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. Author manuscript; available in PMC: 2017 Dec 14.
Published in final edited form as: Cult Health Sex. 2016 Jun 14;18(12):1407–1419. doi: 10.1080/13691058.2016.1189595

‘He’s still with these girls’: Exploring perceptions of HIV risk among men with behaviourally bisexual male partners

Whitney Williams a, Tamar Goldenberg a, Karen L Andes b, Catherine Finneran b, Rob Stephenson c
PMCID: PMC5156575  NIHMSID: NIHMS832719  PMID: 27297775

Abstract

Recent studies have called for more nuanced research into the relationships between behaviourally bisexual men and their sexual partners. To address this, we conducted a longitudinal qualitative study with self-identifying gay men; participants took part in timeline-based interviews and relationship diaries. We conducted thematic analysis of verbatim transcripts to understand how relationship motivations, emotions and relationship dynamics influenced perceptions of HIV risk with behaviourally bisexual male partners. Participants described how partnership types (main and casual) and relationship dimensions (exclusivity, commitment, emotional attachment, and relationship designation) strongly influenced perceptions of HIV risk and shaped their decisions to choose behaviourally bisexual male sex partners. Results revealed the crucial role relationship dynamics play in the shaping of HIV risk perceptions, sexual decision-making and HIV risk between partners and provide potential insight on how to message HIV risk to gay men and their behaviourally bisexual male partners. It is imperative that HIV prevention is able to message key concepts of risk, decision-making and partner negotiation in a way that does not act to stereotype or create stigma against behaviourally bisexual men and their male partners.

Keywords: Behavioural bisexuality, HIV risk, sexual agreements, gay men, USA

Introduction

In the USA, men who have sex with men (MSM) accounted for 65% of new HIV diagnoses in 2013 (Centers for Disease Control and Prevention 2013). While men who have sex with men face the highest burden of new HIV infections, women represent a disproportionate share of HIV infections acquired through heterosexual contact. In 2013, CDC estimates attributed 17% of diagnosed HIV infections to heterosexual contact for women compared to 8% for men, and while women comprised around 21% of new HIV infections, 86% were attributed to male-female sexual contact (Centers for Disease Control and Prevention 2014a, 2014b). Substantial research has investigated drivers of the both epidemics, with particular attention paid to the role of men who have sex with men and women (MSMW) (often referred to as behaviourally bisexual men) in potentially “bridging” the HIV epidemics between men who have sex with men and women (Stokes et al. 1996; Stokes and Peterson 1998; Hightow et al. 2006; Jeffries and Dodge 2007; Mercer et al. 2009; Martinez et al. 2011; Malebranche et al. 2012; Centers for Disease Control and Prevention 2013, 2014a, 2014b; Oster et al. 2015). While there is consensus on the need to understand the drivers of HIV incidence in both groups, some researchers have critiqued the risk-centred framework and tone through which health scientists have historically described and explored same-sex behaviours of men who have sex with men and women (Stokes, Vanable, and Mckiran 1997; Millett et al. 2005; O’Leary and Jones 2006; Pathela et al. 2006; Jeffries and Dodge 2007; Dodge, Iv, and Sandfort 2008; Malebranche 2008; Gorbach et al. 2009; Bond et al. 2009; Beyrer et al. 2010; Mitchell, Moskowitz, and Seal 2012; Tieu et al. 2012). Some argue that the dominance of epidemiological and risk behaviour analysis in the literature presents a potentially reductive and stigmatising portrait of male bisexual relationships, and call for the need for studies that provide greater insight into the relationship dynamics motivations and emotions that inform how gay and behaviourally bisexual men perceive risk from their partners and how those perceptions inform sexual decision-making (Dodge, Iv and Sandfort 2008; Malebranche 2008).

Recent research on the relationship between partner choice, negotiation skills and the decision to engage in condomless anal intercourse provides some insight on the influence of relationship motivations on sexual decision making between male-male partners. Studies by Goodreau et al. (2012) and Sullivan et al. (2009) revealed that one to two thirds of men who have sex with men acquire HIV from a primary partner, indicating that HIV transmission is largely shaped by increased frequency of condomless anal intercourse with main compared to casual partners, a product to some extent of perceptions of trust within relationships (Sullivan et al. 2009). Studies have shown that some men who have sex with men employ elements of partner choice, specifically the use of serosorting (the practice of limiting condomless anal intercourse to partners with the same HIV status) and strategic sexual positioning (engaging in insertive rather than receptive anal intercourse with a HIV infected partner or partner of unknown status) as HIV risk reduction strategies (Parsons et al. 2005; Grace et al. 2014; Wilton et al. 2015). While this research has focused primarily on men who have sex with men, other studies have shown that men who have sex with men and women also employ protective behaviours such as strategic sexual positioning and reduced frequency of anal intercourse with both male and female partners (Dodge, Iv, and Sandfort 2008; Jeffries 2009, 2010).

