Sexual health of heterosexually-identified men who have sex with men

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Questions

What are the sexual health practices and sexual health knowledge of heterosexually-identified men who have sex with men?

Key Take-Home Messages

Identifying heterosexually-identified men who have sex with men (heterosexual MSM) is difficult as most studies use sexual behaviour as a proxy for orientation and men engaging in behaviours that do not align with their stated orientation are often hidden and hard-to-reach for support, service and research purposes.

While the purpose of this review is to identify the sexual practices and knowledge-base of heterosexually-identified MSM, only a few studies have been done among this population, almost all of which recruited their samples through gay clubs, bathhouses, cruising areas, adult books stores, the internet and newspaper ads.

  • Heterosexual MSM are a specific subgroup of men who have sex with men. It is estimated that heterosexual MSM comprise 0.7% (1) to 1.3% (2) of the sexually active male population. One study (1) found that 70% of heterosexual MSM were married to women.
  • Heterosexual MSM constitute a “hidden population” that is difficult to locate and reach (3). However, there is evidence that these men will talk openly about their experiences once they are connected to researchers (4).
  • Since heterosexual MSM do not often disclose their sexual orientation, they are less likely to be screened for HIV and other sexually transmitted infections (STIs) (1) and therefore less likely to know their HIV status (5).
  • Although heterosexual MSM are less likely than gay men to report unprotected anal intercourse with male partners, rates of unprotected anal intercourse are still high as are rates of unprotected vaginal and anal intercourse with women (1;2;5).

The Issue and Why It’s Important

Researchers emphasize that there is a difference between what someone might do sexually (behaviour) and how they view themselves sexually (identity). Behaviour and identity might become “discordant,” meaning a man might identify as heterosexual but have sex with other men (or with men and women).

There are a number of concerns involving heterosexual MSM. One is that they could act as “viral bridges,” transmitting HIV from a discrete population (gay men) to the larger heterosexual population (5). Another concern is that, since the men in this population do not view themselves as gay, they might be cut off from the majority of HIV prevention and education activities (1). Finally, although heterosexual MSM have been identified as a population of concern (5), there are currently no known HIV prevention interventions that specifically target them (5).

What We Found

HIV testing and rates

In one meta-analysis involving men who have sex with men and women (MSMW – a sample that included men who identify as “bisexual”), the mean HIV prevalence rate was 18% (5). In a smaller subset of studies that assessed HIV serologically, the mean HIV prevalence rate was 21% (5). HIV rates for heterosexual MSM were higher than rates for exclusively heterosexual men (4%), but lower than rates for gay men (33%) (5). The HIV prevalence rate was higher among MSMW ethnic minorities, at 33% (5).

The meta-analysis noted that reported HIV rates might be inflated, since some studies drew on samples from HIV clinics. However, the authors stressed that the between-group rates — with MSMW midway between exclusively heterosexual men and self-identified gay men in terms of HIV risk — are likely reliable (5).

A large survey in New York City found that heterosexual MSM were less likely than gay men to have had an HIV test in the past year (25% v. 35%) (1). Similar results were found in a large UK survey: MSMW (this would include self-identified bisexual men) were significantly less likely than gay men to have tested for HIV in the past five years (18% vs. 51%) (2), and were also less likely to have attended at an STI clinic than gay men (20% vs. 47%) (2).

Condom use

Research on the use of condoms by heterosexual MSM with both men and women has been mixed. The meta-analysis showed that MSMW are less likely to engage in unprotected receptive anal intercourse than gay men (16% vs. 35%) (5). The meta-analysis also showed that 44% of MSMW reported unprotected vaginal intercourse, and that 17% reported unprotected anal intercourse with women (5).

The New York City survey found that heterosexual MSM were less likely to have used condoms during their last sexual encounter compared to their gay counterparts (22% vs. 55%) (1). In a small sample of sexually active heterosexual MSM, 22% of the sample group reported both unprotected vaginal sex with a woman and unprotected anal sex with a man in the previous three months (6).

