injection drug use appeared to overlap considerably within the two bisexually defined groups compared to the referent GDHA group. While a causal relationship is not demonstrable from our study, other researchers have asserted that IDU commonly leads to sex work (O'Connell et al., 2004). Unfortunately, the HIV literature sheds little light on the relationship between sexual orientation or bisexuality and injection drug use. Some authors suggest economic factors motivate the bisexual behaviour of many injection drug users who will have sex with men as a means of supporting their chemical dependency (Doll & Beeker, 1996).
Following a review of relevant literature, Rust (2000) theorized that illicit drug use may generally lead to more frequent and varied sexual behaviour, including bisexual behaviour. Other investigators speculate that self-homophobia may explain injection drug use among behaviourally bisexual men (Reitmeiyer, Wolitski, Fishbein, Corby & Cohn, 1998). The role of masculinity has also been raised in that some MSM are believed to consume substances that carry a "macho image" in an effort to escape the stereotype that equates homosexuality with effeminacy (Myers, Rowe, Tudiver et al., 1992). Researchers have pointed to the possibility of "a psychological propensity for high risk behaviours" (e.g., injection drug use) among some behaviourally bisexual men (Rietmeijer et al., 1998, p.357). In contrast, Rust (2000) proposes that bisexuality and drag use may reflect a willingness among their conjoint adherents to defy social conventions.
There appears to be increased agreement that the needs of injection drug using MSM (MSM-IDU) are distinct from the needs of other MSM and of other injection drug users (Bull, Piper & Rietmeijer, 2002; O'Connell et al., 2004). The qualitative and quantitative findings of Bull et al. (2002) suggest that just as the substances used by MSM-IDU (cocaine and methamphetamine) may differ from those of other IDU (predominantly heroin), so may their psychosocial effects and implications for HIV prevention. In contrast with heroin, which is said to dampen sexual desire, cocaine and methamphetamine are understood to increase sexual drive and may be used deliberatively for this purpose. About 40% of the MSM-IDU who completed the Bull et al. (2002) survey used cocaine and methamphetamine specifically to enhance sex and 26% always had sex and did drugs together. The authors explain the implications of their results: "So much of the risk for these MSM-IDU appears related to an overlap with sexual and drug risk that we have asked whether the mode of drug injection (i.e., injection vs. snorting or smoking) is as important a risk as the effect the drug of choice has on sexual behavior(s)" (p.48). In their sample, fully 90% of MSM-IDU had used cocaine, 59%, crystal methamphetamine and 16%, heroine, in the previous year.
Additional exploratory analyses for our own study found group differences among injection drug users in the use of cocaine in the past 12 months, whether administered intravenously or not. The use of cocaine was greater among the BDBA. By comparison, there were no differences between the groups in use of methamphetamines. Among injection drug users in Quebec, irrespective of sexual orientation and gender, it appears that cocaine is the drug of choice for a majority (Parent, Noel, Alary et al., 1997; Schneeberger, 2000). However, this does not undermine the possibility of different motivations for injecting cocaine or other drugs between MSM-IDU and other IDU.
While recreational drug use appears common in the gay milieu, as our findings suggest, injection drug use is, by comparison, marginal. Other Canadian research confirms this observation. Myers et al. (1992) found that in the month preceding their interview, almost half(45.6%) of the Canadian self-identified gay and bisexual men they studied reported the use of at least one of the following drugs: marijuana/hashish, poppers, cocaine, tranquilizers, or injection drugs. However, only a minority (2.9%) had injected drugs in the 5 years preceding their participation in the study. Furthermore, in other research, Canadian MSM-IDU differed from other MSM in their greater likelihood to consume an array of different substances (e.g., tobacco, marijuana, cocaine, crack, speed, acid, heroin, crystal methamphetamine, ecstasy) and to use these more frequently (O'Connell et al., 2004). Within our cohort, multiple substance use may have been more pronounced among some subgroups of MSM-IDU. Our complementary analyses restricted to drug injecting men showed that a greater proportion of the BDBA group had consumed three or more drugs in the previous 12 months when compared with the GDHA.
Collectively, these findings give reason to believe that MSM-IDU may not be well served by current interventions and services. Canadian investigators were surprised to find no "published controlled assessments of sexual interventions for MSM/IDU" (O'Connell et al., 2004). A recent review of initiatives in the primary prevention of HIV and STI in Quebec reveals that interventions are highly group-specific (e.g., youth, MSM, IDU, cultural communities, sex workers, PLHIV) (Godin, Alary, Levy & Otis, 2003). Projects are rarely (4/167) designed to serve more than one type of clientele and none of those that do are directed at IDU. While Godin et al. (2003) recommend an increase in projects tailored to IDU in Quebec, the need for interventions targeted at MSM-IDU has been stressed by others (Bull et al., 2002; O'Connell et al., 2004). When the users themselves were surveyed, a majority of MSM-IDU (54%) expressed a desire for educational services in HIV prevention specifically for MSM-IDU (Bull et al., 2002).
Canadian and American data suggest that while their numbers are relatively small, the risks of MSM-IDU transmitting or acquiring HIV are particularly high. For example, in a prospective study among young MSM in Vancouver, Weber, Craib, Chan et al. (2003) found MSM-IDU had a sevenfold greater risk of seroconversion compared to other MSM. With an American sample of MSM, Wood et al. (1993) found injection drug users were more likely to be HIV infected than non users (33% versus 21%).
