Terminology Should Accurately Reflect Complexities of Sexual Orientation and Identity

In this issue of AJPH, Timmins and Duncan (p. 1666) correctly criticize the ubiquity of the term “men who have sex with men” (MSM) in the public health literature. The proposed use of “sexual minority men” (SMM), however, merely substitutes one problem for another. Instead of reductionist approaches that prioritize search term simplicity over the dignity and identity of research participants themselves, researchers should commit to—and reviewers and editors should demand—the use of terminology that accurately reflects the complexities of sexual orientation and identity.

In limited circumstances related specifically to same-sex sexual behavior, MSM has its uses. But by design, MSM is untethered from identity.¹ Its use thus always begs the follow-up question: Who are the people whose lives are being described? Overreliance on MSM answers this question by elevating sexual behavior (often implicitly characterized as deviant) over other components of sexual orientation, including attraction and identity. MSM also collapses distinctions between men who claim identities such as same-gender-loving, gay, bisexual, or heterosexual.²

However, SMM is no better. Just as MSM fails to serve as a sufficient characterization of the populations to which it is often applied, SMM similarly stumbles.

First, no one would use SMM to describe themselves. Instead of taking away participants’ voices by attempting to banish identity from the discussion, researchers should ask participants how they identify and use those terms to describe the individuals and communities with whom they work.

Second, “sexual minority” obscures the roles that different aspects of sexual orientation can play in structuring exposure to health risks and poor outcomes. For instance, antigay laws or attitudes primarily target how identifying as gay or lesbian transgresses gendered social norms, not same-sex sexual behavior per se.³ As public health research continues to broaden its inquiries into the social, political, and economic determinants of health, it is important for researchers to name the component of sexual orientation—identity, behavior, or attraction—that is actually implicated in the exposures and outcomes of interest.

Third, the history of the term MSM is rife with examples of its inaccurate application to transgender people.⁴ Transgender women are not MSM, but they are often described as such in research. On the other side of the coin, transgender men are often excluded from research that claims to be about MSM.⁵ Timmins and Duncan’s comment that “specific kinds of sex between cisgender men bestow a unique risk of HIV and other illnesses” indicates the degree to which both MSM and its proposed replacement, SMM, are presumed cisgender unless proven otherwise. The debate about the terms MSM and SMM likewise foregrounds and normalizes the degree to which research tends to focus on (presumed cisgender) men, to the exclusion of transgender and cisgender women, nonbinary people, and transgender men.⁶

Most important, the use of “minority” in SMM is deeply problematic. In public health discourse, as in the rest of American life, “minority” is not about numbers; it is about power. The explicit use of identity terms such as same-gender-loving, gay, and queer—rather than reductive catchalls such as sexual minority—is part of reclaiming power that has been systematically withheld from these groups on the basis of sexual orientation. At the same time, the blanket term “sexual minorities” also obscures the dynamics of power within lesbian, gay, bisexual, transgender, and questioning (LGBTQ) communities. The typical experiences of, for example, a Black bisexual transgender man and a White gay cisgender man both in relation to society at large and within LGBTQ communities are vastly different. Subsuming both under the SMM label erases those distinctions, silencing individual voices and hindering the ability of public health researchers to investigate the forces that give rise to these different experiences in the first place.

Public health research has a duty to identify and address disparities by breaking down monolithic edifices in search of the unique resilience and vulnerability held by individuals and communities. Instead of merely replacing a single inadequate term with another, we should reflect true diversity by clearly stating who and what we mean. Rather than hiding our candles under the bushel basket of SMM, we should be pushing ourselves, our editors, and our readers to see and marvel at a thousand points of light.