Similarly, some recent studies provide insight into the emotional context and relationship dynamics that inform sexual decision-making in male-male couples (Goldenberg et al. 2014; Gomez et al., 2012). In a study by Goldenberg et al, participants described how feelings of love, intimacy and trust reduced HIV risk perceptions towards partners and facilitated engagement in condomless anal intercourse. A study by Bauermeister (2012) that applied Sternberg’s Triangular Theory of Love (1986) to examine the relationship between romantic ideation (i.e. passion, intimacy, and commitment) and number of sexual partners with whom participants engaged in condomless anal intercourse found that participants with higher scores on constructs of commitment and exclusivity reported fewer partners with whom they engaged in condomless anal intercourse (Bauermeister 2012). Sternberg’s Triangular Theory of Love (1986) explains interpersonal love in terms of three interrelated components: intimacy (the emotional component encompassing ‘feelings of closeness, connectedness and “bondedness”‘ with a partner), passion (a sexual component encompassing sexual attraction, desire and consummation), and commitment (a cognitive component encompassing ‘in the short term, the decision that one loves another, and in the long term, the commitment to maintain that love’) (Sternberg 1986, p119) (Sternberg 1997; Bauermeister 2012).

While these findings suggest that relationship motivations (i.e. partner choice), emotional context (e.g. trust and love) and relationship dynamics (i.e. romantic ideation, intimacy and commitment) are important influences on sexual decision-making between male-male couples, examinations into the relationship motivations, emotions and relationship dynamics specifically between gay men and their behaviourally bisexual partners and implications for HIV risk are absent from the literature. Through interviews with men who identify as gay and bisexual, this study aims to understand how some gay men conceptualise and perceive HIV risk of behaviourally bisexual partners by understanding why some gay men specifically choose behaviourally bisexual partners and how dynamics within their relationships influence perceptions of HIV risk. Answers to these questions not only add nuance to the body of literature on behavioural bisexuality but also have the potential to inform the messaging of HIV risk for behaviourally bisexual men and their male partners.

Methods

Study population and procedures

A 10-week longitudinal qualitative study was conducted with self-identified gay and bisexual men in Atlanta, GA between November 2012 and April 2013. The Emory University Institutional Review Board approved the study. Participants were men who previously participated in research at Emory University and were eligible if they identified as a gay or bisexual man, were aged ≥18 years, lived in the Atlanta metropolitan area, and had had anal intercourse with a man without a condom in the past three months. A total of 25 men participated in the study with 100% retention during the study period. The majority of participants (92%, n=23) identified as gay, while two identified as bisexual (8%, n=2). The original aim of the study was to explore how emotions shaped HIV risk taking among gay men: these results have been presented elsewhere (Goldenberg et al. 2014). During the interviews, however, it became apparent that a number of gay men were reporting deliberately seeking out bisexual male partners. We thus took the opportunity to explore gay men’s perceptions of HIV risk towards behaviourally bisexual partners within this sample.

Participants first completed a baseline in-depth interview (IDI) during which they described past dating and relationship histories by building a life-history timeline. The timelines allowed for the systematic exploration of relationship histories over time and across partners. Participants discussed up to five partners who they considered “significant or memorable”. For each partner, participants discussed emotional aspects in the partnership by placing predetermined labels on the timeline and answering follow-up questions that examined relationship dynamics, rules, feelings and emotions. To describe their sexual experiences with each partner, participants placed stickers on the timeline to indicate the frequency of anal sex both with and without a condom. To facilitate discussion on participants’ general definitions of risk and comparisons between partners, participants were then asked to rank each partner based on how risky they were for HIV and STIs with a set of stickers defining HIV/STI risk from the riskiest partner (1) to least risky partner (5). Participants were then asked to explain their rankings and definitions of risk.