The focus on bisexuality in our study suggests an overlap between the risk categories of MSM, IDU and sex worker, which are behaviorally defined groups used to orient primary intervention in Quebec. To the extent that interventions largely geared towards and delivered by the gay community are meant to address the collective needs of all MSM in terms of HIV or STI prevention, significant segments of the MSM population may not be adequately reached or served by these efforts.
LOWER EMOTIONAL INVOLVEMENT WITH MSM
In line with this reasoning, our results are indicative of another trait associated with male bisexuality in HIV research, notably, a lesser degree of emotional involvement with other MSM, which could deflect bisexually defined men from perceiving the pertinence of prevention activities oriented towards gay men. Non-gay identified MSM have in fact been named a priority group for AIDS prevention given their potential denial of the risk associated with their homosexual behaviour (Goldbaum et al., 1996). While our study found no differences in unprotected anal sex between the bisexually defined groups and the GDHA, in terms of their sexual partners and practices, both bisexually defined groups were less likely to report a male couple partner. In addition, the BDHA were less likely to have had 2 or more regular partners. The BDBA were less likely to have had sex in a private residence and more likely to have had sex in a public venue with a regular partner. Kissing also had lower odds of being a part of the bisexual defined groups' sexual activities with men, as did masturbation and "soft" anal practices (rimming, fingering) among the BDBA.
Similar findings have been reported by other investigators. Stokes, Damon and McKirnan (1997) showed significantly more behaviourally gay men were currently in a steady relationship with a man (39.5%) than behavioural bisexuals (25.2%). Myers et al. (1995) found among behaviourally categorized Canadian MSM that previously heterosexual gay men were more likely to report being in a relationship with a man (43.8%) than bisexual (23.5%) or exclusively gay men (34.0%). The behaviourally bisexual men in their study were also found to be least likely to have engaged in deep tongue kissing with their male partner relative to the exclusively gay or the previously heterosexual gay group. Furthermore, Australian research discovered behaviourally bisexual men had lower scores on a scale of oral tactile practices, which included kissing and sensuous touching (Davis, Klemmer, and Dowsett, 1991). For their entire sample, consistent with the present study's findings, oral tactile practices showed a greater association with being in a regular relationship.
Given the small sample sizes of our bisexual groups, it is difficult to disentangle the interrelationships among trading sex, injection drug use, and the use of public venues, in relation to their sexual behaviour and HIV risk. Such factors could be understood to limit displays of affection in a sexual encounter and/or the level of emotional involvement with a male partner but other explanations are possible. For example, our study did not address investment in masculinity, which could provide another tentative explanation for the bisexually defined group's apparent lesser involvement with other MSM. Stokes et al. (1998) suggested that internal conflict between a man's traditional masculine ideology and his bisexual behaviour could be avoided as long as the emphasis is on sexual pleasure and not emotional intimacy with men. Qualitative research with older working-class homosexually active men in Australia revealed investment in masculinity to be an important theme in the lives of their interviewees (Chapple, Kippax & Smith, 1998). This coloured the form and meaning of their sexual pursuits (e.g., "Men don't kiss", p.74) and the men's homosexual practice was often compartmentalized from their social-emotional lives.
In contrast with the two bisexually defined groups, the constellation of features particular to the gay defined bisexually active group (GDBA) seems to confirm yet another variant of male bisexuality underscored by HIV researchers, namely youthful sexual experimentation. Though GDBA men showed the most in common with the referent GDHA group, they differed from the GDHA in important ways. The GDBA were markedly younger. Close to three quarters of this group (72.0%) was aged less than 30 years compared to well below half of the other groups (GDHA: 42.4%; BDBA: 42.2%; BDHA: 40.4%). The use of sex toys and participation in all three forms of trading sex (i.e., for money, drugs, or goods and services) differentiated them from the GDHA comparison group. They also showed higher probabilities of using public venues for having sex both with casual and regular partners. Furthermore, the GDBA were more likely to have had unprotected anal sex with a casual partner.
As a relatively young group, the GDBA may include individuals who are in the midst of exploring identity and sexual behaviour of which sex with women would form a part. In fact, studies have found a significant proportion of gay-identified males have a sexual history with women (e.g., Rosario, Meyer-Bahlburg, Hunter, Exner, Gwadz & Keller, 1996).
Regarding the GDBA's increased odds of participating in risky anal sex with a one-night stand, several researchers have identified "coming out" and identity exploration as contexts of vulnerability to HIV infection (Doll &Beeker, 1996; Goldbaum, et al., 1996). Doll and Becker (1996), in their review of bisexuality and HIV risk, suggested that younger men with homosexual attractions, in the absence of socially sanctioned opportunities for dating and sexual exploration, may seek partners in settings for anonymous sex. When faced with a more experienced partner, these youth may lack the skills to negotiate the encounter. Needs for "shelter, money, sexual release and intimacy" may exacerbate their disadvantage in these exchanges (Doll & Beeker, 1996, p.213). Similarly, in their qualitative interviews with working class gay-identified men, Flowers, Smith, Sheeran and Beail (1998) pointed not so much to the process of becoming gay (disclosure and self-acceptance) as to the ensuing process of acculturation into the gay community as an important temporal context for HIV risk. Associated with risk-taking in this situation are a lack of knowledge of gay culture and sexuality, feelings of disempowerment while making one's sexual debut and the predominance of affective needs over prevention concerns during sexual encounters.
