A Comparison of Sexual Relationships among Hispanic men by Sexual Orientation: Implications for HIV/STI Prevention

Abstract

Background

Hispanic men experience high rates of HIV infection and other sexually transmitted infections (STIs) when compared to non-Hispanic whites. Many factors contribute to HIV/STI risk among Hispanic men. Some researchers have suggested that primary relationships may be a source of HIV/STIs because some men engage in sexual relationships outside of the primary relationship. However, little is known about this among Hispanic men, and less is known about how sexual relationships differ by sexual orientation.

Purpose

The purpose of this study was two-fold: 1) to determine if Hispanic men engage in sexual relationships outside of primary relationships; and 2) to compare sex outside of primary relationships by sexual orientation.

Methods

Data for this study were obtained from a larger study that investigated health risks of Hispanic men residing in the U.S.-Mexico border community. Participants were recruited from agencies that provided services to Hispanic men. Participants completed a structured interview that included questions about primary relationships and sex outside of primary relationships. The sample consisted of 103 Hispanic men (50 heterosexual, 43 gay, and 10 bisexual Hispanic men), but two participants refused to answer relationship questions, resulting in a sample of 101 Hispanic men.

Results

About one-third of the participants (n =29) reported sex outside of the primary relationship, but no differences were found between the gay/bisexual and heterosexual men, X² (2, N = 101) = 9.91, p = .128. More gay/bisexual men reported sex with the primary partner and another person at the same time than heterosexual men, X² (2, N = 101) = 13.32, p = .010. More gay/bisexual men reported open relationships when compared to heterosexual men, X² (2, N = 101) = 17.23, p = .008, and more gay/bisexual men reported sex outside the primary relationship without the primary partner’s knowledge, X² (2, N = 101) = 15.09. p = .020. However, more heterosexual men reported that condoms were not used for sex outside the primary relationship when compared to gay/bisexual men, X² (2, N = 101) = 14.01, p = .029.

Implications for Practice

Sex outside of primary relationships presents some implications for HIV/STI prevention among Hispanic men. Because gay/bisexual men experience higher rates of HIV/STI, more attention needs to be focused on all forms of relationships to prevent acquisition of HIV/STIs. Among heterosexual Hispanic men more attention needs to be given to reinforcement of safer sex practices both outside the primary relationship, and within the primary relationship if high risk sex is occurring outside the primary relationship. More research is needed on the reasons for sex outside the primary relationship among Hispanic men, as well as research to promote safer sex practices when sex occurs outside of the primary relationship.

The development of intimate relationships is an important developmental task that begins in adolescence and continues into adulthood, usually ages 18 to 40 years of age. For healthy psychosocial development to occur, Erikson (1968) suggested that relationship exploration in adolescence allows individuals to develop longer relationships in adulthood. An individual masters this developmental task when a successful relationship is established that promotes a sense of commitment, safety and caring.

As much as intimate relationships promote psychological health, some evidence (e.g., De Santis et al., 2012; Harman, O’Grady & Wilson, 2009) suggests that intimate relationships may be a source of sexual risk in terms of acquisition of HIV infection or other sexually transmitted infections (STI). This occurs because one or both of the partners in the relationship are engaging in sexual relationships that involve unprotected sex outside the primary relationship, thereby increasing the risk of infecting the primary partner with HIV infection or another STI (Harman, O’Grady & Wilson, 2009).

Within primary relationships, monogamy or fidelity reduces the risk of HIV/STIs. Researchers have noted that men are more likely than women to engage in sex outside the primary relationship (Harmann, O’Grady & Wilson, 2009; Schmockler & Bursik, 2007). This may be due to the fact that men and women have different views on the importance of fidelity and monogamy. Although both men and women believed that monogamy enhanced the primary relationship, men viewed monogamy as more of a sacrifice (Schmookler & Bursik, 2007).

Despite what is known about monogamy within relationships, little is known about this among Hispanics. Three recent studies were conducted that examined monogamy within primary relationships among heterosexual Hispanic men residing in the Northwestern U.S. A qualitative study of 49 recent Hispanic male immigrants reported that Hispanic men value and respect primary relationships. However, reasons for sex outside of the primary relationship included loneliness, the desire for sexual exploration, and sexual needs that were not fulfilled in the primary relationship (Winett, Harvey, Branch, Torres & Hudson, 2011). Another qualitative study conducted with heterosexual Hispanic men in Miami, Florida reported that sex outside of primary relationship was associated with the negative effects of machismo, which encourages Hispanic men to have multiple sexual partners and to engage in unprotected sex (Gonzalez-Guarda, Ortega, Vasquez & De Santis, 2010).

