Humanizing an Invisible Population in India: Voices from Bisexual Men Concerning Identity, Life Experiences, and Sexual Health

Abstract

Research examining the sexual identities, behaviors, and experiences of bisexual men outside of Western contexts (including in India) is limited. Individuals who self-identify as bisexual due to their orientation towards partners of more than one gender face distinct psychosocial challenges relative to exclusively heterosexual, gay/lesbian or other individuals. We conducted four focus group discussions (n = 22) and in-depth interviews (n = 50) with self-identified bisexual men (age 18 years and older) who were recruited from the metropolitan area of Mumbai, India, between June and August 2013. We triangulated and analyzed focus group and interview data using standard qualitative research techniques. Findings from our study suggest that multiple factors influence the sexual experiences of self-identified bisexual men in Mumbai, including contexts of sexual interactions, sexual positioning, and the gender of sexual partners. Participants described cultural meaning systems and psychosocial dynamics that regulate bisexual identity development, disclosure, and sexual decision making with male, female, and other partners. Secrecy, discretion, and sexual pleasure also influenced sexual behaviors and relationships. Although Western sexual identity categories are not necessarily equivalent in the Indian context, it is interesting and important to note that a number of individuals in India continue to use the identity label of “bisexual.” Before developing interventions to meet unique sexual health needs of bisexual men, it is crucial to understand how these men perceive themselves, reconcile the ordinary aspects of their lives with their sexuality, and structure their relationships with partners.

INTRODUCTION

Public health research on the sexual health of bisexual men has traditionally focused on the problematic category of “men who have sex with men (MSM),” combining self-identified bisexual men and behaviorally bisexual men with self-identified gay men and exclusively homosexual men (Dodge et al., 2013). Studies have begun specifically to examine bisexual men’s health, especially in the context of HIV and other sexually transmitted infections (STI) and mental health concerns, in the U.S. and in other Western countries (Dodge et al., 2012; Jeffries, Dodge, & Sandfort, 2008; Martinez et al., 2011; Muñoz-Laboy et al., 2009; McCormack, Anderson, & Adams, 2014; Muñoz-Laboy, Parker, Perry, & Garcia, 2013).

Bisexual men may face unique health concerns for reasons specifically related to bisexual behavior, orientation, and identity and their dynamics with partners of more than one gender (Dodge et al., 2016a). While behaviorally bisexual men are increasingly segmented into the behavioral category of “men who have sex with men and women (MSMW)” for public health research and practice, less is known about sexual health among self-identified bisexual men. Research examining the identity-related experiences of bisexual men outside of Western contexts is limited, Social and cultural constructions of sexuality and gender in diverse global contexts, such as India, are challenging in terms of translating to/from traditional Western understandings of sexual identities, behaviors, relationships, and potential risk for HIV and other STI. In India, while data specific to MSMW are not available, MSM face an estimated 14–25 times higher prevalence of HIV compared to the general population (National AIDS Control Organization, 2016). Due to stigma associated with male same-sex sexual behavior in a heteronormative context, as well as criminalization of homosexuality via a colonial-era constitutional ban on same-sex activity under the Indian Penal Code (Article 377), many sexual minority men conceal their sexual identity and associated behavior.

Constructions of male sexuality in India are unique in many respects (Banik, 2008; Boyce & Khanna, 2011; Khan, 2001). Researchers have documented diverse sexualities among men in India, including those that are not congruent with Western categories, including sexual orientation labels (Asthana & Oostvogels, 2001; Banik, Fisher, & Anand, 2014; Boyce & Khanna, 2011; Closson et al., 2014; Khan, 2001; Kumta et al., 2010; Verma & Collumbien, 2004). For example, Welles et al (2011) conducted a cross-cultural online survey in the U.S. and India and documented that a larger percentage of Indian MSM did not identify themselves as either gay or bisexual in comparison to U.S. men, even though they engaged in sexual behaviors with other men. Interviews with middle aged MSM recruited in Mumbai demonstrated that a large number of participants did not relate to a sexual identity based on their sexual behaviors (Banik et al., 2014), in some ways parallel to the “down low” phenomenon among Black men in the U.S. (Dodge, Jeffries, & Sandfort, 2008; Millett, Malebranche, & Mason, 2005).

The reasons for men’s relative sexual fluidity may be tied to Indian culture at large, as well as other psychosocial factors. Indian culture places heavy emphasis on family and much of society is organized around the need to have children for resource preservation, specifically continuing the family through material and financial resources, as well as upholding social status (Asthana & Oostvogels, 2001; Safren et al., 2006). Researchers have attributed sexual fluidity among Indian men to several psychosocial and cultural factors, including traditional gender role norms and stricter gender segregation during adolescence (Khan, 2001), homosocial culture (Greig, 2003), and reports of “sexual need” (or the need for biological discharge among men in a strongly gender-segregated environment) (Asthana & Oostvogels, 2001).