As many of the GDBA's characteristic sexual activities (e.g., bisexual behaviour, use of public venues for sex, use of sex toys) may be related to sexual discovery, experimentation and development, so might their participation in trading sex. Based on qualitative interviews with 26 sex workers, Luckenbill (1985) identified two paths of entry into male prostitution: "defensive involvement," motivated by financial need and poor prospects, and "adventurous involvement" where prostitution represented an attractive opportunity to gain extra money and sexual satisfaction. As suggested in the Canadian literature reviewed by Allman (1999), sex work may, in fact, represent a "safe harbour" in which youth can come to a gay identity as well as a means for them to meet other gay males. As the younger GDBA did not differ from the comparison group in income or education (unlike the BDBA, whose involvement in trading sex may have been more "defensive"), it is plausible that trading sex for this group was a way to obtain sexual satisfaction, and/or to experience social contact with men. The perception of prostitution as normative within the gay community and of youth as a valuable characteristic (Koken, Bimbi, Parsons & Halkitis, 2004) are two factors that may make sex work a visible, accessible and viable sexual outlet for some younger gay men.
LIMITATIONS OF THE STUDY
Bisexuality is a complex and multidimensional phenomenon that extends well beyond the gender of one's sexual partners and the self-definition of one's sexual orientation. We recognize that our classification of MSM imposed such an oversimplification. In its creation, many identity patterns were excluded. Alternative forms of bisexual experience and the full diversity of self-definitions within the cohort were thus left unaddressed.
Perhaps the most important limitation of the present study, however, is our use of a convenience sample of MSM, as is common in HIV research (Rust, 2000). Recruitment did not specifically target bisexual men and, like other such studies on male bisexuality, was centred on the gay community (e.g., Heckman et al., 1995; Myers et al., 1995). As a result, the sample may over-represent bisexual men who frequent the gay village or are otherwise attached to this milieu. For some, presence within the gay milieu may even be linked to economic or survival needs. Recruitment within a large urban centre may also have inflated the proportion of participants with marginal practices (e.g., heavy drug use, prostitution). Furthermore, as studies have found bisexual men are less likely to seek HIV testing (e.g., Messiah, Mouret-Fourme & the French National Survey on Sexual Behavior Group, 1995), the fact that submitting to HIV testing was a requirement for membership in our study may have attracted bisexuals with an unusual interest in HIV research. Monetary compensation or risk-taking associated with practices other than sex with men (e.g., sharing injection equipment) may have been the appeal of participation for some. The study's recruitment within clinical settings, was minimal but may also have increased the proportion of bisexually active or defined men following treatment for drug problems. In sum, the bisexual men who responded to our solicitations for participation in this research project are unlikely to be representative of all bisexual men.
Bisexual men (whether behavioural, self-identified or both) accounted for a modest though significant proportion of the Omega Cohort sample used in our analyses (i.e., 11.5%). These men may represent a larger segment of the clientele of specific venues where men who have sex With men congregate. A recent Canadian study involving settings in Ottawa and Hull observed that 26.0% of bathhouse attendees and 16.8% of men cruising urban parks self-identified as bisexual (Huber & Kleinpaltz, 2002). A greater likelihood of bisexuality was also found among samples of MSM who use the Internet (Ross, Tikkanen & Mansson, 2000; Tikkanen & Ross, 2003). As Canadian bisexuals are unlikely to be concentrated in any particular geographic location (Myers & Allman, 1996), approaches to recruitment in future research on male bisexuality should be based on this assumption.
It is still unresolved in the literature whether bisexuals or subgroups thereof are more or less at risk of HIV infection than other homosexually active men and, if so, why. By addressing these questions in the way that we did, we may not have given appropriate consideration to the topic of bisexuality. Hansen and Evans (1985) recommended that researchers treat bisexuality as a distinct entity. While we did isolate bisexual men from the larger homosexually active group, the fact that we used the GDHA majority (homosexually active, gay/homosexual self-defined men) as the yardstick against which all bisexual groups were compared and subsequently characterized, may not have honored this recommendation.
In addition, examining bisexuality in its own fight would demand exploring factors that are relevant to and reflect the interests of those concerned. Minimally, this might have involved presenting the flipside of variables pertaining to socio-sexual practices and relationships with men, for example, the presence and quality of heterosexual partnerships or sexual encounters. Omitting these features of male bisexuality in the analyses and results produces a portrait that may unfortunately be interpreted as confirming many stereotypes about bisexuality. For one, it may bolster the perception that bisexuals are deficient gay men. If, as advanced by Paul (1985), concentrating one's social, affective and sexual ties primarily with members of the same sex is among the requirements for the "truly gay" person that gay identity politics and identity development research have helped to foster, bisexual men, to the degree that their social and sexual ties are indicative of less gender bias, may be seen to fall short of the ideal. Furthermore, in the present study, the bisexual men's fluctuating self-definitions, comparatively greater use of public spaces for sex, and lesser odds of being in a homosexual couple relationship could all be seen to confirm the stereotype of the confused, closeted, transitioning bisexual. Alternative explanations for these characteristics might include the lack of social support for the development of a bisexual identity and the expression of bisexual behaviour (Doll & Becker, 1996) as Western society has offered little social recognition of bisexuality as other than a myth, phase or pathology (Paul, 1984). In support of this assertion, several authors have observed that bisexual identified people are poorly received by members of the gay community as well as by heterosexuals (Armstrong, 1995; Blumstein & Schwartz, 1977). The Montreal component of a national study on the health needs of gay men provides concurring evidence. A majority of bisexual identified men participating in a focus group mentioned having difficulty integrating into the heterosexual and gay milieus in that both urged them to "choose" (Dumas, Lavoie & Desjardins, 2000).