A more recent quantitative study of 113 Hispanic immigrant men residing in New Orleans noted that 32.5% reported multiple sexual partners; 19.5% reported concurrent sexual partners; and 15.0% reported short-term sexual relationships. Multiple sexual partnerships often occurred in the context of substance use and a lack of social support (Althoff et al., 2013). A third study examined factors that influenced STI rates among formerly incarcerated Hispanic men. The researchers reported that a diagnosis of an STI in the previous 12 months was associated with a decreased in spousal relationship quality (Munoz-Laboy et al., 2013).

Compared to what is known about monogamy among heterosexual Hispanic men, more research has been conducted on monogamy and sex outside of primary relationships among Hispanic men who have sex with men (MSM). Perhaps this is related to the fact that sex outside of primary relationships is common among Hispanic MSM (De Santis, Gonzalez-Guarda, Provencio-Vasquez & DeLeon, 2014). Sex outside the primary relationship may occur with the primary partner’s knowledge, and often includes unprotected sex. The primary reason for sex outside of the primary relationship among Hispanic MSM was relationship dissatisfaction; however, sex outside of the primary relationship could either destroy the primary relationship or preserve it (De Santis, Provencio-Vasquez, DeLeon & Gonzalez-Guarda, 2012).

Sex outside the primary relationship is an important health issue among Hispanic MSM because of the risk of HIV infection. A qualitative study of Hispanic MSM in San Francisco noted that many Hispanic MSM used closed agreements in primary relationships that limited sex outside the primary relationship. In the event that sex does occur outside of the relationship, the closed agreement may include plans to decrease HIV/STI risk (Beougher, Gomez & Hoff, 2011).

Despite what is known about sex outside of primary relationships among both heterosexual Hispanic men and Hispanic MSM, no study to date has compared sex outside of primary relationships by sexual orientation. In addition, no studies have been conducted on this topic among Hispanics residing along the U.S.-Mexico border region. Based on this identified gap in the research literature, this study was designed to investigate the occurrence of sex outside of primary relationships of Hispanic men. The purpose of this study was two-fold: 1) to determine if Hispanic men engage in sexual relationships outside of primary relationships; and 2) to compare sex outside of primary relationships by sexual orientation.

Method

Study Design

This study used a descriptive, correlational design. This design was selected because it allows collection of data from participants at one point in time. This design also allows for a description of the phenomenon of interest, particularly when little research has been conducted on the topic. Because no studies to date have investigated this topic among Hispanic men residing in a U.S.-Mexico border community, a descriptive, correlational design is the appropriate design.

Data reported in this study represented unpublished data from a larger study called VIDA-II. VIDA-II (Violence, Intimate relationships, and Drugs Among Hispanics) was a study that collected data from participants on health risk topics that were pertinent to Hispanic men residing in the U.S.-Mexico border area.

Participants

The study sample consisted of 103 Hispanic men: 50 men who identified as heterosexual, 43 who identified as gay or MSM, and 10 who identified as bisexual. A complete demographic description of the study’s participants can be found in Table 1. Inclusion criteria included: a) self-identification as a Hispanic/Latino man; b) residing in the U.S.-Mexico border region; c) willingness to self-disclose sexual orientation; and d) age 18 to 55 years of age.

Table 1.

Participant characteristics of the sample (N = 103) by sexual orientation

Participant Characteristics	Heterosexual Men (n=50) M (SD) or Frequency (%)	MSM (n=53) M (SD) or Frequency (%)
Age	33.8 (11.73)	37.11 (13.91)
Country of Origin
United States	34 (68%)	39 (74%)
Mexico	14 (28%)	13 (25%)
Other	2 (4%)	1(2%)
Years living in U.S.	25.78 (10.93)	28.64 (15.06)
Years of Education	12.78 (3.56)	13.91 (2.82)
Currently Employed	26 (52%)	18 (34%)
Total monthly household income all sources
Less than $999	18 (36%)	28 (52.83%)
Between $1,000–$1999	16 (32%)	15 (28.30%)
More than $2,000	16 (32%)	10 (18.87%)
Relationship Status
Married or in a relationship	23 (46%)	12 (23%)
Preferred Language
English	23 (46%)	26 (49%)
Spanish	21 (42%)	20 (38%)
Living with HIV infection	7 (14%)	32 (60%)
Has health insurance coverage of any type	15 (30%)	16 (30.2%)
Has a regular healthcare provider	17 (34%)	32 (60.4%)

