Behaviourally Bisexual Men
Identifying needs for HIV prevention
Weatherburn P, Reid DS, Beardsell S, Davies PM et al
Health Education Authority, 1996[ Notes:
This report was commissioned from Sigma Research in 1994 by the UK government's Health Education Authority (HEA), then in charge of official HIV prevention work. I strongly suspect it was in order to demonstrate that, as the head of the work with gay and bisexual men loved to say, bisexual men are "a minority of a minority of a minority".
He confidently expected that researchers wouldn't find many, despite what the HEA's 'bisexual development group' kept saying, thus demonstrating that bisexual men weren't worth doing anything for.
Everyone – except the bisexual development group, and who cared about them? – would be happy.
As you will see, it Didn't Quite Turn Out Like That.
The researchers started out by assuming that if they insisted subjects had been sexual with both men and women in the past year, hardly anyone would qualify. They set the limit at five years and started advertising in the contact ads sections of the mainstream press, inviting men to call a freephone number.
They were swamped with calls and had to reduce the number of ads placed. They estimate that between 20,000 and 34,000 men tried to ring them in the eight weeks the number was operating – 2,500 and 4,250 a week, and thousands more than respond to their annual Gay Men's (sic) Sex Surveys – but they only had the resources to speak to just over a thousand, of whom three quarters were interviewed.
To their surprise, virtually all the callers had indeed been sexual with both men and women in the past year. The researchers were struck by the way that the mean number of partners in that time – six – was the same as their cohort of gay men. Half of the partners of the bisexual men were women, and they were having more anal sex – often without condoms – with women than reported figures for heterosexual men. They were a strikingly homogeneous bunch: with just two exceptions, there was no significant correlation between behaviour and any of their demographic characteristics. (It was only the number of male partners with whom anal intercourse occurred that was linked: men living with women did so with a slightly lower average of men, and – as can be expected – older men had a lower average as well.) Contrary to the mythology of the 'deceived wife', many of the women involved with the men knew about his same-sex activities and were themselves sexually sophisticated and adventurous.
When asked, 'How do you think of yourself, in terms of your sexuality?' at the end of the interview, over half the men could not answer and needed to be prompted with a second question: 'What term would you use to describe yourself, sexually?' I was not surprised that even then less than half of the total sample had a bisexual (or similar) identity – many bisexually behaving men simply do not have a 'sexual identity' in the way that activists do. Indeed, more than one in eight identified as straight, despite having just talked about their bisexual behaviour. Fewer than 1% had a gay identity, one reason why materials explicitly aimed at gay men will simply not be seen as relevant by this population.
Looking at the report's conclusions fifteen years on, what is striking is how little has been done since.
- It pointed out that many aspects of the findings could not have been predicted from previous studies, and said that more research had to be undertaken so that many of the new or unanswered questions could be addressed. Nope: research has overwhelmingly concentrated on men reachable via the gay community.
- While the authors thought gay men were a higher priority, having a higher known HIV prevalence, this population 'merit higher priority than a number of groups which have been, and continue to be, targeted for health promotion'. Nope: it is also possible that the bisexual men have a higher prevalence than reported, as testing levels were half that for gay men. Equally, government reporting of HIV prevalence makes no distinction between the two populations.
- They said the men 'will not react well to advertisements that overtly refer to homosexuality and/or identify their target group as gay or bisexual men'. Nope: the vast majority of information for men who have sex with men continues to be labelled 'for gay men'.
- Health promotion had to use the media seen by the men: mainstream publications, not the gay press. Nope: if I wanted to reach bisexual men in London, I'd use the Metro and Evening Standard newspapers, plus put ads on public transport. All of these are far more expensive (because they have a much greater readership) than the gay press, and this is one reason why it has not been done.
- Community development work was vital 'to facilitate the exchange of information and experience and the formation of interest groups' outside the existing gay community. Nope: the bisexual community, while not perfect, remains almost totally unfunded in comparison to 'gay' or 'gay and..' groups.
If any recommendations have been ignored the most, it is probably (emphasis mine):
The received wisdom within health promotion has been that the gay community would act as a 'natural' vector of health promotion for bisexual men since they would, presumably, be having sex with gay men at some time. The demographic make-up of this group, their sexual identities (or lack thereof), and their lack of identification with, and use of, the gay community make this an increasingly untenable proposal. .. The main problem when addressing this group of men is that they will not identify with material produced for 'out' gay men. They also may feel themselves not well served by the material prepared for conventionally straight men, because of their greater perceived sexual sophistication and/or specialised tastes.The report finished by saying that the attitude towards bisexual men and their needs was based 'largely on prejudice and pejorative assumptions backed up by scientific and behavioural research that has, on the whole, failed to ask questions which challenge those assumptions.' That remains true today.
In 1995, the report was given to the HEA.
Oh no! Proof that there is indeed a massive population of bisexual men, having large amounts of potentially risky sex, most of whom are unreachable by going via the gay community! What to do?
Colonel Harry Brighton: Look, sir, we can't just do nothing.
General Allenby: Why not? It's usually best.Robert Bolt and Michael Wilson's screenplay for Lawrence of Arabia
And so the report was sat on for about a year. Each time the bisexual development group asked, the publication date was always "in the next couple of months". During that time, some of the findings were leaked to one newspaper, which did a small story on them. Then there was yet another delay. So when it was finally officially published, in April 1996, it was old news and no-one cared. Coverage was minimal and you can judge how much notice was taken of it by reading chaps.org.uk.
Before long, it went out of print and has remained so ever since. Even Sigma Research dropped any mention of it from their website. It was almost forgotten.
So when someone wanted a copy, I decided to scan mine, OCR it, and convert it to HTML. Some years later, a freely downloadable PDF of the report appeared on library.nhs.uk. So, not least as that version is not searchable (it's a series of scans), and also because I'd added these comments to mine, here it is.
As I'm sure you've realised, the bits in red weren't part of the original. The yellow highlights in some tables were (except that they were orginally grey!) One figure proved difficult to reproduce, thanks to being slanted in my copy - if you need a more accurate version than my attempt, see the PDF.
Ian <at> chaps.org.uk
]
[ back cover ]
The prevention of HIV infection remains a priority for health promotion in the UK. Close monitoring of the epidemic reveals that, since the mid-eighties, the pattern of HIV transmission in this country has been changing. While new reports of infections among men who have sex with men have not significantly increased in the last few years, cases among heterosexuals continue to increase.
This change in the pattern of HIV transmission has prompted interest in behaviourally bisexual men, who are identified as playing a potentially important role in the future course of the epidemic.
BEHAVIOURALLY BISEXUAL MEN IN THE UK is the result of a ground-breaking research study conducted by Sigma Research and the Health Education Authority. Using an innovative method of recruitment, the study examines the sexual practices of a hitherto little-studied group: men who have sex with both men and women.
The report also identifies those aspects of HIV prevention which have succeeded with bisexual men, while highlighting areas that need further consideration in order to reduce the risk of HIV.
BEHAVIOURALLY BISEXUAL MEN IN THE UK is essential reading for all those involved in HIV education, research and policy.
[ inside cover ]
About Sigma Research
Sigma Research specialises in research on all social and behavioural aspects of HIV/AIDS prevention and care. Since 1987 the team has carried out more than 20 research projects, including the UK's largest ever (cohort) study of male homosexual behaviour and HIV seroprevalence. Other research includes projects on HIV testing; HIV-positive people; gay men and safer sex; male sexual assault; male sex workers; and public sex environments. They have also undertaken evaluations of health promotion-materials; needs assessments of HIV prevention for gay men; and audits of HIV-testing services, needle exchanges and palliative care.
Sigma Research is part of the University of Portsmouth.
Acknowledgements
Thanks are to due to many people for their contribution to this piece of work. The thousands of men who phoned up, especially those that were finally interviewed, deserve our thanks, not least for their patience and stamina. Without them the work would have been impossible.
Thanks are also due to those peers who read the first messy draft of the report, including Paul Holland and Laurie Henderson. Not all their comments or dire warnings have been heeded, though all were noted. Of course, the authors remain entirely responsible for all the views expressed herein.
© Health Education Authority, 1996 ISBN 0 7521 0523 X
Health Education Authority
Hamilton House
Mabledon Place
London WCIH 9TXTypeset by Type Generation
Cover design by Threefold Design
Printed in Great Britain by Cromwell Press, Melksham 3M/039/6
Contents
3. Demographic characteristics and sample descriptors
3.3 Highest educational qualifications
5. Sexual partners and sexual practices
5.2 Sexual partners in the past five years
5.3 Male and female sexual partners in the past year
5.4 Vaginal intercourse with female sexual partners in the past year
5.5 Anal intercourse with female sexual partners in the past year
5.6 Anal intercourse with male sexual partners in the past year
5.7 Number of female sexual partners in the past year
5.8 Number of male sexual partners in the past year
5.9 'Predictors' of partner numbers
5.10 Vaginal and anal intercourse with male and female partners in the past year
6. Current regular sexual partnerships and disclosure of (other) sexual activity
6.1 Disclosure of (other) sexual activity to regular female partners
6.2 Effects of disclosure to regular female partners on (homo)sexual practices
6.3 Effects of disclosure to regular female partners on (hetero)sexual practices
6.4 Disclosure of (other) sexual activity to regular male partners
6.5 Effects of disclosure to regular male partners on sexual practices
7. Most recent sexual encounter with new male and new female partners
7.1 Time elapsed since most recent new partners
7.2 Circumstances or location of meeting with most recent new partners
7.3 Previous relationships with most recent new partners
7.4 Responsibility for initiating sexual contact with most recent new partners
7.5 Location of sexual encounters with most recent new partners
7.6 Numbers of participants in sexual encounters with most recent new partners
8. Knowledge and impact of HIV/AIDS
8.1 Knowledge concerning HIV/AIDS
8.2 Sources of information on HIV/AIDS
9.1 Are behaviourally bisexual men and their partners at risk of HIV infection?
9.2 Are HIV prevention campaigns really necessary?
Foreword
The prevention of the spread of HIV infection remains a priority for public health in the UK and other countries. In order to build upon the successes that this country has had in controlling the spread of the epidemic, it is vital that high-quality research is conducted to inform policy about where and how to invest resources effectively.
In 1993 the Health Education Authority (HEA) embarked upon a new and exciting programme of research on HIV prevention among gay and bisexual men – the group most affected by HIV disease. This study represents the main outcome from one element of what has proven to be a valuable and instructive programme of work.
The general aim of the research programme was to support the planning and development of HIV/AIDS prevention at both the national and local level. The HEA's research agenda had four distinct elements:
- the identification and dissemination of the evidence of effectiveness of health promotion among men who have sex with men;
- the identification and dissemination of best practice in relation to gay and bisexual men;
- research to improve our understanding of how safer sex is sustained over time among gay men;
- research to understand the information needs of behaviourally bisexual men in relation to the prevention of HIV infection.
Knowledge of each of these areas is crucial to the implementation of sound and workable HIV prevention activities, yet very little research has been conducted into any of these topics. This makes this programme's contribution both timely and important.
The first two elements of the research programme have now been completed and products are available from the HEA in the form of reports (Aggleton, 1995; Warwick, Orr & Whitty, 1995) and a handbook (Woodhead, Warwick & Whitty, 1995) on how to conduct local needs assessments. A report of the third element will be available from the HEA shortly. This report is the culmination of the fourth element.
Background to the study on behaviourally bisexual men
In 1993 the Public Health Laboratory Services working party on AIDS and HIV disease, under its chair Professor Day, produced a report on the state of the HIV epidemic in the UK. One of the report's principal observations was that since the mid-1980s HIV transmission rates had declined among homosexually active men, but increased among the heterosexual population. This changing pattern of the epidemic focused interest on those groups which might play a role in the sexual transmission of HIV infection within the heterosexual population.
As commentators were quick to point out, behaviourally bisexual men (together with injecting drug users) were identified as a potentially important route of infection. However, relatively little was known of the behaviour of bisexual men that could assist in assessing their role in HIV transmission.
Central to this element of the HEA programme of research was the recognition of the need to understand the behaviour of bisexual men, especially the extent to which they put themselves and others at risk of HIV infection. It was also important to assess their responses to health education, and to investigate their perceptions of risk in acquiring and transmitting HIV
A review of the research literature on men who have sex with men revealed how little was known of behaviourally bisexual men who do not identify as gay. The reasons for this lack of research knowledge were obvious: unlike populations of gay identified men, who have a range of social venues through which access is possible, there are no obvious means of recruiting to research studies behaviourally bisexual men who do not identify as gay.
[ Well, involving the bi community and supporting some bisexual social venues would be a start. ]
Nonetheless, the success of other innovative research techniques used by the HEA in the development of its safer sex advertising aimed at bisexual men indicated that there were means of accessing this particular population. The achievements of researchers in contacting and investigating so-called 'hard to reach' groups – such as drug users and prostitutes – also indicated that problems of access should not be seen as sufficient reason for not attempting to conduct research in this area.
[ The only advertising the HEA ever aimed at bisexual men was the 'hands' ad. They loved that one, even though no-one else in the field did. More about this somewhere else on chaps.org.uk soon. ]
It was in this spirit that the HEA invited proposals to conduct an exploratory study on the needs of behaviourally bisexual men. Sigma Research responded with a proposed study which aimed to recruit and interview over 500 behaviourally bisexual men. The study had the potential to be an important building block in our understanding of a group of men which has been largely overlooked by research and health education alike.
The study reported here is the largest of its type to date and, in addition to leading the research field into large-scale research among behaviourally bisexual men, it provides important insights into the behaviours and attitudes of this group. Nevertheless, as is perhaps inevitable in such a new area of inquiry, many questions remain unanswered, and the study highlights many new areas for future investigation.
It is hoped that this report will generate debate and discussion among those concerned with the prevention of HIV infection and health education, so that better information and advice can be targeted effectively to those at need.
Adam Crosier
Principal Researcher: HIV/AIDS and Sexual Health
Health Education Authority
January 1996
Preface
This report outlines the key findings of one of the largest studies ever to examine the sexual practices of men who have sex with both men and women ('behavioural bisexuals'). Given the dearth of comparable data and the wide-spread assumption that the recruitment of behaviourally bisexual men would be difficult, it was designed as a feasibility study.
Little is known about behaviourally bisexual men, and this study cannot possibly answer all our questions about such men, nor address all our theories about their behaviour. Since we know so little about this population the report is largely descriptive. While more complex and specific analysis will be published in due course, this report outlines the basic findings of the study.
[ There were three places the authors later mentioned: a letter to the British Medical Journal (Survey shows unprotected sex is a common behaviour in bisexual men. BMJ, 1995, 311: 1163-116), an article in AIDS Care (Sexual HIV risk behaviour among men who have sex with both men and women. AIDS Care, 1998, 10(4): 463-471), and a book chapter (Behavioural bisexuality among men. In Sherr L (ed). AIDS in the heterosexual population. Switzerland, 1994, Harwood Academic Press, pp 131-139. (ISBN 3 718654 59 8 (h/b) / 3 718654 60 1 (p/b))). From memory, none of the three add much to what is in this report. ]
The report does not concentrate on the similarities and dissimilarities between this study and previous work in this area. Given the dearth of strictly comparable data and the innovative methodology employed here, such comparisons are hazardous. The deliberate avoidance of comparison was adopted because the aim was not to make substantial generalisations about all men who have sex with both men and women, although the authors feel this study can make a substantial contribution to our understanding of them.
For those that seek to generalise these findings to the whole adult male population there is little but frustration to follow. As Chapter 1 explains, it is not possible to know how prevalent bisexuality is. Although comparisons with the general population are very difficult, they are probably best attempted in relation to the recent UK National Study of Sexual Attitudes and Lifestyles (Johnson et al., 1994).
Of course, this is not a random sample of men that have sex with both males and females, and these findings cannot necessarily be generalised to all bisexual men. The men recruited to this study all read contact advertisements in local and national papers and magazines. While this was not their most important, let alone their only source of male and female sexual partners, bisexual men undoubtedly exist that have never examined a single contact advertisement. For those who are interested in comparisons with other studies of bisexual men, two broadly similar Australian studies have been conducted (Kippax, Rodden & Crawford, 1993; Hood et al., 1994) and just one vaguely comparable UK study (Boulton et al., 1991; Boulton, Hart & Fitzpatrick, 1992). Finally, comparisons with data from gay men's studies are relatively straightforward (Weatherburn et al., 1992; Davies et al., 1993). However, the assumption that comparison with any of these populations will be particularly fruitful is questionable.