Regarding the bisexually defined groups' shifting identifies, the appropriateness of using the typically linear theoretical models of gay and lesbian identity acquisition to understand bisexual identity formation has also been questioned in favor of a view of sexual identity development as ongoing and dynamic (Doll, 1997).
If criteria relevant to a gay socio-political identity are used to evaluate bisexuality, a potentially unique entity, or as expressed by Hansen and Evans (1985), if bisexuality is defined through homosexuality as "what-must-occur," it is probable that, at least on some dimensions, as we have seen, it will appear "less-than." This is not to deny that bisexuality may, in fact, mark a transition towards a positive gay identity or a form of evasion fraught with confusion and internalized homophobia for many individuals. In presenting the opposing theoretical models (flexibility vs. conflict) that he claimed were at the heart of the controversy over bisexuality among clinicians and sex researchers, Zinik (1985) stated that bisexuals may experience both conflict and flexibility. The conflict model, heavily invested in dichotomous notions of sexual orientation (heterosexual vs. homosexual) and gender (male vs. female), is based on two general assumptions about human sexuality: 1) that homosexual interest eradicates the ability to respond heterosexually, and 2) what Zinik calls the "one drop" theory, where the slightest evidence of homosexuality signals a deeply rooted predisposition. Self-identified bisexuals are thus interpreted to be confused, passing through a phase, and using the bisexual label in defense or denial of their "true" homosexual preference. The clinical and academic adherents to the flexibility model of bisexuality instead believe that it is possible for both heterosexual and homosexual feelings, behaviors and identities to coexist harmoniously and to be genuine.
The threat to an open examination of the diversity of human sexual expression and to the further marginalization of bisexuals is clear when conflict is the dominant image being projected while bisexuality has yet to receive sufficient attention as an entity distinct from gay/homosexuality and straight/ heterosexuality. In the current wave of HIV/AIDS research, which has allowed renewed exploration of issues of sexual orientation, scientists are nevertheless to some degree in the business of detecting conflict, in this case, of identifying from an array of psychosocial, cultural, demographic, and behavioral factors, those that may directly or distally interfere with safer sex practices. The cost of identifying areas of potential vulnerability and of effective action for HIV prevention work among bisexual men, combined with the methodological limitations of certain studies (e.g., recruitment strategies focused on the gay milieu, omission of contextual variables relevant to bisexuality), may be delaying the greater visibility of more positive or comprehensive images of bisexuality.
That being said, our strategy for subject classification, which involved crossing a measure of behaviour with one of identification, has nevertheless added a level of complexity to traditional one-dimensional categorizations in HIV research with MSM. This approach revealed marked differences between the compared groups in sexual and drug-related practices that are relevant to HIV/STI prevention. It responded to calls for a continued exploration of the relationship between measures of bisexuality and the differences between bisexual and gay men.
The intersections observed in our study between male bisexuality, sex work and drug use, particularly the use of intravenous drugs, are disconcerting. These findings should serve as an opportunity to reconsider our risk categories when attempting to address the needs of male bisexuals. Hopefully they will inspire interventions guided by "both/and" instead of "either/ or" thinking that are adapted to individuals who belong to more than one target group. Essential to these efforts, it seems, is recognizing that combining the needs identified as particular to each component risk category may be insufficient as a strategy. Therefore, a greater empirical and theoretical understanding of the contexts in which bisexuality, sex work and IDU overlap should be pursued in future research. Our analyses provide tentative support for previous studies which found that a discrepancy between sexual orientation self-identification and sexual behaviour was associated with greater risk of HIV infection. Such investigation should be continued with a larger sample.
ACKNOWLEDGEMENTS: The authors wish to thank Raymond Parent for constructive comments on the first draft of this article.
Allman, D. (1999). Mis for mutual, A is for acts: Male sex work and AIDS in Canada. Retrieved September 1, 2005, from http://www.mutualacts.com
Armstrong, E. (1995). Traitors to the cause? Understanding the lesbian/gay 'bisexuality' debates. In N. Tucker, L. Highleyman & R. Kaplan (Eds.), Bisexual Politics: Theories, Queries & Visions (pp. 199-218). Binghamton, NY: Harrington Park Press.
Bennett, G., Chapman, S., & Bray, F. (1989). A potential source for the transmission of the human immunodeficiency virus into the heterosexual population: Bisexual men who frequent 'beats'. The Medical Journal of Australia, 151, 315-318.
Blumstein, P.W., & Schwartz, P. (1977). Bisexuality: Some social psychological issues. Journal of Social Issues, 33, 30-45.
Boles, J., Sweat, M., & Elifson, K. (1989). Bisexuality among male prostitutes. Paper presented at the CDC workshop on bisexuality and AIDS, Atlanta, GA.
Boulton, M., Hart, G., & Fitzpatrick, R. (1992). The sexual behaviour of bisexual men in relation to HIV transmission. AIDS Care, 4, 165-174.
Bull, S.S., Piper, P., & Rielmeijer, C. (2002). Men who have sex with men and also inject drugs- Profiles of risk related to the synergy of sex and drug injection behaviours. Journal of Homosexuality, 42(3), 31-51.
