Sexual health and life experiences: Voices from behaviourally bisexual Latino men in the Midwestern USA

Abstract

Research on behaviourally bisexual Latino men in the USA has not yet examined sexual health issues among men living in diverse areas of the nation, including the Midwest. A community-based participatory research (CBPR) approach was used to engage a diverse sample of 75 behaviourally bisexual men (25 White, 25 Black, and 25 Latino). Semi-structured interviews were conducted and, in this paper, standard qualitative analysis procedures were used to explore data from the 25 Latino participants. Men described their unique migration experiences as behaviourally bisexual men in this area of the USA, as well as related sexual risk behaviours and health concerns. Lack of culturally congruent public health and community resources for behaviourally bisexual men in the Midwestern USA were identified as significant barriers. As in other studies, familial and community relationships were significant for the participants, especially in terms of the decision to disclose or not disclose their bisexuality. Additionally, alcohol and other drugs were often used while engaging in sexual behaviours particularly with male and transgender, as well as female, partners. Behaviourally bisexual Latino men may benefit from receiving positive and affirmative individual- and structural-level support in regards to their unique experiences in this and other settings.

Introduction

While studies on behaviourally bisexual Latino men have been conducted in large urban centres on the East and West coasts of the USA, little is known about behaviourally bisexual Latino men in the Midwest. In recent years, Midwestern states have seen a large and rapid influx of Latino/a individuals, dramatically transforming the demographics of communities and impacting the way community-based organisations and other systems function. Unfortunately, public health services in the Midwest have been unable to accommodate the needs of the increased number of Latinos, including accessibility to services in Spanish and culturally congruent materials and staff (Riffe, Turner, and Rojas-Guyler 2008).

There is an established relationship between migration experiences and reported health concerns, including depression, anxiety, and acculturation pressures such as the replacement of traditional cultural patterns (Hernandez 2004). Studies have shown the impact of pre-migration and post-migration experience in predicting mental health and other health disparities among newly arrived immigrants (Malmusi, Borrell, and Benach 2010; Carswell, Blackburn, and Barker 2011). Among Mexican migrant workers, in particular, an association has been documented with post-migration loneliness and increased frequency of sexual risk behaviour (Muñoz-Laboy, Hirsch, and Quispe-Lazaro 2009; Parrado and Flippen 2010). However, more data are needed on the impact of pre-migration and post-migration experiences on physical, mental, social, and sexual health concerns of diverse groups of Latinos throughout the USA, including those who are behaviourally bisexual, as programs to address their needs are likely to vary by region and community. The physical sense of isolation among behaviourally bisexual Latino in the Midwestern USA, in particular may contribute to loneliness, and related sexual risk behaviour, as well as other mental health issues.

Latino men are unique in their expressions of sexuality, particularly bisexuality, in comparison to other groups (Aggleton 1996). Previous research highlights that many Latino men maintain a “heterosexual” identity while engaging in sexual activity with both men and women (Muñoz-Laboy and Dodge 2007). There are many institutional and cultural characteristics that might be associated with the retention of heterosexual identity when engaging in same-sex relations, including machismo, the powerful representations and reinforcement of heterosexual masculinity, and the means of structuring power relations between genders (Muñoz-Laboy and Dodge 2007; Carballo-Diéguez et al. 2004; Padilla et al. 2008). Disclosure of sexual behaviours has been found to be part of an individual's decisional balance that may be influenced by situational context or individual sexual partner-specific considerations (Malebranche et al. 2010). Latino men, in contrast to other men, have been found to be more likely to engage in bisexual behaviours but less likely to disclose their bisexuality (Zea, Reisen, and Díaz 2003). Some Latino men's discomfort with their same-sex behaviour, in particular, may be associated with how they present themselves publicly, whether or not this is congruent with their actual sexual behaviour (Sandfort and Dodge 2008; Gonzalez 2007). Additionally, the desire to be perceived as “heterosexual” by some Latino men may be related not only to internal factors but also the fact that social support for bisexual men, in general, is relatively limited (Dodge, Jeffries, and Sandfort 2008). The benefits of being known as “bisexual” may be far outweighed by the barriers, even if this label is more accurately reflective of men's sexual behaviours.