Despite evidence of relatively high prevalence of behavioral bisexuality among adult men in India (Patel, Makadon, & Mayer, 2012; Welles et al., 2011), researchers have not yet focused on the psychosocial experiences of self-identified bisexual men in this context. Although frequently cited as being a “bridge” population for HIV risk from male partners to female partners, empirical research exploring the specific lived experiences of bisexual men in India is limited. Bisexual men in India have been often referred to as “men who are married to women and have sex with men on the side” without taking into consideration these men’s self-identities and patterns of sexual relationships and experiences (Dodge et al., 2016b). Research in Western contexts has shown that individuals who self-identify as “bisexual” face distinct psychosocial challenges and remain underserved (Bostwick & Hequembourg, 2014; Dodge & Sandfort, 2007). Prior to developing interventions to meet the sexual health needs of bisexual men, it is crucial to understand how these men perceive themselves, reconcile the ordinary aspects of their lives with their sexuality, and structure their relationships with male, female, and other partners (i.e., hijra, transgender individuals, and others whose forms of non-binary gender expression unique to the Indian context).

To address these gaps, we conducted an exploratory study on the health and lived experiences of self-identified bisexual men in India. Using qualitative methods, we aimed to explore a wide range of sexual behaviors and related factors among a sample of bisexually-oriented men (Dodge et al., 2016b)-that is, men who both self-identified as “bisexual” and had engaged in bisexual behavior during the past 6 months-in Mumbai, India.

METHOD

This exploratory research project took place in collaboration with the Humsafar Trust (HST), the oldest and largest sexual and gender minority (SGM) community-based organization on the Indian sub-continent. The HST is a nongovernmental organization based in Mumbai that began working on grassroots initiatives for lesbian, gay, bisexual, and transgender (LGBT) rights and has now expanded to include a wide range of resources and services for a diverse range of SGM individuals (Humsafar Trust, 2018). Some of the activities of HST include advocacy, community capacity building, and counseling services as well as opportunities for health care, support, and treatment. The HST maintains a large HIV/STI community outreach and prevention program targeted toward diverse groups of SGM individuals, with a target population of more than 10,000 people. A clinic providing HIV/STI counseling, testing, and care began in 1999 and has provided services to thousands of residents of Mumbai and surrounding areas. Additional outreach services are linked to various public health institutes who provide clinical care to HIV infected individuals throughout the region. All protocols for this study were approved by the internal institutional review board of the Humsafar Trust and by the institutional review boards of the lead authors’ academic institutions.

We based our study in Mumbai (formerly Bombay), India, one of the largest and most populous cities in the world that, according to most recent census data, has a population of approximately 18 million people. Mumbai is situated in Maharashtra, one of the four high HIV prevalence states, accounting for 53% of the infected population in the country (National AIDS Control Organization, 2016). Previous studies among MSM in Mumbai, including large numbers of behaviorally bisexual men, suggest that rates among this population are exceptionally high (Closson et al., 2014; Kumta et al., 1999; Shinde et al., 2009; Welles et al., 2011). However, as with other areas of India, there is a lack of data on HIV/STI prevalence and risk factors specifically among bisexual men in Mumbai. Thus, there is also a gap in targeted intervention efforts geared toward the specific risk and prevention concerns of bisexual men and their partners of all genders that have been highlighted in recent research in other global contexts.

Participants

Based on the insight and expertise provided by our local community-based research partners on the lack of previous research on self-identified bisexual men in India, along with the goal to ensure potential HIV/STI risk relevance with recent male, female, and other partners, we chose to focus on a specific sub-set of bisexual men who had not yet been explored in previous research or intervention efforts in India. Specifically, we exam ined those who self-identify their sexual orientation as “bisexual” and who have also engaged in recent sexual behaviors with male, female, and other partners. In preliminary discussions among researchers and community constituents in Mumbai, it became evident that traditional Western conceptualizations of “sexual orientation” were not readily applicable within the Indian context. For example, a number of diverse “typologies” of male bisexual behavior are prevalent in Mumbai and of relevance for this study. Bisexual behavior among men often takes place in the context of sex work in India (Narayan et al., 2013; Shinde et al., 2009). In other words, predominantly “heterosexually-oriented” men (who also self-identify as “heterosexual”) commonly engage in same-sex behavior in exchange for money or other resources. As another example, it is normative that “heterosexually-oriented” truck drivers routinely engage in sexual behaviors with younger male assistants and/or hijras, a major subgroup of individuals legally recognized as a third gender, while on long-haul drives simply because female sexual partners are not available (Bryan, Fisher, & Benziger, 2011; Singh & Malaviya, 1994). Additionally, some predominantly “homosexually-oriented” men enter into marital relationships with female partners (Asthana & Oostvogels, 2001; Banik, 2008) in order to fulfill cultural expectations of masculinity and procreation.

Eligibility Criteria

Based on discussions among academic and community partners regarding the most novel and relevant sub-population of bisexual men to include for this study, specifically “bisexually oriented” men, participants’ eligibility criteria included two factors: 1. Reporting engaging in penetrative sexual behavior with at least one male, one female or one hijra partner during the past six months, and 2. Self-identifying as “bisexual” (or the equivalent terms in local languages). In the cultural context of Mumbai, men who have sex with hijra partners are likely to fall under the umbrella of MSM as men’s sexual behaviors with hijra partners are understood as male sexual partners based on their genitalia (i.e., the absence of a vagina in most cases) (Herdt, 1994). We limited recruitment to cisgender men (i.e., born male and living as a man) who were at least 18 years of age.

We included bisexual self-identification as an eligibility criterion in order to distinguish from the broad range of other sub-groups of men in India who may engage in bisexual behavior. To ensure relevance in terms of bisexual behaviors in terms of HIV/STI risk, we recruited a sample of men who engaged in bisexual behavior during the past 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 currently behaviorally bisexual men (and therefore distinct from currently exclusively homosexual or heterosexual men). Estimates of bisexual behavior over a participant’s entire life are too broad to adequately reflect the dynamics of their recent sexual repertoire (Dodge et al., 2013; Malebranche, 2008).