After baseline interviews, participants completed three web-based quantitative personal relationship diaries (PRD) in which they entered information on sexual experiences and accompanying emotions with partners over the study period. Participants reported the number of partners with whom they had oral and/or anal sex, the number of oral, penetrative anal, or receptive anal sexual encounters with each partner, and the frequency of condom use for all acts. They ranked each partner on a scale of 1–5 on how well they knew their partner as well as the partner’s emotional risk and HIV/STI risk to them. To capture additional emotional aspects of relationships, participants applied statements describing various relationship characteristics/emotions (e.g. ‘I get jealous when he flirts with other people’, ‘I don’t know the first thing about him’).

To gain insight into participants’ emotions and sexual decisions with partners as well as the changes in these emotions and decision-making processes over the study period, each participant took part in a second debrief interview in which they discussed data extracted from the personal relationship diaries. For the debrief interview, a separate timeline was created and displayed for each partner and the interview guide was tailored to each participant based on his reported experiences in the diaries (e.g. participants with multiple partners, or participants with one sexual partner). Interviewers asked participants to reflect and expand upon the data displayed on the timelines and walked participants through a similar process of using predetermined stickers to add new information.

Of the 25 men who participated in the study, only seven participants discussed relationships with behaviourally bisexual partners. Each of these seven men discussed up to 5 partners per interview, which yielded descriptions of 65 relationships. Therefore the analysis presented here is based on the descriptions of 65 relationships provided by seven men, with the focus on comparing the perceptions and decision-making between their behavioural bisexual and non-behaviourally bisexual male partners. We acknowledge that seven men is a small sample, but the thick descriptions of the 65 relationships provided rich data to compare for the first time the perceived differences between behaviourally bisexual and other sex partners. We acknowledge further limitations later in the paper.

Data analysis

All interviews were audio-recorded and transcribed verbatim. Data were analysed using MAXqda 10 software (Verbi Software, Berlin, Germany). Interviews were first analysed as individual life stories which characterised the relationship styles, patterns of condom use, and risk definitions of each participant. A preliminary codebook was created, tested, and consistently applied to all verbatim transcripts based on recurring themes by a team of six analysts. Discussions of exclusivity, unique relationship dynamics and risk with behaviourally bisexual partners emerged inductively from initial readings of the data. Despite the small number of direct participant responses, analysis was pursued based on the emergence of strong themes, number of partners discussed and the lack of exploration of romantic relationships between gay and behaviourally bisexual men in the literature.

Thematic analysis occurred in two stages. The first stage included a preliminary exploration of recurring themes around relationship types/designations, concurrency, and sexual/emotional risk with behaviourally bisexual partners. This stage focused on segments of text with the codes ‘exclusivity’ and ‘risk’ among participants who described relationships with behaviourally bisexual partners. The code exclusivity encompassed both exclusivity and non-exclusivity and was defined as ‘concurrency, monogamy, cheating, fidelity, sexual agreements or women on the side’. Risk was defined as ‘emotional risk, risk definitions, describing something as risky/not risky, risk ranking, HIV/STI risk, other HIV/STI risk reduction techniques besides condom use, Safe/Unsafe in the context of sexual risk’.

While preliminary analysis was based on responses from seven participants, the second stage used descriptions of each relationship as the final unit of analysis (n=65). Since the study aimed to specifically explore relationship dynamics between partners, changing the unit of analysis from participants to relationships served to not only expand the final analytic sample but also better align the unit of analysis with the study aims. Descriptions of behaviourally bisexual partners (n=22) were categorised by relationship designation, sexual orientation/behaviour, concurrency, and perceptions of HIV/STI and emotional risk. Descriptions of partners who exclusively had sex with other men (MSM partners, n=43) were used as a comparison group. This analysis revealed two predominant partnership types: main and casual partnerships. Coded text describing main behaviourally bisexual partners (n=12), main gay partners (n=20), casual behaviourally bisexual partners (n=10) and casual gay partners (n=23) were analysed and thick descriptions were created on themes, patterns and variations between the groups. We present salient quotes and use pseudonyms to protect the identity and privacy of participants and their partners.