“Biphobia” has been defined as stigma and/or discrimination toward bisexual men and women from both heterosexual and homosexual individuals and communities (Mulick and Wright Jr 2002; McLean 2008). While diverse samples of bisexual men have reported rejection and a lack of support from heterosexual and homosexual community agencies and networks, experiences of biphobia have not yet been explored specifically among Latino bisexual men. It may also be difficult for Latino men to openly express their bisexuality for fear of being ostracised by their families. In addition to general social isolation, Latino men may fear being disconnected from family support and resources if they indicate that they engage in sexual behaviours with both men and women. Familism, a cultural value associated with strong identification with family (including extended family and friends) has been shown to be critical among Latino men, including those who are bisexual (Muñoz-Laboy et al. 2009; Muñoz-Laboy 2008). In order to receive the benefits of the familial network, individuals often conform to the social norms and expectations of the network.

Last, previous research has also shown that alcohol and substance use are commonly reported by Latino men who have sex with men (MSM), who may use these as a “coping mechanism” for dealing with issues associated with their same-sex behaviours (Caetano et al. 2007; Saitz et al. 1999). Migration experiences, isolation, economic hardship, discrimination, and other factors are also associated with an increased use of alcohol and other drugs (McCabe et al. 2010; Rosario, Schrimshaw, and Hunter 2009; Rodríguez-Díaz et al. 2011). Diaz and Ayala studied the use of alcohol by groups of self-identified gay and bisexual Latino men in New York, Los Angeles, and Miami and found that sexual risk behaviours were linked with a loss of control while being under the influence (Diaz and Ayala 1999). However, while there may be commonalities with other groups, information is currently unavailable on alcohol and substance use specifically among behaviourally bisexual Latino men outside these large urban communities in New York, California, and Florida.

In short, there is a need for a more comprehensive research on the unique sexual health needs of behaviourally bisexual Latino men in more geographically diverse areas of the USA. Expressions of behavioural bisexuality have been found to be unique among Latino men in comparison to other ethnic groups and little is known about the lived experiences of Latino men outside of large urban areas on the East and West Coasts. We sought to identify potential individual and socio-cultural determinants related to these men's sexual interactions that may increase transmission risk of HIV and other STI, as well as risk of other adverse health issues. In doing this, we aimed to identify and acquire information that will be useful for the development, implementation, and evaluation of a comprehensive sexual health intervention for diverse groups of behaviourally bisexual Latino men.

Methods

Community-Based Participatory Research (CBPR) Approach

This research involves an interdisciplinary community-based collaboration among researchers at two campuses of Indiana University, the Marion County Health Department (Indianapolis), as well as stakeholders from the broader community. Multiple methods were used including qualitative in-depth interviews and self-administered testing for STI. Community-based research models have been instrumental when exploring sexual health concerns affecting diverse communities, particularly those considered to be “hidden” or “hard to reach” (Israel et al. 2010; Reece and Dodge 2004; Rhodes, Malow, and Jolly 2010). In this study, “behaviourally bisexual” was defined as having any sexual activity with at least one male and at least one female or transgender partner in the previous six months, in accordance with previous research recommendations (Malebranche 2008; Jeffries, Dodge, and Sandfort 2008; Muñoz-Laboy and Dodge 2007). Research partners and community members also reinforced the importance of moving away from sexual identity labels and focusing, instead, on risk-relevant behaviours.

A community advisory committee, including behaviourally bisexual men, representatives from several community-based organisations, delegates from the local health department and the research team, provided essential input throughout the study, including elaborating research questions, determining recruitment venues, designing recruitment materials, and reviewing results for meaning and local relevance. In particular, a bilingual Latino research coordinator worked directly with community-based organisations to ensure representation of bisexual Latino men, and relevance of the research to this community.

Our community partners discouraged us from focusing heavily on traditionally utilised “gay-identified” spaces (bars, clubs, bathhouses, etc.), and instead recommended general community Latino locations including barber shops, video stores, restaurants, newspapers, and radio stations. Flyers were posted within the selected venues. In addition, audio advertisements for our study were aired several times at the major Latino radio station in Indianapolis and surrounding areas. All recruitment materials were general and did not mention the word bisexual, instead focusing broadly on “men's health. Additionally, one of the most valuable successful recruitment methods was participant referral. The method was particularly successful as behaviourally bisexual Latino men comprise a dispersed group with little public visibility. Potential participants were pre-screened during a telephone interview and, if they were eligible, were invited to participate in the study. While these general procedures involved pre-screening dozens of potentially ineligible participants, they enabled our research team to reach a diverse sample of participants that could not have been reached otherwise. All protocols for the study were approved by the institutional review boards of the researchers’ academic institutions.