Recruitment

As participation in social and behavioral science research projects focusing on sexuality is not a common occurrence in India, we relied on recruitment and engagement methods that were feasible and that did not jeopardize potential participants’ confidentially or, indeed, safety (given the current illegality of same-sex sexual behaviors). An initial wave of participants was recruited from the social and professional networks of outreach workers and program staff at the HST. Participants were also recruited online from postings on a variety of general online social and sexual networking sites, allowing us to reach a diverse cross-section of men, including those who may not frequent gay-oriented websites. Additionally, we relied on participant referral. Men who participated were encouraged to refer other potentially eligible men from within their social and sexual networks to take part in the study. In our prior research, this method of recruitment has been particularly important given the sometimes secretive social and sexual networks of bisexual men, as they may not be easily recruited from traditional venues where gay men congregate (Dodge et al., 2013; Martinez et al., 2011).

Procedure

Potential participants were informed of all study procedures prior to data collection. All men who took part in the study were required to give written informed consent to procedures before the data collection took place. We did not collect any identifying information, with the exception of broad demographic characteristic. We collected data in English, Hindi, Marathi, and/or a combination of these local languages.

Focus Groups and In-Depth Interviews

As a first step, we conducted focus group discussions (FGD) with 22 bisexually oriented men in order to inform the development of in-depth interview protocols. A pre-developed semi-structured guide (Table 1) facilitated the FGD discussion. Following the collection and analysis of FGD data, in-depth interviews (IDI) were conducted with 50 bisexually oriented men. Participants in the IDI completed a 90-minute semi-structured interview with a trained research associate. We also used a brief questionnaire to acquire participants’ demographic data (Table 2). In order to gain a deeper understanding of participants’ experiences and expressions of sexual identity, the guide was designed to elicit narratives on four domains, namely: 1. experience and expression of sexual identity; 2. relationships with sexual partners; 3. potential determinants of sexual risk; and 4. sexual health intervention opportunities.

Table 1.

Domains of interest and sample questions for focus group discussions

Domain of Interest	Sample Questions
1. What are the nuances and techniques for describing bisexual behavior and identities in India?	Can you tell me what words do you usually use to describe your sexuality?    How do you identify yourself in your social setting? Do you maintain the same identity across different settings?    (How) would you define a “committed relationship” with a woman /man?    Do any of your recent sexual partners know that you have sex with both women and men? (If yes) How do they know this?
2. What are some of the unique issues, experiences, and challenges faced by bisexual men (or a person who is attracted to or sexually active with men and women)?	What cultural factors and/or social structures (for example, laws or policies) if any, challenge your ability to express your sexuality?
3. What are the motivating factors of sexual and general health seeking behaviors among bisexual men?	How often, and why, do you not use condoms with your sexual partners (any period)? Where do you currently go for health care services?
4. What are the unique sexual health risks of bisexual men and their sexual partners?	Is sex different for you with a woman or a man? How?    What do you think are the major health issues (or risks) for men who have sex with both men and women?    Have you had a recent (any) sexual experience where you thought you might have put yourself, or your partner, at risk for HIV/STD/unintended pregnancy?

Table 2.

Demographic characteristics of participants (N=72)

Age (in years)	Mean	SD
	26.43	5.87
Income (INR)
	17,834.68	11,254.35
Education Level	N	%
Primary (6th grade completed)	5	6.9
Secondary (10th grade completed)	12	16.6
Higher Secondary Education (12 grade completed)	19	26.3
Graduate	35	48.6
Other	2	2.76
Occupation
Unemployed	9	12.4
Government job/Service	17	23.6
Private/Company job	33	45.8
Other	13	18.0
Relationship Status
Never Married	42	58.3
Currently Married/Living with wife	18	25.0
Currently Married/ Not living with wife	9	12.5
Currently living with a male partner	1	1.4
Currently divorced from wife	1	1.4
Children
None	42	58.3
One	19	26.4
Two or more	11	15.3

FGD and IDI data collection took place between June and August 2013 and were led by trained interviewers employed by HST who were proficient in Hindi, Marathi, and English. Upon completion of the FGD/IDI, participants received an incentive of 300 INR (approximately $5 USD) in cash. This amount was in line with similar studies that have been recently conducted at HST.

Data Analysis

The FGDs and IDIs were digitally audio-recorded, transcribed verbatim, and double-checked for accuracy against the recordings. Data collected in Hindi and/or Marathi were translated into English by a professional translation agency in Mumbai prior to coding. We analyzed complete interview transcripts for participants’ utilizing NVivo (Version 10) qualitative software. The principles of grounded theory were used to inductively identify and interpret concepts and themes that emerged from interview transcripts (Corbin & Strauss, 2008). Open coding involved assigning conceptual codes to small sections of words, phrases, and sentences in the transcripts. This was followed by axial coding, whereby we identified relationships among like concepts and combined them into themes. Integration, the process of linking core themes, resulted in our final conceptual model. The conceptual model was constructed to gain a deeper understanding of sexual self-identification among our participants, particularly regarding how and why they identify as bisexual. To ensure credibility of findings and analyses, analytic triangulation was completed by engaging a peer debriefer with knowledge of the issue under study (Charmaz, 2006). Discrepancies in codes were discussed between the investigators and the peer debriefers, research staff from HST who were not part of the study team, until consensus was reached.

