Bisexualities and AIDS

International Perspectives

Peter Aggleton

• Publisher: Taylor & Francis
• Year: 2020
• eBook ISBN: 9781000159141
• Topic: Medicine
• Subtopic: AIDS & HIV

Since early-on in the epidemic, there has been much interest in the role that bisexual behaviour among men may play in HIV transmission. This text reviews from an international perspective what has been learned about male bisexuality in countries as diverse as Peru and Britain. Its authors examine the forms that bisexuality takes in different cultures, what it means to the men concerned, and whether or not such behaviour poses special risks. The implications of such enquiry for HIV prevention efforts are also examined.

Chapter 1

Bisexual Men in Britain

Mary Boulton and Ray Fitzpatrick

Prior to the appearance of the HIV epidemic, bisexuality had received little attention from researchers in the United Kingdom. Whilst in the United States important contributions had been made to the understanding of bisexuality long before the advent of AIDS (Blumstein and Schwartz, 1976, 1977; MacDonald, 1981), in the United Kingdom bisexuality was recognized as a potential option for sexual behaviour and identity (Weeks, 1987), but little had been done to examine empirically the lives of such individuals.

An early effort to counter this lack of recognition came from individuals with bisexual biographies who collaborated in the production of collective accounts of their experiences. A number of national meetings have been held of individuals with personal interests in bisexuality, from which a very helpful volume entitled Bisexual Lives emerged. The book is partly a collection of personal reflections on their lives by bisexual individuals and partly a ‘manifesto’ of the issues facing them and the need for collective action to promote bisexual concerns and interests (Off Pink Publishing, 1988). In addition to confirming the lack of any substantial documentary evidence for bisexuality in the United Kingdom, the volume makes several fundamental points – undoubtedly observations that will appear throughout this current volume as well. Firstly, bisexual individuals are unable to find an acceptable identity for themselves from socially available straight or gay examples. Secondly, and related to the first point, they commonly experience distrust or rejection from both straight and gay communities. A third point made in a variety of ways throughout the book, however, is a quite fundamental feature of bisexuality conveyed by individuals’ accounts. An extraordinary range of patterns of sexual behaviour are viewed and interpreted as bisexual. As has often been observed (Blumstein and Schwartz, 1977; Herdt, 1984), such diversity is so great as to render any essentialist approach to bisexuality profoundly problematic. Fluidity is a core feature of both personal accounts and academic commentary on bisexuality (Herdt, 1984; Rust, 1992). As the collective of authors express themselves:

It is quite usual for the balance of a person’s sexual preferences to change and evolve continuously for many reasons. Relationships may be emotional and/or physical, contemporaneous or consecutive. The emphasis should be on a fluid sexuality rather than a fixed one. (Off Pink Publishing, 1988, pp. 5–6)

The AIDS epidemic has made it necessary to conduct applied research to monitor and model patterns of sexual behaviour and to produce explanations of behaviour to inform predictions, planning, counselling and prevention. Nevertheless bisexuality as a distinct range of experiences has been difficult to discern in much of the research in Britain as elsewhere. As this chapter makes clear, not only are individuals leading bisexual lives difficult to access for research purposes, but much of the available British evidence on HIV and bisexuality collapses categories of sexual orientation so that bisexual patterns that are distinct from gay experience are hard to discern. This chapter draws together what is known from evidence in Britain which does permit an explicit focus on bisexuality. It is concerned exclusively with bisexual men. The chapter acknowledges the fluidity of bisexuality amongst men in Britain but argues that important insights can be gained by imposing ‘typological order’ on such diversity and delineating distinct biographical and contextual forms of bisexuality with quite distinct implications for HIV prevention.

The Epidemiology of Bisexuality

A primary concern of most British research in this area has been to estimate the size of the behaviourally bisexual male population and to assess the prevalence of both HIV infection and the sexual activities implicated in its transmission. Information came first from studies undertaken within the gay community, designed primarily to describe sexual behaviour and changes in sexual behaviour between men. However, these studies also showed that the majority of the men in their samples had also had sex with women at some time in their lives and that a not insignificant proportion had had a recent female partner. Thus, a number of studies reported remarkably similar findings which suggested that about 60 per cent of homosexually active men had also had lifetime sexual experience with women, and that about 10 per cent had had a female partner in the last year, and 5 per cent in the last month (McManus and McEvoy, 1987; Fitzpatrick et al., 1989; Weatherburn et al., 1990).