Data Collection and Analysis

Data were collected during a face-to-face in-depth interview. Interviews lasted approximately 90 minutes and were conducted by a bilingual interviewer in a private location of participant's choosing. The interview guide was developed in English and Spanish. The majority of the interviews with Latino men (n=15, 60%) were conducted in Spanish since many of the Latino participants were not proficient in English. All audio recorded interviews were transcribed verbatim. Those interviews conducted in Spanish were translate into English (n = 15/25) by a certified bilingual translator.

Based on previous research work with other groups of men, and seeking to increase testing availability and services in non-clinical settings, participants were also offered the opportunity to participate in self-administered testing for urine- and rectal-based STI (Dodge et al. 2010). The results of the use of these testing procedures within this sample have been published elsewhere (Dodge et al. In press).

Processing the qualitative interview data occurred in several standard stages of organisation, analysis, and reflection. The thematic analysis we conducted highlighted the themes embedded in the texts in a manner that is sensitive to their subjective meanings. The hallmark of such semantic analysis is the careful fragmentation and coding of the data, involving organising the data into “chunks” before bringing meaning to those chunks. All text data were be coded and analysed using NVivo.

A codebook consisting of theoretically-informed manual of codes and sub-codes, defined by specific definitional criteria that allows for systematic textual coding for qualitative analysis, was constructed. The list of topics was collaboratively organised into a matrix of themes and sub-themes. By structuring the themes in this way, we were able to develop a scheme that was used for analysing all the narrative data in a systematic way.

Results

Participant Characteristics

Over the course of six months, the study team recruited and interviewed a diverse sample of 75 behaviourally bisexual from Indianapolis and the surrounding catchment area; including 25 non-Latino White, 25 non-Latino Black, and 25 Latino men. Demographic characteristics of the sub-sample of 25 Latino participants’ characteristics can be found in table 1.

Table 1.

Participant characteristics (N = 25)

	n	%
Race/Ethnicity
Latino	25	100%
Mexican	12	48%
Venezuelan	5	20%
Salvadorian	2	8%
Brazilian	1	4%
Cuban	1	4%
Dominican	1	4%
Honduran	1	4%
Puerto Rican	1	4%
Spanish	1	4%
Living Situation
Living Alone	5	20%
Living with Someone	20	80%
Marital Status
Single	17	68%
Married	6	24%
Divorced	2	8%
Children
None	16	64%
One	4	16%
Two	3	12%
Three	3	12%
Highest Level of Education
Less than High school	8	32%
High school/GED	6	24%
Some College/Associate Degree	6	24%
Bachelor Degree	1	4%
Professional Degree	1	4%
Employment
Yes	24	96%
No	1	4%

	Mean	SD	Minimum	Maximum
Age	28.76	8.36	19.00	70.00
Monthly Income (USD)	$1672.00	$1042.64	$0.00	$8500.00

Nearly all men (n=24, 96%) were born outside the USA. Additionally, most of the men (n=18, 72%) originally migrated to the U.S. from urban areas and most (n=18, 72%) were living in the USA. for less than 10 years. Participants were given pseudonym names during the data coding process.

Qualitative Themes and Sub-Themes and Proposed Intervention Strategies

Table 2 outlines five qualitative themes and numerous sub-themes that emerged from participants’ interviews. Here we have also proposed a series of potential intervention strategies to address the identified needs among behaviourally bisexual Latino men.

Table 2.

Themes and sub-themes elicited from behaviourally bisexual Latino men in the Midwestern USA, including potential intervention strategies

1. Migration Experiences

a. Discrimination and Lack of Access to Services

i. Lack of culturally and linguistically congruent services and resources

ii. Lack of knowledge among men about available services (including eligibility as migrant, etc.)

iii. Discrimination from health agencies and providers, including governmental and non-governmental institutions

iv. Distrust of US healthcare system and providers, as well as confidentiality issues

Potential intervention strategies

1. Expand collaboration with community-based organisations to increase services, including HIV/STI testing, for behaviourally bisexual Latino men

2. Work with health agencies and educate on the importance of being aware of political immigration rhetoric and reinforce the importance of having culturally congruent services

3. Work with both public and private health providers to ensure that non-judgmental and supportive care is being rendered regardless of immigration status and/or sexual behaviour