[ Given the use of the 'bisexual threat' – the idea that bisexual men would spread HIV infection from those nasty gay men to the nice straight population – in order to get the UK government to do something about the epidemic, the lack of reseach is staggering. Mary Boulton's research was the only one to involve the UK bi community – she spoke to about ten men found via the London Bisexual Group! ]
What this study does prove is the existence of a large group of men who have considerable amounts of sex with both men and women. While many people will always have assumed that such a population exists, few could have guessed how large it seems to be. It also demonstrates a cheap and efficient way of contacting these men, should such contact be deemed appropriate.
[ Well, we on the bisexual development group had been saying for years that a large population did exist. I think we'd even suggested using contact ads to find them. ]
1 Introduction
Males do not represent two discrete populations, heterosexual and homosexual. The world is not divided into sheep and goats. Not all things are black nor all things white... Only the human mind invents categories and tries to force facts into separated pigeonholes. The living world is a continuum in each and every one of its aspects. The sooner we learn this concerning human sexual behaviour, the sooner we shall reach a sound understanding of the realities of sex.
In order to place what follows in some context it is useful first to briefly and selectively examine the existing literature on men who have sex with both men and women. We do this with special reference to three key issues: the assumed impact of bisexual men on the HIV epidemic; what is known of patterns of bisexuality; and the prevalence of bisexuality. While the issue of prevalence is not addressed in this study, we assume that, as a consequence of this work, it will again be raised as an issue of importance.
Empirical evidence concerning bisexual men is sparse and difficult to interpret. Available evidence derives from disparate and isolated studies which have not arisen from any unified research agenda. Many of the studies that include relevant information were not written with bisexuality as a primary focus, so accounts of sexual behaviour are frustratingly incomplete. Until the advent of HIV, the vast majority of studies of bisexuals either concentrated on issues of identity and other broadly psychological factors such as coping or adjustment, or they adopted anthropological and historical methods to examine bisexuality in various cultural or temporal contexts. Most of these studies (see Boulton & Weatherburn, 1990 for a review) describe individuals who self-identify as bisexual, although some define their study group in terms of emotions or intentions. In these contexts 'bisexuals' need not currently engage in sexual behaviour with both males and females, but may identify with the bisexual movement politically or be attracted to, and/or intend to have sex with, both genders at some point in the future.
More recently, it has become increasingly common to define bisexuals solely in terms of their sexual behaviour within a given time period, since most recent research has sought to examine their impact on the spread of HIV (or vice versa). However, adopting a behavioural definition does not exhaust the difficulties, as problems arise over the time period involved. Thus, a person is sometimes termed behaviourally bisexual if they have had sex with both genders during the course of their life, but this is of little epidemiological or practical use. In order to be of any true epidemiological use we have to use 'behavioural bisexuality' to refer to sex with both genders in the preceding five years, or less. Not only is this time period short enough to have epidemiological significance but, in addition to 'lifetime', it is a period commonly used in other studies of sexual behaviour. This report therefore uses the term 'behavioural bisexual' to describe persons who have had sex with both genders during the preceding five years.
[ In private the authors said they picked five years because they thought if they said one year, hardly anyone would qualify! ]
We recognise that the label 'behavioural bisexual' does not define a social category or a group of persons who share a common set of preconceptions, let alone a recognisable lifestyle. This categorisation recognises that there are many men and women who, terming themselves heterosexual, lesbian or gay (or having no sexual identity at all), will engage, regularly or infrequently, in sex with partners of both genders. Hence the term 'behavioural bisexual' describes a population with broadly similar sexual behaviour patterns. We will use the term 'bisexual' to refer only to persons that label themselves as such, irrespective of their current or past sexual behaviour.
Although these two groups are not coterminous, the distinction is useful because the terms identify different populations. Behavioural bisexuals form a 'transmission group' which has epidemiological significance – although it remains to be seen how important their role is in the future of the HIV epidemic. On the other hand, self-identified bisexuals form a potential vector for health promotion, the usefulness and efficacy of which depends largely on the degree of social organisation that exists in the 'bisexual community'. It would be quite wrong, however, to expect initiatives from within the latter to encompass all the former, nor is it automatically the case that bisexuals have any privileged access to all behavioural bisexuals.
[ It'd be nice if they even tried. The proportion of health promotion directed at, or intended specifically for, the bisexual community is minimal compared with that thrown at the gay male community: see chaps.org.uk ]
Although the issue of who counts as a bisexual remains confused, and sound empirical evidence is sparse, during the past ten years bisexual men have often been claimed to be crucial to the future pattern of sexual spread of HIV (Winkelstein et al., 1986; Fay et al., 1989; Bennett, Chapman & Bray, 1989; Tielman, Carballo & Hendriks, 1991). Such statements seem to be underpinned by a belief that homosexual men and heterosexual men form two hermetic communities, giving rise to the problem of containment of infection within the former (sometimes glossed as a 'high-risk group') and avoidance of spread to the latter (referred to as the 'general population'). From this simplistic analysis, the notions of bridge groups and pools of infection emerge; the most popular example of these being bisexual men.
Such an analysis confuses the physical processes of sexual transmission with social identities and labels. It disregards the fact that there is no straightforward relationship between self-proclaimed sexual identity and sexual behaviour (Fitzpatrick et al., 1989; Weatherburn et al., 1990; Stokes, McKirnan & Burzette, 1992; Prestage & Hood, 1993) and fails to recognise that, in terms of HIV transmission, sexual behaviour and not sexual identity is the crucial determinant of risk.
1.1 PATTERNS OF BISEXUALITY
While behavioural bisexuality appears to occur in a large number of diverse contexts, it seems to lead to the formation of a bisexual identity in only a small minority of cases (Blumstein & Schwartz, 1977). Indeed Boulton (1991) has argued that because of the dichotomous notions of sexuality in the West, identity is more likely to reflect the individual's reference group or the subculture in which they are involved, especially where there is no public reference group or community available to validate or support a bisexual identity. Hence, 'most of those who engage in bisexual behaviour remain as isolated individuals, having little contact with other bisexual men and being hidden within the homosexual community or the "general population"' (Boulton, 1991:200).
Similarly, but far more specifically, the comparable Australian study (Hood et al., 1994:65) commented that their sample:
... usually see themselves in terms of their personal and family relationships, not their sexuality. What they do sexually is only of marginal importance to their perception of who they are, whereas their personal relationship to their family and the other people they mix with socially is central.Whilst skilfully evading the question of definition and its impact by reference to a number of extensive theoretical reviews (Paul, 1984; Hansen & Evans, 1985; Klein, Sepekoff & Wolf, 1985; Zinik, 1985; Morrow, 1989) Ross (1991) proposed that there were eight major patterns of bisexuality which could be distinguished worldwide: defensive; Latin; ritual; married; secondary; equal interest in male and female partners; experimental; and technical. Without pausing to explain those categories, the meaning of which is not self-evident, it is easy to see that whilst this ingenious taxonomy of bisexuality is not without considerable surface validity, but it tells us little about patterns of sexual behaviour. The only common factor between persons in any, or indeed all, of these categories is that they must, at some point in their lives, have had sex with both males and females.
Similarly, but far more specifically, Boulton et al. (1989) identified six distinct patterns of bisexuality: transitional (as part of the process of 'coming out' as gay); unique (almost exclusively homosexual or heterosexual with occasional deviations); serial (alternating patterns of exclusive hereto- and homosexuality); concurrent-straight (predominately heterosexual with some homosexual contacts); concurrent-gay (predominately homosexual with some heterosexual contacts); and concurrent-contact magazines (large numbers of male and female partners). Although these patterns have the distinct advantage of describing modes and types of sexual contact, they are far from mutually exclusive and arise from a very small sample (n=35) of men. Hence, their validity with regard to describing all men that have sex with both men and women is questionable.
Clearly then, however we define bisexuality, it is not a unitary concept. It means various things to various people. As some commentators suggest, there may indeed be types of bisexuals (Boulton, 1991). However, this may be fitting into artificially constructed typologies persons who, at best, know nothing of such categorisation and might well refuse to be pigeon-holed in such a way.
1.2 THE PREVALENCE OF BEHAVIOURAL BISEXUALITY
Although it has been argued that since the sexual revolution of the 1960s and early 1970s it has become increasingly easy to self-identify as bisexual, the identity remains stigmatised by wider society and, to some extent, within gay and lesbian culture (MacDonald, 1981; Wolf, 1987) and is still dismissed as a transitory or transitional state, a denial of homosexuality or even a myth (Ross, 1979; MacDonald, 1981). Coupled with the lack of a straightforward and cohesive social or political structure, this makes identification as bisexual both difficult and relatively unusual. Thus, while behavioural bisexuality appears to occur in a number of diverse contexts, it leads to the formation of a bisexual identity in only a small minority of cases (Blumstein & Schwartz, 1977). While we know little of the prevalence of men with a bisexual identity we can safely assume that in the UK it is unusual. However, we can examine rates of behavioural bisexuality among men who neither identify as gay or bisexual.General population surveys often collect data on the overall proportion of men that report ever having had sex with a man. Unfortunately, methodological incompatibilities (such as variations in questions or time-frames) make comparison of these data difficult, and these problems are compounded by cultural and temporal differences, as well as factors such as the failure to collect data relating to sexual identity or sexual practices.
As shown in Figure 1, estimation of the rate of lifetime behavioural bisexuality in the general population varies between 1.5% (Forman & Chilvers, 1989) and 46% (Kinsey, Pomeroy & Martin, 1948). More recently, a meta-analysis of three US national studies (Rogers & Turner, 1991) estimated that lifetime prevalence of homosexual experience in the general population fell within the range 4.8-4.9%, with 1.2-2.4% having engaged in such practices in the previous year. Similarly, the Cox Report (Department of Health/Welsh Office, 1988) suggested that the proportion of the population engaging in homosexual sex on a more than incidental basis was in the range of 3-7%.
Figure 1 Percentage rates of homosexual experience within general population surveys of men Study description Defining characteristics % Kinsey et al (1948)
USA: about 5300 men in convenience sampleHad homosexual experience but not exclusively homosexual 46.0 Had male and female partners during life 33.0 Fay et al (1989)
USA: 1450 men in random household surveySexual contact to orgasm with a man in lifetime 20.3 Sexual contact to orgasm with man since age 19 6.7 Sexual contact to orgasm with man in last year 1.8 Lever et al (1989; 1992)
USA: 62,352 men answering Playboy readers' surveyAdult homosexual and heterosexual experiences 12.0 Adult homo- and heterosexual experiences and identified as bisexual 3.4 Orton and Samuels (1990)
UK: 468-526 men interviewed in 4 waves 1986-7Ever had sexual contact with someone of own sex 4.0-6.0 Johnson et al (1994)
UK: 18,876 men and women from random household surveyEver had homosexual experience 6.1 Ever had homosexual partner 3.6 Ever had both male and female partners 3.4 Ross (1988)
Australia: stratified sample 2601 persons over 21 yearsCurrently married men with male partner in last year 4.2 Previously married men with a male partner in the last year 6.4 ACSF (1992)
France: 9928 men from random household surveyEver had male partner 4.1 Ever had male and female partners 3.2 Sundet et al (1988)
Norway: random sample of about 6300 men and womenEver had male and female partners 2.9 McQueen et al (1991)
UK:Ever had sexual experience with same sex 2.3 Experience with same sex in last 3 years 0.9 Forman and Chivers (1989)
UK: 480 white men aged 15-49 yearsEver had 'homosexual intercourse' and had female partners 1.5 While some of this variation must clearly arise from sampling and design differences, the discrepancies in these estimates remain substantial. While some, if not most, of these estimates include men that identify as gay or bisexual (Sunder et al., 1988; Ross, 1988; ACSF Investigators, 1992; Johnson et al., 1994), failure to report sexual identity makes it difficult to judge exactly what effect this has on estimates of the rate of behavioural bisexuality.
Only a few studies report such issues in sufficient detail to make any estimate of the proportion of 'heterosexual' men that engage in sexual activity with both men and women (Kinsey, Pomeroy & Martin, 1948; Lever et al., 1989; Lever et al., 1992; Johnson et al., 1994). Taking Kinsey, Pomeroy & Martin (1948) first, we must recognise that the study has proved important for two main reasons. First, it revealed that the incidence of homosexual behaviour was much greater than had previously been supposed. Secondly, it suggested that people could be arranged along a continuum of sexual response, moving from those who are completely heterosexual in their behaviour, through varying degrees of mixed heterosexual-homosexual response, to those who are completely homosexual.
With regard to men, Kinsey, Pomeroy & Martin (1948) reported that through the course of their adult lives, 4% were exclusively homosexual and 37% had some overt homosexual experience to the point of orgasm between adolescence and old age, thus making 33% behaviourally bisexual over their lifetimes. Alternatively, if we exclude 'to the point of orgasm', 50% were exclusively heterosexual, 4% were exclusively homosexual and 46% were behaviourally bisexual.
A study by Lever et al. (1989; 1992) of 80,324 readers of Playboy magazine found that 86.7% of men were exclusively heterosexual; 1.3% were exclusively homosexual; 11.1% were predominantly heterosexual; and 0.9% predominately homosexual. If we sum the latter two categories we find that 12% of the male readers of one major soft-porn magazine are behaviourally bisexual. Of these 7484 behaviourally bisexual males 28.2% define themselves as bisexual and 69.9% as heterosexual. Of course there are problems with extrapolating from a readers' survey of a men's magazine to the wider population. However, given that the magazine's imagery relies solely on female models, one could argue that these problems should serve to underestimate the reported rate of same sex activity, rather than exaggerate it.
Recently the figures of the UK's National Study of Sexual Attitudes and Lifestyles (NSSAL) (Johnson et al., 1994) have gained much prominence. Overall, the authors report that 6.1% of men have ever had some kind of homosexual experience and 6.7% have had homosexual attractions. Using their more stringent definition of homosexual partners (that is, 'a male partner with whom anal sex or oro-genital sex or other forms of genital contact had occurred'), 3.6% of men have ever had a homosexual partner; 1.4% report one in the past two years and 1.1% in the past year. The authors explain the major differences in these figures by reference to the transient nature of sexual development. While this may be true, the statement is undermined by their failure to collect data on sexual identity and changes in preferences over time. More importantly, they report that 0.3% of males have only male partners, but more than ten times this number (3.4%) have both male and female partners through the course of their lives. In relation to the past five years, 0.6% of men report only male partners and 0.8% report both male and female partners; for the last two years the figures are 0.6% and 0.5%, and for the past year 0.7% and 0.4%.
Together with a recent national survey in France (ACSF, 1992) these data suggest that Kinsey's figures on the prevalence of homosexual activity are overestimates. The difference is said to emerge from the fact that Kinsey et al. (1948) deliberately recruited homosexuals and collected data during the war years, when homosexual activity is presumed to have been particularly prevalent. On the other hand, as Johnson et al. (1994) recognise, the UK and French national studies underestimate the prevalence of homosexual activity because of factors such as political and moral sensitivity dictating question style and content, and respondents' fears about confidentiality and anonymity. While factors such as these are not necessarily specific to massive random household surveys, they serve as examples of problems that are especially important in such studies. While such studies are necessary to assess broad parameters of sexual behaviour their sheer scale necessitates simple coverage of very complex issues.
With such a collection of seemingly conflicting evidence it is difficult to be sure of the exact proportion of men who are homosexually active. Recognising that, in addition to the behavioural bisexuality of other men, more than half of gay identified men will ever have had sex with men and women, and at least 10-15% (Weatherburn & Davies, 1993) will have been behaviourally bisexual in the preceding five years, the proportion of all men that have sex with both men and women is unlikely to be low. While exact rates are impossible accurately to quantify it seems reasonable to assert that the lifetime figure lies somewhere in the region of 5-15%. Our best guess would be closer to the 12% of Lever et al. (1989; 1992) than the 3-7% of Johnson et al. (1994). However, with little direct evidence, estimates of the proportion of adult men that have had sex with both males and females in the last five years are too hazardous to even attempt.
2 Methodology
We felt that given the absolute and over-riding importance the men were likely to place on protecting their identity, the methods employed would be more successful if we did not rely on face-to-face contact, appointments or repeated contacts. Hence we concentrated on anonymous telephone interviews. Our extensive preliminary work had suggested that a promising source by which to recruit large numbers of behaviourally bisexual men was the print media. The burgeoning of lonely hearts and more overtly sexual advertisements in a vast array of print media made this study possible. Many newspapers (local and national) and magazines (general and specialist) now carry a wide range of advertisements for relationships or sexual contact.