Procedures

After receiving approval from the Institutional Review Board at the University of Texas at El Paso, members of the research team travelled to community-based organizations (CBOs) that provided services to Hispanic men to post recruitment flyer and to recruit participants. Approval was granted by the CBOs to access potential participants at sites on the U.S. side of the border. Members of the research team approached participants and provided a brief explanation of the study. If the potential participant was interested in the study, screening for eligibility occurred in a private room at the CBO. Once eligibility screening was met, the participant was provided with a detailed description of the study, questions were answered, and signed informed consent was obtained in the participant’s preferred language of English or Spanish.

Data Collection

Once signed informed consent was obtained, participants met with a member of the research team in a private room at the CBO to complete the measures. To ensure consistency, a member of the research team read the measures to the participant in the participant’s preferred language. Responses were recorded by a member of the research team using a computerized data storage program on a laptop computer. Paper copies of the measures were also available in the event that the computerized program was not available, but the paper copies were not used. Once a participant completed the study, the participant was asked to refer other men from social/family networks. This use of snowball sampling was used to ensure that a minimum sample size of 100 men was obtained.

Measures

In addition to the demographic questionnaire, participants completed five questions that assessed sex outside of primary relationships. Because no instruments were available to assess sex outside of primary relationships among Hispanic men, the authors developed these five questions, and these questions were called the “Relationship Questionnaire.”

Participants were instructed to consider the current primary relationship when answering the five questions on the “Relationship Questionnaire.” Because some participants were not in a current primary relationship, these participants were instructed to consider their most recent primary relationship when responding to the questions. The questions and the responses to the questions used to assess sex outside of primary relationships among Hispanic men can be found in Table 2.

Table 2.

The Relationship Questionnaire.

Question 1:	I have sex with my partner only.
	Tengo relaciones sexuales con mi pareja únicamente.
Question 2:	I have sex with my partner and another person at the same time (‘three way sex).
	Tengo relaciones sexuales con mi pareja y otra persona a la misma vez.
Question 3:	My partner and I have an open relationship and are allowed to have sex with other people.
	Mi pareja y yo tenemos una relación abierta y nos permitimos tener relaciones sexuales individualmente, con personas fuera de nuestra relación.
Question 4:	I have sex with other people outside our relationship without my partner’s knowledge or consent.
	Tengo relaciones sexuales fuera de mi relación sin el conocimiento y sin el consentimiento de mi pareja.
Question 5:	If I have sex outside of my primary relationship either with or without my partner’s knowledge or consent, I use a condom.
	Cuando tengo relaciones sexuales con alguien fuera de mi relación, con o sin el consentimiento y conocimiento de mi pareja, uso un condón.

Possible Responses: 0 =Never/Nunca, 1= Sometimes/Algunas veces, 2=Most of the Time/La mayoria de las veces, 3=Always/Siempre. 99=Refused to answer/Se niega a responder.

Data Analysis

Data were analyzed using SPSS 20.0. Before data analysis began, some re-coding of the variable of sexual orientation was necessary. Because only 10 participants identified as bisexual and this number was much smaller than the heterosexual and gay men, a meaningful comparison between the three groups of men would not be possible. Therefore, the men who identified as bisexual were included with the gay men. Because men self-reported sexual identity, including gay and bisexual men in the same group supports a shared identity, and does not necessarily focus on sexual behaviors (Young & Meyer, 2005). Men who identified as heterosexual were coded as 0, and gay/bisexual men were coded as 1, and this variable was renamed MSM.

Possible responses on the “Relationship Questionnaire” included “never”, “sometimes”, “most of the time”, and “all of the time.” Because of the relatively small sample, the responses were recoded into a dichotomous variable with “never” re-coded as no = 0, and the other responses re-coded as yes = 1. Descriptive statistics and chi-square analysis were used to analyze the data.

Results

The five questions contained in the “Relationship Questionnaire” provided data for the analysis. Two participants who had identified as heterosexual on the demographic questionnaire refused to answer any of the “Relationship Questionnaire” items, resulting in a final sample size of 101 participants: 48 heterosexual men and 53 MSM (43 gay men and 10 bisexual men).

Each of the five questions on the “Relationship Questionnaire” was first examined using frequencies and descriptive statistics so that the number of participants engaging in sex outside of the primary relationship could be known. Once this was completed, each of the five questions on the “Relationship Questionnaire” was compared using chi-square statistics to determine if differences existed by sexual orientation.