4. Fill knowledge gaps and correct misconceptions about the migrant population

5. Build a comprehensive referral system and establish partnerships with legal service agencies

b. Isolation as a Result of Migration

i. Loneliness associated with post-migration experiences leading to risky sexual behaviours with both male and female partners

ii. Struggle to overcome loneliness

Potential intervention strategies

1. Create safer spaces for Latino behaviourally bisexual men

2. Provide information related to social activities, such as soccer clubs and English classes for newly immigrants (usually these do not require prove of documentation to enrol in these courses)

3. Focus on increasing awareness and acceptance of bisexuality within social networks

c. Migration-Related Family Separation

i. Issues related to family separation, divorce, and how to maintain healthy relationships with families (including children)

ii. Financial burden and responsibility for sending remittances

Potential intervention strategies

1. Offer spaces to facilitate group discussion about family planning, including maintaining healthy relationships with family

2. Provide mental health support to address issues related with financial burdens

3. Provide support services to those who left their families or for those whose families have left them

d. Acculturation and Identity

i. Some benefits associated with acculturation in the USA, including access to educational services and connected to social support networks

ii. Benefits associated with disclosure of bisexuality after migrating

iii. Benefits associated with being documented after migrating

Potential intervention strategies

1. Strengthen the importance of education and build collaboration with educational institutions in order to provide scholarships and opportunities for Latinos

2. Establish collaboration and partnership with free and confidential English as a Second Language tutoring services

2. Family Issues in Relation to Bisexuality

a. Family as a system of judgment

Potential intervention strategies

1. Provide guidance in how to cope with family pressure and build skills on disclosure of bisexuality

2. Offer mental health support in how to maintain and build communication with family and partner in regards to health-related matters, including bisexuality

3. Create a positive and comprehensive sexual health education and use structural interventions reduce or eliminate stigma toward bisexuality in both heterosexual and homosexual communities

3. Lack of “Community”

a. Lack of support from the local Latino community and not having a safe space for support

b. Presence of rigid cultural and social norms in the Latino community, affecting disclosure and acceptance of bisexuality

c. Lack of community and perceived spaces for bisexual men

Potential intervention strategies

1. Establish in-roads with informal “hidden” social networks created by behaviourally bisexual men to provide services and channel information

2. Train health providers and mental health professionals on specific issues related to bisexuality

3. Social marketing campaign that normalises bisexuality, including positive representations of behaviourally bisexual men

4. Alcohol and Substance Use during Sexual Activity

a. Alcohol and substance use/abuse as a coping mechanism to engage in sexual activities, in particular with male and transgender partners

Potential intervention strategies

1. Provide mental health counselling and substance abuse treatment services and referrals

2. Address masculinity, machismo, homophobia and prejudice through one-on-one counselling

5. Resiliency, Hope and Self-Acceptance

a. Some participants showed self-acceptance

b. Some participants reflected on the importance of love, respect and companionship with both male and female partners

Proposed intervention strategies

1. Incorporate message of self-esteem and respect in intervention and outreach activities targeted toward behaviourally bisexual men

2. Diminish stereotypes and prejudice by providing role models, leadership and acceptance among behaviourally bisexual Latino men

Migration Experiences

Discrimination and Lack of Access to Services

Participants reported issues related to immigration status, discrimination and alienation from health agencies, and providers in the Indianapolis community. Indiana recently approved bill SB 590 which requires individual suspected of being “illegal” to provide proof of their legal status. The bill also calls for public meetings, websites, and documents to be written in English only. This particular political and immigration rhetoric is crucial for when exemplifying health disparities and access services among undocumented and documented Latinos in the Midwestern USA. It is important to note that only one organisation in the study site and surrounding areas focuses its work specifically on sexual health issues (particularly HIV/AIDS) affecting the Latino community, despite the fact that Indianapolis currently ranks as the third largest city in the Midwest. Participants expressed that the community lacks adequate public health infrastructure and health resources to meet the needs of the growing Latino population and even when those resources are available, some participants felt discriminated against by some of these scarce health agencies.