Several of these studies also provided details of the sexual activities of the men in their samples (Fitzpatrick et al., 1989; Weatherburn et al., 1990). Again, a remarkably consistent picture emerged, particularly concerning two key points. On the one hand, amongst those who had both male and female partners, the number of female partners was substantially less than the number of male partners for any given time period. On the other hand, the rates of high risk sexual activities with female partners were much higher than they were with male partners. Almost all men engaged in penetrative vaginal intercourse with their female partners, while only a much smaller proportion engaged in penetrative anal intercourse with male partners. Anal intercourse with female partners was not common and rates were similar to those for exclusively heterosexual men. Men were also less likely always to use condoms in penetrative sex with female compared to male partners, and more likely never to use condoms in penetrative sex with female partners. These data suggested that while men were less often engaging in high risk sex with male partners, they were continuing to engage in unsafe sex with female partners, particularly non-regular partners.

Studies of men attending genito-urinary medicine clinics presented a similar picture of the proportion of homosexually active men who also had sexual contact with women (Evans et al., 1989), though uncertainty over the definition of bisexuality used and the criteria by which men were classified as homosexual or bisexual makes comparisons across studies difficult (Boulton and Coxon, 1991). Clinic studies were especially valuable, however, in providing information on the prevalence of HIV infection amongst homosexually active men classified as bisexual, particularly as government statistics used a combined category of ‘homosexual/bisexual men’ (e.g. PHLS Working Group, 1990). Rates of infection amongst those requesting HIV testing were reported as higher in London and the south-east than in other parts of the country. But in all testing sites and at all times, the rates of infection reported have been two to three times greater among ‘homosexual’ men (3 to 17 per cent) compared with ‘bisexual’ men (0.7 to 10 per cent) (Welch et al., 1986; Joshi et al., 1988; Collaborative Study Group, 1989). In one particularly detailed study of over a thousand homosexual and bisexual men attending a London clinic and wanting an HIV test, rates of infection declined as men were more ‘actively bisexual’: 30 per cent of homosexual men tested HIV positive, while the rate of infection amongst men who had had a female partner in the last year was only 12 per cent and amongst those who had had a female partner in the last month as low as 5 per cent (Evans et al., 1989).

The consistency of the finding that rates of HIV infection were lower amongst bisexual than exclusively homosexual men led to the suggestion that gay and bisexual men might constitute distinct populations (Evans et al., 1989). Distinctive social characteristics have been noted in several studies, which report that bisexual men are more likely than exclusively homosexual men to be, or have been, married and more likely to be young (Davies et al., 1990) and middle-class (Fitzpatrick et al., 1989). Nevertheless, these same studies found few differences in attitudes and behaviour between exclusively homosexual and bisexual men. For example, Fitzpatrick et al., (1989) found that bisexual men were just as likely as gay men to have been the active partner in anal sex with a man and only slightly less likely to have been the passive partner. Most notably in relation to risk of HIV infection, the histories of sexually transmitted diseases were similar in the two groups.

The last and potentially most compelling source of information on the population prevalence of behaviourally bisexual men is the National Survey of Sexual Attitudes and Lifestyles (NSSAL) (Johnson et al., 1994). A fundamental limitation of both clinic-based studies and surveys within the gay community is the unknown relationship between their samples and the populations from which they are drawn. This makes generalizations from their findings problematic. The NSSAL is important in providing detailed information on the sexual behaviour of a representative sample of the population as a whole. The researchers took a stratified random sample of almost 20,000 households and obtained information from over 8,000 men (65 per cent response rate). Data were collected through both face-to-face interviews and confidential self-completed booklets. The study found that 6.1 per cent of men reported having had ‘any homosexual experience’ ever and 3.6 per cent a homosexual partner involving genital contact. However, only 1.4 per cent reported a homosexual partner in the last five years and 1.1 per cent in the last year. The research team also found that exclusively homosexual experience was rare. Of the men who reported ever having had a male partner, 90.3 per cent had also had a female partner; of those who had had a male partner in the last five years, 58.4 per cent had also had a female partner; and of those who had had a male partner in the last year, 29.9 per cent had also had a female partner. In comparison with studies conducted in the gay community, these figures show a substantially higher proportion of homosexually active men as also having a female sexual partner: for the last year, the rate is three times as high. This may be because the NSSAL has recruited from a slightly different population of homosexually active men. In particular, it is likely that the NSSAL has included a higher proportion of non-gay-identified men who have female sexual partners but who also engage in covert sex with men than were included in gay community studies, whose samples were drawn largely from amongst ‘out’ gay men. If this is the case, then the implication is that the great majority of behaviourally bisexual men are not involved in the gay community.

