Homophobia and heteronormativity as dimensions of stigma that influence sexual risk behaviors among men who have sex with men (MSM) and women (MSMW) in Lima, Peru: a mixed-methods analysis

Men who have sex with men (MSM) have 50 times the odds of HIV infection compared to the general population in Peru [1]. “MSM,” however, are a heterogeneous population and research in multiple international settings suggests that programs targeting gay-identified MSM may not be effective at reaching men who have sex with men and women (MSMW) [2‐4]. While HIV prevalence among MSMW has been reported to be less than that among men who have sex with men only (MSMO), recent research shows that MSMW are less likely than their MSMO counterparts to access HIV prevention and testing services [2, 5]. They are also at higher risk for other sexually transmitted infections (STIs) than both MSMO and men who have sex with women only [4, 6‐8].

Previous global studies have identified substantial heterogeneity within the category of “MSM,” documenting increased substance use, partner concurrency, and transactional sex in MSMW compared to MSMO [4‐6, 9]. However, behavioral risk factors only tell a part of the story about how these men are exposed to STIs and HIV. Stigma has been described as a central mechanism increasing HIV vulnerability among gay, bisexual, and other men who have sex with men, all of whom violate societal expectations of gender roles and sexual behaviors, and often experience homoprejudice [10]. In heteronormative societies, where social, cultural, and institutional processes elevate heterosexuality as natural and normal and devalue other sexual orientations, non-gay identifying MSM may experience psychosocial stress over the prospect of being “outed” [11‐13]. Similarly, as Peruvian sexual and gender norms are derived from social standards of machismo, heteronormativity may intersect with other forms of marginalization and stigma experienced by sexual/gender minorities to discourage disclosure of same-sex behavior by MSMW to their female partners [14, 15]. Accordingly, an in-depth understanding of sexual and gender politics, and how they inform partner expectations and disclosure practices, is critical to the development of successful interventions to promote sexual health among MSMW [15‐18].

Stigma influences routine HIV care for all MSM, with MSMW less likely to access STI and HIV prevention programs targeted to MSM populations—usually due to fear of being identified as gay or homosexual [2, 18, 19]. Historically, stigmatizing language describing MSMW as a “bridge population” (i.e., responsible for transmitting STIs/HIV to their female partners) [16, 17] has had the unintended consequence of increasing psychosocial stress [6] and limiting the acceptability among MSMW of HIV prevention strategies targeted to gay men and transgender women (TW) [6]. However, little work has been done to address vulnerabilities particular to MSMW, which is crucial to increasing their access to prevention and treatment tools, and to reducing HIV infection within their sexual networks [20].

To address this gap and to provide an improved understanding of HIV/STI risk factors, we used mixed quantitative and qualitative methods to: 1) Describe similarities and differences in risk behavior and HIV prevalence between MSMO and MSMW, and 2) Assess and describe sex-specific partnership characteristics of sexual risk behavior among heterogeneous sexual identities and behaviors within the umbrella category of MSM recently diagnosed with HIV and/or an STI.

Mixed-methods results are drawn from 332 participants who completed the bio-behavioral survey and the narratives of a subset of 30 participants. For quantitative data, 13.9% of 332 participants (n = 46) reported sex with at least one female partner and were classified as MSMW. MSMW often endorsed a bisexual (45.4%) or heterosexual (43.2%) identity, and reported a mean of 3.5 partners (SD = 4.5) in the past 3 months. Most MSMO identified as gay or homosexual (84.3%) and reported a mean of 4.6 partners (SD = 9.7) in the past 3 months. More than half of MSMO in our sample were recently diagnosed with HIV (51.4%), compared to 23.9% of MSMW (See Table 1).

The quantitative survey also assessed partnership -specific characteristics of the last three sexual partners of each participant. Of 1073 sexual partnerships reported, 8.0% (n = 86) were with female partners. Across participants, men reporting female partners were more likely to report any unprotected insertive sex as compared to those reporting only male partners in the last 3 months: 77.9% versus 43.1% (p < 0.01).

In the qualitative data, 43.3% of participants were living with HIV (i.e., HIV-infected). Results below present quantitative relationships and qualitative findings to explore possible explanations for these associations. Notably, participant narratives highlight intersecting themes related to the pervasive role of stigma across MSMO and MSMW, and the heteronormativity embedded within MSMW partnerships.

Table 2 summarizes results from the multivariable model assessing factors associated with female partnerships. Participants with a female partner were less likely to have a college education (aPR, 95% CI: 0.46, 0.22–0.99) and less likely to test positive for HIV (0.26, 0.11–0.61). Participants had decreased likelihood of reporting they would disclose their HIV or STI diagnosis to their partner in female partnerships compared to male partnerships (0.52, 0.31–0.85). Multiple forms of stigma were discussed across the qualitative interviews as a reason for decreased likelihood to disclose a recent HIV and/or STI diagnosis. Participants noted that they would not disclose due to “fear of rejection” (PTID#59, HIV-positive, heterosexual) and “fear of being discriminated against” (PTID #56, HIV-negative, gay). Furthermore, “one always thinks that [if they disclose] they will be rejected. This is due to one’s life experiences, which lead one to fear and to be scared to say something” (PTID #18, HIV-positive, gay). A few participants voiced anxiety about an unknown and potentially violent reaction, as illustrated by one HIV-uninfected bisexual participant, “it’s a fear, a fear that we will lose contact, their friendship, or whatever else, it is a fear, a fear in their primordial response” (PTID #05, HIV-negative, bisexual).