Results

Participants described how relationship dimensions and partnership type shaped dynamics with behaviourally bisexual male partners. Variations in relationship dynamics informed how participants defined and perceived HIV risk from their partners. Partnerships types were described as main or casual and relationship dimensions included: exclusivity, commitment, emotional attachment, and relationship designation. Participants perceived main behaviourally bisexual partners as among their most risky for HIV among main partners. Partnerships with main behaviourally bisexual partners were generally characterised by fluid sexual agreements, a desire for commitment and unreciprocated emotional attachments towards the behaviourally bisexual partner. Participants generally described main behaviourally bisexual partners as ‘Hook Ups’, ‘Friends with Benefits’, ‘Booty Calls’, or ‘Fuck Buddies’. While participants also described casual behaviourally bisexual partners as ‘Hook Ups’, ‘Friends with Benefits’, ‘Booty Calls’, or ‘Fuck Buddies’, they were generally perceived as among the least risky for HIV among casual partners. Casual partnerships with behaviourally bisexual partners generally lacked explicit sexual agreements, commitment and emotional attachments between partners. We present participants’ definitions and variations of each dimension by partnership type to demonstrate qualitative differences in relationships with main and causal behaviourally bisexual partners as well as the underlying relationship dynamics that informed perceptions of HIV risk. Where appropriate, comparisons with gay partners are presented to further describe and distinguish relationship dynamics between partners.

Exclusivity

Participants described exclusivity as a relationship state where they explicitly negotiated and maintained sexual agreements with main partners. Participants formed exclusive partnerships by establishing rules and boundaries with main partners.

‘[we made a] conscious decision saying… we are exclusive to each other …obviously you always have to have a conversation about certain boundaries that are alright in certain people’s books but not in other people’s books…that’s something that actually caused us to eventually break up because we didn’t really have a conversation about it.’ (Dean discussing Ricardo).

While participants described exclusivity as ‘arbitrary [relationship/sexual] rules that… [weren’t] necessarily static [but] kind of changing’ (Dean), some discussed how establishing and maintaining rules and boundaries was more difficult with main behaviourally bisexual partners compared to main gay partners.

‘…we really didn’t set guidelines… it really was no boundaries…I know he said I better not ever hear that you slept with another man… but women, it was no boundaries (Carl describing relationship with Alan, main behaviourally bisexual partner)’.

Carl described how his established agreement with Alan only referred to male partners. While he and other participants considered their relationship with a behaviourally bisexual partner as ‘exclusive’, the presence of external female partners created fluid sexual agreements/boundaries where sexual agreements either did not exists or frequently changed and boundaries were difficult to define.

‘[Derek] was bisexual…he had a girlfriend during the day and then we would mess around at night… [Julian and I] were best friends so I knew everything about him, he knew everything about me…we even had two girls that were cousins pretend to be our girl... [Peale] was straight…I’m still trying to adjust to that psychologically… [Trey] we worked together. So we pretty much hung out every day at work…We were definitely exclusive. [Malcolm describing four main behaviourally bisexual partners]’.

Participants also discussed how a lack of boundaries prevented the development of an exclusive partnership. No participant described a casual partnership as exclusive, yet several participants described casual partnerships in which ‘unspoken’ decisions and ‘same mind-sets’ guided parameters of sexual encounters (Dean describing Alan). This pattern did not differ between behaviourally bisexual and gay casual partners.

Commitment

Participants described commitment as the will to maintain relationship and sexual agreements with a partner. Most participants expressed commitment through ‘unconditional feelings’, expectations of relationship longevity and exclusivity.

‘…you have no interest in looking for somebody else at all…when I was with my partner of 6 years… I met guys that were nice and cute and great to hang out with… it just never crossed my mind to date them…I couldn’t see myself with anybody else and I felt like I wanted to spend the rest of my life with [him]’ (Brad discussing Silas).’

‘…I wasn’t afraid of intimacy or being exclusive with somebody and I could actually see… us together for the long haul’ (Malcolm discussing Julian).

Participants described the difference between the presence of and desire for commitment in relationships. While commitment was discussed solely in the context of main partnerships, some participants described a desire for commitment with main behaviourally bisexual partners compared to the presence of commitment with main gay partners.

‘…I feel like I was more committed to him than he was to me…we would be together as long as it was convenient for him. We would go out, he would flirt with other people at the clubs and still think that it was OK for him to do that and come home…I don’t think that there was ever an emotional commitment between the two of us’ (Jared discussing Drake, main behaviourally bisexual partner).

‘…we were committed… we weren’t seeing other people or anything like that (Andrew discussing Jackson, main gay partner)’.

