Abstract
The Midwestern United States (U.S.) has a high number of recent Latino migrants, but little information is available regarding their sexual behaviors. A total of 75 behaviorally bisexual men (25 Latino, 25 Black, and 25 White) participated in an exploratory study on sexual health. The data presented in this paper are restricted to the 25 self-identified Latino men. Qualitative in-depth interviews were conducted and optional self-administered sexual transmitted infection (STI) screening was provided. The measures used were taken from the National Survey of Sexual Health and Behavior (NSSHB), a probability study of the sexual behaviors of nearly 6000 individuals aged 14-94 in the U.S. In our sample of bisexual men, the most commonly reported sexual behaviors were masturbation, vaginal intercourse, and receiving oral sex from male and female partners. The majority of the participants were the insertive partner during anal sex with male partners. Many of the participants reported alcohol use during their most recent sexual activity. A fair number reported not using condoms during their last sexual event. Pleasure, arousal, orgasm, and erectile functioning were markedly similar despite partner gender. A small number of participants also engaged in sexual activities with transgender individuals. All of the Latino participants took part in the optional self-collection for STI specimens. The results of the study provide rich insights into the sexual behavior and related factors, as well as potential risk behaviors of bisexual Latino men that may be targeted for future sexual health promotion efforts.
Keywords: Bisexuality, Latino, Men Who Have Sex with Both Men and Women (MSMW), Sexual Behavior, Sexual Experience, Hispanic
Introduction
Latinos represent 14% of the United States population but account for 18% of new reported HIV/AIDS infections (MMWR, 2005). Midwestern states have seen a recent increase of the Latino population who is becoming an important part of the economy and political process in these states (Halloran, 2005; Riffe, Turner, & Rojas-Guyler, 2008). For example, according to the U.S. Census, Latinos accounted for 7.8% of the population in Marion County (Indianapolis, Indiana) (2009). In addition, Indianapolis has historically had some of the highest rates of sexually transmitted infections (STI) in the nation (Health, 2006). The state of Indiana is dramatically underserved in terms of public health funding; indeed, it was recently ranked by the Trust for America’s Health and the Robert Wood Johnson Foundation as the state with the lowest amount of federal funding for health programs (50th out of 50 states) (Business, 2009). However, research on factors associated with sexual behavior that may lead to new HIV infections among Latinos, especially those new immigrants coming to the U.S. and settling in this region of the country, are notably absent from the literature. Despite the fact that behaviorally bisexual Latino men have been identified as a high risk group in terms of HIV/STI infection and transmission, little is known about the behavioral characteristics and related experiences associated with sexual activity among these men in the Midwestern U.S. (Martinez, et al., 2010).
There are many potential behaviors associated with the increase of HIV and other STI among bisexual Latino men, including inconsistent condom use, the use of alcohol and drugs when having sex, and a number of potentially risky sexual activities with both men and women. In the U.S., overall, some studies suggest that men who have sex with both men and women (MSMW) are at greater risk of HIV infection and transmission than men who exclusively have sex with men (MSM) (Izazola-Licea, Gortmaker, de Gruttola, Tolbert, & Mann, 2003; Muñoz-Laboy & Dodge, 2007; Prabhu, Owen, Folger, & McFarland, 2004). Studies have shownevidence that bisexual men have a relatively high behavioral risk for HIV and STI compared with exclusively homosexual and heterosexual men (L. Doll, Myers, Kennedy, & Allman, 1997; Muñoz-Laboy & Dodge, 2007; Stokes, McKirnan, & Burzette, 1993). Muñoz-Laboy and Dodge found that bisexual Latino men who reported recent bisexual behavior presented a larger proportion of sexual risk than those who identified themselves as bisexual but did not report recent bisexual behaviors (Muñoz-Laboy & Dodge, 2007). While their study contributed to the knowledge on behavioral factors associated with sexual risk behavior among Latino men, it was limited to an urban sample of men in New York City.
Zeller and colleagues conducted a study on sexuality among a diverse group of 680 Latino men, most of them born in Mexico, and two thirds in the U.S. for 5 or fewer years (Zellner et al., 2009). They found that out of the 30 heterosexually-identified MSMW, 40% (n=12) reported having sex with at least one man and one women in the past 60 days. A number of the men (n=11) reported engaging in unprotected sex with both men and women. On the other hand, out of those bisexually identified MSMW (n=16, 25%), 4 reported sexual activity with men and women in the previous 60 days and only one reported unprotected sex with both genders. The study highlights diversity of sexual expression among Latino bisexual men. In addition, other studies have found that Latino men are more likely to engage in bisexual behaviors but are less likely to disclose bisexual behaviors than White men (Montgomery, Mokotoff, Gentry, & Blair, 2003; Susan, Peterman, Doll, Buehler, & Curran, 1992; Zea, Reisen, & Díaz, 2003).
Additionally, as shown in the previous, some Latino men maintain a heterosexual identity even when they engage in same-sex sexual activities (Magaña & Carrier, 1991). There may be event-specific and culturally-specific factors that shape sexual behaviors of Latino men, including the sexual partners’ gender identity, who is engaging in the insertive or receptive role in sexual practices, levels of acculturation, having sex with transgender individuals, and whether or not they engage in sexual activities under the influence of alcohol and drugs (Deardorff, Tschann, Flores, & Ozer, 2010; Fernandez-Esquer, Diamond, & Atkinson, 2010; Nakamura & Zea, 2010; Reisen et al., 2010; VanDevanter et al., 2011). In addition, stigma within the Latino community may be a factor influencing Latino men’s decision to not disclose their bisexuality or same-sex behavior with others, including friends, family and community (Diaz & Ortega, 1998; L. S. Doll & Beeker, 1996; Zea et al., 2003). Bisexual men’s stigma and discrimination experiences from both homosexual and heterosexual individuals have also been found in other studies to have a negative impact on their mental health (Bruce, Ramirez-Valles, & Campbell, 2008; Haile, Padilla, & Parker, 2011).
At the structural level, studies and reports have shown that public health programs and systems have not yet adequately met the sexual health needs of bisexual Latino men, for instance, providing culturally and linguistically congruent services (Perreira, Chapman, & Stein, 2006; Riffe et al., 2008; Trossman, 2004). In particular, interventions have not fully distinguished the behavioral differences and risk behaviors between bisexual and gay men (Lynda S. Doll, Petersen, White, Johnson, & Ward, 1992; Muñoz-Laboy & Dodge, 2007). Therefore, it is important to fill these research and practice gaps and expand services specific to the needs of this specific population.
Our study team assessed the range of sexual behavioral characteristics of behaviorally bisexual Latino men. Research has not yet explored male bisexuality for its potential contributions to sexuality beyond disease transmission and other “risky” and negative consequences. Little is known about the diversity of Latino bisexual men’s sexual behaviors with both male and female partners including oral sex, vaginal sex, anal sex, and other sexual activities. This information would be useful to public health professionals and others seeking to understand the actual sexual health behaviors among Latino bisexual men and appropriately intervene. The aim of this study was to offer a comprehensive overview of sexual behaviors and other factors related to sexual experience in a diverse sample of Latino behaviorally bisexual men in the Midwestern U.S.