Specific to MSMW, fear of disclosure encompassed an additional dimension of homophobia. For example, when discussing why he would not disclose to his female partner, one participant stated, “for the fear that she will say, ‘What are you doing with men?” (PTID #71, HIV-positive, heterosexual). Another stated, “because she would ask me who I’d been with and I couldn’t tell her” (PTID #81, HIV-uninfected, bisexual). Notably, these sentiments were echoed by MSMO as well, who noted pervasive stigma rooted in homophobia in the perception of gay men as high-risk for HIV and other STIs, as stated: “Most heterosexuals think that only us gays have infections and that is a lie. They, those who are bisexual, have sex with both men and women. That is the reason women are also infected” (PTID#17, HIV-negative, gay).

Female partnerships were associated with an increased prevalence of unprotected insertive sex in the last 3 months (aPR = 3.97, 95% CI 1.98 to 8.00). Partnerships with women were also more likely to be classified as “primary” (2.10, 1.34 to 3.31). These findings were corroborated across the interviews. Men who reported having sexual relations with both men and women frequently described their female partners as “my actual partner, my true partner” (PTID #59, HIV-positive, heterosexual) and “she is my only partner, the others are friends” (PTID #64, HIV-negative, heterosexual). Participant narratives frequently named a female partner as the primary partnership. For example, one self-identified gay participant who reported only having sex with other men (MSMO) described his experience with a behaviorally bisexual partner:

“I think he suffered because he enjoyed what we did but I think he got tired of it and now only likes women…Within his community they found out about us and they punished him, and now he doesn’t spend time with homosexual people. You understand?” (PTID #73, HIV negative, gay).

Our findings demonstrate that about 14% of the sample reported both male and female sexual partners, with specific partner-level factors (e.g., decreased disclosure of HIV/STI diagnosis and lower likelihood of condom use for insertive sex) associated with female sexual partnerships. By accounting for two levels of quantitative analyses (individual and partnership) and incorporating mixed-methods, these results highlight the unique risks for behaviorally bisexual MSM and their varying partnership characteristics. Perspectives of MSMO and MSMW highlight the pervasive influence of heteronormativity and homophobia in their sexual risk-taking and partner notification. Jointly, these results underscore the need to recognize sexual diversity within the category of “MSM” and to incorporate strategies into STI and HIV prevention that do not unintentionally exclude stigmatized and/or hidden subgroups, like those of non-gay identifying behaviorally bisexual men.

At the individual level, our sample exhibited a high heterogeneity of sexual identity, with almost 50% of MSMW identifying as heterosexual. Qualitative results emphasize the centrality of heterosexual identity for many MSMW, and suggest a community-wide perception that their identity may put them at lower risk for HIV infection, regardless of their same-sex sexual risk behavior. This finding parallels existing literature [18], and underscores the difficulty of successfully directing STI and HIV prevention resources to this high-risk population frequently described as “hidden” in the interstices between traditional heterosexual and homosexual networks. Furthermore, mixed-methods results evidence the internal and community-level processes that position homosexual practices as aberrant and bisexual identity as deviant, though differentiating the two as separate categories of socially unacceptable behavior. It is against this broader backdrop that barriers to disclosure of recent HIV and STI diagnosis and differential partnership status between female and male partners must be understood.

Previous studies have detailed behavioral vulnerabilities of MSMW [23, 25]. We extend this literature by exploring partner-level factors and individual experiences to assess how MSM maintain different sexual risk behaviors with female and male partners. The men in our sample were more likely to report condomless insertive sex with female compared to male partners, consistent with the literature [2]. Peruvian MSM are more likely to engage in condomless anal intercourse with stable partners, at least partially as a result of the association of condomless sex with fidelity and trust [21]. In this case, females were more likely to be considered primary partners and primary partnerships with females were associated with a higher frequency of condomless intercourse. Qualitative results supported this finding as MSMW reported hiding their same-sex sexual behavior, and as a result concealing their HIV/STI diagnoses, from their “true,” or female, partners. While men with female partners had a lower prevalence of HIV than those with only male partners, the overall prevalence of HIV in our sample of MSMW (23.9%) was much higher than the 0.3–0.5% prevalence observed in the general adult male Peruvian population [1]. Previous analyses of this same population also found a lower likelihood of notification among men diagnosed with HIV compared to those with other STIs, suggesting that HIV-specific notification would be even lower in this population with already low frequencies of informing female partners of their potential STI exposure [26]. Given the key role of partner notification in network-based approaches to HIV and STI prevention, efforts to address the behavioral, cultural, and structural barriers to notification of both male and female partners of MSMW are a critical area for future research on population-level approaches to combined HIV-STI prevention.

Our findings should be considered in the context of several limitations. First, results may not be generalizable to all MSM in Lima due to the convenience sampling methods employed. As a recent STI or HIV diagnosis was a criterion for enrollment, our sample is likely to be higher risk, and to have a higher prevalence of HIV and STIs, compared to the general MSM population. Second, the risk profile of MSMW presenting for testing and treatment services at a center for STI/HIV research associated with the MSM community and a municipal STI clinic may be different than that of other MSMW. Finally, our study was cross-sectional and causation cannot be inferred from the observed associations.

Our study advances knowledge on the heterogeneity of sexual risk behaviors and identities among MSM by providing individual and partner-level factors associated with bisexual behavior among individuals recently diagnosed with HIV and other STIs. Our results account for the unique perspectives of the community regarding their sexual relationships with male and female partners, highlighting the roles of homophobia and heteronormativity in sexual risk practices and partner notification behavior. MSMW recently diagnosed with HIV/STI report varying partnership characteristics with different associated risk contexts and prevention needs. Given the extent to which their partnerships cut across traditional risk group boundaries, developing prevention strategies that successfully understand and address the diversity of their partnership-specific risk settings may significantly impact the spread of HIV/STIs in Lima, Peru.