The only component of such an approach that remained unclear was the explicitness with which we could advertise that we were undertaking a survey and the other services that we would reasonably expect to provide. Two similar Australian studies (Kippax, Rodden & Crawford, 1993; Hood et al., 1994) suggest that placing advertisements that do not emphasise (or completely disguise) the survey component results in larger numbers of men calling the telephone line. However, such an approach means that the interviewers have to field a number of callers that are expecting to make contact for sex or engage in telephone sex. The dubious ethics of this, as well as the practical considerations, led us to decide that it was not acceptable to disguise the nature of the contact. However, we recognised that it was unreasonable to expect the men to call the line simply to contribute to a broader understanding of their sexual practices. Hence, all telephone interviewers were men with an understanding of sex with other men who were trained to provide accurate basic information about HIV and a comprehensive list of referral sources, although relatively few men asked for information or referral.
2.1 QUESTIONNAIRE DEVELOPMENT
A questionnaire was developed and extensively pre-tested. It was designed to take not more than 15-20 minutes to administer. A short introduction stated that it was completely anonymous and confidential, and that the results would inform future safer sex campaigns. Ongoing interviewer training was built into the pre-testing and piloting processes.
The final version included questions concerning:
- use of contact advertisements in newspapers and magazines;
- first sexual experiences (with males and females);
- numbers of male and female sexual partners;
- numbers of male and female penetrative sexual partners;
- numbers of male and female unprotected penetrative sexual partners;
- sale and purchase of sex;
- regular partnerships (with males and females);
- disclosure of sexual practices to regular partners;
- venues for meeting sexual partners;
- detailed accounts of most recent sexual experiences with new male and female sexual partners;
- the perceived impact of HIV/AIDS on sexual practices;
- knowledge concerning HIV/AIDS (including sources of information);
- HIV antibody testing and contact with the HIV epidemic;
- demographic details.
Questions were asked in the order outlined above. A number of characteristics of the questionnaire were fairly unusual. First, the demographic details were deliberately left to the last section of the questionnaire in order to minimise suspicion. Although we promised that we were not interested in the identity of respondents, piloting had proven that to ask a man's age, occupation, marital status or partial postcode immediately after making such a promise did not inspire trust. By leaving these questions until the end of the questionnaire we were able to first build up rapport.
Secondly, the questions regarding partner numbers and sexual practice, which many people would assume were the most intrusive or problematic, were pushed to the front of the questionnaire, following a few minutes of fairly bland questions concerning where they had seen the advertisement and their use of contact sections. The primary purpose of this approach was to ensure that all questions in the first half of the questionnaire could be answered by stating yes/no or reporting a number. This overcame some problems associated with respondents calling from semi-public places.
Finally, after piloting, it was decided to place all the questions concerning HIV/AIDS near the end of the questionnaire. This ensured that if men refused to continue the interview when asked such questions (because they perceived it as a test of their knowledge) then the bulk of their data would still have been collected and could be included in the analysis.
Having installed one freephone telephone line, we undertook a week of time sampling. During this time the line was staffed for 12 hours per day (10 a.m. to 10 p.m.), seven days per week. In addition to recruitment and interviewing, it was possible to monitor the frequency of calls. After analysis we decided to staff the line for 10 hours per day (10 a.m. to 8 p.m.) Monday to Friday, and from 10 a.m. to 4 p.m. on Saturdays and Sundays, when specific adverts appeared on those days. This gave a minimum of 50 hours of interviewing per week and a maximum of 62 hours.
Ultimately we did eight weeks of interviewing on one telephone line (excluding Christmas week).
Timetabled interviewing hours: 420
Allocated hours cancelled: 42
Allocated hours completed: 378
2.2 ADVERTISING STRATEGY
After initial contact with a wide range of magazines and newspapers, a decision was taken to target a few types of publication: soft-porn magazines, listings magazines, local papers and advertisers, and a Sunday paper with national circulation. We could have also advertised in 'men's interests magazines' and the national daily papers. Given our limited budget we decided to concentrate on publications with contact sections or which carried advertisements for sex-related products. All adverts were placed in, or as near to, these sections as possible.
Two major assumptions were made concerning the best way to word an advertisement to recruit behaviourally bisexual men. First, our many years of experience as sex researchers had taught us that most men are willing to discuss their sexual practice in considerable detail if their concerns about confidentiality and anonymity are met. Indeed, many men seem only too delighted to discuss their sexual practice as long as the topic is dealt with sensitively. Secondly, given the typical readership of the majority of magazines and papers we intended to recruit from, we took a strategic decision to give the impression in the advertisement that, 'of course', having sex with women was the norm. Hence, men were asked if they 'had sex with men as well', with no mention of homosexuality or a gay identity. Also, bisexuality was not mentioned, since we did not assume this would be the predominant sexual identity of the men.
Contact with the appropriate media to negotiate placement of adverts was undertaken. In addition to agreeing text for advertisements, the costs were established. All newspapers and magazines were sent a short explanation of the project with a letter from the HEA confirming the scientific validity of the study. Although we targeted only papers with contact or personal sections, a few refused to carry our advertisement. The most common reason was that the publication was a 'family paper' and they did not like the explicit sexual connotations of the advertisement. While this occurred with a range of local papers it was especially common with the papers which serve black and minority ethnic communities. Adverts were not placed with a few papers because their request to alter the basic wording made the advertisement far too ambiguous.
Hence, the typical advertisement read:
MEN WANTED
Do you ever get off with men as well?
Tell us about it.
We're sex researchers.
Freephone 0800 xx xx xx
COMPLETELY CONFIDENTIAL.While the phrase 'Do you ever get off with men as well?' was originally used because papers did not appreciate the explicit mention of 'sex', others requested the use of the word 'sex' rather than the more colloquial 'get off with'. In these cases the second line read 'Do you ever have sex with men as well?'
Although advertisements were placed from mid-November 1994 in order to pre-test questionnaires, advertising began in earnest on 5 December, and ran through January 1995. In total £1895 was spent on advertising. The newspapers and magazines used are listed below.
The most obvious problem with the range of (local) papers is its London bias. While we had not intended to prioritise the city, we did concentrate on it in the early stages of advertising. Since our strategy proved very successful, it became unnecessary to place as many subsequent advertisements as we had originally planned.
2.3 NUMBERS OF CALLS DURING THE EIGHT WEEKS OF INTERVIEWING
Outlined below is the overall number of calls made to the phone number during the eight-week period during which interviewing occurred. This information was provided by British Telecom and supplied in relation to BT call catchment areas. For comparison the equivalent postcode region is listed.
Figure 3 Overall number of calls made by postcode regions and the equivalent British Telecom call catchment areas Postcode region Catchment area (BT) Calls % Newcastle and the North Newcastle and Darlington Yorkshire and Humberside Sheffield, Leeds and York Lancashire Preston Liverpool Liverpool Manchester and Cheshire Manchester and Chester East Midlands Leicester and Nottingham West Midlands Birmingham, Coventry, Stoke-on-Trent and Wolverhampton South Midlands and Chiltern Luton and Oxford East Anglia Cambridge, Ipswich, Norwich and Peterborough Essex Chelmsford London All Kent and Sussex Maidstone and Tunbridge Wells Berkshire and Surrey Reading, Crawley and Guildford Solent and Wessex Portsmouth and Salisbury South West Exeter and Plymouth Bristol and the Severn Gloucester and Bristol Wales and the Borders All and Shrewsbury Northern Ireland All Scotland All Total Apart from the quite startling number of calls received during the eight week period of interviewing, the most striking feature is the spread of the region of origin of the calls. While Greater London is over-represented because of its inadvertent emphasis in the advertising strategy, all other regions of the UK are represented, and a considerable proportion of the callers came from regions where no local advertising was placed.
Of the 67,766 calls that were made to the number during the period of interviewing, 7398 were effective, in that they resulted in callers speaking to an interviewer or to the answering machine (which was on whenever interviewing was not scheduled). We estimate that 15-20% (or 1200) of these effective calls resulted in a conversation between an interviewer and a potential interviewee. The total number of ineffective calls was 60,368. These callers heard an engaged tone and their calls resulted in no personal contact.
As soon as we realised that the very high number of calls was going to be sustained throughout the period of interviewing we began to ask respondents how many times they had called before getting through. This question was asked of 234 different men. The average number of times they had called (including the call that resulted in the question) was between 2 (median, IQR 1-4) and 31/3 (mean, SD=3.07). Hence we conclude our 67,766 calls came from at least 20,000 and as many as 34,000, different men.
[ I saw the ad in Loot and called twice, failing to get through both times, so this seems about right to me. ]
Given the massive response in the first few weeks of interviewing we monitored 200 consecutive telephone calls in an attempt to ascertain how many interviews could have been undertaken with more human and telephone resources (though with no increase in the advertising budget).
Figure 4 Sample call analysis (n=200) n % Agreed and completed 109 54.5 Agreed but aborted 45 22.5 Silent/hung up on answering 35 17.5 Non-qualifiers 11 5.5 More than three-quarters of all answered calls resulted in the caller agreeing to be interviewed. Of those that agreed to be interviewed, the majority (71 %) completed the questionnaire. If our 67,766 calls came from approximately 25,000 different men, then at an agreement rate of 77% and a completion rate of 71 % we could have recruited approximately 13,667 different men on an advertising budget of less than £2000.
Of the approximately 1200 men to whom we spoke, about three-quarters agreed to be interviewed. Of these approximately three-quarters completed the entire schedule. Outlined in Figure 5 is the exact breakdown of the outcome of all those calls in which the men agreed to be interviewed and qualified for the study.
Of the 889 men that agreed to be interviewed, 745 were eventually included in the data analysis. Of those excluded (marked 'cut') most completed less than half of the question schedule. The others were excluded on the basis that their data failed internal validity checks (their sexual behaviour data were incompatible when different time periods were compared) and/or the interviewer was suspicious that the caller had been interviewed before – that is, he recognised the voice and/or the information given.
Those calls which resulted in completed interviews lasted an average (mean) of 15.2 minutes. It is difficult to say precisely what caused those men who did not complete the interview to hang up. However, our impression of the aborted calls was that they were usually attributable to two majors problems: embarrassment (the questionnaire was more demanding than many men had assumed) and interruption (a problem exacerbated by many men's attempts at calling from public or semi-public places).
Of those callers that did not start the interview (23%) the vast majority (76%) said nothing or hung up as soon as the telephone was answered. While it is impossible to tell what caused these callers to hang up on answering, it was our impression that a number of these calls originated from the same persons, as they came in clusters but with no obvious other pattern. The remaining portion of the calls came from men that were willing to be interviewed but did not meet the qualifying criteria, that is they had not had sex with both males and females in the preceding five years. These men were not interviewed, although they were thanked for their interest and effort.
3 Demographic characteristics and sample descriptors
The following section describes the demographic characteristics of the 745 men whose telephone interviews form the basis of this study.
3.1 AREA OF RESIDENCE
Respondents came from 90% (107 of 120) of the postcode areas in the UK. Although areas such as London and Manchester, where specific local advertising was placed, are over-represented, the spread of responses was relatively good (see below). Examination of the 13 postcode areas from which no respondents are included shows that in addition to areas that are relatively sparsely populated, a number of urban areas are not represented. The 13 missing postcode areas were the City of London, Dumfries, Halifax, Harrogate, Hereford, Hull, Kirkwall, Llandrindod Wells, Northampton, Sunderland, Swindon, Truro and Wolverhampton.
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If we examine postcode regions we can confirm that the distribution of responses is relatively good. As we would expect the vast majority (83.7%) of respondents lived in England including almost a third (29.7%) who lived in Greater London. While this undoubtedly over-represents the populations of London, and to a small degree Wales, it reflects closely the proportion of advertising placed. This is illustrated above.
The average (median) age of the respondents was 32 (mean 33.3, standard deviation 8.7), although they ranged in age between 16 and 73. A quarter of respondents were between 16 and 27 years of age and three-quarters were 38 or younger. As Figure 8 illustrates, the sample is over-represented in the age groups between 20 and 39. Since the men in this study were chosen on the basis of their sexual activity it is not surprising that it is a somewhat younger group than the general population (Office of Population Censuses and Surveys [OPCS], 1993).
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[ Note: my copy of the original diagram has a uneven Y-axis, so it's not possible to accurately recreate it. The figures used above are the result of trying to make the respondents total 100%, but each bar could be up to 2% out. ]
3.3 HIGHEST EDUCATIONAL QUALIFICATIONS
The highest educational qualification of more than half of the men was the equivalent of 'O' levels or less, that is they left school at the earliest opportunity (aged 16). Fewer than 1 in 4 men had any post-school education and fewer than 1 in 8 had a university degree. While direct comparisons are not straightforward we cannot find a single study of men who have sex with men that has a sample with a lower level of education. Studies which rely exclusively or predominantly on gay community sources are invariably biased towards those with more years of education than the general population.
3.4 SOCIAL CLASS
In order to make an assessment of the social class of respondents we used the Registrar General's classification of occupations.
With fewer than a quarter of the men working in professional, managerial, or higher professional or managerial roles, and almost half in manual occupations, this sample represents a diverse range of social classes. There are difficulties in matching these data to general population data (OPCS, 1993) due to categorisation and geographical distribution. However, our sample dramatically under-represents retired men, who encompass approximately 23% of the British male population (OPCS, 1993).
As was previously mentioned the men in this study were chosen on the basis of sexual behaviour and this has resulted in a younger group than the general population. Our sample also under-represents the higher professional/managerial and, to a lesser degree, the professional managerial category. While the sample does not perfectly match the general population, we could find no other study of men that have sex with men, from anywhere in the world, with such a balance of occupational classes.
3.5 ETHNICITY
In order to gain some idea of ethnic origin we asked the very loose question, 'What is your nationality or ethnic origin?' The majority of respondents answered British, English, Scottish or Welsh (93.4%).
Figure 11 Nationality of respondents n % British Irish Other European Indian/Asian Caribbean Australian African American While the proportion of men that did not consider themselves British is not particularly low, members of black and minority ethnic populations are somewhat under-represented. While this may, of course, be the consequence of many men of black or minority ethnic descent identifying as British, this is unlikely to explain the whole deficit.
3.6 LEGAL MARITAL STATUS AND LIVING ARRANGEMENTS
Almost a third of respondents were legally married at the time of interview, and almost half had been married at some point in their lives.
Figure 12 Legal marital status of respondents (%) Single or never married Married Divorced Separated Widowed Overall, almost half (49.4%) of the respondents lived with a female partner at the time of interview. Thus, assuming that all those who were married (31.6%) lived with their female partner, almost a fifth (17.8%) were unmarried but living with a female sexual partner.
Apart from those men who lived with a female partner, the vast majority of the others lived alone. Few lived with other family or friends, and even fewer with a male partner or with both male and female partners.
3.7 SEXUAL IDENTITY/SEXUALITY
Although we realised that such a question would be problematic we wanted to ask about respondents' sexual identity. Realising that the concept of sexual identity may not be of any importance to a large proportion of the men we asked, 'How do you think of yourself, in terms of your sexuality?' Well over half the sample could not answer this question or did not know. In these cases we prompted with the question, 'What term would you use to describe yourself, sexually?' and still nearly a fifth didn't know or answered 'no term'.
In addition, more than a third said they had no sexual identity or answered by reference to sexual practices, sexual prowess or attitudes, rather than identity. This suggests that a high proportion of behaviourally bisexual men do not see their sexual practice as central to their identity or, that when they do, the catch-all terms that describe broad sexual preference (bisexual, homosexual, gay) are not appropriate to the way they view themselves.
Less than half the respondents identified as bisexual, even though we included in the classification colloquial descriptions that denoted bisexuality (AC/DC, 50/50) and all descriptions that included bisexuality (bisexual TV). However, the term may still be over-represented. This question was asked at the end of the study when respondents had talked about being behaviourally bisexual. Comments such as 'I suppose I must be bisexual: I've had sex with both', suggest that many of the men did not currently identify as bisexual (or necessarily have any sexual identity) but rather saw it as a possible answer that would fit. Certainly, all interviewers reported that while the term 'behavioural bisexuality' described respondents' sexual practice, it did not describe a homogenous lifestyle; as one respondent stressed: 'It [bisexuality] is something I do, not something I am!'
One in eight (13.2%) stated that they were straight or heterosexual, even though they had previously spoken about having sex with men. Finally, it is interesting that fewer than 1% identified themselves as gay or homosexual. The lowest comparable figure we could find in studies of behaviourally bisexual men was 18.4% in an Australian study (Hood et al., 1994).