Carballo-Dieguez, A., & Susser, E. (2001). Commentary: Sex trade involvement and rates of HIV-positivity among young gay and bisexual men. International Journal of Epidemiology, 30, 1455-1456.
Cass, V.C. (1984). Homosexual identity: A concept in need of definition. Journal of Homosexuality, 9, 105-126.
Chapple, M.J., Kippax, S., & Smith, G. (1998). 'Semi-straight sort of sex': Class and gay community attachment explored within a framework of older homosexually active men. Journal of Homosexuality, 35, 65-83.
Chu, S.Y., Peterman, T.A., Doll, L.S., Buehler, J.W., & Curran, J.W. (1992). AIDS in bisexual men in the United States: Epidemiology and transmission to women. American Journal of Public Health, 82, 220-224.
Davis, M.D., Klemmer, U., & Dowsett, G.W. (1991). Bisexually Active Men and Beats." Theoretical and Educational Implications." The Bisexually Active Men's Outreach Project. (ISBN 085837 652 0). AIDS Council of New South Wales and Macquarie University AIDS Research Unit.
Diaz, T., Chu, S.Y., Frederick, M., Hermann, P., Levy, A., Mokotoff, E., Whyte, B., Conti, L., Herr, M., Checko, J.P., Reitmeijer, C.A., Sovillo, R., & Mukhtar, Q. (1993). Sociodemographics and HIV risk behaviors of bisexual men with AIDS: Results form a multistate interview project. AIDS, 7, 1227-1232.
Dobinson, C., MacDonnell, J., Hampson, E., Clipsham, J., & Chow, K. (2005). Improving the access and quality of publich health services for bisexuals. Journal of Bisexuality, 5(1), 39-77.
Doll, L. (1997). Bisexuality and HIV risks: Experiences in Canada and the United States. Annual Review of Sex Research. Retrieved online September 12, 2005 from http://www.findarticles.com/p/articles/mi_qa3778/ is_199701/ai_n8748437/print
Doll, L.S., &Beeker, C. (1996). Male bisexual behavior and HIV risk in the United States: Synthesis of research with implications for behavioural interventions. AIDS Education and Prevention, 8, 205-225.
Doll, L.S., Petersen, L.R., White, C.R., Johnson, E., Ward, J.W., & The Blood Donor Study Group. (1992). Homosexually and non-homosexually identified men who have sex with men: A behavioral comparison. Journal of Sex Research, 29, 1-14.
Dufour, A., Alary, M., Otis, J., Remis, R.S., Masse, B., Turmel, B., et al. (2000). Risk behaviours and HIV infection among men having sexual relations with men: Baseline characteristics of participants in the Omega cohort study. Canadian Journal of Public Health, 91,345-349.
Dumas, J., Lavoie, R., & Desj ardins, Y. (2000, December). Projet national : << three cities >> : Volet Montreal : Etude de besoins en matiere de sante des hommes gais de Montreal. Retrieved January 21, 2005, from the Web site of Action Sero Zero: http://www.serozero.qc.ca/corpo/nosrecherches.htm
Earl, W.L. (1990). Married men and same sex activity: A field study on HIV risk among men who do not identify as gay or bisexual. Journal of Sex & Marital Therapy, 16, 251-257.
Evans, B.A., Bond, R.A., & MacRae, K.D. (1998). Heterosexual behaviour, risk factors and sexually transmitted infections among self-classified homosexual and bisexual men. International Journal of STD &AIDS, 9, 129-133.
Fitzpatrick, R., Hart, G, Boulton, M., McLean, J., & Dawson, J. (1989). Heterosexual sexual behaviour in a sample of homosexually active men. Genitourinary Medicine, 65, 259-262.
Flowers, P., Smith, J.A., Sheeran, P., & Beail, N. (1998). 'Coming out' and sexual debut: Understanding the social context of HIV risk-related behaviour. Journal of Community & Applied Social Psychology, 8, 409-421.
Godin, G., Alary, M., Levy, J., & Otis, J. (2003). Bilan analytique des initiatives de prevention primaire des ITS et du VIH. Sainte-Foy, Quebec: Universite Laval, Groupe de recherche sur les comportements dans le domaine de la sante (ISBN No. 2-923002-00-8).
Goldbaum, G., Perdu, T., & Higgins, D. (1996). Non-gay-identifying men who have sex with men: Formative research results from Seattle, Washington. Behavioral Science in HIV Prevention, 111 (Suppl. 1), 36-40.
Goldbaum, G., Perdue, R., Wolitski, R., Rietmeijer, C., Hedrich, A., Wood, R., Fishbein, M., & the Community Demonstration Projects. (1998). Differences in risk behaviour and sources of AIDS information among gay, bisexual and straight-identified men who have sex with men. AIDS and Behavior, 2, 13-21.
Goodenow, C., Netherland, J., & Szalacha, L. (2002).AIDS-related risk among adolescent males who have sex with males, females, or both: evidence from a statewide survey. American Journal of Public Health, 92, 203-210.
Hansen, C.E., & Evans, A. (1985). Bisexuality reconsidered: An idea in pursuit of a definition. In F. Klein & T.J. Wolf(Eds.), Bisexualities: Theory and Research (pp. 1-6). New York: The Haworth Press.
Heckman, T.G., Kelly, J.A., Sikkema, K.J., Roffman, R.R., Solomon, L.J., Winett, R.A., etal. (1996). Differences in HIV risk characteristics between bisexual and exclusively gay men. AIDS Education and Prevention, 7, 504-512.