The first question on the “Relationship Questionnaire” asked participants if sex occurred with the primary partner only (I have sex with my partner only). Of the total sample of 101 Hispanic men, 29 men (28.7%) reported sex outside the primary relationship: 12 heterosexual men (25%) and 17 MSM (32%). Although there were differences found between the two groups of men in terms of the numbers that engaged in sex outside of the primary relationship, these differences were not statistically significant, X² (2, N = 101) = 9.91, p = .128.

The second question on the “Relationship Questionnaire” asked participants to report if sex occurred with the primary partner and another person at the same time (commonly referred to as ‘three-way sex’, a ‘menage-a-trois’ or a ‘trio sexual’ in Spanish (I have sex with my partner and another person at the same time). No heterosexual participants reported engaging in sex with the primary partner and another person at the same time. However, 12 MSM participants (n = 12) reported engaging in sex with the primary partner and another person simultaneously. These differences were statistically significant, X² (2, N = 101) = 13.32, p = .010. This indicates that MSM participants in this sample were more likely to engage in sex with the primary partner and another person at the same time when compared to heterosexual Hispanic men.

The third question on the “Relationship Questionnaire” asked participants if an open relationship existed with the primary partner, and are allowed to have sex with other partners outside the primary relationship (My partner and I have an open relationship and are allowed to have sex with other people). Only one heterosexual participant (2.1%) reported an open relationship. Eight MSM participant (15.1%) reported an open relationship. These differences were statistically significant, X² (2, N = 101) = 17.23, p = .008. This indicates that more MSM participants in this sample were likely to have open relationships when compared to heterosexual Hispanic men.

The fourth question on the “Relationship Questionnaire” asked participants if sex occurred outside the primary relationship without the primary partner’s knowledge and consent (I have sex with other people outside our relationship without my partner’s knowledge or consent). Of the total sample of Hispanic men (n = 101), 20 participants (19.8%) reported that sex occurred outside the primary relationship without the partner’s knowledge or consent. Five heterosexual men (10.4%) and 15 (28.3%) of the MSM reported sex outside of the primary relationship without the partner’s knowledge or consent. These differences were statistically significant, X² (2, N = 101) = 15.09. p = .020, indicating that the Hispanic MSM in this sample were more likely to have sex outside of the primary relationship without the primary partner’s knowledge or consent when compared to heterosexual Hispanic men.

The final question on the “Relationship Questionnaire” asked participants to report if sex occurred outside of the primary relationship, then a condom would be used (If I have sex outside my primary relationship either with or without my partner’s knowledge or consent, I use a condom). Among the total sample of 101 Hispanic men, 53 men (52.5%) reported that a condom would be used for sex outside the primary relationship. Twenty-two (45.8%) heterosexual men and 31 MSM (58.5%) reported that a condom would be used during sex with a partner outside of the primary relationship. This difference was statistically significant, X² (2, N = 101) = 14.01, p = .029. This indicates that among this sample of Hispanic men, heterosexual men would be less likely to use a condom during sex outside the primary relationship when compared to MSM.

Discussion

The purpose of this study was to determine if Hispanic men engage in sex outside of primary relationships, and to compare the occurrence of sex outside the primary relationship by sexual orientation. The results of this study provide some important implications for HIV/STI prevention programs for Hispanic men.

Almost one-third (28.7%) of the total sample of men in this study reported sex outside of primary relationships. These findings support previous research (e.g., De Santis et al., 2012; Winett et al., 2011) that noted sex outside of primary relationships occurs among both heterosexual Hispanic men as well as Hispanic MSM.

This finding on sex outside of primary relationships has implications for the clinical care of Hispanic men. Sex outside of primary relationships exposes at least three people to HIV/STIs: the man, the primary partner, and the secondary sex partner. Participants were not asked if the secondary sex partners were random sexual encounters (“one night stands”), or if the participants had long-term sexual relationships with the secondary sex partners. Therefore, it is not known to what degree these outside sexual relationships contribute to HIV/STI risk among the men and sexual partners. Sex outside of primary relationships increases the risk for HIV infection and STI transmission in two ways. First, research has demonstrated that multiple sexual partners increases HIV/STI risk. Second, Hispanics have the second highest rates of HIV/STIs of all ethnic groups. Populations with high prevalence and incidence have the potential to increase the transmission of HIV infection to others (Centers for Disease Control and Prevention [CDC], 2014), these findings have important implications for clinicians providing care to Hispanic men. Clinicians must realize that sex outside of primary relationships may occur among Hispanic men. A detailed sexual history and subsequent sexual risk assessment is warranted that includes the number of different sexual partners, the specific sexual behaviors, and the frequency of protected versus unprotected sex. Based on this, STI/HIV testing may be needed, and client education is essential to assist Hispanic men decrease their sexual risk as well as the sexual risk of their partners.