[ One of my favourite spotted personal ads (ITV's Teletext service c.1996) said 'Straight man seeks other straight men to have sex with'.
The very low figure identifying as gay is one reason why materials explicitly aimed at gay men will often (mostly?) not be seen as relevant by this population. ]
These data on sexual identity and all the other demographic characteristics strongly suggest that the men who took part in this study represent a group that is strikingly absent both from national studies of variations in sexual behaviour and from those which concentrate on men who have sex with men. Most striking is the representation of men from 'lower' socio-economic groups and/or with fewer educational qualifications, which assume and require relatively sophisticated linguistic ability of their participants. These results also point to the fallacy of many other studies of bisexuality which rely solely on groups catering for bisexually identified individuals. All these studies seem to have managed to overlook this significant group of men.
3.8 CONTACT WITH THE HIV EPIDEMIC
Though not strictly demographic characteristics, we asked a range of other questions in order to gauge respondents' likely contact with the HIV/AIDS epidemic. These were: attendance at genito-urinary medicine (GUM) clinics or sexually transmitted diseases (STD) clinics, HIV testing, and personal acquaintance with people with HIV and AIDS.
GUM/STD clinic attendance
Approximately one-tenth (9.1%) of the entire sample had attended a GUM or STD clinic in the year preceding interview. Estimates from general population surveys (Johnson et al., 1994) have suggested that the norm for the UK is less than 1% per year. While they stress that these are minimal estimates, they also report that:
... the likelihood of attending an STD clinic increased markedly with increasing number of heterosexual partners, over one in seven of those with five or more heterosexual partners in the last 5 years had attended a clinic in that time and ... among men reporting homosexual partners, more than half of those with five or more partners in the last year had attended a clinic in the same period.While direct comparisons are not possible, due to differing time-frames on sexual behaviour data, these behaviourally bisexual men are more likely to have attended a GUM/STD clinic in the previous year than men in the general population. Considering that they appear substantially more sexually active than most of those men sampled by the NSSAL this is not surprising.
HIV testing
Almost a quarter (23.0%) had ever taken a test for HIV antibodies and almost half of those (11.3% overall) had done so in the year preceding interview. Studies of samples of gay and bisexual men in the UK (Davies et al., 1993) generally report that at least half of gay men had ever tested for HIV. Alternatively, general population surveys (Johnson et al., 1994) report that approximately 13.1% of males had tested for HIV. Clearly, behaviourally bisexual men are less likely to test for HIV than gay men, but more likely than men in general.
Those men that had ever tested for HIV were asked where they went for their most recent HIV test. As Figure 15 shows, the majority had tested in GUM/STD clinics or other hospital departments. However, it is likely that the figure for GUM/STD clinics is under-represented, with those reported in the 'hospital clinic' including GUM/STD attenders. While we were very strict in our attempts to ascertain where exactly the last test occurred, many respondents were very vague as to where in the hospital (clinics) they had been tested.
With no additional data relating to the reason the test was taken, it is unwise to speculate why these venues were chosen. However, it is notable that a quarter had taken their most recent HIV test through their GP. With no comparable data for the UK it is impossible to ascertain if this is unusual, though anecdotal evidence would suggest the figure is high. A large proportion of these men live outside London and the other large metropolitan areas and may not know of, or be able to access, any other testing sites.
All those respondents who had ever tested (n=150) were asked what the result of their last test was. Though this question is not commonly asked, we felt that the anonymity associated with our methods would allow respondents to answer freely. Only one man (<1%) reported having been diagnosed as HIV antibody positive. He also identified as gay.
Personal contact with persons with HIV and AIDS
Almost one-fifth (19.9%) of all respondents reported that they had known someone personally who had HIV, of which a not inconsiderable proportion (13.3%) had known someone personally who had died from an AIDS-related illness. While it is impossible to know how well these persons were known, the figures were considerably higher than we expected. While a proportion of this population has clearly had personal contact with the HIV epidemic, with no comparable data for the general population of men we cannot speculate as to what extent this is a result of their sexual practice.
It is perhaps not surprising that on many of the sample descriptors this group falls somewhere between reported figures for gay samples and for the general population. This reflects the fact that many of these men recognise that their sexual behaviour places them at some risk of sexually transmitted infections, including HIV.
4 Sources of sexual partners
4.1 CONTACT ADVERTISEMENTS
As stressed in the discussion of methodology, all respondents were recruited via contact sections in the print media. They were first asked where they had seen the study advertised. Almost all reported that the advertisement had been seen in a newspaper or magazine in which we had placed an advertisement. The few men who reported being told of the study by a third party all reported that they also used contact or personal sections. While some of the advertising locations proved more fruitful than others, all resulted in the recruitment of some respondents.
In total, 65 different papers and magazines were reported as the source of recruits, if we include all the papers owned by the newspaper groups outlined in Chapter 2 (see Figure 2).
Respondents cited other newspapers, magazines and sources of contact advertisements they read. A total of 127 other sources of contact or personal advertisements were reported. Non-print media were included, such as contact (telephone) lines and 'chat-lines', cards in shop windows, graffiti on toilet walls, and television listings (such as teletext). While some respondents used generic terms such as 'contact or adult magazines' and 'local or national newspapers', the vast majority listed at least one, and up to five, specific newspapers or magazines. These included general soft-porn magazines and a range of specialist publications including contact and other magazines (such as those for men interested in SM or transvestism, for example). They also included a considerable number of local newspapers, local advertisers and some listings papers (especially in London), as well as the majority of national newspapers (ranging from the Sun and Daily Mirror through to the Guardian and the Independent). While no minority ethnic community newspapers were listed, all the major gay publications (Gay Times, the Pink Paper, Capital Gay, Boyz) were mentioned, though not by many men.
While we had assumed that the vast majority of respondents would read personal or contact sections, we did not assume that all would have met a sexual partner as a result of using such sources. Hence, we asked whether respondents had ever placed or answered a contact or personal advertisement. Although just over two-thirds (67.1%) reported having answered an advertisement, fewer than one-third (28.9%) had ever placed one themselves.
Of those respondents (67.1%) that had ever answered a contact or personal advertisement:
15.2% had met neither a male nor a female for sex;
12.9% had met a female for sex but not a male;
23.1% had met a male for sex but not a female;
48.8% had met both a male and a female for sex.Of those respondents (28.9%) that had ever placed a contact or personal advertisement:
21.8% had met neither a male nor a female for sex;
14.7% had met a female for sex but not a male;
30.3% had met a male for sex but not a female;
33.2% had met both a male and a female for sex.Between 15 and 22% of those who had placed or responded to contact or personal advertisements had never met a partner for sex as a consequence. Apart from these, and the proportion (between one-third and nearly a half) that had met both males and females, twice as many had met male partners through contact advertisements as had met females.
4.2 OTHER SOURCES OF SEXUAL PARTNERS
We asked all respondents in which other venues or circumstances they had met partners. Those venues or circumstances starred (*) in Figure 16 were offered as possibilities, while the other listed venues or circumstances were volunteered by respondents. While the shaded rows highlight sources used predominantly to meet male partners and the unshaded rows are predominantly sources of female partners, all venues or circumstances listed had resulted in respondents meeting both male and female partners. The first column of figures gives the overall percentage that had met any partner at a particular venue or in a certain circumstance. The second column lists the percentage of respondents that had met both a male and a female partner at a particular venue or in a particular circumstance. The third column lists the percentage that had met only male partners, and the fourth column those who had met only female partners.
As Figure 16 shows, both male and female partners are met in a variety of circumstances and venues. General (that is, not gay) pubs, bars and (night)clubs are by far the most common source of sexual partners, with more than two-thirds (70.1%) having met a partner in one. While marginally more respondents had met a female than a male there, they are common sources of both partners. The next most important sources of partners were 'through friends' and 'parties' (both having been a source of partners for more than half of the respondents). Again they are predominantly sources of female partners, although almost half who had used these sources had met a male partner in them.
Advertisements in (non-gay) magazines and papers and 'at work' are the next most productive sources of sexual partners, followed by trips to other towns and countries, and the pool or beach. Of these eight most common sources of sexual partners, only advertisements in (non-gay) magazines are more commonly sources of male partners than female, and then only marginally.
Of the remaining nine sources of partners, all but one ('family connections') are predominantly a source of male partners. However, none has been used by more than a quarter of all respondents, and the majority have been used by between one-fifth and one-tenth. Included here are gay bars (21.6%) and adverts in the gay press (10.0%). The relatively widespread use of both these gay facilities is noteworthy, especially since so few of the men (<1%) identify as gay or homosexual. While their identification with the gay community is very limited, the use of gay bars and publications by some of these behaviourally bisexual men has notable implications for health promotion.
Also included are venues where sex may occur in situ (toilets, saunas, gyms, sports clubs, parks, 'sexually explicit/implicit'), all of which are predominantly sources of male partners. The last of these categories covers all venues or circumstances where sex is the sole, or primary, purpose of using the venue. It includes sex cinemas, parties and clubs, massage parlours and freelance sex workers.
Other venues (<5%) included public buildings/shops; school/college; sport/leisure facilities; public transport; personal recommendations; *naturist societies/clubs; away from home.
Clearly a considerable proportion of the men had paid for sex at some point in their lives (see Figure 17). Assuming that this would be the case, we asked whether they had paid, or been paid money for sex in the year preceding interview. We found that almost a quarter (23.6(%) of these behaviourally bisexual men had paid for sex in the year preceding interview, and a substantially smaller, though not inconsiderable, proportion (7.6%) had been paid for sex.
Even though we asked only about the year preceding interview, the purchase of sex from both male and female partners was very common. Among those respondents that had paid for sex, it was more likely that they had paid a female than a male partner. With more than a tenth (10.9%) of the entire sample having only bought sex from a female, and another 6.4% having paid both a female and a male, the purchase of sex from female partners is common. However, purchasing sex from male partners was not uncommon, with an eighth (12.7%) of the entire sample having done so in the year preceding interview.
NSSAL (Johnson et al., 1994) reports that 6.8% of its random sample of British men had ever paid for sex and that 1.8% had done so in the past five years. It also reports a 2.5-fold increase in the proportion of men who had had a male partner and who had ever paid for sex. It suggests that although these figures should be considered a minimum estimate, 'the implication of this finding is that women in the sex industry may encounter a disproportionate number of bisexual men as clients' (Johnson et al., 1994). This study seems to support this.
Although the sale of sex by respondents was considerably less common than its purchase, it was still more common than might be expected. In contrast to the purchase of sex, respondents that had been paid for sex were more likely to have been paid by a male than a female partner. While only 1.0% had sold sex to a female and not a male, twice as many (1.9%) had sold sex to both males and females and five times as many (4.7%) had sold sex only to males. Among this sample, the sale of sex to males is considerably more common than the sale of sex to females. However, the sale of sex to both is considerably more common than might have been predicted.
The data relating to the respondents' most recent sexual encounters with new male and female partners, as well as anecdotal evidence from interviewing staff, suggest that relatively few of the respondents that had sold sex did so regularly or systematically. While it was the stated occupation of a few respondents (<1%), the majority of the men that appear in the above figures had been paid for sex in very particular circumstances, often having been offered money after having sex with a (usually male) partner or having answered an advertisement that implied the advertiser was willing to pay.
4.3 SUMMARY
Respondents were recruited via contact sections in 65 different papers and magazines. Respondents reported reading a total of 127 other sources of contact or personal advertisements. These included contact (telephone) lines and 'chatlines', cards in shop windows, graffiti on toilet walls and television listings. While some respondents used generic terms such as 'contact or adult magazines' and 'local newspapers', the vast majority listed at least one, and up to five, specific sources. These included general soft-porn magazines and a range of specialist publications. They also included a number of local newspapers, local advertisers and the majority of national newspapers.
Just over two-thirds (67.1%) reported ever having answered a contact advertisement, of which half had met both male and female partners as a result. Fewer than one-third (28.9%) had ever placed one themselves, of which a third had met both male and female partners.
Male and female partners were met in a variety of circumstances and venues. General (that is, not gay) pubs, bars and (night)clubs were the most common source of sexual partners. The next most important sources of partners were friends and parties, advertisements in (non-gay) magazines and papers and work. Of the eight most common sources of sexual partners, only advertisements in (non-gay) magazines were more commonly sources of male rather than female partners, and then only marginally.
Of the remaining nine sources all but one were predominantly a source of male partners. However, none had been used by more than a quarter of respondents. Included were gay bars, advertisements in the gay press and venues where sex may occur in situ (toilets, saunas, gyms, sports clubs, parks), all of which were predominantly sources of male partners.
A quarter (23.6%) had paid for sex in the last year, and 7.6% had been paid for sex. Those that had paid for sex were more likely to have paid a female than a male sexual partner. Although the sale of sex was considerably less common than its purchase, it was still more common than might be expected. In contrast to the purchase of sex, those who had been paid for sex were more likely to have been paid by a male than a female.
5 Sexual partners and sexual practices
The next four chapters contain details of the sexual practices of these behaviourally bisexual men. This chapter deals with sexual partners and sexual practices. Although it starts with details of first sexual experiences with males and females, and of partner numbers during the five years preceding interview, the bulk of the data pertains to the year preceding interview. First, it highlights the proportion of men having regular and casual male and female partners, and the proportion engaging in anal and vaginal intercourse with and without condoms. Secondly, it examines numbers of male and female casual and regular partners, and the impact of demographic characteristics on these data. Finally, it examines the proportion having both anal intercourse with male partners, and vaginal and anal intercourse with female partners.
5.1 FIRST SEXUAL EXPERIENCES
The average (median) age of first sexual experience with a woman was 16 years (mean 15.8), with first vaginal intercourse, on average, about 7 months afterwards (see Figure 18). While a small number of men had their first heterosexual experience in early childhood, half had their first experience between the ages of 14 and 17, and half first experienced vaginal intercourse between the ages of 15 and 18.
The average (median) age of first sexual experience with a man was 20 years (mean 21.2) with first anal intercourse with a man, on average, about 17 months afterwards. While a small number of respondents had their first homosexual experience in early childhood, half had their first experience between the ages of 16 and 25, and half first experienced anal intercourse with a man between the ages of 17 and 27.
The majority (75.2%) had sex with a woman before they had sex with a man, and a small proportion (3.1%) had their first sexual experiences with both genders at the same age (see Figure 19). Indeed fewer than one-fifth (19.6%) had sex with a man before a woman. Overall, the average (mean) age of first homosexual experience was some 5 years and 4 months after the first heterosexual experience.
Similarly, almost two-thirds (63.2%) had vaginal intercourse with a woman before anal intercourse with a man, while a further small proportion (3.1%) reported the two experiences at the same age. Only one-tenth (10.9%) had their first penetrative sexual experience with a man before a woman. Since almost a quarter (22.4%) had never had penetrative sex with a man the vast majority (86%) had their first penetrative sexual experience, or only penetrative sexual experience, with a female. The mean age of first penetrative sexual experience with a man was some 6 years and 2 months after their first penetrative experience with a woman.
5.2 SEXUAL PARTNERS IN THE PAST FIVE YEARS
As outlined in Chapter 2, the only selection criterion for the study was that respondents had had both male and female sexual partners in the past five years. Below are the average numbers of male and female partners reported in that time period.
Figure 20 Average numbers of male and female sexual partners in the past five years Female Male Median Inter-quartile range Mean Standard deviation On average these men report having 6 female partners and 4 male partners in the five years preceding interview. Overall, half the men reported between 3 and 12 female partners and between 2 and 10 male partners. However, there is considerable variation, and the markedly higher means reflect the presence of small numbers of men reporting very high numbers of both male and female partners. While only just over 1%, reported 100 or more male or female partners, 10% reported more than 20 female or 20 male partners.
Although partner numbers are higher than might have been predicted (especially with females) it would appear that the numbers of male and female partners are remarkably similar. However, the correlation between the numbers of male and female partners each man reported is not strong (r=0.1069, p<0.01), signifying that although the numbers are significantly related the strength of that association is not great.
Lay wisdom and previous studies (Boulton et al., 1991) suggested that these men were likely to have had considerably more male than female partners, but (whether you consider the mean or the median) the average number of female partners is higher. In fact, only just over one-third (34.2%) had more male than female partners in the past five years, and more than half (55.0%) had more female than male partners.