Methods
Procedures
The assessment involved an interdisciplinary collaboration among researchers at two campuses of Indiana University, the Marion County Health Department (Indianapolis), as well as partners and stakeholders from the broader community. A multi method approach was used in the overall context of a community-based participatory research (CBPR) approach. Ninety minute in-depth qualitative interviews were administered in English and Spanish to the participants. After the interviews were conducted, participants were offered optional self-administered STI screening, including urine and rectal chlamydia, gonorrhea, and trichomonas at no cost (Dodge, in press 1). Upon completion of the interview, and STI specimen collection when agreed upon, participants received $50 for their participation in the study. This amount of reimbursement is in line with similar interview studies conducted in the research setting by the study team.
In this study, “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. Studies have varied greatly in the time period for which sexual behavior may be classified as “bisexual,” but we chose six months as the duration defining bisexual behavior to obtain a more accurate account of participants who are currently behaviorally bisexual (and therefore distinct from currentlyexclusively homosexual or heterosexual). Research and community partners reinforced the importance of moving away from sexual identity labels and focusing, instead, on relevant behaviors (Malebranche, 2008).
Our study team relied on the CBPR approach to reach a diverse group of bisexual men since this framework has been successfully used to assess the sexual health needs of diverse communities (Reece & Dodge, 2004; (Rhodes, Hergenrather, Bloom, Leichliter, & Montaño, 2009; Rhodes et al., 2006; Rhodes, Malow, & Jolly, 2010). For example, community advisory committee members participated in the development of study protocols, including recruitment materials and methods. Based on their feedback, the Latino participants, in particular, were recruited from a wide range of venues including bars, barber shops, neighborhood stores, newspapers, and local radio stations. One of the most valuable forms of recruitment used to recruit bisexual Latino men was through participant referrals (i.e. snowball sampling from previous participants). In addition, community members provided feedback on the recruitment materials. In particular, community partners helped develop intentionally vague culturally and linguistically recruitment materials in English and/or Spanish that were distributed through a wide range of venues. In order to determine participant’s eligibility, the recruitment materials contained a phone number and email address so that they could call or email for screening. Most of the participants were not eligible to participate after they were screened by the research coordinator because they did not meet the criteria of being sexually active in the past six months with at least one male and female partner. Around 400 participants were screened using the methods described above.
Measures
This paper presents descriptive findings from quantified data collected via an interviewer-administered questionnaire assessing sexual behaviors and a variety of other contextual factors associated with Latino participants’ recent sexual experiences with both male and female partners (for an overview of findings from the total sample of participants, see Dodge, et al., in press 2). The measures were taken directly from the National Survey of Sexual Health and Behavior (NSSHB), a study examining recent and lifetime prevalence of sexual behaviors in a nationally representative probability sample of 5,865 men and women ages 14 to 94 in the U.S. (Reece, et al, 2010). In terms of sexual behaviors, participants were given the options of stating whether they had done a specific sexual behavior within the past 30 days, within the past 90 days, within the past year, or more than a year ago. For instance, participants were asked “How often have you done the following?” They could also indicate if they had never engaged in a particular behavior. For behaviors at last sexual event with both male and female partners, participants also responded to a series of questions indicating their experiences with pleasure and arousal. For example, in relation to pleasure, participants were asked “How pleasurable was this most recent sexual act?” and were given the option of indicating their response on a 5 point scale ranging from not at all pleasurable, a little pleasurable, moderately pleasurable, quite a bit pleasurable, to extremely pleasurable. Participants were asked about their experiences of orgasm (and perceived partner orgasm) erectile functioning, and whether or not they used any medications designed to attain or maintain an erection. Last, men indicated whether or not (and to what extent) they used condoms with male and female partners.
Data Analysis
Analysis in this paper is restricted to the 25 participants who identified themselves as Latinos. Text from transcribed qualitative interview data served as the basis for analysis. All text data were coded and analyzed using NVivo. The data from the 15 interviews conducted in Spanish were transcribed and translated by a certified translator. Data organization, analysis, and interpretation took place in several standard stages (Elliott, 1999). Data were analyzed for initial codes utilizing a team coding strategy to ensure reliability. Initial codes were then organized into categories to develop more abstract theoretical codes from the data. This paper provides an overview of “quantified” data collected via an interviewer-administered instrument. The questionnaire assessed the most recent sexual behaviors as well as the lifetime sexual experiences with female and male partners. All analyses were conducted using SPSS version 17.0.
Results
Participant Characteristics
A diverse sample of 75 bisexual men from Indianapolis and surrounding areas took part in the study. Findings regarding the sub-sample of Latino participants’ demographic characteristics can be found in Table 1. Additionally, Table 2 presents an overview of participant pseudonyms that were created for using quotes within the text of this paper. Among Latino participants, (n=12, 48%) identified as ‘Mexican,’ (n=5, 20%) as ‘Venezuelan,’ (n=2, 8%) as ‘Salvadorian,’ (n=1, 4%) as ‘Brazilian,’ (n=1, 4%) as ‘Cuban,’ (n=1, 4%) as ‘Dominican,’ (n=1, 4%) as ‘Honduran,’ (n=1, 4%) as ‘Puerto Rican,’ and (n=1, 4%) as ‘Spaniard.’
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 | 0% | |
| 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 | min. | max. | |
|---|---|---|---|---|
| Age | 28.76 | 8.36 | 19.00 | 70.00 |
| Monthly Income | 1672.00 | 1042.64 | 0.00 | 8500.00 |
Table 2.
Pseudonym Names (N = 25)
| Participant Number | Pseudonym Name | Age | Country of Origin |
|---|---|---|---|
| 2 | Camilo | 33 | Puerto Rican |
| 3 | Pablo | 48 | Mexican |
| 4 | Claudio | 23 | Mexican |
| 11 | Alberto | 21 | Honduran |
| 13 | Fermin | 42 | Dominican |
| 14 | Raul | 25 | Spanish |
| 15 | Zack | 34 | Venezuelan |
| 17 | Alejandro | 27 | Mexican |
| 19 | Yosmani | 24 | Cuban |
| 25 | Roberto | 28 | Venezuelan |
| 27 | Amador | 29 | Venezuelan |
| 28 | Aguado | 34 | Venezuelan |
| 29 | Carlos | 22 | Mexican |
| 30 | Virgilio | 45 | Mexican |
| 32 | Ricky | 21 | Mexican |
| 50 | Felipe | 22 | Mexican |
| 51 | Daniel | 21 | Salvadorian |
| 52 | Wilfredo | 24 | Mexican |
| 53 | Damian | 21 | Brazilian |
| 55 | Tony | 40 | Salvadorian |
| 58 | Agustin | 29 | Venezuelan |
| 59 | Eladio | 38 | Mexican |
| 60 | Stephen | 19 | Mexican |
| 70 | Michael | 33 | Mexican |
| 73 | Renato | 21 | Mexican |
Most of the Latino participants in our sample were not born in the U.S. (n=24, 96%). Most of the men came from urban areas in their native countries but those coming from Mexico were more likely to be from rural areas. In addition, the majority of the men in the study have been living in the U.S. for less than 10 years. While some of the interviews were conducted in English, most of the men (n=15, 60%) preferred to conduct the interviews in Spanish.