Studies have pointed to different factors as influencing condom use. One study showed that condom use by heterosexual MSM depended on HIV status, with HIV-positive heterosexual MSM more likely to use condoms with both men and women (3). Three other studies have shown that heterosexual MSM are more likely to use condoms with women as opposed to men (2-4), possibly due to a “heterosexual ideology” that makes men feel more responsible for their female partners. However, another study found that condom use was best predicted not by gender but by relationship type – In one study, heterosexual MSM reported less condom use with men and women they were in relationships with, and more condom use with casual relationships or “one-night stands” (6).

It has been noted that condom use might be challenging for heterosexual MSM for at least three reasons. First, use of a condom implies a degree of planning that is inconsistent with the notion of same-sex behaviour as something that catches a heterosexual man “off-guard” (4). Second, the introduction of a condom into a long-term relationship with a woman might arouse suspicion about casual sex (6). Third, spontaneous or anonymous sex with men in parks or via the Internet might not lend itself to safer-sex practices (4).

Sexual practices and number of partners

There is conflicting evidence about whether heterosexual MSM have fewer male sex partners than gay men or multiple sex partners in general (5). The differences in numbers of sexual partners and types of sexual practices might be due to how heterosexual MSM are recruited for study purposes. For instance, one study that recruited from gay bars, cruising parks, and bathhouses found that heterosexual MSM had roughly six male sex partners a year (6). However, the large UK survey found that 46% of heterosexual MSM had never been to a gay bar or club, and that they had significantly fewer partners than those who had (2). The New York City survey found that 96% of heterosexual MSM had only one sex partner in the previous year (1). The UK survey found that 70% of heterosexual MSM had had only one or two male partners in the previous five years (2).

There are also different views in the studies about how men connect with male partners. Some studies present a view of “quick and anonymous” sex with strangers found at sex clubs, parks, adult book stores or online (3;4). However, another study found that 57% of MSMW had a steady male partner (though this partner was not considered a “boyfriend”) (6). The reason MSMW might not be having “one-offs” with strangers is that a regular partner restricts the number of people who know about the same-sex activity (6). Similarly, it can be difficult to find sex partners willing to be discrete, so—upon finding one—men might not want to terminate the relationship (6).

In terms of sexual practices, heterosexual MSM are more likely to engage in insertive rather than receptive anal intercourse (3;5;6), less likely than gay men to report any type of anal intercourse (41% v. 89%) (2), and more likely to report only oral sex during same sex encounters (Jeffries). It has been suggested that heterosexual MSM might be using certain sexual practices (such as insertive anal sex) to reduce their HIV risk (2). However, heterosexual MSM are more likely to report paying for sex, and also more likely to report acquiring new partners while overseas (2).

Although heterosexual MSM report fewer sexual risk behaviours overall, they are more likely than gay men to have sex under the influence of drugs or alcohol (7). In one study of low-income heterosexual MSM, 58% of the sample reported current problems with substance use (3). In another study, 65% of African American heterosexual MSM reported being under the influence of drugs or alcohol during all episodes of anal sex with male partners (8).

Cultural factors

Heterosexual MSM are more likely than gay MSM to be foreign-born (43% vs. 15%), and much less likely to be gay-identified (1). It has been suggested that foreign-born men might have a different or narrower definition of what it means to be “homosexual” (1).

There is not enough data on heterosexual MSM to analyze issues such as HIV prevalence by race or ethnicity (5). Most of the work on cultural factors (such as ideas of masculinity) has been done with African American men (4;9), however, one large multi-racial survey saw 8% of heterosexual MSM describe sex between men as “always wrong” (2). One way to maintain a heterosexual identity is to “compartmentalize” sex into an infrequent or accidental behaviour (10) and to remain silent about sexual encounters with other men (4).

Implications for outreach

Several studies included in this review have considered how to best reach heterosexual MSM. Since a large portion of MSMW report sexual attraction only to women, safer sex messaging aimed at gay men is not likely to be helpful (2). HIV education programs that use the words “straight” or “heterosexual” might have a better chance of reaching this population (3).