RESULTS

The demographic characteristics of the participants are shown in Table 2. The mean age of the participants was 26.43 years (SD = 5.87). The participants tended to be relatively highly educated, with almost half of the participants having completed a post-secondary (“graduate”) level of education and 26% a 12^th grade (“higher secondary”) level of education. Either most men were employed in a private job (46%) or were full-time students (17%). The mean monthly income for participants was 17,834.68 Indian rupees (INR), approximately $262.22 U.S. dollars (USD) (SD = $192.65). Over a third (38%) of the participants were currently married to a woman, with approximately 13% not currently living with their wife due to migrant work and similar circumstances. Only one participant was currently living with a male partner.

Analysis of data from FGDs and IDIs suggested that bisexual men’s patterns of sexual identities, behaviors, and relationships constituted a constellation of distinctive life experiences in Mumbai. Participants described sets of cultural meaning systems and psychosocial dynamics that regulated bisexual identity development, disclosure, and sexual decision making within a variety of contexts, including relationships with male and female partners. Few participants discussed sexual behaviors and experiences with hijra partners as distinct from female partners, with the exception that encounters were most likely to occur in the context of sex work and that hijra are commonly seen as “an orifice” (to be used solely for sexual release when opportunities arise).

Cultural and Social Dynamics of Bisexual Identity

A number of participants (n = 25) defined a bisexual identity as encompassing individuals who “enjoy” sex with and have the capacity for romantic “attraction” to male, female, and other partners. Participants reported different sexual acts as enjoyable with male partners versus others, such as anal sex and oral sex. One participant captured a succinct definition of bisexual identity:

Bisexual in local language is said that who can do (e.g., have sex) with male and female both, he is called bisexual. I didn’t know about this earlier but in last one and half year, I got knowledge about this. I didn’t know earlier what is bisexual. [26 years old participant]

Another participant noted that emic constructions of bisexuality are different from homosexuality:

I know that if a person is interested in the same sex then he will be called homosexual. And bisexual means a person who is interested in both sexes. A homosexual can be a bisexual too, especially when married and have kids. And a bisexual person can be called by so many names. But since “bi” means two, a person who is interested in both sexes is bisexual. I was interested both boys and girls when I was in college. But, I did not know what to call it. Now I know the term bisexual from my friends and after chatting on the internet. [30 years old participant]

Social networks, social media, and popular Bollywood media seemed to influence both bisexual identity development and disclosure among the participants. Some participants reflected on the lack of appropriate terminology in their local language concerning sexual orientation in general, and specifically for bisexual identity. At the same time, participants indicated that they often played a balancing act with multiple identities in their private versus public lives. Safe spaces such as community organizations, including HST, provided a critical space for bisexual participants to find social support and community as a sexual minority individual. However, as one participant described, it was only possible to talk about bisexual identity with other bisexual-identifying friends.

So we share it [our bisexual identity] only when I am here [Humsafar Trust] with other bisexual friends but we can’t share with parents or sisters. So we share with people who are from this field, who are bisexual. We are closer with them than our family. [29 years old participant]

Lack of Perceived Bisexual Community Spaces

Participants who did not have support systems were not able to openly discuss sexual identity. Similar to research done in Western contexts (Dodge et al., 2012), many of the men interviewed expressed feelings “not belonging anywhere” as a bisexual man. Men expressed two interrelated concerns regarding lack of belonging to a community. This included a fear of disclosure due to stigma against same-sex behavior, as well as a genuine lack of a community to which to belong as a bisexual man.

Mostly, there is no as such group as bi community in my neighborhood…Mostly, there is group of gay people in which there are more bottoms. They have a good group but you will rarely find group of tops. [29 years old participant]

Several participants described finding space within gay male communities (such as groups that met at HST), but this did not represent the range of their bisexual experiences or identities. Other participants discussed the more progressive Bollywood film industry as a space for non-heteronormative activity and conversation, while also questioning a lack of awareness about bisexual identity in the general society.

In Dostana movie, Abhishek Bacchan played character of gay man and John (Abraham) played as a bi guy. But nobody knew what John is. Everyone thought that both were gay. So why is it that society knows about gays but don’t know about bisexuals? [37 years old participant]

Many participants expressed feelings of not belonging in either “straight” or “gay” communities. This could possibly be similar to gay men who are not “out” concerning their sexuality and operate in heterosexual and homosexual communities. However, it is also reflective of similar findings from bisexual men in Western contexts who do not feel they belong as bisexual men in such communities (Dodge et al., 2012).

Beyond the public-private divide, bisexual men described the role of stigma and discrimination in disclosure of identity, feelings of isolation, and liminality. Stigma against bisexuality within general society, as well as within gay communities, left the participants without any way of relating to a particular social group. This was exacerbated by a lack of appropriate words for describing the “orientation” instead of the “behavior.” A relatively small number of participants (n = 12) found kinship among gay community members, including at Humsafar Trust. One focus group discussion turned to Section 377, the part of the Indian Penal Code that criminalizes same-sex sex acts between men, and the challenges this poses in relation to community involvement.

Compartmentalized Identities

The above statements also highlight unique taxonomies of bisexual identities among our participants. A number of participants described emic constructions and typologies of bisexual identity and their linkage with same-sex behavior. Notably, constructions of sexual identity did not always correlate with behavior. Participants highlighted the lack of awareness of bisexual identity, in general, as bisexuality was often conflated with homosexuality. Other emic constructions that emerged from the study include A Grade, B Grade, and Versatile/Double Decker. Along with other more widespread categories of straight, top, and bottom, these typologies implied a sexual hierarchy, as described in Table 3.