The finding on sex with the primary partner and others (“three way sex”) among the Hispanic MSM participants in this study is an interesting finding. Although no research could be located that describes this type of sexual behavior among Hispanic MSM, research literature is available on the general population of gay men which documents that this and other types of sexual agreements are common among gay men (Hosking, 2013). Because no research is available that documents this type of sexual behavior among Hispanic MSM, more research is needed to explore this, and the sexual risk that this type of sex has for each sexual partner in the relationship.

Another finding of interest concerns open relationships among the Hispanic MSM participants in this study. No research was available that focused on this topic among Hispanic MSM, but research on the general population of MSM has noted that open relationships may occur (Mitchell, 2014). Because no research has been conducted with open relationships among Hispanic MSM, more research is necessary to explore the differences in relationships among Hispanic MSM who are in open relationships versus those in closed relationships.

More MSM in this study had sex outside the primary relationship without their primary partner’s knowledge or consent. No research could be located that focused on this area. More research is needed among Hispanic MSM which focuses on reasons for concealment of outside sex, and the impact of sex outside the primary relationship on relationship quality. This has been studied among the general population of MSM (Bricker & Horne, 2007), but not among Hispanic MSM.

When sex occurred outside of the primary relationship, heterosexual men were less likely than MSM to use a condom. This finding is important, but difficult to interpret because no other information was collected from the heterosexual participants that would explain the reason for lower rates of condom use with secondary sex partners when compared to MSM. A couple of explanations could be offered for this finding, however. First, support for this finding includes a study by Essien and colleagues (2005) which noted that Hispanic men reported more difficulties in using condoms, and that heterosexual Hispanic men had the lowest rates of condom use compared to men of other racial/ethnic groups. Second, perhaps heterosexual men in this study endorsed one of the negative aspects of machismo, a Hispanic cultural construct that may be associated with sex with multiple partners and more sexual risk-taking behaviors (Arciniega, Thomas, Tovar-Blank & Tracey, 2008). If the heterosexual participants endorsed this concept, part of the sexual risk-taking could be unprotected sex. This cannot be determined with this sample of men, however, because machismo or other reasons for not using condoms during sex outside of primary relationships was not assessed.

Limitations

There are a few limitations which need to be addressed that might affect the study’s results. First, the study’s relatively small sample size (n = 103) requires cautious interpretation. Although some differences were found regarding sex outside of the primary relationship when compared by sexual orientation, the small sample size limits generalizability beyond the sample. However, because little is known about how sex outside of primary relationships differ by sexual orientation among Hispanic men, this study provides some pilot data on this topic.

Second, the inclusion of the small number of men who identified as bisexual (n =10) in the “MSM” category is a limitation. These men may be different from men who identify as gay/homosexual, but because of the small number of these participants, meaningful comparisons were not possible.

Third, the use of an unstandardized instrument to collect data on sex outside of primary relationships may have influenced the results. Because no psychometric data were available on these questions, the researchers cannot be sure how the five individual items performed. Although no instrument was available to measure the variable and previous research with Hispanic men has documented that sex outside the primary relationship occurs among Hispanic men, the researchers believe that these questions may have been useful in studying this variable among Hispanic men, and allowing a basic comparison of this variable by sexual orientation. Further testing of the “Relationship Questionnaire” is necessary, and is currently being conducted with a sample of Hispanic MSM in another area of the U.S. that has a large concentration of Hispanic MSM.

Conclusions

Regardless of this study’s identified limitations, the results of this study provide some unique information on a population of Hispanic men that have not been previously studied. In addition, the study’s findings provide some pilot data on sex outside of primary relationships among Hispanic men that can be used to guide future research, and to develop HIV/STI risk reduction interventions for both groups of Hispanic men.

Key Considerations.

• Primary relationships may be a source of HIV/STI risk.

• Nurses and other healthcare providers need to question clients about sexual risks of primary relationships, as well as secondary relationships.

• Healthcare encounters provide an opportunity to provide client education about sexual risk reduction and safer sex behaviors.

• Safer sex messages that will help Hispanic men decrease sexual risk need to be reinforced at each clinical encounter.