Alberto, a young Honduran migrant, reflected on the institutional discrimination among public health agencies by requesting legal documentation before accessing the public health services:

Well there are places you go and they don't serve you because you don't have social security. One time I wanted to get a blood exam for HIV, and they didn't want to do it because of the same thing, I didn't have papers. (Participant 11, Honduran, 21, Translated from Spanish)

One of the participants further elaborated on the self-perception of services and resources. Carlos described that if he was found to have any infection, including HIV and other STIs, he did not feel that he had resources to seek help and support from:

Principally, if you end up having one of those diseases [HIV, gonorrhoea, chlamydia, trichomonas, syphilis], you don't have many resources that will help you. (Participant 29, Mexican, 22, Translated from Spanish)

Participants also reported problems with other systems in the Indianapolis community. Alejandro, Pablo, and Stephen reported the lack of security and instability in the USA because of their legal status leading to desperation. When asked about how he felt in this country, Alejandro responded:

A little bad because you already see that we cannot have a license, to drive and all of that. (Participant 17, Mexican, 27, Translated from Spanish)

Pablo added:

There are times one feels desperate, there aren't jobs, and one doesn't feel like people that have papers here. (Participant 3, Mexican, 48, Translated from Spanish)

Stephen explained:

I feel worried. I do not feel afraid, you feel because you do not know at what moment you will leave work and someone will be waiting for you at the door. (Participant 60, Mexican, 19, Translated from Spanish)

These participants’ concerns were centred on their status as undocumented immigrants and reflected on its relation to access to care and services, as well as the institutional prejudices and discrimination they experienced.

Isolation as a Result of Migration

Others shared stories about loneliness and how their migration to Indianapolis (including leaving their families) was often linked to their sexual behaviours. Aguado, a medical professional, reflected on how his migration experience and separation led him to engage in risky sexual behaviours. For many of the participants, frequent sexual encounters became a temporary relief for loneliness.

Well, yeah, of course and I think part of my life in this country is kind of empty like you don't have your parents, you miss your country, your home town and part of this is you are looking for a partner or people in order to fill that emptiness that you have in heart, in your life and probably most of the time, we have sex just because we got confused like oh yeah, I'm looking for something but you don't even know what you're looking for. And you said like having sex is fun but part of this is you feel really empty and so that's why you are looking for someone very often. (Participant 28, Venezuelan, 34, Conducted in English)

A common theme among this group was a continuous struggle against isolation, both in their attempts to prevent loneliness and how this often led them to risky sexual encounters as coping mechanism. Michael reflected on his situation:

Yes, when I felt depressed like that, or perhaps, I felt like I could not find happiness in my home. I said better I get with a woman if I felt the desire to be with a woman. (Participant 70, Mexican, 33, Translated from Spanish)

Some of the participants reported in engaging in sexual behaviours as a direct result of feeling lonely. For Agustin, sexual activities served as a chance to find companionship and time to not think about being alone, even temporarily:

Because I don't have anybody right now. I mean I go out and fuck people but it's like in the next day, there's nobody there..... Because I think if I have more sex, I won't have that feeling.....I just think it's on my mind. If I have more sex, I get the love from somebody. (Participant 58, Venezuelan, 29, Conducted in English)

Migration-Related Family Separation

Others reflected on the burden of being responsible for the financial support of the family in their native country. Many Latinos come to the USA for economic reasons, including improving their living situations and the wellbeing of their families. After they arrive in the USA, some experience pressure to send remittances to their families. In addition, family separation could lead to the dissolution of family ties, as in the case of Claudio:

In Mexico just with my wife. Right now no, we have lost a lot of the communication between the two of us. We were together two years. The relationship was good, because of our daughter we learned a lot, and her way of being changed a lot. One comes to work for the little they can earn, and the more you give the more they want. The day I give them little they get mad. I now send them things and if they want it they can accept it or not accept it. My daughter is not missing anything, she has everything. I only knew my daughter until she was two years old. (Participant 4, Mexican, 23, Translated from Spanish)

While some of the remittances are used to provide for basic needs such as rent, food and household supplies, others prioritise and allocate their remittances to pay for education, as with Eladio.

And since I have my son and he depends on me, my mind is only focused on helping him because he is going to school in Mexico. (Participant 59, Mexican, 38, Translated from Spanish)

Acculturation and Identity

It is important to note that while some of the participants disclosed their undocumented status and how it negatively impacted their access to health services and care, others mentioned the fact that they were documented and positively reflected on their experiences in the community. In addition, some of the men talked about their access to social support networks with other Latino individuals and a sense of acceptance and feeling welcomed in the USA. Amador, a divorced college graduate, talked about the importance of learning and grasping the cultural benefits from the USA. This migration experience helped to further build his identity:

I am me and I grab from all of the communities or from religions that serve me, what can apply, I do not limit myself. Obviously, I belong to the Latin community but I like a lot of things about American life, and those things I grab on to, too. (Participant 27, Venezuelan, 29, Translated from Spanish)

Aguado reflected on the fact that the USA served as a safe place to disclose his bisexual behaviours. While in his native country he could not do so because of fear of rejection and once settled in and being exposed to the American life, then he felt safer in terms of his sexuality.