Compared to main partnerships, casual partnerships were characterised by short-term sexual encounters ‘we fucked one time…we didn’t talk too much’ and the absence of or lack of desire for commitment between partners (Carl describing Charles). Participants described them as ‘just sexual’ rather than ‘life partner[s]’ (Dean describing Ethan). This pattern did not vary between behaviourally bisexual and gay casual partners.

Emotional attachment

Participants described the presence of strong emotional attachments in all main partnerships – characterised by emotional availability/support and intimacy; however, many participants described how behavioural bisexuality, particularly the commitment to a female partner, prevented partners from reciprocating strong emotional attachments. Unreciprocated emotional attachments characterised over half of relationships with main behaviourally bisexual partners (58% n=12) compared to very few relationships with main gay partners (10% n=2).

‘Because [his partner, Derek] was bisexual… he could not be as open…his emotional attachment was to females whereas mine was to him and we had sex. [Several partners] were not as emotionally available for me as I [was] for them…’ (Malcolm describing relationships with three main behaviourally bisexual partners).

‘They say friends with benefits…one of the two always get attached and it was me. He always loved me as a best friend, I knew that much at least… [but] obviously he wasn’t down for having a relationship like I was because he’s straight’ (Dean describing Jude, main behaviourally bisexual partner).

While strong emotional attachments were a key aspect of relationships with main partners, participants described weak emotional attachments in relationships with casual partners. While Brad described his feeling towards Silas (main gay partner) as being ‘in love’, Carl described no emotional attachment to his partner Jared ‘there really was no emotional risk to it, you know…it’s just a fuck thing’. This pattern of emotional detachment from casual partners did not vary between gay and behaviourally bisexual partners.

Relationship designation

Participants ascribed a range of relationship designations to behaviourally bisexual partners that not only revealed dynamics of their relationships, but also reflected variations in emotional attachments. Main partners designated as ‘boyfriend’, ‘lover’, ‘partner’, and ‘husband’ typically reflected relationships with strong, reciprocated emotional attachments, high levels of commitment, and trust. For example, one participant described a lover as someone for whom one had ‘really strong feelings of being in love’ and a willingness to ‘endure… if things get harder’ (Andrew). Another described feelings of trust with his ‘lover’, ‘he wouldn’t do anything to intentionally hurt me…he’d be honest’ (Carl discussing Raymond). Given that most participants characterised relationships with main behaviourally bisexual partners by unreciprocated emotional attachments, participants described only 2 of 12 (17%) main behaviourally bisexual partners exclusively as ‘my man’, ‘boyfriend’, ‘lover’, ‘husband’, ‘partner’, or ‘soul mate’ (Compared to participant descriptions of 85% of main gay partners).

Emotional attachments between partners differentiated the meaning of ‘hook up’, ‘friends with benefits’, ‘fuck buddy’, and ‘booty call’ between casual and main partners. Participants ascribed those terms to all casual partners and main partners who did not reciprocate emotional attachments. Participants designated the majority (7 of 12, 58%) of behaviourally bisexual partners as ‘hook ups’, ‘friends with benefits’, ‘booty calls’, and ‘fuck buddies’ (compared to only 5% of main gay partners).

‘…because this is friends with benefits, fuck buddies and a hook up, it really isn’t a ring attached to that…I enjoy just his presence because it’s hot…I would consider [him] like a notch on my belt…But he has zero personality’ (Victor describing Caleb, casual gay partner).

‘I was like a booty call to him…he would just call me up and be like hey, come over, I want to fool around. As that [relationship] ki[n]d of escalated it kind of got a little less equal because I was putting a whole lot into the relationship because I really cared about him…as one of the first boys showing me a lot of attention… at the same time, I was really upset because he didn’t feel the way I felt’ (Dean describing relationship with Jude, main behaviourally bisexual partner).

Perceptions of HIV risk

Participants described how biological risk behaviours (e.g. type of sex, number of sexual partners, condom use) and feelings of trust informed perceptions of risk towards partners. Overall, participants discussed how knowledge of a partner’s ‘actual…experiences’, ‘the different opportunities that they would have to contract something’ as well as how well they ‘kn[e]w the person…their sexual history and the people in their sexual history’ informed who posed the most STI/HIV risk. Trust in a partner’s sexual history and current behaviour lowered the perception of risk.