Lifetime Sexual Behaviors
Findings regarding lifetime sexual behaviors can be found in Table 3. In terms of lifetime experience, all of the Latino men (n=25, 100%) engaged in solo masturbation. In addition, in terms of lifetime sexual behaviors, all of the Latino men (n=25,100%) reported vaginal intercourse and receiving oral sex from a woman (n=25, 100%). A large number of participants reported receiving oral sex from a man (n=23, 92%). In addition, the majority of the participants reported giving oral sex to a woman (n=24, 96%) but noticeably a fewer reporting giving oral sex to a man (n=13, 52%). Further, participants were primarily the insertive partner during anal sex (n=22, 88%) and far fewer reported being the receptive partner during anal sex (n=12, 48%). In terms of internet use, a small number of the participants (n=9, 36%) reported having sexual interaction with someone online. A small number received something from a male in exchange for sex (n=4, 16%) and a smaller number (n=2, 8%) received something from a female in exchange for sex. On the other hand, a fair number of the men (n=6, 24%) gave something to a female in exchange for sex compared to a smaller number of men (n=2, 8%) that gave something to a man in exchange for sex.
Table 3.
Reported Recency of Sexual Behaviors (N = 25)
| Recency of Reported Behavior | Never Done |
Past 30 Days |
Past 90 Days |
Past Year | Over A Year |
No Response |
||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Sexual Behaviors | n | % | n | % | n | % | n | % | n | % | n | % |
| Solo Masturbation | 0 | 0.0 | 21 | 84.0 | 1 | 4.0 | 1 | 4.0 | 2 | 8.0 | 0 | 0.0 |
| Partnered Masturbation with Male | 8 | 32.0 | 7 | 28.0 | 5 | 20.0 | 3 | 12.0 | 2 | 8.0 | 0 | 0.0 |
| Partnered Masturbation with Female | 8 | 32.0 | 2 | 8.0 | 5 | 20.0 | 7 | 28.0 | 3 | 12.0 | 0 | 0.0 |
| Received Oral Sex from Male | 2 | 8.0 | 10 | 40.0 | 7 | 28.0 | 4 | 16.0 | 2 | 8.0 | 0 | 0.0 |
| Received Oral Sex from Female | 0 | 0.0 | 7 | 28.0 | 5 | 20.0 | 8 | 32.0 | 5 | 20.0 | 0 | 0.0 |
| Gave Oral Sex to Male | 12 | 48.0 | 7 | 28.0 | 4 | 16.0 | 2 | 8.0 | 0 | 0.0 | 0 | 0.0 |
| Gave Oral Sex to Female | 0 | 0.0 | 5 | 20.0 | 4 | 16.0 | 9 | 36.0 | 7 | 28.0 | 0 | 0.0 |
| Vaginal Sex | 0 | 0.0 | 8 | 32.0 | 7 | 28.0 | 9 | 36.0 | 0 | 0.0 | 0 | 0.0 |
| Insertive Anal Sex | 3 | 12.0 | 9 | 36.0 | 4 | 16.0 | 7 | 28.0 | 2 | 8.0 | 0 | 0.0 |
| Receptive Anal Sex | 13 | 52.0 | 7 | 28.0 | 1 | 4.0 | 3 | 12.0 | 1 | 4.0 | 0 | 0.0 |
| Sex Online | 16 | 64.0 | 3 | 12.0 | 5 | 20.0 | 0 | 0.0 | 1 | 4.0 | 0 | 0.0 |
| Gave Something for Sex with Male | 23 | 92.0 | 2 | 8.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 |
| Gave Something for Sex with Female | 19 | 76.0 | 0 | 0.0 | 2 | 8.0 | 2 | 8.0 | 2 | 8.0 | 0 | 0.0 |
| Received Something for Sex with Male | 21 | 84.0 | 3 | 12.0 | 0 | 0.0 | 0 | 0.0 | 1 | 4.0 | 0 | 0.0 |
| Received Something for Sex with Female | 23 | 92.0 | 2 | 8.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 |
Vaginal intercourse was the most commonly sexual behavior reported by the men in the study. Fermin described his sexual experiences when having vaginal intercourse:
Well, I like the wetness of the vagina and the warmth like it’s supposed to be…(Participant 13, Dominican, 42).
Eladio talked about his frequent visits to commercial sex houses for sex and reported the frequency of vaginal sex with female partners at these venues:
Well, the same, like I told you before, it was with one of those women I met in the houses. The last woman was Honduran, since I heard from my friends that Honduran woman are good at having sex. So this time, the guy had a Honduran woman … all of the women are seated and I pick one and she goes with me to the bed (Participant 59, Mexican, 38).
In general, oral sex was a commonly reported behavior with both male and female partners. Some men described reasons for oral, and non-oral, sexual behaviors with their female partners and how the moral role and respect for their wife or committed female sexual partners played an important role in their sexual interactions. Pablo discussed:
No, I have more respect for her. Oral sex is different, with my wife I have more respect, I would not be more open with my wife. I would be more embarrassed with my wife. Well, if she suggests it, maybe I would do it. (Participant 3, Mexican, 48)
Claudio added:
We’ll say, women go along with it up to a certain point, they don’t like talking much about it, and having relationships with men goes along more with it. To go along with it more means “I want you to do this, I am going to do that to you,” it is more communicative. With a woman it is different, there is more of a pretext. With a gay person you don’t have that. A gay person always likes to change and do different thing. (Participant 4, Mexican, 23)
In regards to specific oral sex behaviors, the majority of the men did not report giving oral sex to other men. For instance, while Alejandro showed that he was comfortable engaging in the same type of sexual activities and behaviors with both male and female partners, giving oral sex to a man was not a behavior that he had ever engaged in:
The same things I would do with a woman I would do with a man. To suck on them [give oral sex] to men, I do not like to do it to but to women I do. (Participant 17, Mexican, 27)
Engaging exclusively in oral sex with a man served for some of the men who engaged in oral sex as a protective or safer behavior not associated with “being bisexual.” Ricky mentioned the fact that he only engages in oral sex with men unlike his more fluid and sexual interaction with female partners:
That oral sex with the guy I guess is kind of bisexual but I don’t really consider myself bisexual because I see that time as just being that one time, just being curious as to see what it was like. (Participant 32, Mexican, 21)
Some of the men reflected on experiences with receiving something from a male in exchange for sex (i.e., money, work). For Tony, the first sexual experience with a man was prompted because of his financial needs and the necessity to support himself and his family as a recent migrant:
The first time that I was with a man it was the necessity, the necessity of money. That was in Los Angeles, I did not have a job and I was “cornering it,” or, looking for work on a corner, any type of work, like construction and that. Well there they choose one to work. They are work corners. Well, in the end they chose me to work, supposedly, but it was something else. That was the first opportunity. (Participant 55, Salvadorian, 40)
Although all men were asked, a small number of Latino participants (n=3, 12%) reported being HIV positive at the time of the interview and discussed on the impact of their HIV status in terms of their sexual behaviors and sexual experiences. Virgilio talked about his sexual experiences with his wife:
I think she is afraid that I will infect her….We do not even have oral sex. For nothing do we have oral sex….We barely have sex….There is always a reason, well I always want to and she almost never wants to. I barely look for it because she always rejects me. So on that day I began to look for it and she responded. Perhaps we could have more sexual relations, more frequently, if I looked for it more. I feel bad when she rejects me. Sometimes when I look for it with her, and I am lucky then yes. One knows when you are rejected. (Participant 30, Mexican, 45)
When asked whether or not the he has been to support groups or has sought sexual health support from his care coordinator to explore ways to improve his sexual experiences with his wife, he responded:
Yes there are, but what happens is what I told you before, “that I do not get depressed.” But I do get very depressed going to a meeting where there are, for example, they invite me to meetings where people get together, and everyone there is talking about their experiences and how they feel and that depresses me. It depresses me to go to meetings and get together with other people, and that does depress me. I, I do not need that. (Participant 30, Mexican, 45)
A small number of the participants reported engaging in sexual activities with male and female partners when returning to their native countries. Virgilio talked about his sexual activities with his female sexual partner when he goes back to Mexico:
Yes, always. Well, I had a relationship with a girl for like five years. I would go to see her every year. (Participant 30, Mexican, 45)
Amador also talked about his sexual experiences when going back to his native country:
When I go to Venezuela I go for 15 days or for a week. I go with my family, later nothing, when I go out with my friends, they do not know that I am bisexual. Yes there is hand play, but no sex. (Participant 27, Venezuelan, 29)
Sexual Behaviors During the Past Year
In addition to lifetime sexual experiences, we collected data specific to sexual behaviors during the past year and most recent sexual behaviors with both male and female partners. Findings regarding sexual behaviors within the past year can also be found in Table 3. Vaginal sex was the most frequently reported sexual behavior during the past year (n=25,100%), with many of the respondents reporting it in the last 30 days (n=8, 32%) and others (n=7, 28%) in the last 90 days. Most of the men received oral sex from a male in the last year (n=21, 84%) and 20 (80%) received oral sex from a female partner. The majority of men (n=20, 80%) participated in insertive anal sex and less than half (n=11, 44%) were the receptive partner during anal sex. The majority of the men (n=18, 72%) reported performing oral sex on a female sexual partner and a smaller number (n=13, 52) performed oral sex on a man. Most of the men (n=15, 60%) experienced partnered masturbation with a male partner and 14 (56%) with female partners. A smaller number (n=8, 32%) engaged in sexual activity with partners online and giving something to a male (n=2, 8%) or female (n=4, 16%) in exchange for sex. A small number (n=3, 12%) received something from a man in exchange for sex and two (8%) from a woman in exchange for sex.
Sexual Behaviors at Last Event
Findings about the most recent sexual activity can be found in Table 4. All of the men engaged in vaginal sex with female sexual partners in their last encounter with women (n=25, 100%). The vast majority received oral sex from males (n=18, 72%) and females (n=18, 72%) and rubbed genitals with males (n=18, 72%) and females (n=20, 80%). Only eight (30%) reported being the receptive partner when performing anal sex with a male and one (4%) with a female. Most of the men engaged in insertive anal sex with a male (n=15, 60%) in their last sexual experience and three (12%) reported having insertive anal sex with a female.
Table 4.
Sexual Behaviors Performed During Most Recent Event (N = 25)
| Yes | No | |||
|---|---|---|---|---|
| n | % | n | % | |
| Rubbed Genitals with Male | 18 | 72.0 | 7 | 28.0 |
| Rubbed Genitals with Female | 20 | 80.0 | 5 | 20.0 |
| Performed Oral Sex on Male | 13 | 52.0 | 12 | 48.0 |
| Performed Oral Sex on Female | 12 | 48.0 | 13 | 52.0 |
| Received Oral Sex from Male | 18 | 72.0 | 7 | 28.0 |
| Recieved Oral Sex from Female | 18 | 72.0 | 7 | 28.0 |
| Vaginal Sex | 25 | 100.0 | 0 | 0.0 |
| Receptive Anal Sex with Male | 8 | 32.0 | 17 | 68.0 |
| Receptive Anal Sex with Female * | 1 | 4.0 | 24 | 96.0 |
| Insertive Anal Sex with Male | 15 | 60.0 | 10 | 40.0 |
| Insertive Anal Sex with Female | 3 | 12.0 | 22 | 88.0 |
Alcohol and Drug Use at Last Sexual Event
A substantial number of the participants reported that they were using alcohol with their male sexual partners during the most recent sexual act (n=11, 44%), and five (20%) reported that they were drinking alcohol by themselves in the most recent sexual activity with a man. Very few of participants (n=2, 8%) were using drugs in the most recent sexual activity with a man. A small number of participants (n=4, 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 act with a woman. Again, very few participants (n=2, 8%) were using drugs during the most recent sexual activity with a woman.
Alcohol became a “tool” for many of the men to engage in sexual activities with male partners; participants described how it often enabled the behavior. Aguado talked about his alcohol use when engaging in sexual activities with male partners, in particular:
I think I feel more comfortable doing this when I do drink alcohol more when I’m sober. (Participant 28, Venezuelan, 34)
Other participants reflected on dependence to alcohol and how it became the center of many of their experiences and sexual activities. Agustin reflected on his alcohol use and how it was essential to enable his interactions with others:
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. I like to communicate with people and stuff like that but when I have alcohol in my system, I don’t know who – I mean like when I’m drunk, they see [ ----] and look at me. I’m funny and whatever but if I’m not on alcohol, something is missing. (Participant 58, Venezuelan, 29)
Condom Use During at Last Sexual Event
Table 5 presents a summary of condom use during most recent sexual activities with both male and female partners. A fair number of men (n=10, 40%) reported not using a condom in their most recent sexual encounter with their male partner and only four (16%) reported using a condom the entire time. In regards to condom use during the most recent sexual activity with a female, nine (36%) reported not using a condom at all and two (8%) reported using it the entire time.
Table 5.