Table 3.

Emic identity categories described by participants.

Straight	Identity and sexual behavior where individual enjoy romantic and sexual attraction with women.
Gay	Identity and sexual behavior where individual has enjoys romantic and sexual attraction with men. They are often also described as “flamboyant” and “effeminate.”
Top	Sexual behavior category that includes anal sex in which the individual is the penetrative partner.
Bottom	Sexual behavior category that includes anal sex in which the individual is the receiving partner.
A Grade	Corresponds with “top” category, but they do not perform oral sex and do not serve as the receptive anal partner with male, female or other partners. They are often referred to as “pure top.”
B Grade	Corresponds with “bottom” category, but they may perform oral sex and serve as the receptive anal partner with male, female or other partners.
“Double Decker”/Versatile	Sexual behavior category that includes both penetrative and receptive sex wit.

When asked what words or signals were used in relation to their sexual identities, participants described a process of multiple identifications. Not only did they use different identities across time, indicating that they engaged in varied processes of identity disclosure, but participants also utilized multiple concurrent identities, and did so strategically. Identity disclosure entailed decision-making processes related to specific social and cultural contexts. Identification was based on multiple factors, including perceived stigma, professional status, and social settings. Some participants used labels for themselves differently depending on the context, often with homosexual behaviors having a negative connotation. One participant indicated that his identity was influenced by the people he was with, but also that his private and public identities represented “two worlds” and that they “don’t mix” (related to compartmentalized identities).

Just depends on the group of friends that I’m with. If I’m with straight friends, then I’m in the straight world and I act as if I am straight. When I am with my straight friends, then I try not to look at the boys. I try to just give a look and that’s it. And when they talk about girls, I also try to involve in their conversation and talk about girls in the same manner. But when I am with the gay friends all we talk about is boys and sex and all. [23 years old participant]

Most participants also noted that at work, or among certain friends or family members, they publicly presented as heterosexual men. In their places of employment, in particular, participants did not discuss their sexual identity or behaviors. This censorship was either because they felt it was not their colleagues’ business or because they feared that such information might have a negative impact on their work life. Multiple identifications also allowed participants to exercise agency in determining who they were, and/or how they wanted to be understood, by their peers and others in their social networks.

Negotiating Secrets, Discretion, and Sexual Pleasure

Participants in focus group discussions and interviews reported that secrecy, discretion, and sexual pleasure influenced sexual behaviors and relationships. Sexual opportunity, socioeconomic structure, career ambition, heteronormativity, family, and perceived masculinity shaped these themes. Participants pointed to two major paradoxes: (1) a contradiction between public heterosexual identity and their private bisexual identity, and (2) the ethical boundary of being unable to disclose bisexual identity to otherwise close wives and girlfriends. Participants described this tension as leading to frequent conflict, as bisexual men (and all men in India) are expected to manage family responsibility, marriage, and the socioeconomic pressures of everyday life. In this way, bisexuality may be a difficult construct for many people to comprehend given strict binary sexual roles and gender expectations that are socially prevalent in India (including social expectations of monogamy). Many participants alluded to a difficulty in accepting their own bisexuality, which influenced their perceived mental health. One participant described an inability to fully share himself with female partners, from whom he feels the need to hide his identity. He managed this circumstance by only engaging in male-male sex infrequently, and not on a regular basis.

Ideally, we should not do it [male-male sex] but if you have a feeling like that then you should not stop your feelings. If you try to hide that feeling, then maybe someday it will be erupted anyhow. So you should do it in controlled manner and you don’t need to do it daily after marriage. You can do it once in a month and like that. [25 years old participant]

Thus, sexual acts with other men are most often hidden from wives and girlfriends, as participants described them as “cheating” and unacceptable under the terms of presumably monogamous marriages, in particular. This idea was further reflected by comments suggesting that some men may not have accepted their own bisexuality and were struggling with the process.

It was really hard for me to accept that I liked guys more than as a friend and confront the fact that I liked to have sex with men and women. I am now married and I want to start a family but I feel like I am not fulfilling my duty as a husband. I feel sad for her when I am with another man. But I enjoy the sexual pleasure with my boyfriend and I enjoy my wife emotionally. [32 years old participant]

Such comments illustrate the potential for mental health challenges among this population as they search for validation of their sexuality in a culture that does not fully recognize their existence. As further illustrated by one participant:

In our family, nobody knows about our [sexual] activities, today everyone wants to do sex with men for fun. But people think it is not good thing. You can call it hobby or shauk [fun], we can’t reveal it at home, those who are in this field know about our behavior. Normally, we are straight and whatever else we do for any reason, be it for fun or internal feelings, we cannot talk about it openly. [24 years old participant]

Sexual freedom, in contrast to emotional intimacy, was often cited as a common factor that drive sexual relationships with other men, in particular. As suggested by a participant:

Actually, when I did it with my girlfriend then she wanted me to do everything by payyar [tenderness and with emotion]. Actually, all girls want to do that. But if you are doing it with a man, then he will cooperate with you and do it according to your wish. For example, my girlfriend doesn’t get involved or you may say they are not that much vocal as compare to men. Men are more active in the sense of energy or force. [35 years old participant]