‘[Jude] was not an HIV risk to me because I know his sexual history. It wasn’t a particularly long sexual history. People he had been with, I know… So I trusted him on that aspect… Obviously you can’t be 100% certain unless you have the science. But… trust is key. It’s about one of the, only thing that really matter to, to that kind of risk equation (Dean discussing Jude)’.

As mentioned earlier, most participants characterised main partnerships with gay partners by high levels of trust, security, and safety. Consequently, participants predominantly described their main gay partners as among their least risky for HIV risk. For Dean, Ricardo’s lack of sexual experience and their mutually monogamous agreement made him seem like a low sexual risk.

‘I didn’t see him as an HIV risk because he did share the fact that he had never done anything before and I did share with him who I’d done things with before. So that’s sharing our feelings and our thoughts and then the agreement not to be with anyone else, I know while in the context of the relationship, he wasn’t going to go anywhere and I wasn’t going to go anywhere (Dean describing Ricardo, main gay partner)’.

Conversely, relationship tension expressed through unreciprocated emotional attachments, lack of trust in either a partner’s sexual behaviour/activity, or perceived promiscuity increased the perception of risk. These elements were especially common in main partnerships with behaviourally bisexual partners. Many participants ranked their main behaviourally bisexual partners as among their most risky for STIs/HIV.

‘… with Tyrell, we never used a condom because he looked at a condom as I was cheating on him which scared the hell out of me… With him, he was a 1 (the highest risk out of 5) because he was so dishonest with himself, his sexuality’ (Victor discussing Tyrell, main behaviourally bisexual partner).

‘I really like Jeremy and I really want to be his boyfriend and I really want to get to that point someday. But we’re not there yet … he doesn’t want to be in a relationship just yet… he’s probably my second risky because I don’t, I don’t have any proof that he’s clean…I do trust him…I know he’s told me about his sexual partners but, you know, people lie’ (Dean describing Jeremy, main gay partner).

In relationships that lacked tension or a desire for trust or commitment, emotional and STI/HIV risk was determined by perceived biological risk posed by a particular sex act.

‘Least risky? None of them technically. But I would have to say Damien and Glen, I guess, would be about the same…because it’s just oral sex’ (Malcolm discussing Damien and Glen, casual gay partners).

However, some participants employed stereotypes and misconceptions about partners to inform perceptions of HIV risk. Some participants considered casual behaviourally bisexual partners as among the least risky for STIs/HIV compared to casual gay partners based on misconceptions on the biological risk posed by women.

‘I used to think…well if he got kids, they ain’t no way that he can be HIV positive because the kids are OK… until I realised that they can bypass that through birth…that was my ignorance’ (Victor describing Tyrell, main behaviourally bisexual partner).

Participants also described cases where they considered casual gay partners as more risky based on assumptions and stereotypes regarding their/the ‘gay’ lifestyle. Some participants employed these stereotypes in their perception of risk.

‘Even though I didn’t use a condom, I still felt like the risk was kind of low… this sounds so hypocritical…I still have stereotypes that I’m working with because I felt like this was a straight environment… And I know it has nothing to do with it but I have my own little cue card that I pull out … and I consider being gay a very high risk factor because of the sexual activity…this is not a scientific, this is my personal’ (Victor describing Tristen, casual behaviourally bisexual partner).

Discussion

Our findings suggest that partnership types (main and casual) and relationship dimensions (exclusivity, commitment, emotional attachment, and relationship designation) strongly influence how gay men perceive the HIV risk of behaviourally bisexual sex partners. In the majority of main partnerships with behaviourally bisexual partners discussed by men in this study, unreciprocated emotional attachments and the desire for commitment hindered relationship progression resulting in relationship tension and dissolution. Relationship dimension patterns that distinguish main and casual partnerships echo constructs of Sternberg’s Triangular Theory of Love, which highlights interpersonal love as having three interrelated components: intimacy (emotional component), commitment (cognitive component), and passion (sexual component) (Sternberg 1997; Bauermeister 2012). Participants described the ability and willingness to develop and maintain sexual and relationship agreements as shaped by notions of relationship exclusivity and emotional commitment. Participants’ descriptions of exclusivity and commitment align with Sternberg’s definition of commitment as ‘the decision that one loves a certain other [in the short term], and one’s commitment to maintain that love [in the long term]’ (1997, p315).