Condom Use at Last Event by Partner Gender (N = 25)
| Male Partner |
Female Partner |
|||
|---|---|---|---|---|
| n | % | n | % | |
| The entire time | 4 | 17.3 | 9 | 8.0 |
| Not at all | 10 | 33.3 | 2 | 36.0 |
Wilfredo discussed use of condoms with the male sexual partners and how condoms prevented him from not having “complete” sexual pleasure:
It is harder for me to use condoms with men. I have more pleasure with men and I don’t like giving oral sex with condoms. It is like eating an ice cream chocolate with the bag covering it. (Participant 52, Mexican, 24)
In terms of unprotected sex with female partners, some of the men reflected on the positive aspects of pregnancy and did not want to use a condom as a preventive measure of pregnancies. Felipe, a young migrant from Mexico reflected on the fact that he did not use condoms with his female partners because unintended pregnancy is not a major sexual health concern:
It would not be a problem for me because I want a child. (Participant 50, Mexican, 22)
Amador, an immigrant from Venezuela added:
Because I knew my wife and at that time I wanted to have babies but she was going to college. She wanted to have her career and that. (Participant 27, Venezuelan, 29)
Participants were asked to select from a list of factors they consider to be major sexual health risks. When asked to Michael, whether or not unintended pregnancy was a risk, as the result of not using condoms or other preventive measures, he reflected on the fact that pregnancy is not as big of a health concern as HIV:
Or perhaps, a pregnancy can have a solution, after so many months of being pregnant you are going to love what you are going to have in your arms when it is born. And when one already has HIV, what is it you are going to feel? (Participant 70, Mexican, 33)
Sexual Pleasure, Arousal, Orgasm, and Function at Last Event
Findings regarding sexual pleasure, arousal, orgasm and function can be found in Table 6. We assessed pleasure, arousal, orgasm and erectile difficulty during the most recent sexual act by partner gender, making this one of the first studies to gather data related to sexual experience from behaviorally bisexual Latino men. When asked about pleasure in the most recent sexual event with male partner, eleven (44%) reported having moderate pleasure with male partners and ten (66.7%) with female partners. In terms of arousal during the last sexual event, eight (32%) reported having a moderate arousal with male partners and twelve (48%) with female partners. Most of the participants reported having an orgasm during their last sexual activity with male partner (n=21, 84%) and twenty two (88%) with a female partner. In terms of erectile functioning, most of them reported not having erectile difficulty in their most recent sexual activities with male (n=21, 84%) and female (n=17, 69.3%) partners. We did not find notable differences between genders in terms of pleasure, arousal, orgasm and erectile functioning.
Table 6.
Pleasure, Arousal, Orgasm, and Erectile Difficulty During Most Recent Sexual Event by Partner Gender (N = 25)
| Male Partner | Female Partner | |||
|---|---|---|---|---|
| n | % | n | % | |
| Pleasure | ||||
| Extremely | 2 | 8.0 | 3 | 20.0 |
| Quite a bit | 5 | 20.0 | 3 | 20.0 |
| Moderately | 11 | 44.0 | 10 | 66.7 |
| A little | 5 | 20.0 | 6 | 40.0 |
| Not at All | 2 | 8.0 | 3 | 20.0 |
| Arousal | ||||
| Extremely | 7 | 28.0 | 4 | 16.0 |
| Quite a bit | 6 | 24.0 | 4 | 16.0 |
| Moderately | 8 | 32.0 | 12 | 48.0 |
| A little | 2 | 8.0 | 5 | 20.0 |
| Not at All | 2 | 8.0 | 0 | 0.0 |
| Orgasm | ||||
| Participant Orgasm | 21 | 84.0 | 22 | 88.0 |
| Sexual Partner Orgasm | 17 | 68.0 | 16 | 64.0 |
| Erectile Difficulty | ||||
| Not at all | 21 | 84.0 | 17 | 69.3 |
| A little bit | 2 | 8.0 | 4 | 18.7 |
| Somewhat | 0 | 0.0 | 1 | 6.7 |
| Very | 1 | 4.0 | 3 | 5.3 |
| Extremely | 1 | 4.0 | 0 | 0.0 |
| Erectile Medication Use | 0 | 0.0 | 1 | 4.0 |
Roberto was asked how pleasurable his most recent sexual act with his female partner was and he mentioned that “intercourse” with a female enhanced pleasure, in particular:
I have to say extremely because it was the full intercourse. (Participant 25, Venezuelan, 28)
When asked about pleasure, Alejandro talked about the frequency of his sexual acts with his wife and pleasure:
A lot, I would not know how to tell you, we have been married two years and it was almost every day. (Participant 17, Mexican, 27)
Ricky met a female sexual partner and had sex with her only once; while he reported arousal and did not have difficulty having an orgasm, he mentioned the lack of pleasure when engaging in casual sexual activity with this specific female partner:
It was one of those things that you wish you didn’t do but it’s just kind of I wish it never happened but I can’t really do anything about it anymore so no, it wasn’t pleasurable at all. (Participant 32, Mexican, 21)
When asked about excitement in the most recent sexual act, Felipe mentioned the lack of excitement with his male sexual partner because he knew it was not going to last and it was more of a one-time sexual interaction:
Because in the moment that I am with the person, I tell myself, “What am I doing?” because I know he is going to leave after that and things like that and I cannot help but to think about it. (Participant 50, Mexican, 22)
For Daniel, his sexual relationship with the most recent female sexual partner was only for sexual pleasure, unlike his previous relationship with his girlfriend back in El Salvador:
Ah, it does not mean anything, just pleasure at that moment, but later it does not mean anything to me, nothing important…. I used to have a girlfriend, it was a stable partner; I was with her for like four years. It was a stable relationship; I had sexual relations but it was because of love. That was in El Salvador. The girl I was with two months ago was just simply about sex. (Participant 51, Salvadorian, 21)
Daniel reflected on the differences between sexual partners in or outside a “relationship” and how sexual interactions might vary, affecting pleasure, arousal and orgasm. In addition, while there were not major differences reported between genders, there were some participants, like Daniel, who felt that the gender of their partner played a major role impacting pleasure:
No, I like to do everything. I feel more pleasure doing it with a man, I feel more used to doing it with a man, I know how I want them to treat me, and I also know how men want to be treated. I feel more sure and safe. With a woman, I actually do not know when she is satisfied. (Participant 51, Salvadorian, 21)
Transgender Sexual Experiences
It is important to note that, as in other samples of bisexual Latino men, a small number of participants reported engaging in sexual activity with transgender, cross-dressed, or transsexual individuals (n=2, 8%) during the most recent sexual event. Some also reported that they are only attracted to transgender or transsexual partners. Several of the Latino participants reported having sexual activity with transgender, transsexual or cross-dressed individuals during their lifetime.
Alejandro felt comfortable socializing and interacting with transgender, cross-dressed, or transsexual individuals, as well as the fluidity of sexual expressions and sexuality while interacting with transvestites:
Oh yes, yes at work for example I am straight and in my house too. But among my friends that are transvestites or gay, no, with them I am like I am. (Participant 17, Mexican, 27)
Claudio, a young Mexican immigrant who is only attracted to transgender, cross-dressed, or transsexual partners further explained the communication and relationship bonds with transgender females.