Prevention messages should also focus on behaviour (unprotected anal intercourse) rather than identity (1). Since heterosexual MSM are less likely to report attending at a clinic, messaging should focus on health promotion (2). Interventions should also encourage heterosexual MSM to view condoms as a component of all forms of intercourse (vaginal and anal) and to talk about condoms with all sex partners (4).

Since alcohol and drug use can play a key role in participants’ decisions to engage in sex with men and is also contributing to sexual risk-taking (3), harm reduction programs might be useful and could provide opportunities to intervene and lower high-risk sexual behaviours in this population (3).

Factors That May Impact Local Applicability

All studies included in this review were conducted in Canada or in high income countries similar to Canada. There was limited data available on heterosexual MSM. Some of the results reported in this review come from small samples that might not be representative of the heterosexual MSM population as a whole.

What We Did

We searched Medline using heterosexual* or women or married (text terms) in combination with [Bisexuality (MESH term) or bisexual or MSM or men who have sex (text terms)] AND [HIV (MESH term or text term) or Sexually Transmitted Diseases (MESH term) or STI (text term)]. The search was limited to articles published since 2004 in English. The search was conducted on September 24, 2014. We only included studies from high-income countries. We also reviewed reference lists of identified studies.


Reference list

  1. Pathela P, Hajat A, Schillinger J, Blank S, Sell R, Mostashari F. Discordance between sexual behavior and self-reported sexual identity: A population-based survey of New York City men. Annals of Internal Medicine 2006;145(6):416-25.
  2. Mercer CH, Hart GJ, Johnson AM, Cassell JA. Behaviourally bisexual men as a bridge population for HIV and sexually transmitted infections? Evidence from a national probability survey. International Journal of STD & AIDS 2009;20 (2):87-94.
  3. Reback CJ, Larkins S. HIV risk behaviors among a sample of heterosexually identified men who occasionally have sex with another male and/or a transwoman. Journal of Sex Research 2013;50(2):151-63.
  4. Operario D, Smith CD, Kegeles S. Social and psychological context for HIV risk in non-gay-identified African American men who have sex with men. AIDS Education & Prevention 2008;20(4):347-59.
  5. Friedman MR, Wei C, Klem ML, Silvestre AJ, Markovic N, Stall R. HIV infection and sexual risk among men who have sex with men and women (MSMW): A systematic review and meta-analysis. PLoS ONE 2014;9(1):e87139.
  6. Siegel K, Schrimshaw EW, Lekas HM, Parsons JT. Sexual behaviors of non-gay identified non-disclosing men who have sex with men and women. Archives of Sexual Behavior 2008;37(5):720-35.
  7. Jeffries WL. Sociodemographic, sexual, and HIV and other sexually transmitted disease risk profiles of nonhomosexual-identified men who have sex with men. American Journal of Public Health 2009;99 (6):1042-5.
  8. Harawa NT, Williams JK, Ramamurthi HC, Manago C, Avina S, Jones M. Sexual behavior, sexual identity, and substance abuse among low-income bisexual and non-gay-identifying African American men who have sex with men. Archives of Sexual Behavior 2008;37(5):748-62.
  9. Harawa NT, Williams JK, Ramamurthi HC, Bingham TA. Perceptions towards condom use, sexual activity, and HIV disclosure among HIV-positive African American men who have sex with men: Implications for heterosexual transmission. Journal of Urban Health 2006;83(4):682-94.
  10. Reback CJ, Larkins S. Maintaining a heterosexual identity: Sexual meanings among a sample of heterosexually identified men who have sex with men. Archives of Sexual Behavior 2010;39(3):766-73

Suggested citation

Suggested citation: Rapid Response Service. Rapid Response: Sexual health of heterosexually-identified men who have sex with men. Toronto, ON: Ontario HIV Treatment Network, December 2014.

Prepared by

Emily White and Jason Globerman.