Participants’ discussions of emotional availability, communication, emotional support, and reliability in their descriptions of stable and trusting relationships with partners typically referred to as ‘boyfriend(s)’, ‘partner(s)’, or ‘lover(s)’, directly align with several characteristics or ‘clusters’ of Sternberg’s intimacy construct (1997). For participants, it is possible that despite strong emotional attachments, the perceived emotional unavailability of behaviourally bisexual partners hindered the establishment of commitment and development of intimacy. This finding is consistent with a study by Bauermeister (2012) which found that bisexual participants ascribed less importance to a monogamous relationship and were less likely than gay men to rate sexual exclusivity as important in their ideal relationship (Bauermeister 2012).

Our results suggest that relationship tension may contribute to the reported lack of or fluid sexual agreements between participants and their behaviourally bisexual partners. The frequent use of ambiguous titles such as ‘hook up’, ‘friend with benefits’ and fewer designations as ‘boyfriend’ and ‘lover’ compared to relationships with main gay partners, potentially reflects difficulties in establishing relationship boundaries and agreements with behaviourally bisexual sex partners. Our results also indicate that the relationship dynamics that resulted in tension, insecurity and negative emotions for the participant increased the perception of acquiring HIV from their partner. Participants’ increased perception of risk from main behaviourally bisexual partners and lower perception of risk from main gay partners is in line with studies that indicate positive relationship dynamics among male couples may encourage the creation of satisfying agreements, have the potential to reduce the occurrence of broken agreements and eventually, reduce HIV risk (Gomez et al. 2012), and that men in main partnerships are more likely to perceive zero risk of HIV infection and be very confident they will remain HIV-negative (Stephenson et al. 2015). Participants’ lower perception of risk from main gay partners in our study is consistent with results from another study among the same group of men that found feelings of love, intimacy, and trust reduced HIV risk perceptions towards partners (Goldenberg et al. 2014)

With non-regular (casual) partners, perceptions of HIV risk were informed by a partner’s disclosed or presumed sexual history and biological risk rather than relationship dynamics. Participants also employed stereotypes of gay male promiscuity and misconceptions of HIV risk among women to inform their perceptions of risk from casual behaviourally bisexual partners. The fact that participants used assumptions of promiscuity and sexual activity when assessing and characterising the risk from casual partners is consistent with findings in qualitative studies among men who have sex with men and women who describe varying perceptions of HIV risk from both male and female partners (ORC Macro International Incorporated 2005; Dodge, Iv, and Sandfort 2008; Malebranche et al. 2009).

Limitations

Our analysis was conducted on a relatively small sample of men and the results are not generalisable. Despite the small sample size, however, the results provide nuanced insight into the experiences and relationship dynamics in a select group of gay men and their behaviourally bisexual partners – descriptions and insight currently absent from the literature. Moreover, since this study only collected and analysed information from the perspective of one partner, we miss the perspectives of behaviourally bisexual men and their female partners. Further studies should purposefully investigate the relationship dynamics as perceived by behaviourally bisexual men and both their male and female partners.

Conclusion

This study provides understanding into motivations and relationship dynamics that may influence the perception of HIV risk between gay men and their behaviourally bisexual partners. Our findings show that some gay men’s perceptions of HIV risk from behaviourally bisexual partners were strongly influenced by relationship dynamics shaped by partner type (whether the partner was considered a main or casual partner) and relationship dimensions (such as emotional attachments and commitment). In partnerships characterised by relationship tension, unreciprocated emotional attachments, a desire for commitment and lack of trust, behaviourally bisexual partners were perceived as among the most risky for HIV. However, in more casual partnerships that lacked emotional attachment, the desire for commitment or tension and misconceptions of the low risk of HIV from women led participants to perceive them as among their least risk for HIV.

Our findings also provide potential insight on how to message HIV risk to behaviourally bisexual men and the men who specifically choose them as sex partners. Messages and counselling based interventions that encourage the discussion, development and maintenance of explicit sexual agreements between partners may improve relationship dynamics by allowing men to clarify relationship intentions, boundaries and agreements before either partner develops strong emotional attachments. It is imperative that messages address key concepts of risk, decision-making and partner negotiation in a way that does not act to stereotype or create stigma against behaviourally bisexual men and their male partners.

Acknowledgments

Funding for this project was provided by University Research Council at Emory University. The authors report no conflicts of interest.

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