Now, if I am with a woman that is my type, the first thing I see is that she is my type. I have met a lot of gays that are dressed, and we don’t get along, but with this person there is a lot of communication. I tell her, let’s go out and all that. I give her the place of a woman and not the place of someone gay. I give her the place of a woman, well I say, you have a pretty face. I tell her, I am giving you the place of a woman, realize what I am doing. If you go out to dance and are very shameless in your dancing, I tell them to try to watch that because it is disrespectful. She tells me, but look at the slutiness, and I say that to get respect you have to give respect. As your friend, I don’t like them to come and touch you. She tells me that I am jealous, and I tell her that I am not jealous but I look after your wellbeing and that you are fine. I tell her if you go out with a small skirt they will kill you and rape you, I say it for your own good what I feel, and that’s how it is. (Participant 4, Mexican, 23)
Virgilio expanded on his sexual attractions to transgender, cross-dressed, or transsexual individuals and mentioned that he was only attracted to those dressed like women but also mentioned his consciousness rejection to sexual behaviors with these individuals:
I did look at the men dressed as women and I am attracted to them but I always said that I am not like that and that I am not going to get involved with a transvestite. (Participant 30, Mexican, 45)
Self-Administered STI Specimen Collection and Implications for Future Testing Efforts
All the Latino participants participated in the STI testing, which included a self-sampling for urine and rectal infections. Overall, two (8%) Latinos tested positive for STI. Three of them (12%) reported being HIV positive, one who was HIV positive also tested positive for STI.
Some of the participants talked about the positive aspect of offering the STI screening as part of the study. Yosmani has been tested before but since he has unprotected sex with his female and male partners, he perceived the self-administered STI screening as a positive aspect of being part in the study:
Although I haven’t felt any symptoms and I have checked myself and I haven’t gotten anything, but I think when you don’t protect yourself you can expose yourself to those diseases. (Participant 19, Cuban, 24)
Other participants reflected on the embarrassment of conducting the self-administered STI screening but acknowledged the importance of testing and screening accessibility for sexually active men. Carlos had never been tested for rectal infections and saw the screening as an opportunity to find out more about his health status:
Well it wasn’t that difficult, yes a little embarrassing, but at the same time it is very good because I will find out a lot of things. I will find out if I am fine or not. (Participant 29, Mexico, 22)
Alberto, a Honduran migrant, had never been tested for HIV or any other STI even though he has been sexually active and had regular unprotected sex with both with both male and female partners. He talked about the benefits of the self-sampling by being part of the research study. In addition, he discussed discrimination and prejudice he experienced with some health care professionals in clinics:
In the clinic sometimes they reject you; I feel good because I didn’t expect to get these tests. I feel good because it will resolve a big doubt of mine, I will be done doubting. It never went through my mind to get these exams. (Participant 11, Honduran, 21)
Discussion
This study presents one of the first comprehensive assessments of sexual behaviors and related factors of behaviorally bisexual Latino men in the Midwestern U.S. The study responds to previous concerns as well as the future steps recently reported by the Institute of Medicine in order to better serve the growing public health needs of a wide diverse range of bisexual, lesbian, gay, and transgender people (Institute of Medicine, 2011).
Specifically, we assessed sex at the most recent sexual event, as well as past year sexual behaviors with male and female partners and the lifetime sexual experiences. We found that behaviorally bisexual Latino men engage in a wide range of sexual behaviors and are a unique group with distinct sexual behavioral characteristics, making them distinct from men who have sex exclusively with men (MSM). The most commonly reported sexual behaviors were masturbation, vaginal intercourse, and receiving oral sex from male and female partners. Most of the participants were the insertive partner during anal sex with male partners and a fewer reported being the receptive partner during anal sex.
Migration seems to play an important role in some of the participants’ sexual behaviors; for instance, a small number reported having sex with male and female partners when visiting their native countries. It seems to be an essential part of many of these men to engage in a wide range of sexual behaviors in their native country, particularly with female sexual partners. Programs should be able to incorporate an essential component of sexual behavior understanding the fluidity of sexual activity as it relates to their migration experience.
Many of participants reported alcohol use during their most recent sexual activity with a male partner, while a smaller number reported alcohol use with their most recent female partner. A fair number of participants reported not using condom in their last sexual encounter with both male and female partners. Particularly, some of the men did not use condom with their female partners because of their desire to have children or did not see pregnancies as a negative sexual health concern. Interestingly, there were not major differences in terms of pleasure, arousal, orgasm and erectile functioning during the most recent sexual event by partner gender. Further, a small but fair amount of men engaged in sexual activities with transgender, transsexual, and crossed-dressed partners. All of the participants in the study participated in the optional self-administered diagnostics for STI and discussed about the benefits of the procedure since many of the men in our study never had been tested for STI.
We did not found major differences in pleasure, arousal, orgasm and erectile functioning during the most recent sexual event based on the gender of the partner. While there were not major differences, some of the participants did reflect on the significance of pleasure in their sexual activities depending on the gender of their partner. For instance, many of the men reported how pleasurable was to engage in vaginal intercourse with their female sexual partners as well as being the insertive partner with their male partners. In addition, other reflected on their sexual behaviors, exclusively with transgender, cross-dressed and transsexual partners. Interventions addressing the needs of behaviorally bisexual Latino men should acknowledge these activities and their unique public health implications.
When developing interventions for behaviorally bisexual Latino men, it is important to consider the cultural and demographic characteristics, as well as the unique sexual behaviors of this group. Public health interventions may target the most common sexual behaviors such as vaginal intercourse, as well as oral sex with both male and female partners and may focus on the risks associated with unprotected sex when engaging in insertive anal sex with male partners. In our study, a small number of men reported being HIV positive and reflected on the lack of sexual health information and support in how to improve their sexual experiences with their non-positive partners. In addition, a component of the potential intervention should take into consideration the alcohol use among these men, particularly when engaging in sexual activities, in particular with male partners.
Programs targeting Latino bisexual men should place a strong emphasis on the importance of condom use in order to prevent HIV and other STI since many of the men reported the infrequency of condom use with both male and female partners. Many of the participants noted that they did not use condoms with female partners in particular, because of the desire to have children. Public health professionals and counselors should emphasize the importance of family and procreation, as necessary, but it should also emphasize on the significance of bearing children and the major responsibilities associated with it as well as the potential for disease transmission so that individuals make informed decisions.
Future public health assessments and programs for bisexual men may benefit from the incorporation of self-administered STI screening options since all of the Latino participants in our sample took part and reflected on the benefits of screening and testing availability, even men who had never been tested for STI. Since most of the Latino Interviews were conducted at Casa Mateo, a community based organization serving the community, some participants also wanted to get tested for HIV and the certified staff from Casa Mateo, a community based organization serving the sexual health needs of Latinos in the community, conducted the HIV testing for those who were interested. Educational information was provided in English and Spanish to all of the participants after completing the study interview. In fact, all of the participants received a document with a list of resources in the community, including testing centers and online websites with HIV/AIDS and STI information.
The results of this study must be considered while also taking into account limitations. As probability samples of bisexual men are difficult to obtain due to the nature of the community (Jeffries & Dodge, 2007), we relied on convenience sampling techniques. Community members helped to reach a wide range of men in Indianapolis and surrounding areas but the sample might not reflect the sub-populations within the behaviorally bisexual community. Even though we included a diverse group of men in terms of marital status, we might have missed other group of men engaging in same sex behaviors.