Overall, the proportion of men in the survey who reported both male and female partners was 3.4 per cent ever, 0.8 per cent in the last five years, and 0.4 per cent in the last year. These figures are low but consistent with those reported by national surveys conducted using very different methods in both Norway (Sundet et al., 1988) and France (ACSF Investigators, 1992). As the only ones available based on a random sample of the population, these figures are likely to gain wide acceptance as the ‘official’ statistics for Britain. Nevertheless, they have been met by considerable surprise and scepticism, particularly by those involved in the gay community who maintain that they substantially under-represent the proportion of homosexually active men. Weatherburn and Davies (1993), for example, argue that there are a number of methodological reasons why the NSSAL is likely to give an underestimate of the homosexually active male population and hence the behaviourally bisexual population. They consider the findings of several surveys conducted in the ‘heterosexually identified population’ in the USA and settle for much higher estimates of homosexual activity. With regard to the prevalence of bisexual behaviour, they suggest that between 5 and 15 per cent of ‘heterosexually identified men’ are behaviourally bisexual at some point in their lives and between 1 and 2 per cent are behaviourally bisexual in any given year.

This debate points to some of the problems inherent in survey research on behaviourally bisexual men. On the one hand, large-scale population surveys inevitably have difficulty in recruiting appropriate numbers of individuals involved in stigmatized or covert activities and may have further problems in eliciting accurate information from them. The population estimates they give are therefore open to question. On the other hand, studies conducted in the gay community are likely to exclude non-gay-identified men and to view questions to do with bisexuality from a gay perspective. The picture they present is thus again limited and potentially misleading. Few studies have attempted to recruit behaviourally bisexual men directly, however, as the absence of significant social institutions to draw them together leaves such men as inaccessible to research as they are invisible to the public in general.

The Complexity of Bisexuality

The public health concerns which have underpinned much of the survey research on sexuality in the last decade or so have served to focus attention largely on sexual behaviour. To some extent, this represents the success of social scientists in making clear the distinction between sexual behaviour and social labels and in underlining the need to look specifically at behaviour (and the details of sexual activities) to understand the epidemiology of HIV/AIDS. A focus on behaviour alone, however, can present only a partial and limited picture of sexuality. This is particular...

Table of contents

• Cover
• Half Title
• Series Page
• Title Page
• Copyright Page
• Table of Contents
• Acknowledgments
• Introduction
• Chapter 1 Bisexual Men in Britain
• Chapter 2 Bisexuality and HIV/AIDS in Canada
• Chapter 3 Not Gay, Not Bisexual, but Polymorphously Sexually Active: Male Bisexuality and AIDS in Australia
• Chapter 4 Bisexuality and AIDS: Results from French Quantitative Studies
• Chapter 5 Bisexuality and HIV/AIDS in Mexico
• Chapter 6 Bisexual Communities and Cultures in Costa Rica
• Chapter 7 AIDS and the Enigma of Bisexuality in the Dominican Republic
• Chapter 8 Male Bisexuality in Peru and the Prevention of AIDS
• Chapter 9 Bisexuality and HIV/AIDS in Brazil
• Chapter 10 Under the Blanket: Bisexualities and AIDS in India
• Chapter 11 Male Homosexual Behaviour and HIV-Related Risk in China
• Chapter 12 The Homosexual Context of Heterosexual Practice in Papua New Guinea
• Chapter 13 Silahis: Looking for the Missing Filipino Bisexual Male
• Notes on Contributors
• Index