Huber, J.D., & Kleinplatz, P.J. (2002). Sexual orientation identification of men who have sex with men in public settings in Canada. Journal of Homosexuality, 42 (3), 1-20.
Kennedy, M., & Doll, L.S. (2001). Male bisexuality and HIV risk. Journal of Bisexuality, 1, 109-135.
Klein, F., Sepekoff, B., & Wolf, T.J. (1985). Sexual orientation: A multi-variable dynamic process. Journal of Homosexuality, 11, 35-49.
Koken, J.A., Bimbi, D.S., Parsons, J.T., & Halkitis, P.N. (2004). The experience of stigma in the lives of male Internet escorts. Journal of Psychology & Human Sexuality, 16, 13-32.
Lever, J., Kanouse, D.E., Rogers, W.H., Crason, S., & Hertz, R. (1992). Behavior patterns and sexual identity of bisexual males. The Journal of Sex Research, 29, 141-167.
Luckenbill, D.F. (1985). Entering male prostitution. Urban Life, 14, 131-153.
McKirnan, D.J., Stokes, J.P., Doll, L., & Burzette, R.G. (1995). Bisexually active men: Social characteristics and sexual behavior. The Journal of Sex Research, 32, 65-76.
Messiah, A., Mouret-Fourme, E., & the French National Survey on Sexual Behavior Group. (1995). Sociodemographic characteristics and sexual behavior of bisexual men in France: Implications for HIV prevention. American Journal of Public Health, 85, 1543-1546.
Montgomery, J.P., Mokotoff, E.D., Gentry, A.C., & Blair, J.M. (2003). The extent of bisexual behaviour in HIV-infected men and implications for transmission to their female partners. AIDS Care, 15, 829-837.
Myers, T., & Allman, D. (1996). Bisexuality and HIV/AIDS in Canada. In P. Aggleton (Ed.), Bisexualities and AIDS: International Perspectives (pp. 23-43). Great Britain: Taylor & Francis.
Myers, T., Allman, D., Jackson, E.A., & Orr, D. (1995). Variation in sexual orientation among men who have sex with men, and their current sexual practices. Revue Canadienne de Sante Publique, 86, 384-388.
Myers, T., Calzavara, L., Millson, M., Graydon, M., Leblanc, M., & Major, C. (1998). The BISEX Survey: A pilot study to recruit non-gay (hidden) and gay-identified bisexual men: Toward a comparative analysis of HIV prevention issues. HIV Social, Behavioural and Epidemiological Studies Unit, Faculty of Medicine, University of Toronto.
Myers, T., Rowe, C.J., Tudiver, F.G., Kurtz, R.G, Jackson, E.A., Orr, K.W. et al. (1992). HIV, substance use and related behaviour of gay and bisexual men: An examination of the talking sex project. British Journal of Addiction, 87, 207-214.
O'Connell, J.M., Lampinen, T.M., Weber, A.E., Chan, K., Miller M.L., Schechter, M.T., & Hogg, R.S. (2004). Sexual risk profile of young men in Vancouver, British Comumbia, who have sex with men and inject drugs. AIDS and Behavior, 8, 17-23.
Parent, R., Noel, L., Alary, M., Hankins, C., Claessens, C., Blanchette, C., & Le Groupe Survudi. (1997). Prevalence et incidence du VIH et de certains facteurs de risque chez les UDI qui frequentent des programmes d'echange de seringue. Paper presented at the 65e Congres de l'Acfas, Trois-Rivieres, Quebec.
Paul, J.P. (1984). The bisexual identity: An idea without social recognition. Journal of Homosexuality, 9, 45-64.
Paul, J.P. (1985). Bisexuality: Reasessing our paradigms of sexuality. In F. Klein & T.J. Wolf(Eds.). Bisexualities: Theory and Research (pp. 21-34). New York: Haworth Press.
Reitmeijer, C.A., Wolitski, R.J., Fishbein, M., Corby, N.H., & Cohn, D.L. (1998). Sex hustling, injection drug use, and non-gay identification by men who have sex with men: Associations with high-risk sexual behaviors and condom use. Sexually Transmitted Diseases, 25, 353-360.
Rekart, M.L., Chan, S., James, E., and Barnet, J. (1989). HIV testing "on the street." Paper presented to the Vth International Conference on AIDS, Montreal, June.
Roffman, R.A., Downey, D., Beadnell, B., Gordon, J.R., Craver, J.N., & Stephens, R.S. (1997). Research on Social Work Practice, 7, 165-186.
Rosario, M., Meyer-Bahlburg, H.F.L., Hunter, J., Exner, T.M., Gwadz, M., & Keller, A.M. (1996). The psychosexual development of urban lesbians, gay and bisexual youths. The Journal of Sex Research, 33, 113-126.
Ross, M.W., Tikkanen, R., & Mansson, S.-A. (2000). Differences between Internet samples and conventional samples of men who have sex with men: Implications for research and HIV interventions. Social Science and Medicine, 51, 749-758.
Ross, M.W., Wodak, A., Gold, J., & Miller, M.E. (1992). Differences across sexual orientation on HIV risk behaviours in injecting drug users. AIDS Care, 4, 139-148.
Rust, P.C.R. (Ed.). (2000). Bisexuality in the United States: A social science reader. New York: Columbia University Press.