Another participant further described these differences with male partners versus his wife and other girlfriends:

Some [boy] friends are like….they say, “idhar maro” [do it this way,], “udhar maro” [do it that way], so there is some difference in it, and we like to do it at that time. With wife, such things doesn’t happen, even with girlfriends such things doesn’t happen. Many wives think oral sex is dirty or anal sex is too painful. My boyfriends and I enjoy all those things. 25 years old participant]

In relation to secrecy and discretion, participants reflected on how they navigated the sexual scripts (Gagnon & Simon, 1973) or the cultural codes set by social institutions (e.g., family) when finding casual or steady partners. While cultural and socioinstitutional factors are crucial to understanding the structuring effect of sexual interaction (Laumann, Ellingson, Mahay, & Paik 2004), we stress the term navigation because these norms were open to some degree of autonomous engagement. The family was an important “institution” that was mentioned by most of our participants as important for organizing norms of silence about sexual expression, but it was one that could be navigated around. As reflected by one participant:

You should learn to balance two boats. If you marry her without telling and after you tell. The main thing is that how you keep her [wife] happy in sex life and have a family. After a lady has a child, she becomes relaxed and thinks that now her family is complete and we feel proud as a ‘father.’ At present time, one child is enough, so after having one baby family life is complete. So wife is more around baby and family and sex part becomes less. We do [have sex] if we get chance on Saturdays or Sundays. In weekdays, we don’t have time to have sex with wife. And, you meet your boyfriend whenever there is opportunity and location [place for sexual liaison] available. [29 years old participant]

Most of the participants, in relationships with women were concerned with their social standing and, thus, kept their sexual behaviors with men hidden from their female partners. “No one knows about [his practices with men], behind closed doors, it should stay there…as a man they must protect their parents, wife, and kids. If it goes into our homes, that is a different story … I will not be able to bear the shame” [37-year old participant]. Most participants navigated norms by keeping their bisexual behaviors and identities private.

Sexual Opportunities and Sexual Disclosure

Looking further into the interpersonal aspects of sexual opportunity structures (Garcia et al., 2014), we found that for many of our participants, a common set of norms was involved in the negotiation between having sex and forging intimate relationships. This negotiation took different forms with men in comparison to women. The FGD captured the meanings of commitment that some men used in describing the process of investing in the sexual relationship.

See you can understand this thing or we six guys sitting here, we can understand feeling of each other. If we say this in the society, then this thing is not considered good in our society. If we do sex with other girl and not with our wife, then this is not considered good in our society. Just think if we do sex with men, we don’t have any answer. How can we develop committed relationship with a man in this kind of situation? [25 years old participant]

There were differences in the way many of the participants reported “feeling” towards men and women: “With girls, I care more about their feelings, I want to have a family and children with her and guys, it is just, like they are guys” [26-year old participant]. This exemplifies a participant with internal struggles with fidelity and love. It is evident that the ability to form and maintain faithful, affectionate relationships (especially with men) was difficult for some of the participants. Secrecy, thus, also mediated the ability for the participants to form and maintain relationships with other men. This, along with heteronormative attitudes in society, certainly contributes to a feeling of stigma and discrimination.

Further, participants discussed a sexual hierarchy in India, one that moves beyond the dichotomous heterosexual-homosexual divide. Participants compared and contrasted the organization of sexual partnerships with male and female partners. They highlighted their preference for male partners for sexual versatility and their preference for female partners for intimate and fulfilling relationships and for parenthood. Partnership with women was also influenced by personal, societal, and logistical factors (e.g., male partners are “easier” to find and engage in casual sex with than female partners). Incidentally, some participants (n = 8) also illustrated the transactional nature of sexual partnership with male and female partners both for financial reason as well to fulfill career goals, especially in Mumbai’s entertainment industry. In this context, it appears that sexual opportunity structure (Garcia et al., 2014) played an important role in sexual decision making among the participants.

Earlier involvement was with girls and afterward, due to financial problem, I entered in this field [sex work with men]. When I started getting money then gradually involvement increased. Then it happened that I need this and I need that too. Satisfaction is not with one only. I go for enjoyment with both sexes. [22 years old participant].

Approximately one quarter (26%) of the participants had received money or other items in exchange for sex with male partners at some point in their lives (with an additional 14% having done so with female partners). While the majority of these interactions occurred in the secrecy of the clients’ hotel or house, negotiation took place in cruising areas, online or at their places of employment. An additional quarter (24%) had given money in exchange for sex with female partners, in particular (with a smaller proportion, 4%, having done so with male partners). Thus, sex work influenced men’s experience and expression of their sexuality in a variety of ways.

Some participants attributed sexual partnership with other men to the lack sexual variety of excitement with their female partners.