5.3 MALE AND FEMALE SEXUAL PARTNERS IN THE PAST YEAR
Of the 745 men interviewed <1% had neither a male nor a female sexual partner in the year preceding interview. As Figure 21 indicates, almost 95% had a female partner, and almost 92% had a male partner. Indeed the vast majority (87%) had both male and female partners in the past year. Thus, although we defined as 'behavioural bisexual' any man who had sex with both a male and a female partner in the five years preceding interview, most of these men would have met a stricter, one-year definition.
Figure 21 Percentage of respondents who had partners in the year preceding interview No males 1 or more males Total No females 1 or more females Total We find that almost 85% had a female regular partner, but only 45% had a regular male regular partner in the year preceding interview (Figure 22). Therefore, while almost 90% of the men who had a female partner had at least one female regular partner, fewer than half who had a male partner had a male regular partner. Just over one-third (37.2%) had both male and female regular partners.
As Figure 23 demonstrates, almost three-quarters (73.9%) of the men had a female casual partner and more than half (58.8%) a male casual partner in the year preceding interview. While more than three-quarters (78%) of those that had a female partner had at least one casual female partner, just over two thirds (64%) of those with a male partner had a casual male partner. Just under half (47.8%) had both male and female casual partners in the year preceding interview.
Clearly then, almost all respondents had been sexually active in the year preceding interview. Less than one man in ten had not had sex with a male, and an even smaller proportion had not had sex with a female. Indeed, the vast majority had had sex with both male and female partners in the year preceding interview. While all the figures are relatively high, a higher proportion of respondents had female partners than male (94.7% compared to 91.9%), a higher proportion had female regular partners than male (84.3% compared to 45.5%), and a higher proportion had female casual partners than male (73.9% compared to 58.8%).
5.4 VAGINAL INTERCOURSE WITH FEMALE SEXUAL PARTNERS IN THE PAST YEAR
Of respondents that had a female partner in the year preceding interview, 99.1% (or 93.8% of all respondents) had vaginal intercourse at least once. Although vaginal intercourse was marginally less common with casual partners (92.9% of those with a casual partner and 54.8% of all respondents) than with regular partners (99.4% of those with a regular partner and 83.5% of all respondents), it is still the norm. Indeed vaginal intercourse occurs, on average, with 95% of all female partners. If we consider only regular partners, the (mean) percentage (rises to 99% and with casual partners it falls, but only to 89%.
While engagement in vaginal intercourse is almost universal, use of condoms is not. More than two-thirds (71.8%) of those that had vaginal intercourse with a female partner (or 67.1% of the entire sample) did so without a condom at least once in the year preceding interview. This rises slightly to 72.9% (or 60.6% overall) of those that had vaginal intercourse with a regular female partner, but falls considerably, to 51.9% (23.4% overall), with casual partners. Respondents are therefore more likely to use condoms with casual rather than regular partners. However, as Figure 24 demonstrates, one-sixth (16.5%) of respondents engaged in unprotected vaginal intercourse with both casual and regular female partners in the year preceding interview.
5.5 ANAL INTERCOURSE WITH FEMALE SEXUAL PARTNERS IN THE PAST YEAR
Of those who had a female partner in the year before interview, almost half (47.0%, or 44.4% of all respondents) had anal intercourse with at least one of them. Although engagement in anal intercourse was more likely with regular partners (40.8% of those that had a regular partner or 34.2% of all respondents), it was common with casual partners (34.2% of those that had a casual partner or 20.1% of all respondents). Hence, engagement in anal intercourse is very common among men who have female partners. While it is less likely with casual partners it is still common. Indeed anal intercourse occurs, on average, with more than a quarter (28%) of all female partners. With regular partners, the mean proportion rises to a third (34%), and if we consider only casual partners it falls to just under a quarter (23%).
Half (50.8%) of those that had anal intercourse with a female partner (22.6% of all respondents) did so without a condom at least once in the year preceding interview. Again, condom use for anal intercourse was less common with regular partners (55.2% of those that had anal intercourse with a regular partner, or 18.7% of all respondents) than with casual partners (34.7%, or 7.0% of all respondents). Overall then, half of those that had anal intercourse with a female in the year preceding interview had done so without a condom at least once, although condom use is mediated by partner type. However, as Figure 25 demonstrates, only 3.1 % of all respondents engaged in unprotected anal intercourse with both casual and regular female partners.
5.6 ANAL INTERCOURSE WITH MALE SEXUAL PARTNERS IN THE PAST YEAR
Anal intercourse with male partners is common even though almost a quarter (22.4%) of respondents had never engaged in the activity. Of those that had a male partner in the year before interview (91.9%) almost two thirds (67.7%, or 62.2% of all respondents) had anal intercourse with at least one. This increases to three-quarters (75.7%, or 33.6% of all respondents) with regular partners and falls to 59.2% (43.9% of all respondents) with casual partners. On average we find that anal intercourse occurs with more than half of all male partners (55%), including more than three-quarters (78%) of regular partners and just under half (49%) of casual partners. Almost a third (29.3%) of those who had anal intercourse with a male partner (18.2% of all respondents) did so without a condom at least once in the year preceding interview. This rises to 34.5% (11.6% of all respondents) with regular partners and falls to less than a quarter (24.3%, or 10.7% of all respondents) with casual partners. However, as Figure 26 demonstrates, only 4.1 % of all respondents engaged in unprotected anal intercourse with both casual and regular male partners.
5.7 NUMBER OF FEMALE SEXUAL PARTNERS IN THE PAST YEAR
Having described the proportion of men having both male and female partners, and examined rates of engagement in vaginal and anal intercourse (with and without condoms), it is necessary to comment on the number of partners respondents have.
In the year preceding interview, 5.4% did not have any female sexual partners. Among those who did, the average (median) number was 2 and the mean was 3.22 (see Figure 27). Similarly, the average number with whom vaginal intercourse occurred was 2 (mean 3.00). If we consider only those respondents that engaged in each activity, the average (median) number of female partners with whom vaginal intercourse without a condom, anal intercourse, and anal intercourse without a condom occurred is 1 (mean between 1.67 and 1.99).
As Figure 27 demonstrates, those men that engaged in any sexual activity report higher numbers of female partners than other studies suggest (Boulton et al., 1991). However, variation in the number of female partners was relatively wide. Figure 28 demonstrates that while a third of men had one female partner or none, more than a quarter had four partners or more. While a similar pattern emerges for vaginal intercourse, if we consider vaginal intercourse without a condom, the majority (70.5%) had one partner or none, and fewer than one in ten had four partners or more.
Although the majority of men did not have anal intercourse with female partners, a quarter had done so with one female partner, and almost a fifth with two or more. Fewer than a quarter had engaged in anal intercourse without a condom and the majority of these had done so with only one female partner.
5.8 NUMBER OF MALE SEXUAL PARTNERS IN THE PAST YEAR
In the year preceding interview, 8.2% of respondents did not have any male sexual partners. Among those that had a male partner the average (median) number was 2 (mean 3.75, see Figure 29). For those respondents that engaged in anal intercourse, the average number with whom they had done so was 2 (mean 2.90) and, coincidentally the figures were exactly the same for men who engaged in anal intercourse without a condom.
Clearly the number of male partners is somewhat higher than female partners and variation in numbers was wider. Figure 30 demonstrates that while a third had one male partner or none, the majority had more than one, including more than a quarter who had four partners or more. Although almost a quarter (22.4%) had never engaged in anal intercourse with a male, the majority of men had anal intercourse with male partners in the year preceding interview. Overall, one quarter had engaged in anal intercourse with just one male partner, almost a quarter had anal intercourse with two or three, and an eighth had done so with more than three. While most (81.8%) had not engaged in anal intercourse without a condom, of those that had, approximately half had done so with just one partner, but one-fifth (3.9% overall), had done so with four or more partners.
5.9 'PREDICTORS' OF PARTNER NUMBERS
While the purpose of this study remains largely descriptive, it was felt that we should examine which, if any of the demographic characteristics and sample descriptors (see Chapter 3) were significantly related to sexual partners or practices. The demographic characteristics with which the partner data were compared included age, occupation, marital status, living arrangements (including living with a female), highest educational qualifications and sexual identity (including bisexually identified and not). We also compared the sexual partner data with the following sample descriptors: HIV tested in the preceding year; GUM/STD clinic attendance in the preceding year; personal acquaintance with anyone with HIV; and personal acquaintance with anyone who has died as a consequence of an AIDS-related illness.
We used appropriate statistical techniques to assess which factors effected engagement in sexual activities, and the overall number of partners they occurred with in the year preceding interview. That is, we assessed whether or not the factors (above) had an effect on the proportion having female and male partners, or engaging in vaginal intercourse (and vaginal intercourse without a condom) and anal intercourse (and anal intercourse without a condom) with them. As well as assessing their impact on the overall number of male and female partners, we examined whether they had any effect on the number of partners each activity occurred with.
None of the demographic characteristics or sample descriptors were significantly related (at p<0.01) either to whether or not respondents had female partners or to whether they had vaginal intercourse (or vaginal intercourse without a condom) or anal intercourse (or anal intercourse with a condom). Neither did they have any effect on the overall number of female partners or the number that any of these activities occurred with.
Similarly, none of the sample descriptors were significantly related (at p<0.01) to whether or not respondents had male partners or to whether they had anal intercourse (or anal intercourse without a condom), or to the overall numbers of male partners, or to the number that anal intercourse (or anal intercourse without a condom) occurred with. Of the demographic characteristics, only two had any significant effect on sexual practice, and then only on the number of male partners with whom anal intercourse (but not anal intercourse without a condom) occurred.
Living with a female did not have a significant effect on whether respondents engaged in anal intercourse with male partners (χ2=4.272, df=1, p=0.04), but those that lived with a female and engaged in anal intercourse with males did so with significantly fewer (F=6.750, df=1,394, p<0.01). That is, men who lived with a female but had anal intercourse with a male did so with a mean number of 2.38, compared to a mean of 3.12 among men that did not live with a female.
Finally, there is a weak but significant correlation between age and the number of male partners with whom anal intercourse occurred (r =-0.126, p<0.01). Respondents who engaged in anal intercourse with male partners were significantly younger (F=8.354, df=1,651, p<0.01) than those that did not (mean age of 32.6 years compared to 34.5 among those that do not have anal intercourse). This age effect is neither surprising nor particularly important. It merely confirms what is widely known: that sexual activity, but not necessarily sexual repertoire, declines with age.
It is surprising, with such large numbers, that more significant relationships were not found. The lack of any substantial effects in these data is strong evidence that this is a homogenous group of men with respect to sexual behaviour.
5.10 VAGINAL AND ANAL INTERCOURSE WITH MALE AND FEMALE PARTNERS IN THE PAST YEAR
In order to make any comment on the likely impact of behavioural bisexuals on the HIV epidemic it is insufficient to report separately their behaviour with each gender. We have to examine their behaviour with both males and females. First, we examine the proportion who have both vaginal intercourse with female partners and anal intercourse with males (see Figure 31). As the figure clearly demonstrates, engagement in vaginal intercourse is almost universal, and unprotected vaginal intercourse is the norm. Concentrating on the shaded cells we see that more than half (58.2%) of the men had engaged in both vaginal intercourse with a female and anal intercourse with a male, including 14.0% who had done both without a condom and 15.7% who had always used a condom with both sexes. Condom use is more common with male partners than females, when there is a difference.
Secondly, we examined the proportion having anal intercourse with both female and male partners (Figure 32). Examining the shaded cells we see that more than a third (34.2%) had engaged in anal intercourse with both females and males. Slightly under a half of these (15.3%) always used a condom and about a third (9.8%) had done both without a condom. Again, condom use, where inconsistent according to gender, is more common with male partners.
5.11 SUMMARY
In the last five years:
- all respondents had both male and female partners;
- on average they had sex with 6 female and 4 male partners.
In the year preceding interview:
- very few (8.1%) had not had sex with a male, and even less had not had sex with a female (5.3%).
The sample is highly sexually active with both males and females, but:
- a higher proportion had female partners than male (94.7% vs. 91.9%);
- a higher proportion had female regular partners than male (84.3% vs. 45.5%);
- a higher proportion had female casual partners than male (73.9% vs. 58.8%).
The majority (87%) had had sex with both male and female partners:
- almost half (47.8%) had both female and male casual partners;
- just over a third (37.2%) had both female and male regular partners.
The vast majority (93.8%) had engaged in vaginal intercourse with a female partner; two-thirds (67.1%) had engaged in unprotected vaginal intercourse.
Almost half (44.4%) had engaged in anal intercourse with a female partner; one-quarter (22.6%) had engaged in unprotected anal intercourse.
Two-thirds (62.2%) had engaged in anal intercourse with a male partner; less than a fifth (18.2%) had engaged in unprotected anal intercourse.
Less than a third (29.3%) of those that had anal intercourse with males had done so without a condom, compared to half (50.9%) of those that had anal intercourse with females.
More than half (58.2%) had engaged in both vaginal intercourse with a female and anal intercourse with a male (14.0% had done both without a condom and 15.7% had always used condoms). Where there is a difference, condom use is more common with male than female partners.
A third (34.2%) engaged in anal intercourse with both females and males (9.8% had done both without a condom and 15.3% had always used condoms).
Demographic and sample descriptors have no substantial effect on sexual behaviour. This is strong evidence that this is a homogenous sample of men with respect to sexual behaviour.
6 Current regular sexual partnerships and disclosure of (other) sexual activity
In addition to details of sexual partners and sexual practices in the year preceding interview, we asked a range of questions regarding current sexual partnerships. It emerged that only one-fifth (20.8%) of respondents did not have a regular sexual partner at the time of interview (see below).
At the time of interview, more than twice as many respondents had a regular female partner than had a regular male partner (71.3% compared with 31.5%). While almost a quarter (23.6%) had both male and female regular partners, just under half (47.7%) had only a regular female partner, compared to less than one in ten (7.9%) having only a regular male partner.
Not only were regular relationships with males less common, but they were far less likely to be the only (or primary) sexual relationship. Among those that had regular partners, the proportion having more than one male (19.3%) was twice the proportion having more than one female (10.5%).
Similarly the average length of respondents' only, or primary, relationship with regular partners varied according to gender. The average length of the current regular relationships with female partners (42 months) was more than twice that with male partners (18 months).
Figure 34 Average length (in months) of regular relationships With females With males
6.1 DISCLOSURE OF (OTHER) SEXUAL ACTIVITY TO REGULAR FEMALE PARTNERS
As we have discussed previously (Weatherburn & Davies, 1993) research concerning the impact of bisexual men on the HIV epidemic has been characterised by recurrent moralistic debates concerning the danger bisexual men pose to their female partners. While we do not seek to inflame such debates, we recognise that it is essential to consider the disclosure of behaviourally bisexual men to their (regular) sexual partners. Given our methodology we did not seek to examine the motives for, or against, disclosure or the methods used to avoid detection if disclosure had not occurred.
All respondents with a current regular female partner were asked a range of questions regarding disclosure of their (other) sexual activities to her.
Of respondents with a current regular female partner:
- 35.3% of those partners knew he was attracted to men, of which 54.0% knew before they had sex with him;
- 35.1 % knew he had ever had sex with men, of which 56.8% knew before they had sex with him;
- 32.9% knew he currently had sex with men, of which 63.4% knew before they had sex with him;
- 35.1% knew he currently had sex with other women.
About one-third of respondents stated that their regular female partner (or primary female partner if they had more than one) knew of their sexual interest in, and/or activities with, men. The proportion who were certain that their regular female partner knew of their (homo)sexual inclinations or past or current activities was very similar. It might be argued that the rate of disclosure is low, but the dearth of comparable data means that such instant judgements should be avoided. However, it is noteworthy that the proportion that had disclosed their current sexual practice with (other) women is not significantly higher than the proportion that disclosed their current sexual activity with men. While any conclusion must remain conjecture at this stage, it is possible that disclosure is primarily an issue of faithfulness or fidelity, rather than any issue related to the stigma associated with having sex with men.
It is also worthy of comment that between roughly half and two-thirds (54.0-63.4%) of those who disclosed to their regular female partner had done so before they first had sex with them. While this may seem a high proportion it is difficult to interpret such data without any examination of the context, content or means of disclosure.
Those respondents whose regular female partner/s knew about their sexual activities with men were asked how she found out. More than half (51.8%) disclosed explicitly and unprompted (including only 5.9% that were 'out' as bisexuals). A further quarter (24.3%) had threesomes with that regular female and other males, and an eighth (13.5%) had discussed or fantasised about sexual activities involving men with that regular female partner. Finally, a relatively small proportion (10.3%) reported that the female regular partner guessed or asked about (homo)sexual tendencies and he confirmed it.