Rust, R.C.R. (2001). Too many and not enough: The meanings of bisexual identities. Journal of Bisexuality, 1, 31-68.
Schneeberger, P. (2000). Portrait des consommateurs de cocaine contemporains au Quebec. Gouvernement du Quebec, Ministere de la Sante et des Services Sociaux, Comite permanent de lutte a la toxicomanie, Quebec.
Seibt, A.C., McAlister, A.L., Freeman, A.C., Krepcho, M.A., Hedrick, A.R., & Wilson, R. (1991). Condom use and sexual identity among men who have sex have with Dallas, 1991. MMWR, 42, 7-14.
Sell, R.L. (1997). Defining and measuring sexual orientation: A review. Archives of Sexual Behavior, 26, 643-658.
Shively, M.G., Jones, C., & De Cecco, J.P. (1984). Research on sexual orientation: Definitions and methods. Journal of Homosexuality, 9, 127-136.
Stokes, J.P., Damon, W., & McKirnan, D.J. (1997). Predictors of movement toward homosexuality: A longitudinal study of bisexual men. The Journal of Sex Research, 34, 304-312.
Stokes, J.P., McKiman, D.J., & Burzette, R.G. (1993). Sexual behavior, condom use, disclosure of sexuality, and stability of sexual orientation in bisexual men. The Journal of Sex Research, 30, 203-213.
Stokes, J.P., Miller, R.L., & Mundhenk, R. (1998). Toward an understanding of behaviourally bisexual men: The influence of context and culture. The Canadian Journal of Human Sexuality, 7, 101-113.
Stokes, J.P., Vanable, P., & McKirnan, D.J. (1997). Comparing gay and bisexual men on sexual behavior, condom use, and psychosocial variables related to HIV/AIDS. Archives of Sexual Behavior, 26, 383-397.
Taywaditep, K.J., & Stokes, J.P. (1998). Male bisexualities: A cluster analysis of men with bisexual experience. Journal of Psychology & Human Sexuality, 10, 15-41.
Tikkanen, R., & Ross, R.W. (2003). Technological tearoom trade: Characteristics of Swedish men visiting gay Internet chat rooms. AIDS Education and Prevention, 15, 122-132.
Weber, A.E., Craib, K.J., Chan, K., Martindale, S., Miller, M.L., Cook, D.A., Schechter, M.T., & Hogg, R.S. (2003). Determinants of HIV seroconversion in an era of increasing HIV infection among young gay and bisexual men. AIDS, 17, 774-777.
Weinberg, M.S., Worth, H., & Williams, C.J. (2001). Men sex workers and other men who have sex with men: How do their HIV risks compare in New Zealand? Archives of Sexual Behavior, 30, 273-286.
Weinrich, J.D., & Klein, F. (2002). Bi-gay, bi-straight, and bi-bi: Three bisexual subgroups identified using cluster analysis of the Klein sexual orientation grid. Journal of Bisexuality, 2, 110-139.
Wood, R.W., Krueger, L.E., Pearlman, T.C., & Goldbaum, G. (1993). HIV transmission: Women's risk from bisexual men. American Journal of Public Health, 83(12), 1757-1759.
Worth, H. (2003). The myth of the bisexual infector? HIV risk and men who have sex with men and women. Journal of Bisexuality, 3, 69-88.
Zinik, G. (1985). Identity conflict or adaptive flexibility? Bisexuality reconsidered. In F. Klein & T.J. Wolf (Eds.), Bisexualities: Theory and Research (pp. 7-20). New York: The Haworth Press.
Kim Engler (1), Joanne Otis (1), Michel Alary (2,3,4), Benoit Masse (2), Robert S. Remis (5,6), Marie-Eve Girard (1), Jean Vincelette (7), Bruno Turmel (3), Rene Lavoie (8), and Roger Le Clerc (8)
(1.) Universite du Quebec a Montreal, Departement de sexologie, Montreal, Quebec
(2.) Centre hospitalier affilie universitaire de Quebec, Quebec, Quebec
(3.) Institut National de Sante Publique du Quebec, Montreal, Quebec
(4.) Departement de medecine sociale et preventive, Universite Laval, Sainte-Foy, Quebec
(5.) Department of Public Health Sciences, University of Toronto, Toronto, Ontario
(6.) Direction generale de la sante publique Montreal-Centre, Montreal, Quebec
(7.) Department of Microbiology and Infectious Disease, Hopital Saint-Luc du Centre hospitalier de l'Universite de Montreal, Montreal, Quebec
(8.) Coalition des Organismes Communautaires Quebecois de lutte contre le sida, Montreal, Quebec
Please address correspondence to the first author: Kim Engler, Departement de sexologie, Universite du Quebec a Montreal, C.P. 8888, Succ. Centre-Ville, Montreal, QC, H3C 3P8. Email: firstname.lastname@example.org.