I would say like two years ago when I moved to America, to the United States, before I used to say straight even though that I knew that I feel attraction for men but I would never ever use the word ‘gay’ in my home country, never. When I moved here, I was really afraid of this and part of the reason that I moved to America was in order to live my own life and see what's going on and two years ago was when I understood that I was bisexual and I felt attraction for women and men. (Participant 28, Venezuelan, 34, Conducted in English)

Family Issues in Relation to Bisexuality

While some men reported loneliness and isolation due to migration, others acknowledged that distance helped them to express their sexual behaviours more freely and not be judged and condemned by their families. Many of the men in our sample reported experiences of rejection and prejudice within the family context. For Amador, a migrant from Venezuela, his family became a “barrier” to be himself and a system of judgment because of his sexual identity.

Sometimes I feel alone; I always miss my family but one always learns how to manage that part. Sometimes, like I told you, being here, above all not having a barrier, your family is not here, there is no one to judge you, “you can let go of your monkey here.” But it is up to you and how you want to live your sexuality and what values you have. (Participant 27, Venezuelan, 29, Translated from Spanish)

Many of the participants lived in fear in terms of their sexuality in relation to their families.

Yosmani shared his fear of his family finding out about his sexuality and how this impacted his sexual behaviours in Cuba and the USA.

In Cuba I only did it [sex with another man] one time and I was scared my mom and my dad would find out. Since Cuba I knew what I liked, when I was attracted to a man. It is unusual for someone to attract me, they have to be clean and nice, but I knew since Cuba that I liked both sexes. Here was where I started having more relations with men; I had more freedom here and I feel safer. (Participant 19, Cuban, 24, Translated from Spanish)

Lack of “Community”

Many of the participants reflected on Latino community dynamics and how they would feel rejected by other Latino individuals if they disclosed their bisexuality. Thus, participants did not find a great deal of social support in the Indianapolis Latino community due to their sexual behaviours. Some participants reflected on the prescribed cultural and social norms within the local Latino community and how they do not offer opportunities to be liberated about their sexualities, to disclose their sexual behaviours to others, and to receive the appropriate sexual health care they might need.

Other participants felt that they could not disclose their sexual behaviours due to stigma and rejection. Felipe, a recent migrant from rural Mexico, expanded on the closed nature of the Indianapolis Latino community and the lack of communication and respect in terms of sexual diversity.

It is very difficult because the American community is different from the Hispanic community. The Hispanic community has to be more closed, because it is very mocking. For example, if I have my family they take it as mockery, like they make fun of you and things like that. There is no respect. (Participant 50, Mexican, 22, Translated from Spanish)

Renato, a young recent migrant who came with his single mother to the USA, talked about the fact that he has not been able to disclose his sexual behaviours to contextual factors in the community.

Of course but I don't talk with anybody. Sometimes I have the feeling or I feel bad or I want to talk with somebody about my situation, about what I'm doing because you have to talk with somebody, with a friend or in your job or with a partner or something but I feel like what the big question is like what they're going to think about me if I told them. So that's why I never talk with anybody. I just go to my room and talk with myself and think with myself what is wrong, what is good, if I'm doing good, if I'm doing wrong. (Participant 73, Mexican, 21, Conducted in English)

All 25 participants discussed the lack of a visible bisexual community and perceived bisexual spaces in Indianapolis, as well as not feeling belonging to any “group.” Zack elaborated:

I don't’ know any bisexual community in Indianapolis like I told you so I don't know if there is any bisexual community. (Participant 15, 34, Latino, Conducted in English)

Aguado added:

People being bisexual, we are really depressed because we feel that they don't belong to any group. (Participant 28, 34, Latino, Conducted in English)

Interestingly, all of the participants in our sample study also expressed a desire for potentially talking about their sexual behaviours with a professional or someone that could listen to them without judgment. Many of them expressed gratitude after the interview because it was the first time they talked about their bisexuality with any other person.

Alcohol and Substance Use during Sexual Activity

As in other studies of Latino MSM, almost half of the participants reported that both they and their male sexual partners were using alcohol during the most recent sexual act (n=11, 44%). One in five (n=5, 20%) reported that they were drinking alcohol by themselves during the most recent sexual event with a man and two (8%) were using other drugs during the most recent sexual activity with a man. In addition, as behaviourally bisexual men, four (16%) reported using alcohol with their female sexual partners during the most recent sexual act and five (20%) reported that they were drinking alcohol by themselves during the most recent sexual activity with a woman. Furthermore, two (8%) were using other drugs during the most recent sexual activity with a woman.