A very similar picture emerges when sexual activity with other women is concerned. Again, almost half (47.1%) had disclosed unprompted and explicitly. A further quarter (23.5%) reported that they had regular threesomes with a second female involved and a tenth (9.2%) stated that their regular female had suggested or initiated this activity with other females. Finally, a fifth (20.2%) reported that the female regular partner guessed or asked about his sexual activities with other women and he confirmed it.
Although there are obvious similarities in these disclosure patterns some differences do arise. Regular female partners are twice as likely to have guessed and/or asked about sexual activities with (other) females rather than males. However, although a very similar proportion (about a quarter) engage in threesomes with their regular female partner and others, regular female partners are more likely to have initiated or suggested that the respondent have sex with other women, rather than them both discussing or fantasising about sex with other men.
6.2 EFFECTS OF DISCLOSURE TO REGULAR FEMALE PARTNERS ON (HOMO)SEXUAL PRACTICES
As we discussed earlier, when the likely impact of behaviourally bisexual men on the HIV epidemic is addressed it is usually assumed that they pose a significant danger to their regular female partners. It is far less likely that any mention is made of the danger to other female partners or to any male partners. However, as we have demonstrated these men have sex with men and women in a range of ways and circumstances. When sweeping judgements are made concerning behavioural bisexuals, little account is taken of this variety, or of the kinds of sex they have with their male or female partners, or of the degree of disclosure of other sexual activities to (regular) partners.
In order to make any assessment of the risk behaviourally bisexual men pose to their regular female partners, it is necessary to consider disclosure to those partners of other sexual activities. Using our measurement of disclosure of current sexual activity with men we find that disclosure to regular female partners regarding sexual activities with males has an effect on sexual practices with those males (or vice versa).
As Figure 35 demonstrates, men that have disclosed their current sexual activity with males to their regular female partner are significantly more likely to have engaged in anal intercourse (χ2=15.619, df=1, p<0.001) and to have engaged in anal intercourse without a condom (χ2=19.219, df=1, p<0.001) with a male partner.
While these overall effects are strong, they seem to be mainly accounted for by differences associated with male regular partners. Thus, men who have disclosed to regular female partners are significantly more likely to have had a regular male partner (χ2=29.359, df=1, p<<0.001), significantly more likely to have anal intercourse with a regular male partner (χ2=30.584, df=1, p<<0.001), and significantly more likely to have anal intercourse without a condom with a regular male partner (χ2=22.5732, df=1, p<<0.001). While a similar pattern emerges with casual male partners, the effects of disclosure are not statistically significant.
This pattern is intuitively valid. It suggests that those men that have disclosed their current homosexual activity to their regular female partners are more likely to have regular male partners. While we should not speculate whether disclosure predated the acquisition of a regular male partner, it may be that non-disclosure is far more difficult to manage if they have a regular male partner. That is, if your regular female partner does not know of current homosexual activity it is far more difficult to sustain a relationship with a male. Alternatively, it may be that the majority of these sexual activities with male (especially regular) partners are not only known to the female regulars but are encouraged and/or witnessed by her (see Chapter 7). Disclosure to regular female partners has a significant effect on sexual practices, or perhaps sexual practices have a significant effect on disclosure. While the rates of engagement in anal intercourse without a condom are never insubstantial, they are considerably lower among men who have not disclosed their homosexual activity. This contradicts accounts which see the 'danger' posed by bisexual men as arising solely from the ignorance of their female partners about their casual sexual encounters with men. While disclosure of homosexual practice to regular female partners is not the norm, where it does occur sexual behaviour with male partners (especially regulars) is significantly more likely to involve anal intercourse and anal intercourse without a condom.
While these findings challenge widespread assumptions, they also raise questions which cannot be answered here. Are the increased rates of 'risky behaviour' (in Figure 35) the result of strategic decisions made by the primary male/female couple? What sort of relationships are there between the three (or more) people involved? How common is disclosure to casual female partners?
6.3 EFFECTS OF DISCLOSURE TO REGULAR FEMALE PARTNERS ON (HETERO)SEXUAL PRACTICES
We can also examine the effect of disclosure to regular female partners on other sexual activities with women. About one-third of men with regular female partners had disclosed to that partner that they also had sex with other females. At the time of interview relatively few (10.7%) of those with regular female partners had more than one. However, most of the men (56.9%) with current regular female partners also had casual partners in the year preceding interview. Hence, we can examine whether disclosure of this type has any effect on the proportion having casual female partners and on sexual practices with them.
As Figure 36 demonstrates, disclosure of other female partners to regular females does not have a significant effect on having casual female partners, engagement in vaginal intercourse with them, or engagement in vaginal intercourse without a condom. However, men who have disclosed to regular female partners are significantly more likely to have had anal intercourse with female casual partners (χ2=6.665, df=1, p<0.01), but not significantly more likely to engage in anal intercourse without a condom. Overall, the same basic pattern emerges: that is, men who have disclosed are somewhat more likely to have engaged in these activities.
While this adds considerably to our understanding of the sexual activities of behaviourally bisexual men, it would be unwise, based on these data alone, to make any substantial claims regarding their likely impact on the HIV epidemic or the 'danger' they pose to their regular female sexual partners. Clearly non-disclosure, especially regarding homosexual activities, has an effect on sexual practice. Men who do not disclose appear less likely to have sex that might be considered unsafe, at least with their other (male) partners.
However, without further investigation it is impossible to be sure what exact effects disclosure has. It is especially important to note that we did not ask respondents whether their female partners knew they had anal intercourse with men (if they did), or whether they knew they had anal intercourse without a condom (if they did). Furthermore, we have not commented directly on the sexual behaviour of respondents with their only (or primary) regular female partner. Without such information it would be very unwise to make any substantial assumptions about the public-health impact of behavioural bisexuality.
6.4 DISCLOSURE OF (OTHER) SEXUAL ACTIVITY TO REGULAR MALE PARTNERS
Turning to disclosure to male partners, we find that levels are much higher. Almost all (between 93.0% and 96.0%) of male regular partners know of the respondents' sexual attraction to, and/or activities with, women. Also, two-thirds (66.3%) stated that their regular male partner (or primary male partner if they had more than one) knew of their sexual activities with other men, twice the proportion of regular female partners who know about sexual activities with other women.
Of respondents that have a regular male partner:
- 93.0% of these partners knew he was attracted to women, of which 88.2% knew before he had sex with him;
- 95.6% knew he had ever had sex with women, of which 88.9% knew before he had sex with him;
- 93.1 % knew he currently had sex with women, of which 90.0% knew before he had sex with him;
- 66.3% knew he currently had sex with other men.
While disclosure of (hetero)sexual tendencies to male regular partners is clearly the norm, disclosure of current homosexual activity is less common. Although any conclusion must remain conjecture, it is possible that disclosure of heterosexual activity is expected, given that the majority of these men live with female partners, but where other male partners are concerned there remains an issue of faithfulness or fidelity.
Finally, it is worthy of comment that the vast majority (88.2-90.0%) of those who had disclosed their sexual inclinations towards, and/or activities with, females to their regular male partner did so before they first had sex with him.
While this may seem a high proportion, it is difficult to interpret such data without any examination of the context or means of disclosure.
Those respondents whose regular male partner/s knew about their sexual activities with men were asked how they found out. Almost two-thirds (62.6%) had disclosed their sexual activity unprompted and explicitly, a further eighth (12.1%) stressed that the regular male partner always knew or assumed he had sex with other men, and a relatively small proportion (8.4%) reported that the male regular partner guessed or asked about his sexual activities and he confirmed it. Finally, about one sixth (16.8%) had threesomes with that regular male and other males.
The proportions are very similar with regard to disclosure of heterosexual behaviour. Again, almost two-thirds (61.3%) had disclosed unprompted and explicitly, about one-sixth (16.0%) stressed that the regular male partner always knew or assumed he had sex with females, and a small proportion (5.2%) reported that the male regular partner guessed or asked about his (hetero)sexual tendencies and he confirmed it. Again, about a sixth (17.5%) had threesomes with that regular male and females. In these cases it was quite common that either the respondent was the regular third partner of a male/female couple, or that the respondent's regular male partner was also a regular partner of his regular female partner.
Again, the means by which respondents disclose to their regular male partners about their (other) sexual activities are very similar. Almost two-thirds did so explicitly and without prompting, of which the vast majority did so before they first had sex with the regular male partner, and a further proportion stress that these matters are assumed. Unlike disclosure to regular female partners, few real differences arise in relation to disclosure of other male or female partners.
6.5 EFFECTS OF DISCLOSURE TO REGULAR MALE PARTNERS ON SEXUAL PRACTICES
Even among commentators that feel it is important to discuss the risk behaviourally bisexual men pose to the wider population, the risks posed to their (regular) male partners are never considered. Although we attempted to collect identical data on disclosure to regular male and regular female partners, discussion of disclosure to males is problematic. First, at the time of interview less than a third of all respondents (31.5%) had a regular male partner, compared to more than two-thirds (71.3%) having a female regular partner. Hence, numbers for comparison are diminished. Secondly, the vast majority (93.1%) with a regular male partner had disclosed their current sexual activity with females, and almost two-thirds (66.3%) had disclosed that with other males. Hence, the numbers of men with regular male partners who have not disclosed their other sexual activity is very small (15 men had not disclosed heterosexual activity and 57 had not disclosed other homosexual activity).
Telling regular male partners about heterosexual activities has little effect on sexual practice with females. Although men who have disclosed their heterosexual activity are marginally more likely to have sex with female partners, and to have vaginal intercourse and vaginal intercourse without a condom, none of these effects is statistically significant. The only significant difference occurs in relation to unprotected anal intercourse with casual females. Those men that have not disclosed are significantly more likely to engage in anal intercourse with casual female partners (χ2=14.873, df=I, p<0.001).
We can also examine the effect of disclosure of other sexual activities with men. While less than a fifth (19.3%) of those with regular male partners had more than one at the time of interview, most (61.4%) had casual partners in the year preceding interview. Disclosure to regular male partners concerning other (casual) male partners has no significant effect on the proportion having casual male partners, engaging in anal intercourse with them, or engaging in anal intercourse without a condom.
As we have said, without further investigation it is difficult to be sure what effects disclosure to male regular partners has. It seems that disclosure to male regular partners concerning other sexual activities is far more normative than is disclosure to regular female partners. Indeed disclosure to regular male partners of sex with female partners is so common that comparisons with non-disclosers are difficult. While considerably fewer had disclosed that they had sex with other men, it is still common, and seems to have relatively little effect on sex with other male partners.
6.6 SUMMARY
At the time of interview:
- more than twice as many respondents currently had a regular female partner (71.3%) than had a regular male partner (31.5%);
- nearly half (47.7%) had only a regular female partner;
- nearly a quarter (23.6%) had both a regular female and a regular male partner.
The average length of respondents' only, or primary, relationship with regular partners varied according to gender. With female partners it was 42 months and with males 18 months.
Regular female partners
A third (32.6%) of regular female partners knew the respondent was currently having sex with men, of which half (54.0%) knew before they had sex with him.
Men who had disclosed their current (homo)sexual practices to a regular female partner were significantly more likely to have anal intercourse with male partners, and more likely to have unprotected anal intercourse with their male partners. They were also significantly more likely to have a regular male partner, to have anal intercourse with a regular male partner, and to have unprotected anal intercourse with a regular male partner.
A third (35.1%) of regular female partners knew the respondent was having sex with other women. Men who had disclosed their current sexual activities with other women to a regular female partner were more likely to have anal intercourse with female casual partners (but not unprotected anal intercourse).
Regular male partners
Almost all (93.1%) male regular partners knew the respondent was currently having sex with women. Most of which (90.0%) knew before they had sex with him.
Men who had disclosed their current sexual activities with females to their regular male partner were more likely to have anal intercourse (but not anal intercourse without a condom) with female casual partners.
Two-thirds (66.3%) of regular male partners knew the respondent was having sex with other men. Disclosure of current sexual activities with other men to a regular male partner had no effect on sexual practices with other males.
7 Most recent sexual encounter with new male and new female partners
In order to begin to understand sexual practice it is essential to collect a broad range of information. Having examined sexual partnerships in the past five years, sexual partners and practices in the year preceding interview, and current regular sexual relationships, we can also outline both the circumstances of, and sexual practices in, the respondents' most recent encounter with new male and female partners.
All respondents were asked to recall 'the last time you had sex with a woman you had never had sex with before'. In addition to recording the respondents' own account (verbatim if possible) all interviewers ensured that a core set of information was recorded. This included how long ago the encounter was; where it was; how they met their partner; their relationship to them; who initiated the encounter; how many people were involved (in the sexual encounter); where they had sex; what kinds of sex they had; whether condoms were used (if appropriate); and if they ever had sex again. All this information was also collected for the most recent sexual encounter with a new male partner.
In addition to providing some details of sexual practices that were not recorded elsewhere, it was hoped that these data would provide validity checks for other sexual behaviour data. Most of the accounts do match well with data reported elsewhere in this report. That is, data reported in this section all fall within the boundaries that we might predict on the basis of data on partners in the past year, condom use, sources of partners, and so on.
7.1 TIME ELAPSED SINCE MOST RECENT NEW PARTNERS
Dealing first with the time elapsed since the most recent encounter with a new female partner, 50% stated that it was 5-6 months ago or less (see Figure 37), and 50% reported their most recent sexual encounter with a new male partner (n=635) was in the previous 4-5 months. Both these figures are broadly in line with the median number of two female and two male partners in the year preceding interview (see Chapter 5).
Compared to the data on the most recent new female partner, we find that the latest encounter with a new male was somewhat more recent (a third had a new male partner in the past two months compared to a quarter having a new female). However, with nearly a fifth having a new female partner in the month preceding interview and nearly a quarter (23.6%) having an encounter with a new male partner in that time, it is clear that the rates of partner change in the annual figures are a true reflection of the 'high' levels of partner change occurring within this population.
7.2 CIRCUMSTANCES OR LOCATION OF MEETING WITH MOST RECENT NEW PARTNERS
If we examine the circumstances in which these new partners were met, we find that three major sources (pubs/bars/nightclubs; contact advertisements; friends and acquaintances) account for almost three-quarters (74.5%) of new female partners (see Figure 38). While contact advertisements and friends and acquaintances are important sources they account for far less than pubs, bars and nightclubs. As we report elsewhere (see Chapter 4) the other most likely sources of female partners are work, parties and public spaces, although there are a vast array of other sources and circumstances in which they are met.
Other sources (each <1%) of new female partners (in order of the most to the least common) include: sports events, holidays, dating agencies, telephone conversations, bus and taxi journeys, and a call from a door-to-door researcher.
Examining circumstances in which new male partners were met we find that three major sources (pubs/bars/clubs; contact advertisements; public sex environments) account for more than three-quarters of all these encounters (see Figure 39).
Again, pubs, bars and clubs account for the largest proportion, and contact advertisements the second largest. However, contact advertisements account for nearly twice as many new male partners as new female partners. Also, friends and acquaintances are relegated from third to fourth spot (in comparison to sources of new females) by public sex environments. These included public toilets and parks, and account for more than one-eighth of most recent new male partners. Broadly speaking, the remaining sources of partners shown compare to those general sources reported elsewhere (see Chapter 4).
Other sources (each <1 %) of new male partners (in order of most to least common) include public places, telephone conversations, the cinema, beach, introductions through a regular partner, train and taxi journeys, cafes and Job Centres.
7.3 PREVIOUS RELATIONSHIPS WITH MOST RECENT NEW PARTNERS
All respondents were asked if they had any previous relationship with their most recent new sexual partners. Almost two-thirds (65.0%) reported that their most recent female partner was a casual partner whom they had not previously met, and a third (32.0%) reported that she was previously know to them. While some of these partners were good friends, the vast majority were mere acquaintances, friends of friends, or work colleagues. The remainder (3%) were sex workers. With new male partners, the majority (84.5%) reported that he was a casual partner whom they had not previously met. Only an eighth (12.1%) reported they were a friend or acquaintance, with the remainder (3.4%) being sex workers. Compared to the data on new female partners, far fewer of these new males were previously known (however passingly) by the respondent.
7.4 RESPONSIBILITY FOR INITIATING SEXUAL CONTACT WITH MOST RECENT NEW PARTNERS
Asked to recount who had been primarily responsible for initiating the sexual contact between the respondent and the new female partner, most (45.6%) reported that there had been a mutual attraction and indication of a desire for sexual contact with new partners. A further fifth (20.0%) stated that the encounter had been pre-arranged, often before there had been any face-to-face contact. Of these, the vast majority were arranged through contact advertisements or included a sex worker. Of the other encounters, more respondents (23.3%) reported that they had been primarily responsible for the sexual contact than reported that they had not (11.1%).