Table 1 Polytomic Regression Analyses of the Groups' Sociodemographic Variables Group compared with GDHA (n = 994) BDBA (n = 83) BDHA (n = 47) Variable OR (95%CI) OR (95%CI) Sociodemographic More than high school education 0.34 (0.22-0.54) 0.92 (0.48-1.77) Annual income $20,000 or more 0.50 (0.31-0.80) 0.68 (0.38-1.23) Aged 30 or older 1.00 (0.64-1.59) 1.09 (0.60-1.97) GDBA (n = 25) Variable OR (95%CI) P Sociodemographic More than high school education 0.53 (0.23-1.19) 0.0001 Annual income $20,000 or more 0.60 (0.26-1.38) 0.01 Aged 30 or older 0.29 (0.12-0.69) 0.05 Note. GDHA = gay defined homosexually active; BDBA = bisexual defined bisexually active; BDHA = bisexual defined homosexually active; GDBA = gay defined bisexually active; OR = odds ratio; CI: confidence interval. Because of missing values n's varied slightly for some variables. The ORs have been adjusted in the polytomous logistic regression model for age, education and income. Table 2 Polytomic Regression Analyses of the Groups' Sexual Practices, Partners and Sex Venues Group compared with GDHA (n = 994) Variable BDBA (n = 83) BDHA (n = 47) OR (95%Cl) OR (95%CI) Sexual practices Kissing 0.46 (0.38-0.57) 0.62 (0.48-0.79) Masturbation 0.57 (0.46-0.71) 0.91 (0.67-1.24) Soft anal practices 0.59 (0.44-0.79) 0.89 (0.65-1.22) Toys 1.30 (0.75-2.26) 0.95 (0.42-2.14) Oral sex with regular 0.36 (0.19-0.68) 0.41 (0.18-0.93) Anal sex with regular 0.55 (0.33-0.92) 0.62 (0.32-1.20) UAS (Casual) 0.92 (0.52-1.62) 0.97 (0.47-2.01) Partner types Couple 0.21 (0.12-0.34) 0.48 (0.25-0.92) No. of partners Regular (> 2) 0.80 (0.50-1.29) 0.50 (0.27-0.92) Sex venues Private/regular 0.65 (0.51-0.82) 0.86 (0.65-1.15) Public/regular 2.45 (1.12-5.38) 1.95 (0.63-6.01) Sauna/regular 1.09 (0.79-1.52) 0.89 (0.55-1.44) Public/casual 0.87 (0.41-1.89) 1.99 (0.98-4.05) Variable GDBA (n = 25) P OR (95%CI) Sexual practices Kissing 1.30 (0.75-2.24) 0.0001 Masturbation 1.73 (0.88-3.39) 0.0001 Soft anal practices 1.07 (0.71-1.61) 0.0050 Toys 2.76 (1.44-5.30) 0.0205 Oral sex with regular -- -- Anal sex with regular 0.84 (0.30-2.35) 0.0784 UAS (Casual) 3.46 (1.46-8.21) 0.0430 Partner types Couple 2.01 (0.46-8.86) 0.0001 No. of partners Regular (> 2) 2.29 (0.89-5.88) 0.0302 Sex venues Private/regular 1.30 (0.85-2.00) 0.0019 Public/regular 4.54 (1.48-13.91) 0.0164 Sauna/regular 1.72 (1.06-2.81) 0.1540 Public/casual 3.21 (1.38-7.43) 0.0138 Note. GDHA =gay defined homosexually active; BDBA = bisexual defined bisexually active; BDHA = bisexual defined homosexually active; GDBA = gay defined bisexually active; OR = odds ratio; CI: confidence interval. Because of missing values n's varied slightly for some variables. The ORs have been adjusted in the polytomous logistic regression model for age, education and income. Table 3 Polytomic Regression Analyses of the Groups' Trading Sex and Drug Use Group compared with GDHA (n = 994) Variable GDHA (n = 994)% * Traded sex for: Money 3.6% Drugs 1.6% Goods/ services 2.3% Drug use 53.9% Injection drug use 2.7% Variable BDBA (n = 83) BDHA (n = 47) OR (95% CI) OR (95% CI) % % Traded sex for: Money 3.19 (1.49-6.82) 2.52 (0.82-7.75) 14.6% 8.9% Drugs 5.54 (2.21-13.91) 4.28 (1.17-15.66) 11.0% 6.8% Goods/ 2.49 (0.94-6.55) 2.91 (0.81-10.48) services 7.4% 6.8% Drug use 1.97 (1.17-3.32) 1.25 (0.68-2.28) 72.0% 59.6% Injection 6.02 (2.85-12.75) 4.59 (1.62-13.05) drug use 19.8% 11.1% Variable GDBA (n = 25) OR (95% CI) P % Traded sex for: Money 4.36 (1.33-14.31) 0.0026 16.0% Drugs 5.64 (1.15-27.76) 0.0007 8.0% Goods/ 4.57 (1.20-17.44) 0.0318 services 12.0% Drug use 2.56 (0.93-7.05) 0.0210 72.0% Injection -- -- drug use 0.0% Note. GDHA = gay defined homosexually active; BDBA = bisexual defined bisexually active; BDHA = bisexual defined homosexually active; GDBA = gay defined bisexually active; OR = odds ratio; CI: confidence interval. Because of missing values n's varied slightly for some variables. The ORs have been adjusted in the polytomous logistic regression model for age, education and income. * Percentage reporting participation in the activity over a 12-month period.
|Printer friendly Cite/link Email Feedback|
|Author:||Engler, Kim; Otis, Joanne; Alary, Michel; Masse, Benoit; Remis, Robert S.; Girard, Marie-Eve; Vincel|
|Publication:||The Canadian Journal of Human Sexuality|
|Date:||Sep 22, 2005|
|Previous Article:||Young women's sexual adjustment: the role of sexual self-schema, sexual self-efficacy, sexual aversion and body attitudes.|
|Next Article:||Influence of teens' perceptions of parental disapproval and peer behaviour on their initiation of sexual intercourse.|