Our research team successfully implemented a community-based participatory research approach in this study. Community members and health care professionals were able to contribute to the study by working with researchers on the development of the study materials, including the study protocol and recruitment strategies. Latino community members, including health and outreach workers as well as bisexual men, helped with the development of the study protocols, making it culturally and linguistically congruent. The community members identified a wider range of recruitment venues, including stores in the formed “Latino enclave,” barber shops, restaurants and also resources that could be used by the participants, including testing venues and online information about HIV/STI. In particular, the work with our main community Latino partner enabled the research team to have access and connect with Latino radio stations and build trust with these community venues. Research findings have been distributed and disseminated among our community partners in order to raise knowledge and awareness on issues affecting behaviorally bisexual men. Future research may continue to use community-based approaches in order to reach this ‘hidden’ and underserved community.
For the majority of our participants, various aspects of their sexuality including behaviors, pleasure, arousal, function, and orgasm, were similar whether they were with a woman or a man. However, these men are unique by virtue of that fact that they share these experiences with both male and female and sometimes transgender sexual partners. Given the distinct patterns of sexual behaviors and experience of these men, traditional HIV/STI interventions targeting exclusively heterosexual or homosexual individuals may not be appropriate. Ironically, previous narrow examinations of sexual risk among bisexual men may have resulted in work that provides us with a very limited understanding of the behaviors and interactions that much of this work seeks to change. Future research should investigate the development, implementation, and evaluation of sexual health interventions tailored for diverse groups of behaviorally bisexual men in order to determine their utility and effectiveness in meeting the needs of this unique population. Based on the assessment conducted and the wide array of findings in regards to sexual behaviors and related issues, our study team is in the process of developing a comprehensive sexual health intervention in order to address the needs and concerned raised by the participants in our study (Dodge, et al., in press 3).
Acknowledgements
Funding for this study was provided by the National Institutes of Health grant R21 HD059494 (Brian Dodge, Ph.D., Principal Investigator). We would like to express our deepest appreciation to the members of the study’s Community Advisory Committee, whose insight guided the researchers throughout the study process. We thank Caridad Austin, a certified translator and a law school student at Indiana University Maurer School of Law transcribed and translated all interviews that were conducted in Spanish. In particular, we acknowledge the efforts of one community-based organization, Casa Mateo/Latino Action League, Inc., for their assistance with and commitment to this research initiative to reach out to Latino bisexual men.
References
- Bruce D, Ramirez-Valles J, Campbell RT. STIGMATIZATION, SUBSTANCE USE, AND SEXUAL RISK BEHAVIOR AMONG LATINO GAY AND BISEXUAL MEN AND TRANSGENDER PERSONS. [Article] Journal of Drug Issues. 2008;38(1):235–260. [Google Scholar]
- Business II. Report Ranks Indiana Last in Federal Public Health Funding. 2009. 2010.
- Deardorff J, Tschann JM, Flores E, Ozer EJ. Sexual Values and Risky Sexual Behaviors Among Latino Youths. [Article] Perspectives on Sexual & Reproductive Health. 2010;42(1):23–32. doi: 10.1363/4202310. doi: 10.1363/4202310. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Diaz RM, Ortega AN. Latino gay men and HIV: culture, sexuality, and risk behavior. 1998.
- Dodge B, Van Der Pol B, Reece M, Malebranche DJ, Martinez O, Goncalves G, Schnarrs PW, Nix R, Fortenberry JD. Rectal self-sampling in non-clinical venues for the detection of rectal sexually transmitted infections (STI) among behaviorally bisexual men. Sexual Health. doi: 10.1071/SH11068. (in press 1) [DOI] [PMC free article] [PubMed] [Google Scholar]
- Dodge B, Schnarrs PW, Reece M, Martinez O, Malebranche D, Goncalves G, Van Der Pol B, Nix R, Fortenberry JD. Sexual behaviors and experiences among bisexual men in the Midwestern United States. Archives of Sexual Behavior. doi: 10.1007/s10508-011-9878-2. (in press 2) [DOI] [PMC free article] [PubMed] [Google Scholar]
- Dodge B, Schnarrs PW, Goncalves G, Reece M, Martinez O, Malebranche D, Nix R, Van Der Pol B, Fortenberry JD. The significance of privacy, trust, and comfort in providing health-related services to behaviorally bisexual men. AIDS Education & Prevention. doi: 10.1521/aeap.2012.24.3.242. (in press 3) [DOI] [PMC free article] [PubMed] [Google Scholar]
- Doll L, Myers T, Kennedy M, Allman D. Bisexuality and HIV risk: Experiences in Canada and the United States. [Article] Annual Review of Sex Research. 1997;8:102. [PubMed] [Google Scholar]
- Doll LS, Beeker C. Male bisexual behavior and HIV risk in the United States: synthesis of research with implications for behavioral interventions. AIDS Education And Prevention: Official Publication Of The International Society For AIDS Education. 1996;8(3):205–225. [PubMed] [Google Scholar]
- Doll LS, Petersen LR, White CR, Johnson ES, Ward JW. Homosexually and Nonhomosexually Identified Men Who Have Sex With Men: A Behavioral Comparison. [Article] Journal of Sex Research. 1992;29(1):1–14. [Google Scholar]
- Elliott R, Fischer CT, Rennie DL. Evolving guidelines for publciation of qualitative research studies in psychology and related fields. British Journal of Clinical Psychology. 1999;38:215–229. doi: 10.1348/014466599162782. [DOI] [PubMed] [Google Scholar]
- Fernandez-Esquer ME, Diamond P, Atkinson J. Lazos que Atan: The Influence of Normative Gender Beliefs on Sexual Risk Behaviors of Latino Men and Women. [Article] Journal of Applied Social Psychology. 2010;40(12):2969–2994. doi: 10.1111/j.1559-1816.2010.00689.x. [Google Scholar]
- Haile R, Padilla MB, Parker EA. ’Stuck in the quagmire of an HIV ghetto’: the meaning of stigma in the lives of older black gay and bisexual men living with HIV in New York City. [Article] Culture, Health & Sexuality. 2011;13(4):429–442. doi: 10.1080/13691058.2010.537769. doi: 10.1080/13691058.2010.537769. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Halloran L. UNDER THE SUN. [Article] U.S. News & World Report. 2005;138(23):20–25. [Google Scholar]
- Health, I. S. D. o. Spotlight on HIV/STD/Hepatitis: Indiana semi-annual report. 2006.