Again, with new male partners the most common response was that there had been a mutual attraction and indication of a desire for sexual contact (36.0%), or that the encounter had been pre-arranged (19.6%). This last figure is comparable to the 30.8% that reported contact advertisements as the source of their most recent new male partner. While the mutual attraction figure is lower than with new females and the pre-arranged figure is higher, the remainder of encounters offers a complete contrast. Far less (8.1%) of respondents reported they had initiated their most recent encounter with a new male partner than reported that they had not (26.3%).
7.5 LOCATION OF SEXUAL ENCOUNTERS WITH MOST RECENT NEW PARTNERS
The majority (82.7%) of these encounters with a new female partner occurred in one of the participants homes. However, they more commonly (54.4%) occurred in the new female partner's home than in the respondent's own home (28.3%). Of the encounters with females that occurred elsewhere, almost half (7.5% in all) occurred in a car. Others occurred in hotels (2.7%), at a third party's home (2%), or outdoors (1.5%). Other venues (in order of popularity) were parties, nightclubs, toilets, at work and in saunas.
Similarly, with new male partners, more than three-quarters of the encounters occurred in the home of one of the participants. However, the disparity between whether this was in the partner's home (59.6%) or the respondent's home (15.6%) was even more marked than with new female partners. Of the encounters that occurred elsewhere, the most popular venue was a public sex environment (usually a toilet) with nearly a tenth (9.1 %) taking place there. Other venues included cars (4.3%), outdoors (3.1%), hotels (2.9%), saunas (1.9%) and the home of a third party (1.5%). Also mentioned (by <1 % of respondents) were work, cinema, nightclubs, showers, pubs, trains and massage parlours.
With both new male and new female partners, sexual encounters are more likely to occur in the partner's home than the respondent's. This we explain by reference to the large proportion of respondents (49.4%) who lived with a female partner (who may not have been aware of these encounters or who may have been aware, but unwilling for them to occur in their shared home).
7.6 NUMBERS OF PARTICIPANTS IN SEXUAL ENCOUNTERS WITH MOST RECENT NEW PARTNERS
Although the majority (85.8% of those with a new female and 80.8% of those with a new male partner) of these sexual encounters involved only the respondent and the new partner, a significant proportion involved more than two participants.
With new female partners, more than a tenth (11.3%) of the encounters involved three participants, and a small proportion (2.9%) involved more than 3 (usually 4). With new male partners, the proportion which included three or more was even higher (15.8% involved 3, and 3.4% involved 4 or more).
While we could find no comparable data on the prevalence of encounters with three (or more) people, these figures are higher than we might have expected. Although little can be said of the impact of these types of encounters on sexual practices, a number of key points emerge. The vast majority of threesomes with new female partners occurred between the respondent and his regular partner (almost invariably female) and a third female, or between the respondent and a male/female couple. Where the threesome involved two females and the respondent, it was very common for the female partners to have direct sexual contact with each other and for both to have sex with the man. In these circumstances, one of the female partners was usually in a regular relationship with the respondent. Alternatively, when the threesome was between a male/female couple and the respondent, it was usual for the men to have direct sexual contact, though accounts where the respondent had sex with a female while her male partner just watched did occur. Finally, some of the encounters with new male partners were all-male threesomes or foursomes. In both these scenarios it was the norm to have direct sexual contact with all the other parties.
It is noteworthy that whilst these threesomes often occur as a result of a contact advertisement explicitly intended to solicit a partner for this purpose, they also occur in other circumstances. Some (where only males were involved) occurred in public sex environments and circumstances in which a respondent or his regular partner introduced a partner of theirs with the intention (or hope) of having a threesome. A number of the accounts suggest these threesomes can also occur relatively spontaneously, when sexual contact had not been the intended purpose of the meeting. They also occur as a result of meetings between all parties in the whole range of circumstances outlined in Figures 38 and 39.
7.7 SEXUAL PRACTICES WITH MOST RECENT NEW PARTNERS
Of the reported sexual encounters with new female partners, just over 90% included vaginal intercourse, and more than an eighth (13.4%) included anal intercourse. These figures closely match those reported elsewhere (see Chapter 5), that is, from the year preceding interview we found that vaginal intercourse occurred with 89% of all casual female partners and anal intercourse occurred with 23% of such partners.
With new female partners condoms were used with just under two-thirds of all penetrative sexual acts (62.9% for anal and 64.2% for vaginal). While these data cannot be compared directly to those collected for sexual practices in the year preceding interview, it is not incompatible with our finding that 65.3% of those that had anal intercourse with a female casual partner always used a condom and that 48.1% of those that had vaginal intercourse with a female casual partner always used one.
Asked whether they ever had sexual contact with this (new) female partner again, just over half (53.0%) said that they did. Although no details were requested concerning the length or intensity of the subsequent relationship, some respondents reported that they had developed into long-term relationships. Others reported sporadic sexual contact over a range of time periods or just one subsequent meeting for sex.
Of these sexual encounters with new male partners, more than half (51.3%) included anal intercourse. Of those that included anal intercourse (n=355) almost half (44.7%) included both insertive and receptive. Among the others, marginally more (28.8%) included only receptive anal intercourse than included only insertive (26.5%). A small proportion (3.9%) of the most recent sexual encounters with a new male partner also included vaginal intercourse with a female.
Of those sessions that included anal intercourse, more than three-quarters (79.7%) included condom use. Whether or not condoms were used was not dependent on the modality (receptive, insertive) of anal intercourse. Again, comparisons are difficult, but it has been suggested (Coxon, 1996, personal communication) that among gay men at least 70% of instances of anal intercourse do not include condoms, although this figure includes anal intercourse between regular partners. Within this data set, this figure is comparable with the 75.7% of men reporting anal intercourse with casual partners who always used a condom. Of those instances of vaginal intercourse with a female partner, two thirds (66.7%) of the encounters were with condoms.
Two-fifths (39.7%) of the respondents ever had sex with their most recent new male partner for a second time. This is significantly less than had sex again with their most recent new female partner (53.0%). Though there is little in the data to suggest why this should be the case, it must be borne in mind that regular relationships are far less common with male partners, and far fewer of the most recent new male partners were known to respondents before their first sexual encounter.
7.8 SUMMARY
Two-thirds (66.8%) of respondents had a new female partner in the year preceding interview; three-quarters (78.6%) had a new male sexual partner in that time.
Most (74.5%) new female partners were met through pubs/nightclubs, contact advertisements, or friends and acquaintances; most (64.6%) new male partners were met in pubs/nightclubs or through contact advertisements.
Two-thirds (65.0%) of new female partners were not previously known; most (84.5%) new male sexual partners were not previously known.
With new female partners, almost half (45.6%) respondents reported that there had been a mutual attraction and indication of a desire for sexual contact or stated that the encounter had been pre-arranged (20.0%). Of the others, more respondents (23.3%) reported that they had been primarily responsible for the sexual contact than reported that they had not (11.1%).
With new male partners, a third (36.0%) of respondents reported that there had been a mutual attraction and indication of a desire for sexual contact, and a further fifth (19.6%) stated that the encounter had been pre-arranged. In contrast to new female partners far less (8.1%) reported they had initiated their most recent encounter with a new male partner than reported that they had not (26.3%).
A seventh (14.2%) of the most recent encounters with a new female involved a third party; nearly a fifth (19.2%) of the most recent encounters with a new male involved a third party.
Most (90.0%) of the encounters with a new female involved vaginal intercourse, for which 35.8% did not use a condom.
One in eight (13.4%) of the encounters with a new female involved anal intercourse, for which 37.1 % did not use a condom.
Half (51.3%) of the encounters with a new male involved anal intercourse, for which 19.7% did not use a condom.
Over half (53.0%) ever had sex with their most recent new female partner for a second time; two-fifths (39.7%) ever had sex with their most recent new male partner for a second time.
8 Knowledge and impact of HIV and AIDS
Given the sexual practices of these behaviourally bisexual men it could (and undoubtedly will) he assumed that they are putting themselves and their (female) partners at risk of HIV infection. Before any such judgement is made, and certainly before any intervention is planned, it is absolutely essential to consider their knowledge and understanding of HIV issues. It is also important to consider the sources from which they have acquired any knowledge of HIV and AIDS, and the impact of HIV information on their sexual attitudes and practices.
It is notoriously difficult to design reliable and valid measures of HIV and AIDS knowledge. These difficulties were compounded by our reliance on telephone interviews, which made it difficult to go into much detail because the questionnaire had to be relatively short and hold the respondent's interest. Furthermore there was always the danger that respondents would hang up at this stage because these questions were difficult or challenging. Hence, it was important to prompt in a way that was not threatening and did not seem too much like a test.
We decided that rather than ask specific questions in relation to the risk of HIV transmission attached to a number of sexual practices we would ask a range of open-ended questions (with specific queries and prompts). First we asked respondents what impact HIV and AIDS had on their sex life (reported later in this chapter). We then asked them whether they felt they were well informed about HIV and AIDS, and followed this up with a broad open-ended question about what they knew about HIV and AIDS. (If they had not covered four key points we then prompted for further information on these.)
We were specifically looking for responses which covered
- the difference between HIV and AIDS;
- how HIV is transmitted (especially by reference to body fluids);
- the hierarchy of risks involved in different sexual practices;
- whether it is possible to tell (visually) if someone has HIV.
Since we were looking for a general understanding of concept, marking was reasonably generous. This is probably reflected, to an extent, in the high scores. For example, correct answers for 'Do you know what is the difference between HIV and AIDS?' would include 'HIV is the virus and AIDS is when it is full blown' or 'AIDS is when you're sick and HIV means you have the infection.'
8.1 KNOWLEDGE CONCERNING HIV/AIDS
Asked if they felt they were well informed about HIV and AIDS the majority (approximately 80%) answered with an emphatic 'yes' and very little else. Some of those that said 'yes' qualified it with statements like 'as well as anyone' or 'as well as the next man'. A further 7% answered affirmatively but with some uncertainty, particularly over oral sex:
'Reasonably well informed about it, but there are other things I'd like to know... though I don't do much to find out.'
'Would question oral sex, otherwise yes.'Only about one-eighth (approximately 12%) said they felt they were not well informed. The most common answer was 'no', or 'no I don't really think so'. A few respondents expressed less common beliefs or attitudes such as 'I don't think anyone is, I don't believe scientists know what they're talking about.' Outlined below is the percentage of respondents who answered correctly the specific prompts or questions.
Do you know what sex acts are most risky? 88.6% Do you know how people get HIV? 82.5% Do you know how to tell if someone is infected? 77.7% Do you know the difference between HIV and AIDS? 73.2% Just over half (53%) got all the answers correct and, of these, the vast majority felt well informed or reasonably well informed. A very small proportion (3%) felt they were not well informed and still got all the answers correct. Of those respondents who did not get all the answers correct (47%), the majority felt that they were well informed or reasonably well informed. Just under one tenth (9%) said they did not feel well informed and did not get all the questions correct.
Do you know what sex acts are most risky?'
The vast majority (88.6%) of respondents correctly identified anal intercourse, or both anal and vaginal intercourse, as the most risky sexual acts for HIV transmission. By far the most common answer included anal sex or suggested only anal sex:
'Anal sex, 'cause it's quite physical.'
'Anal is the worst one.'Of those men that identified anal intercourse as the most risky sexual act, relatively few distinguished between receptive and insertive or mentioned ejaculation:
'A guy coming up your arse is the most risky.'Slightly less commonly, answers also included vaginal intercourse. However, it was usually mentioned as less of a risk than anal intercourse:
'Anal sex is a higher risk than anything, vaginal is not such a high risk'.
'Anal, of course, even vaginal these days, but from the rear is the main one.'Only a small number of people specified that it was unprotected anal or vaginal sex that was the most risky.
While a few respondents listed oral as the most risky, this was rare. The majority did not mention oral sex as being a risk of HIV transmission. As we expected there was some confusion over oral sex:
'Not sure about oral. They say it's risk free but I'm not sure.'Although there was some differentiation in risk between male or gay partners and female partners this was rare:
'Anal intercourse with a gay man.'
'Anal sex with men I guess.'Incorrect answers (11.4%) included refusals and simple statements that they did not know. They also included vague answers such as 'get it through sex' or 'sexually transmitted', with no other information forthcoming after prompting.
'Do you know how people get HIV?'
The majority of men (82.5%) correctly identified the main means of transmitting HIV. The most common answer was 'through bodily fluids'. A lot of men mentioned blood first then, with prompting, other body fluids. Those who mentioned only blood, and stuck to only that answer after prompting were marked as incorrect:
'Blood; ... can't think of anything else.'
'Not sure of this, all I know is blood but no idea what else.'While some respondents were unable to give any answer, the majority of men knew that HIV can be transmitted through a variety of body fluids.
'Do you know how to tell if someone is infected?'
Respondents that answered 'no' to the question were prompted with 'Do you mean that you don't know how to tell or that it is not possible to tell?' We were looking for an understanding that it was not necessarily possible to tell from appearance if someone has HIV. The most common correct answers were 'You can't tell, can you?' or 'I didn't think you could tell.'
The most common incorrect answers assumed that it was possible to tell, but that the respondent did not know how to do so, or mentioned various symptoms, such as:
'Pale and honey complexion and shrivelled skin – almost skeletal like.'
'Sores on genitals.'
'Sniffing, watery eyes, bad skin, etc.''Do you know the difference between HIV and AIDS?'
Almost three-quarters (73.2%) knew the basic differences between HIV and AIDS. Among those who answered this question correctly there was a general understanding that the two were different. Most understood that there was some asymptomatic period where the person has the virus and is infectious, but is not necessarily ill or noticeably ill. We looked mainly for an understanding of this progression of disease and any mention of 'the virus'.
There were some very clear answers:
'HIV is when you're a carrier but it is not directly affecting your health. AIDS is when the immune system breaks down.'
'HIV is the virus and AIDS is where it destroys the immune system and you contract various diseases.'However, the most common answer involved HIV being the infection and AIDS being 'when you were full blown', a term which came up repeatedly:
'HIV is when you haven't got the full thing.'
'HIV is the disease and AIDS is the full blown disease.'Having HIV was widely perceived to be the 'latent' or 'asymptomatic' part of the disease and AIDS the symptomatic stage which involves noticeable and obvious symptoms.
The word 'carrier' was also commonly used:
'I think HIV is just a carrier. AIDS is when you're a gonner.'Generally speaking there seems to be a high standard of basic knowledge concerning HIV. The majority of these behaviourally bisexual men feel well informed, or at least that they have some knowledge of the essential information regarding HIV and its transmission. The majority can adequately describe the main ways HIV is transmitted and the sexual acts that are most risky. Most also have a rudimentary understanding of the differences between HIV and AIDS. While their understandings are functional or pragmatic, and are certainly not as sophisticated as those associated with samples of gay men (Davies et al., 1993), it could be argued that most know as much as they need to about HIV.
8.2 SOURCES OF INFORMATION ON HIV/AIDS
Assuming that this research might generate interest in targeting HIV prevention campaigns, we asked respondents which sources of HIV information had been most useful to them personally. To ascertain where they had got their information about HIV and AIDS, we asked a general question and then prompted for the likely sources of information that had not been mentioned by asking if any of the other potential sources (listed below) had been personally useful. In Figure 41, the first column of figures indicates the percentage of men who spontaneously mentioned that source of HIV information as being important to them personally. The second column indicates the percentage of men that named that source spontaneously or, after specific prompting regarding that potential source, stated that it had been important to them. Those sources that are starred (*) were not prompted for.
Television and the mainstream press were by far the most commonly cited sources of information. Both were important sources of information to the majority (72.2-75.0%) of these men. Even unprompted, they had been of use to twice as many respondents as the next most important source of information (leaflets and posters). While television includes documentaries and news coverage, it also presumably includes national advertising campaigns. Mainstream press coverage was intended to include only news coverage and not (national) press advertising campaigns, which were given a category of their own. However, it is impossible to tell how many of these men managed to distinguish the impact of press advertising from other press influences.
Although none of the other sources of information was important to more than half the respondents, with prompting HIV-specific leaflets and posters were a source of information for almost half. The only other sources of information that had been important to more than a quarter of the men were press advertisements (34%); literature, books and magazines (27.7%); and friends (25.2%). GI's, STD/GUM clinics and other medical contexts had not been important sources of information for many men. Similarly, HIV-specific sources of information, such as AIDS organisations or helplines, had not been commonly used.
