28 Jul, 14 | by Leslie Goode, Blogmaster
Across many cultural contexts, men who have sex with both men and women (MSMW) have levels of STIs/HIV comparable to those we find in men who have sex only with men (MSM); but MSMW have often proved particularly hard for health services to access. Mercer & Cassell (M&C) (UK) and STIs/Beyrer & Baral (B&B) (South Africa) refer to poor rates of HIV testing as compared to MSM (RR 0.31 and 0.62 respectively). Both studies stress the need to find ways of targeting safe-sex messages for MSMW who do not identify as gay.
In an intriguingly entitled reivew of the literature on MSMW sexual health in the US 2008-2013 (“Beyond the bisexual bridge”) Jeffries corroborates this general picture of high STI risk and poor accessibility. But he seeks to get beyond what he considers an obsession on the part of researchers with the role of MSMW as a “bridging” population with women. He claims this “characterization” is not justified by the research – at least where the US is concerned (Chu & Curran; Satcher & Dean; Kahn & Catania). He also views it as ultimately detrimental to the sexual health of MSMW, which needs to be founded on the “recognition of MSMW’s unique sexual and social experiences”.
The article reviews both the sexual health, and socio-cultural challenges to MSMW’s health. Sexual health challenges include: levels of STIs other than HIV equalling and exceeding MSM levels, alongside levels of HIV lower than MSM, yet higher than MSW (as in the UK (see M&C)); also enormously higher levels of injection drug use, sex in exchange for money or drugs, and drug and alcohol use during sex than in MSM; also sex within female networks (as well as male) that imperil sexual health, with a high proportion of female partners having injected drugs, being under influence of drugs during sex, and having concurrent partners. Socio-cultural challenges include biphobia in society at large, and fairly extreme socio-economic marginalization, as indicated by lack of education, poverty, homelessness and incarceration.
Some corroboration of the role that Jeffries attributes to settled identities in moderating at risk behaviour is provided by the success of a number of ongoing initiatives aimed at black or Latino MSMW. These all appear to address MSMW’s masculinity concerns and heterosexual identities in a non-judgmental and culturally sensitive manner. Men of African American Legacy Empowering Self (MAALES) has been evaluated in a RCT discussed in an earlier blog (STI/blog/Are bisexuals well served by interventions that assume gay identity?). Jeffries also mentions: Hombres Sanos; the Bruthas Project; the Enhanced Sexual health Intervention for Men (ES-HIM).
A puzzle remains in the lower susceptibility of MSMW, as against MSM, to HIV – alongside equivalent or higher susceptibility to other STIs . Jeffries discusses this, but offers no explanation. Could the less than expected levels of HIV in MSMW be the result of an association between MSM identity and sexual networks that carry particular risk of HIV transmission?