- HIV prevalence, unrecognized infection, and HIV testing among men who have sex with men--five U.S. cities, June 2004-April 2005. MMWR. Morbidity And Mortality Weekly Report. 2005;54(24):597–601. [PubMed] [Google Scholar]
- IOM . The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. The National Academies Press; Washington, DC: 2011. [PubMed] [Google Scholar]
- Izazola-Licea JA, Gortmaker SL, de Gruttola V, Tolbert K, Mann J. Sexual behavior patterns and HIV risks in bisexual men compared to exclusively heterosexual and homosexual men. Salud Pública De México. 2003;45(Supp 5):S662–S671. doi: 10.1590/s0036-36342003001100012. [DOI] [PubMed] [Google Scholar]
- Jeffries WL, Dodge B. Male bisexuality and condom use at last sexual encounters: Results from a national survey. Journal of Sex Research. 2007;44:278–289. doi: 10.1080/00224490701443973. [DOI] [PubMed] [Google Scholar]
- Magaña JR, Carrier JM. Mexican and Mexican American Male Sexual Behavior & Spread of AIDS in California*. [Article] Journal of Sex Research. 1991;28(3):425–442. [Google Scholar]
- Malebranche DJ. Bisexually Active Black Men in the United States and HIV: Acknowledging More Than the “Down Low”. [Article] Archives of Sexual Behavior. 2008;37(5):810–816. doi: 10.1007/s10508-008-9364-7. doi: 10.1007/s10508-008-9364-7. [DOI] [PubMed] [Google Scholar]
- Martinez O, Dodge B, Reece M, Schnarrs PW, Rhodes S, Goncalves G, Muñoz-Laboy M, Malebranche D, Van Der Pol B, Nix R, Kelle G, Fortenberry JD. Sexual health and life experiences: Voices from behaviourally bisexual Latino men in the Midwestern USA. Culture, Health & Sexuality. 2011;13(9):1073–1089. doi: 10.1080/13691058.2011.600461. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Montgomery JP, Mokotoff ED, Gentry AC, Blair JM. The extent of bisexual behaviour in HIV-infected men and implications for transmission to their female sex partners. AIDS Care. 2003;15(6):829–837. doi: 10.1080/09540120310001618676. [DOI] [PubMed] [Google Scholar]
- Muñoz-Laboy M, Dodge B. Bisexual Latino Men and HIV and Sexually Transmitted Infections Risk: An Exploratory Analysis. [Article] American Journal of Public Health. 2007;97(6):1102–1106. doi: 10.2105/AJPH.2005.078345. doi: 10.2105/ajph.2005.078345. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Nakamura N, Zea MC. Experiences of homonegativity and sexual risk behaviour in a sample of Latino gay and bisexual men. [Article] Culture, Health & Sexuality. 2010;12(1):73–85. doi: 10.1080/13691050903089961. doi: 10.1080/13691050903089961. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Perreira KM, Chapman MV, Stein GL. Becoming an American Parent. [Article] Journal of Family Issues. 2006;27(10):1383–1414. doi: 10.1177/0192513x06290041. [Google Scholar]
- Prabhu R, Owen CL, Folger K, McFarland W. The bisexual bridge revisited: sexual risk behavior among men who have sex with men and women, San Francisco, 1998-2003. AIDS (London, England) 2004;18(11):1604–1606. doi: 10.1097/01.aids.0000131366.05823.87. [DOI] [PubMed] [Google Scholar]
- Reece M, Dodge B. A study in sexual health applying the principles of community-based participatory research. Archives of Sexual Behavior. 2004;33(3):235–247. doi: 10.1023/B:ASEB.0000026623.69017.df. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Reece M, Herbenick D, Schick V, Sanders SA, Dodge B, Fortenberry JD. Background and considerations on the National Survey of Sexual Health and Behavior (NSSHB) from the investigators. Journal of Sexual Medicine. 2010;7(suppl 5):243–246. doi: 10.1111/j.1743-6109.2010.02038.x. [DOI] [PubMed] [Google Scholar]
- Reisen CA, Zea MC, Bianchi FT, Poppen PJ, Shedlin MG, Penha MM. Latino Gay and Bisexual Men’s Relationships with Non-Gay-Identified Men Who Have Sex With Men. [Article] Journal of Homosexuality. 2010;57(8):1004–1021. doi: 10.1080/00918369.2010.503510. doi: 10.1080/00918369.2010.503510. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Rhodes SD, Hergenrather KC, Bloom FR, Leichliter JS, Montaño J. OUTCOMES FROM A COMMUNITY-BASED, PARTICIPATORY LAY HEALTH ADVISER HIV/STD PREVENTION INTERVENTION FOR RECENTLY ARRIVED IMMIGRANT LATINO MEN IN RURAL NORTH CAROLINA. [Article] AIDS Education & Prevention. 2009;21:103–108. doi: 10.1521/aeap.2009.21.5_supp.103. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Rhodes SD, Hergenrather KC, Montaño J, Remnitz IM, Arceo R, Bloom FR, Bowden WP. USING COMMUNITY-BASED PARTICIPATORY RESEARCH TO DEVELOP AN INTERVENTION TO REDUCE HIV AND STD INFECTIONS AMONG LATINO MEN. [Article] AIDS Education & Prevention. 2006;18(5):375–389. doi: 10.1521/aeap.2006.18.5.375. [DOI] [PubMed] [Google Scholar]
- Rhodes SD, Malow RM, Jolly C. COMMUNITY-BASED PARTICIPATORY RESEARCH: A NEW AND NOT-SO-NEW APPROACH TO HIV/AIDS PREVENTION, CARE, AND TREATMENT. [Article] AIDS Education & Prevention. 2010;22(3):173–183. doi: 10.1521/aeap.2010.22.3.173. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Riffe HA, Turner S, Rojas-Guyler L. The Diverse Faces of Latinos in the Midwest: Planning for Service Delivery and Building Community. [Article] Health & Social Work. 2008;33(2):101–110. doi: 10.1093/hsw/33.2.101. [DOI] [PubMed] [Google Scholar]
- Stokes JP, McKirnan DJ, Burzette RG. Sexual Behavior; Condom Use, Disclosure of Sexuality, and Stability of Sexual Orientation in Bisexual Men. [Article] Journal of Sex Research. 1993;30(3):203–213. [Google Scholar]
- Susan YC, Peterman TA, Doll LS, Buehler JW, Curran JW. AIDS in Bisexual Men in the United States: Epidemiology and Transmission to Women. [Article] American Journal of Public Health. 1992;82(2):220–224. doi: 10.2105/ajph.82.2.220. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Trossman S. No easy answers. [Article] American Nurse. 2004;36(6):1–6. [PubMed] [Google Scholar]
- VanDevanter N, Duncan A, Burrell-Piggott T, Bleakley A, Birnbaum J, Siegel K, Ramjohn D. The Influence of Substance Use, Social Sexual Environment, Psychosocial Factors, and Partner Characteristics on High-Risk Sexual Behavior Among Young Black and Latino Men Who Have Sex with Men Living with HIV: A Qualitative Study. [Article] AIDS Patient Care & STDs. 2011;25(2):113–121. doi: 10.1089/apc.2010.0100. doi: 10.1089/apc.2010.0100. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Zea MC, Reisen CA, Díaz RM. Methodological Issues in Research on Sexual Behavior With Latino Gay and Bisexual Men. [Article] American Journal of Community Psychology. 2003;31(3/4):281. doi: 10.1023/a:1023962805064. [DOI] [PubMed] [Google Scholar]
- Zellner JA, Martínez-Donate AP, Sañudo F, Fernândez-Cerdeno A, Sipan CL, Hovell MF, Carrillo H. The Interaction of Sexual Identity With Sexual Behavior and Its Influence on HIV Risk Among Latino Men: Results of a Community Survey in Northern San Diego County, California. [Article] American Journal of Public Health. 2009;99(1):125–132. doi: 10.2105/AJPH.2007.129809. doi: 10.2105/ajph.2007.129809. [DOI] [PMC free article] [PubMed] [Google Scholar]