With my female partner [girlfriend], I have to perform only the normal sex [penile-vaginal penetration]. They do not want to do oral sex or anal sex. They are thus receiver. You are always at giver side, so you have to give as much as possible. So when you want some amount of other pleasure that you will get from other [men] side. [26 years old participant]

This was further illustrated by another participant who expands on the demands by female partners:

Wives always expect that they should get maximum amount of love. They wanted to know where you are, what you are doing, are you with only them 24 hours. They will always keep a watch on you. That is one part which irritates me. [28 years old participant]

Finally, participants described approaches to disclosure of same-sex sexual behavior to female sexual partners, family members, and healthcare providers as part of a complex decisional balance influenced by both situational and individual factors. As in other studies of bisexual men (Dodge, Jeffries, & Sandfort, 2008; Dodge et al., 2013), condom use was less likely with female partners than with male partners. Influences on sexual behavior and condom use practices included: 1. type of relationship, 2. gender-specific considerations, 3. perceptions of comfort or trust, and 4. fear of disease or pregnancy. Participants also attributed the lack of condom use with female partners to the fear of their wives discovering that they were engaging in extramarital sexual behavior (with male and female partners). Additionally, several participants indicated participation in group sex with other male partners although one participant also suggested that he was “seduced” into group sex by another woman with her female friends. The contexts and meaning of these experiences varied. One participant attributed the reason for group sex to lack of private space for sexual liaison in a collectivist society such as in India. His narrative also suggested that “penetrative sex” was the primary qualifier of “sexual act” in this context.

One friend had a hotel room and we took advantage of that privacy. We had a party with booze. We then had some fun. I only did kissing and oral when my friend and his boyfriend fucked. I do not know if I would call it group sex. [26 years old participant] When probed about condom use during that encounter, he continued, “They were regular boyfriends and why should they use condom? And I only did oral. I don’t like to get penetrated. I am not a gay.”

When asked about disclosure of sexual identity or behaviors to healthcare providers, only one participant expressed being able to disclose his sexual behaviors with his doctor; as such, this was certainly not the norm in the sample. The more common experience was one of living in a state of non-disclosure, as participants described hiding “non-normative” sexual behaviors from their female sexual partners, family, and healthcare providers.

DISCUSSION

This study provides insight into the everyday lived experiences of bisexually oriented men in Mumbai, India. Public health researchers in Western contexts are beginning to study a more comprehensive range of bisexual men’s health issues (Dodge et al., 2012; 2013; Jeffries et al., 2008; Martinez et al., 2011; Muñoz-Laboy et al., 2009, 2013; Severson et al., 2014), however such studies have not yet examined experiences of self-identified bisexual men in settings like India. Of particular interest are men who routinely engage in sexual interactions with partners of diverse genders and who also self-identify their sexual orientation as “bisexual” (rather than “heterosexual,” “gay,” or other labels). These men are seemingly invisible in the existing research on Indian male sex workers, “married MSM,” and other men who may engage in bisexual behavior due to a variety of contextual circumstances, but who may not necessarily be bisexually oriented in terms of their attractions, desires, identities, behaviors, and partnerships. Thus, our study was the first to strategically recruit and engage self-identified bisexual men in India.

The unique typologies of bisexual identities based on penetrative behavior is also noteworthy in our study, which suggest a sexual hierarchy based on sexual acts and partnerships. While considerable diversity exists among the men in terms of how and why they identify as they do, several themes emerged that highlight unique issues in this population compared to other sexual minority populations. The results point to new directions for targeted HIV/STI prevention programs, and provide several specific challenges to the existing framework for understanding the relationships between sexual identity and behavior. The findings suggest that self-identified bisexual men in Mumbai are influenced by multiple factors, including contexts of sexual interaction, sexual positioning, and the gender of sexual partner. One common theme for all the participants was “attraction to more than one.” In this context, it is important to highlight that identity is not a one-dimensional construct, but instead is composed of an array of identities that intersect with each other in various realms of a person’s life (e.g., political, sexual, cultural, religious); and each of these identities may form at varying rates and be influenced by both similar and unique factors. Similar to research with Latino men in the U.S., predominant insertive behaviors may be suggestive of concerns of the desire to maintain a masculine image, as well as other factors, while engaging in sexual activity with other male partners (Carballo-Dieguez et al., 2004; Muñoz-Laboy & Dodge, 2005).

Previous studies with middle-aged homosexually oriented men from Mumbai (Banik et al., 2014) highlight that for Indian men who engage in same-sex relationships, sexuality does not become a central focus of their identity. Rather, social identity (e.g., family name, social status, parental status, etc.) becomes an integrated part of their identity. However, with globalization, an increasing number of men in India who engage in sexual activity with other men are identifying with the Western labels of “gay” and “bisexual” (Banik et al., 2014). This is especially true for the younger population in urban settings. However, expression and disclosure of this part of their identity varies based on partner, place, and context. Our findings suggest that bisexual men do not feel belonging in any space and this may make it more difficult for them to express their sexuality to others compared to other men. One mechanism for coping with a sense of “not belonging” by the participants was to attempt to mirror sociocultural norms by enacting either “straight” or “gay” identities or compartmentalizing sexuality into binary roles, similar to one study of Latino bisexual men in the U.S. (Muñoz-Laboy, 2008). Not only did participants suggest that social space for bisexual men was limited beyond sporadic conversations on the internet, their identities were also compartmentalized. How these men saw themselves in any given moment depended on the space they were in, the other individuals they were with, and the norms and expectations associated within these contexts. It appears that a potential solution to the lack of community belongingness would require construction of bisexual “safe spaces,” both symbolically and concretely. Additionally, programs emphasizing self-acceptance and internalized stigma reduction of bisexuality are warranted given the stigma reported by these men.