Many reported a sense of power and strength when drinking alcohol during sex and felt that it enhanced their feelings to engage in sexual activity. Agustin, a professional graduate from Venezuela described his own experience.

When I'm drunk, I feel powerful like I can do anything. I'm not care to talking to nobody or I think I can show people really who I am when I'm drunk like I'm not shy at all.... but if I'm not on alcohol, something is missing. (Participant 58, Venezuelan, 29, Conducted in English)

Others only felt comfortable engaging in same-sex behaviour, in particular, under the influence of alcohol as it enabled them to “be themselves” and engage in a variety of sexual acts. Being under the influence of alcohol was one way for Aguado to feel comfortable about engaging in same-sex sexual behaviours:

I think I feel more comfortable doing this when I do drink alcohol more when I'm sober. (Participant 28, Venezuelan, 34, Conducted in English)

Fermin, a business professional of Dominican descent, explained his desires under the influence of alcohol and often enabling him to engage in occasional bisexual activities:

It was more or less casual just on the side, went for a couple of drinks and partying a little bit, a little bit more loose, and then sometimes you might have a feeling that maybe you'll go both ways or something and just sort of happened like that but mostly with friends. But I'm mostly heterosexual but play around on the side. (Participant 13, Dominican, 42, Conducted in English)

Some reported drinking alcohol before going to gay-identified venues in order to feel more comfortable. There was a general expectation of negative consequences if they were seen at gay venues. Eladio, who is HIV positive and also a father, explained the need to drink alcohol before going to gay-identified venues:

But yes, I took a few drinks to be “happy.” When I arrived at his house, he tells me “Let's go,” and he takes me to the centre [part of town] where it is “gay” also, but they are like strippers. (Participant 59, Mexican, 38, Translated from Spanish)

For some participants, alcohol not only became a coping response but also enabled them to engage in certain sexual behaviours with male partners. Wilfredo reported attending several parties and how being under the influence of alcohol enabled him to engage in group sexual activities.

No, but I have been in several parties [all male parties] where everything ends up in the bed. We all end up having sex because of the influence of alcohol. (Participant 52, Mexican, 24, Translated from Spanish)

Wilfredo also reported how the use of alcohol became a barrier to condom use.

I did not think about the risk until I was done with that specific situation. I could have used condoms but could not do it because I was under the influence of alcohol. (Participant 52, Latino, 24, Translated from Spanish)

Interestingly, some of the participants reported engaging in sexual activities with transgender individuals but also reflected on the need for alcohol in order to engage in these activities. Virgilio reported on his sexual behaviours with transgender partners.

Well, to start, I did not have my five senses. Because with my five senses I do not think I would have done it. I was a little halfway drunk; I had drunk a few beers. Well, since I was drinking. I tell you, if I had not been drinking, I would not have done it..... But I tell you, I am attracted to the dressed ones, it is not that I want to be with them, but it is that I am attracted. Being sober, without alcohol, I would not be with them for nothing. (Participant 30, Mexican, 45, Translated from Spanish)

Resiliency, Hope and Self-Acceptance

Many of the participants reflected on stressors in their life experiences as behaviourally bisexual Latino men. It is also important to highlight that some of the men discussed positive factors including resiliency, hope and self-acceptance. In addition, some of them mentioned the importance of love, companionship, as well as a sense of self-acceptance in terms of their sexual behaviour and relationships.

Pablo was recently divorced and is a father of two. He expressed his desire of finding a serious relationship, for which love, respect, and communication were essential components. He also talked about the happiness and self-acceptance that came to his life after his divorce.

Well something more serious. Or perhaps, there would be love; we would share a lot of things in our lives, things together, projects....After I got divorced, I felt freer and surer about my life. (Participant 3, Mexican 48, Translated from Spanish)

Zack described the fluidity of his sexuality and his satisfaction with his sexual behaviours and desires. In addition, he also explained about the importance of connection with his sexual partner to engage in sexual activities, regardless of gender, as a behaviourally bisexual man.

I don't’ know how to describe my sexuality. I'm different. I like to experiment. I like sex. I don't have any addiction to the sex and stuff like that. I don't’ feel addicted to the sex but I really like to have sex because I think I feel in connection with the other person. When you have sex with someone, whoever it is, a girl or a man, and when you're having sex with that person because you like the person, I think when you have sex with the person, you feel really, really, connected.... I feel like I have an internal connection while I like that person and I have sex with him or with her. (Participant 15, Venezuelan, 34)

Discussion

Our findings shed a new light on the migration experiences and sexual health issues associated with being behaviourally bisexually Latino men in the Midwestern USA, including those which may be related to numerous health concerns. Overall, post-migration experiences seemed to play a significant role in terms of shaping these men's health and wellbeing. Many of the men reflected how their legal status in the geographically isolated Midwestern community led to isolation and loneliness. Many of the participants reflected on the stigma, discrimination and prejudice they experienced in their social environments, including family and community. Family, in particular, played a significant role in the lives of these men. Some of the participants felt lonely in the Midwestern USA because they were far away from their family. This sense of isolation often led them to engage in potentially risky sexual behaviours with male and female, and sometimes transgender, partners.

The study responds to the recent report from the US Institute of Medicine on the need to increase research and foundational infrastructure to address the growing health needs and concerns of diverse groups of bisexual, lesbian, gay, and transgender people (Institute of Medicine 2011). The findings of this study are invaluable for community-based organisations and public health programs attempting to address the growing health concerns among Latino men in the Midwestern USA, in general, particularly those who are behaviourally bisexual. Most of the men in this study reported lack of local public health acknowledgment of their unique issues, including and lack of community and resources for behaviourally bisexual. Programs aimed at decreasing the overall sense of isolation among these men would be most beneficial. A fair number of participants reported using alcohol in order to cope with the guilt associated with engaging in sexual activity with male and transgender partners, in particular, so interventions should also target these issues.

As seen in our proposed potential intervention strategies in table 2, an ecological perspective should be taken into consideration when designing efforts to address the health concerns and needs of behaviourally bisexual Latino men throughout the USA. Such a perspective would emphasise individual and contextual factors and the interdependence between these, as well as their potential impact on health. Therefore, public health agencies and programs may consider creating comprehensive referral systems in place in order to address the diverse array of issues affecting these men, particularly in diffuse communities such as the study site. Given the importance of community in these men's lives, they may also benefit from receiving positive and affirmative community support in regards to their unique experiences as bisexually active Latino men. Those community-based organisations involved in outreach and awareness events both in the Latino and LGBT communities should bring attention to the unique issues and challenges of behaviourally bisexual men.

While the study used CBPR and established qualitative methods, there are some limitations to our research study. As probability samples of men who have sex with men and women are difficult to obtain (Jeffries and Dodge 2007), we relied on purposeful convenience sampling techniques in order to acquire study participants. We do not know how well our approach sampled the wide array of existing sub-populations of behaviourally bisexual men. For example, even though we included a good number of married men and men with children, it is possible these men are even more difficult to reach through the types of methods we employed. Therefore, the findings are not generalisable. A comprehensive understanding of sexual behaviour among bisexual men could be achieved by comparing ethnic groups and future efforts may undertake this. However, this paper aims to bring the life experiences and unique challenges faced by Latinos, such as post-migration experiences that are closely related to health outcomes and health disparities.

As has been demonstrated in previous research on underserved Latino communities, we found that using a community-based participatory approach was critical for this study (Rhodes et al. 2009; Rhodes, Malow, and Jolly 2010). By using CBPR in this Midwestern community, we acquired formative data to inform the project from the perspectives of community members themselves at key points throughout the study. The community-based research approach was also helpful to the study participants themselves. Several participants reported knowing of the sole community-based organisation that serves the sexual health needs of the Latino community in the study site (Casa Mateo/Latino Action League, Inc.). Since many of the participants felt comfortable doing the interview at this specific community-based organisation, it may serve as a model location for providing services to these men in future sexual health promotion efforts. Privacy and trust were utmost concerns of the participants.

Importantly, community-based organisations also benefited from participating in the study. By working with the study team and researchers, they have had access to data that could be used for informing programs and services. Additionally, the research coordinator and principal investigator were able to apply for several community service grants with our partners, including successful grants from the Minority AIDS Council and the Ryan White HIV/AIDS Services Program. Through continuing outreach, the study team has also helped to coordinate educational and outreach events for the Latino community in the Indianapolis community. We have worked closely with our community partners in the process of dissemination of research findings, reports, and information. Last but not least, our community advisory committee members are continuing to collaborate with developing a comprehensive sexual health intervention for behaviourally men in this community and beyond.