The stigma and discrimination associated with bisexuality within general society as well from other sexual minority groups have the potential to cause great distress among these men. Research in the U.S. has shown that for homosexually oriented individuals, the experience and even the anticipation of stigma and discrimination can cause substantial psychosocial stress (Herek, 2004). In India, the prevailing social stigma and legal environment in India can lead to “covert” behavior among MSM (Dandona et al., 2005). Even though same-sex sexual activity is common in India (Verma & Collumbien, 2004), traditional culture creates pressure to marry, and many MSM, irrespective of the way they identify themselves in terms of sexual behavior or gender, are likely to ultimately marry irrespective of their sexual identity (Khan, 2001). Many of these men are not self-identified bisexual men. Additionally, researchers have surmised that since “married MSM” are perceived as heterosexual individuals, they may be isolated from other men who engage in same-sex behavior and therefore less likely to access sexual health resources, especially community-based HIV care (Kumta et al., 2010).

To our knowledge, no prior studies have explored the lived experiences of self-identified bisexual men in India. The experience of identifying as bisexual in India brings with it distinct psychosocial challenges, including stigma associated with same-sex sexual behavior, stigma associated with receptive anal sex, and perceived discrimination from family and relatives. Additionally, bisexual men face discrimination from both heterosexual and homosexual (gay-identified and other MSM) peers due to their bisexual identities and/or behaviors, lack of “bisexual” community involvement or interaction, and unique challenges to protective sexual practices with partners of different genders. Our findings also demonstrate that bisexual men’s self-identity, patterns of sexual relationships and lived experiences constitute a constellation of distinctive experiences in urban Mumbai, India. Participants described sets of cultural meaning systems and psychosocial dynamics that regulate bisexual identity development, disclosure, and sexual decision-making.

Overall, bisexual male participants face two major paradoxes in their lives: 1. the contradiction between their perceived heterosexual public identity which places them in the mainstream of society, and their stigmatized bisexual desires and behavior; and 2. the ethical issues of not disclosing their sexuality to wives and girlfriends, male partners and boyfriends, family members and others to whom they are intimately connected. Stigma against bisexuality both within general society, as well as among gay communities leave the participants without any way of relating to other minoritized social groups. This is exacerbated by a lack of an appropriate word for describing the “sexual orientation” instead of their “sexual acts.” Participants also described the emic constructions and typologies of bisexual identity and their linkage with different types of same-sex behaviors. Secrecy, discretion, and sexual pleasure shape sexual behavior and relationships; these are regulated by sexual opportunity, socioeconomic structure, career ambition, heteronormativity, family, and perceived masculinity.

Limitations

The findings of this study must be considered while taking into consideration its limitations. This exploratory qualitative study was relatively small in scope and relied on non-probability sampling methods. Thus, we cannot determine prevalence of sexual behavior and risk from this data. As probability samples of behaviorally bisexual men are very difficult to obtain in any context (Jeffries & Dodge, 2007), not to mention in India, we relied on convenience sampling techniques recommended by our local community-based partners in order to recruit study participants. Because a probability sample was not feasible, we do not know how well our approach sampled our target population of bisexually oriented men, let alone the array of other sub-populations of behaviorally bisexual men in India. This study was conducted in Mumbai, one of the largest and most developed cities in India where access to and influence of Western media is higher than small town and rural areas. Additionally, the participants in the study were relatively younger and reported fairly higher levels of educational attainment. Thus, the findings may not be representative of other contexts of India.

Implications and Future Directions

These findings suggest that we should focus on identifying other salient features of sexual self-identification, beyond attraction and behavior, and incorporate these into future sexual health promotion efforts for men in India and other contexts. The quantitative findings from the second phase of this study published elsewhere (Dodge et al., 2016b) show that for the majority of our participants, various aspects of their sexuality, including sexual behaviors as well as subjective experiences of pleasure, arousal, and orgasm were relatively similar whether they were with male or female partners. However, these men are unique by virtue of that fact that they actively sought out and shared these sexual experiences with partners of more than one gender. Since vaginal intercourse and oral sex with men and women were the most commonly reported behaviors, traditional MSM-oriented risk reduction messages (i.e., avoiding unprotected receptive anal sex with male partners) will likely not target the most relevant behaviors of these men, particularly in terms of sexual behaviors with female partners. Perceived pregnancy risk can also impact bisexual men’s decisions to engage in behaviors with their female sexual partners. Previous programs that sought to achieve traditional rigid outcomes of reduced unprotected anal sex for other groups of MSM may be less relevant for bisexual men in India and other similar contexts. Given that oral sex was commonly practiced among our participants, it is important to provide relevant information related to possible STI transmission during oral sex with any partner, and information related to testing and treatment options available.

In terms of new directions, we recommend more in-depth research on experiences associated with sexual identity among self-identified bisexual men in India. While many gay men find personal and social benefits from “coming out,” the situation is markedly different for self-identified bisexual men, who are most often met with suspicion and scorn by both their heterosexual as well as gay peers (Dodge et al., 2012). In addition to research on sexual risk reduction, future intervention efforts should focus on skills building with bisexual men in order to assist them with disclosing potential sexual risk behaviors with all partners, regardless of gender. Interventions that emphasize self-acceptance, community building, and maximizing social support may be promising. Public health researchers and practitioners must also develop ways to work pragmatically and non-judgmentally with bisexual men, as separate and distinct from heterosexual and gay men or other MSM, in order to assist in improving health outcomes in this underserved population. Since social support for bisexual men is scarce in any context, particularly in India, such efforts must take into account that not all sexual partners will be open to relationships with bisexual men and must consider the implications this may have on expectations of disclosure. Finally, future studies should also explore the perspectives of the sexual and relationship partners of bisexual men in India, as their lived experiences remain relatively invisible.