8.3 IMPACT OF HIV/AIDS ON SEXUAL PRACTICES
Before we asked any questions concerning knowledge of HIV/AIDS, we asked all respondents what impact HIV/AIDS had on their sex life. Almost two-thirds (62%) said that HIV had some impact on their sex life, and about one-third (38%) said it had made little or no impact.
Among those who said that it had made little or no impact, the vast majority stated that they had never engaged in sexual practices that would have put them at risk of HIV infection. While there were some comments that indicated that respondents were unconcerned about the risks, these were very rare:
'Haven't really thought about it.'
'I don't give a monkey's. You've got to die sometime; I'd rather die happy.'Initially many respondents made quite general comments in reference to the degree of impact HIV/AIDS had on their sex life. The most common was that it had made them more careful or cautious, wary or aware. Others said that it had made a big or profound impact:
'Yes, I'm always aware and very conscious of it.'Some said that it had made 'a little impact' or 'a bit' of an impact because they were frightened by it:
'I'm terrified of it.'All those respondents who reported that HIV had some impact on their sexual practice were then prompted for details of changes in sexual lifestyle or sexual behaviours. Three major strategies had been adopted: sexual strategies, partner selection strategies and condom use strategies.
Approximately one-third (33%) mentioned sexual strategies. These generally involved a change in attitude to sex or in the types of sex they had. In general these respondents were more cautious or careful, and were more choosy about the kinds of sex they had:
'It made me wary and stopped me doing a lot of things; I won't take risks.'Almost a fifth (18%) specifically mentioned a difference in their approach to sexual partners and/or a decrease in the number of sexual partners. For example, where once they may have looked actively for sex, now it was more opportunistic: 'A lot more care. Not sort of going around picking up people. It's killed off any looking around for it.'
Somewhat fewer (14%) explicitly mentioned that they use condoms now, whereas they had not necessarily done so in the past. While not all of these always used condoms, all used them in certain circumstances, or at least intended to do so:
'Always use a condom now, no exception to the rule, whereas before [they were] not always essential.'A few men mentioned HIV testing, and adopted strategies such as asking sexual partners prior to sex if they had tested and what their status was. Of course, many of the men had adopted more than one of these strategies or a combination of all of them.
Sexual strategies
The first strategy revolves around sexual practice. The most common sexual strategy was to use safer sex:
'Basically I always go for safe sex. Anyone with any doubts about that can forget it.'More specifically some respondents always used safer sex with men. The next most common strategy was not to have penetrative sex:
'I've never had penetrative sex and I've never sucked a man without a condom',and specifically no penetrative sex with men (or sometimes women):
'Probably would have tried anal with men if it hadn't been for AIDS'.Other sexual strategies included: not looking for sex; not doing oral sex; having alternative kinds of sex (especially non-penetrative); having penetrative sex only with regular partners or not with casual partners; sticking to safer sex until getting to know partners.
Partner selection strategies
This strategy involves changes in the way respondents select sexual partners, changes in numbers of partners, or having fewer casual partners. It also involves men claiming to be more 'choosy'. While this was articulated in a number of ways ('check them out first'; 'avoid promiscuous people'; 'make sure they're clean') it is best summed up by the respondent that stressed:
'Nine times out of ten I don't do it if I don't like the look of them.'It also involved men limiting their overall number of partners, choosing to have exclusively regular partner(s) or only having sex with people they 'know' as a way of reducing their risk of coming into contact with HIV:
'Drastically cut down partners.'
'Cut down on partners too. Tend to have one regular partner now.'
'I know the bloke and he's OK.'Other strategies include avoidance of men or the gay scene:
'l feel safer with women, though I don't know why',or of sexual contact with drug users or prostitutes.
The first of these approaches, a vague strategy of being more choosy or only having sex with partners if they look 'healthy' or do not seem too 'promiscuous' is the most common. The second most common was avoiding casual partners or one-night stands, limiting the number of partners, or only having sex with people that are known. Less common was avoiding specific types of partner (gay men or sex workers) or avoiding particular locations where partners could be met (gay bars, for example).
Almost all of these strategies centre around avoiding sexual partners who are perceived to be more likely to have HIV or cutting down on partners in order to minimize the chances of coming into contact with HIV.
Condom use strategies
While relatively few men (14%) explicitly mentioned condoms, among those that did they usually formed the cornerstone of their approach. However, relatively few men stated that they absolutely always used condoms.
It was far more common for respondents always to use condoms except with regular partner(s), or always to use them with women (for vaginal) or men (for anal). Some even differentiated between insertive anal intercourse and receptive (always using condoms for the latter). Others stressed that they usually or sometimes use condoms, even while acknowledging the riskiness of this approach:
'Condoms? Depends – I just look at the person and see how I feel (I know you can't really tell).'Some stated that they used them at first or until they got to know a partner (or with new partners):
'Always use condoms first few times until you get to know them.'These condom strategies are sometimes hard to differentiate from sexual strategies and partner selection strategies. In short, condoms were used specifically with men for anal sex or with women for vaginal, or only with regular partners, or it depended on how the partner looked, or just with unfamiliar partners. Many men mentioned an intention to use them, with the qualification that they were not always used; they were always carried or handy and the man tried to use them or usually used them. Among those respondents that mentioned not always using condoms, some explicitly stated that they would not or had not ever used them:
'Makes me think about condoms, but I still don't bother.'However, this was often still dependent on their partner:
'Never use condoms with males or females unless they insist',or sometimes dependent on availability or the level of excitement:
'If I've got condoms on me I use 'em. Otherwise I get carried away with the moment.'Like the partner selection and sexual strategies, most of the condom strategies reduce the risk of contracting HIV, although very few are epidemiologically perfect. They highlight the diversity of these, and other men's, responses to the threat/s posed by HIV. While some seem strange, the majority are pragmatic and personal responses to a difficult situation.
8.4 SUMMARY
Most respondents (88%) consider themselves to be reasonably well informed about HIV and AIDS.
More than half displayed a correct understanding of all the four basic concepts we examined:
88.6% understood which sexual acts were the most risky for HIV transmission;
82.5% could explain how HIV is transmitted;
77.7% correctly stated that it was not necessarily possible to tell from appearance if someone has HIV;
73.2% knew the basic differences between HIV and AIDS.Only two major sources of HIV information were listed as having been important to more than the majority (almost three-quarters) of respondents: television and the mainstream press. The only other source of HIV information that was listed as important by more than half the respondents was HIV-specific leaflets and posters, and the only sources that had been important to more than a quarter were: press advertisements (34%); literature, books and magazines (27.7%); and friends (25.2%). GPs, STD/GUM clinics and other medical contexts had not been important sources of information for many men. Similarly, HIV specific sources of information, such as AIDS organisations or helplines, had not been commonly used.
In addition to relatively high levels of HIV knowledge, most respondents had made changes in their sexual lifestyle as a consequence of HIV. Of those for whom HIV had little or no impact, the majority stated that they had never engaged in sexual practices that would have put them at risk.
Those that had made changes reported using a wide range of strategies to minimise their chances of getting HIV. These included changes in sexual behaviour (such as only doing safer sex) and partner selection strategies (such as having only regular partners or avoiding partners they perceived as likely to be infected). In conjunction with these strategies were others concerned with condom use (either always using them for penetrative sex or with particular types of partners). Although few of these risk minimisation strategies are epidemiologically perfect, most are perfectly rational.
9 Conclusions
In the preceding eight chapters we have reported a considerable amount of information on a large sample of behaviourally bisexual men. Much of what we have reported is contrary to lay beliefs about them and many aspects of the findings could not have been predicted from previous studies. Until now we have not sought to make substantial generalisations about behaviourally bisexual men, although we feel this work can make a substantial contribution to our understanding of them.
In this final chapter we outline our interpretation of these findings. In particular, it is important to identify the major implications for HIV prevention and health promotion. While we hope that sufficient straightforward information has already been included for readers to draw their own conclusions, we are aware that it is not fair to completely avoid any comment or interpretation.
We must acknowledge that this study cannot be expected to answer all our questions about behaviourally bisexual men, nor address all theories about their behaviour. Many questions remain unanswered and many more have arisen. Although it has become so commonplace as to be something of a joke, we must recommend that more research be undertaken. Using the methods employed in this study, and other methods, many of the new or unanswered questions could be addressed.
9.1 ARE BEHAVIOURALLY BISEXUAL MEN AND THEIR PARTNERS AT RISK OF HIV INFECTION?
Just because we have now identified and begun to describe this group of sexually active men, it should not necessarily be assumed that these men must be targeted for HIV prevention or other sexual-health interventions. First we must assess whether their sexual practices put themselves or their partners at risk. We should then examine their needs with respect to HIV-related information.
These men are certainly highly sexually active. While they do not have as many male partners as gay men (Hunt et al., 1991; Davies et al., 1993) they have a significant number of male partners, and probably have more female partners than do the general population of men (Johnson et al., 1994). Notable also is the fact that they have at least as much sex with females as they do with males. That is, they do not have just one regular female partner and multiple (casual) male partners as other studies have suggested (Boulton et al., 1991). While they are more likely to have regular female than regular male partners, they have roughly equal numbers of male and female partners.
In addition to a high number of male and female partners, the vast majority (93.8%) had engaged in vaginal intercourse with females in the year preceding interview, and a very high proportion had engaged in anal intercourse with females (44.4%). Furthermore, almost two-thirds (62.2%) had engaged in anal intercourse with a male partner during that time. While no direct comparisons are possible, it seems likely that these men have more anal intercourse with females than the general population of males, and they are almost as likely to have anal intercourse with men as are gay men (Hunt et al., 1991). Perhaps most pertinent is the finding that more than half (58.2%) had engaged in both vaginal intercourse with a female and anal intercourse with a male (including 14.0% that had done both without a condom) and a third (34.2%) had engaged in anal intercourse with both females and males (of which 9.8% had done both without a condom).
In order to assess whether these men are putting themselves and their partners at risk of HIV infection we must also examine their condom use for penetrative sex. For vaginal intercourse the use of condoms is far from universal (overall 67.1% had engaged in unprotected vaginal intercourse), but their use is far more common for anal intercourse, especially with male partners. Overall, one-quarter (22.6%) had engaged in unprotected anal intercourse with a female, compared to less than a fifth (18.2%) that had done so with a male. While condom use is far from universal it is mediated by partner type: respondents are far more likely to use them with casual than with regular partners.
In addition to examining respondents' sexual practices we investigated levels of disclosure to regular partners. Disclosure of current sexual activities to regular female partners was not the norm, though it was to regular male partners. We found that only one third (32.6%) of respondents with regular female partners were certain that she knew of their current homosexual activities, and a similar proportion (35.1%) knew their partner was having sex with other women. While disclosure to regular females had the general effect of increasing engagement in anal intercourse and unprotected anal intercourse with their male partners, engagement in these activities was not uncommon among those that had not disclosed. While significant numbers of these men are clearly putting themselves and their partners at risk of sexually transmitted disease, no specific sub-sample could be identified that was most likely to be doing so. In fact, demographic and sample descriptors have no substantial effect on sexual behaviour, indicating that this is a homogenous group of men, at least with respect to sexual behaviour.
Before we make any judgement of their need for HIV information campaigns it is important to consider HIV prevalence among this group. We found a HIV prevalence of <1% among those that have tested and disclosed their status to us. Hence, one might argue that although some of these men's behaviours put them at risk of sexually transmitted infection the risk of coming into contact with HIV is minimal. However, this argument assumes that behavioural bisexuals form a hermetic group who do not have sex with gay men or others who might be at increased risk of HIV. Clearly, given their sexual practice there is scope for HIV to become a major threat. The extent to which it does so in practice depends on the overlap with core groups in which levels of infection are high and the mixing ratios within the group. These data provide the information for modellers to predict the patterns of spread.
Given the apparent danger inherent in the sexual practices of at least some of these men, it is easy to assume that they are in urgent need of HIV-prevention campaigns that concentrate on basic information about transmission and risk. In assessing the need for HIV-prevention campaigns there is one final factor that must be taken into account: this group's current knowledge of HIV. Most (88%) already consider themselves reasonably well informed about HIV, and over half displayed a correct understanding of all four of the basic concepts we examined. This included a very high (almost 90%) level of understanding of which sexual acts were the most risky for the transmission of HIV and how HIV is transmitted. While their understandings were relatively unsophisticated, it could be argued that the vast majority knew as much as they needed to about HIV and AIDS. They had gained this HIV information primarily from television and the mainstream press. While the national advertising campaigns and HIV-specific leaflets and posters were also cited as a source of information, HIV specific sources such as AIDS organisations or helplines had not been commonly used.
In addition to a sound but basic level of understanding of HIV and its transmission, many respondents had already made changes in their sexual lifestyle as a consequence of HIV, and most of those that had not made changes claimed that they did not engage in sexual practices that put them at risk. Those that had made changes reported using three main strategies to minimise their chances of getting HIV (changes in sexual behaviour, partner selection strategies and condom use). Although few of these risk minimisation strategies are epidemiologically perfect, the majority are perfectly reasonable responses to a difficult situation.
9.2 ARE HIV-PREVENTION CAMPAIGNS REALLY NECESSARY?
Clearly then, the sexual behaviour of some of these men puts them at some risk of HIV infection. However, their knowledge of HIV is good and a fair proportion (20%) have had some personal contact with the epidemic. Moreover, the vast majority have already made changes to their sexual practice in order to minimise their chances of becoming infected.
While the choice of whether or not to target behavioural bisexuals for HIV-prevention activities obviously rests with individual agencies, it is not an easy one. While we cannot make a strong recommendation, we feel behavioural bisexuals clearly should not represent as great a priority as groups (such as gay men) where HIV is already very prevalent. However, they probably still merit higher priority than a number of groups which have been, and continue to be, targeted for health promotion.
Although we cannot offer any stronger advice on whether behaviourally bisexual men should be targeted for HIV prevention, we outline those options that we believe are most likely to be effective should a decision be taken to do so.
9.3 HOW CAN BEHAVIOURAL BISEXUALS BE CONTACTED?
This study has pointed to the existence of a large group of men who have sex with both men and women. While many will always have assumed that such a population exists, few could have guessed how large it appears to be. With very limited resources we received over 67,000 telephone calls in an eight-week period, thus demonstrating a cheap and efficient way of contacting these men. If it is deemed necessary, it might be assumed that contact should not prove too difficult.
The most obvious option is to advertise helpline or advice services that rely on telephone contact in the same way as we advertised this study. This would provide the men with an option of specific helplines (such as the National AIDS Helpline) for advice and information if, or when, they felt it necessary. While some men would undoubtedly welcome and use such a service, many more would access services whose main purpose is to allow them to talk about their homosexual activity; like London Lesbian and Gay Switchboard, such a service may also be proactive about giving advice about HIV and sexual health generally. Many respondents in this survey had never had the opportunity to talk about their sexual experiences before, and were both fascinated and relieved to hear how many other men had called our interview line.
[ The idea of the London Lesbian and Gay Switchboard being a suitable resource for this population is particularly clueless. At the time this report was published, there had been two bisexual phonelines in the UK for almost a decade. They were extremely used to callers reporting being told things like 'you're the only one' when they had rung LLGS. In part, this was because it was not until 2003 that LLGS allowed anyone with a bisexual identity to be a volunteer – you had to identify as lesbian or gay, even though for long periods they were absolutely desparate for volunteers. In the 90s, two of their office holders started a mixed-sex relationship together, and despite the fact that they retained their gay and lesbian identities, when it became known, it almost tore the organisation apart. ]
However, there are a number of pitfalls to even this most straightforward approach of advertising a telephone service.
- Confidentiality arrangements have to be made absolutely plain even in the smallest of advertisements. Many of these men have a lot to lose if their sexual practice becomes common knowledge. Considerable effort must be taken to assure them that this will not occur.
- It should not be assumed or implied that all behaviourally bisexual men need such advice or information.
- Given their demographic characteristics and identities they will not react well to advertisements that overtly refer to homosexuality and/or identify their target group as gay or bisexual men.
There is no reason in principle why the various publications used by these men should not also be used to carry informative advertising campaigns. It is equally clear that the content and form of the adverts should be carefully matched to the style, layout and appearance of these individual publications. There is a wide range of publications, ranging from the professionally produced, glossy wide-circulation magazine to the photocopied newsletter produced by an enthusiast and catering for a very specialised and select audience. It is unlikely that a single campaign will, in either style or content, be appropriate for all of these.
The men in this study pointed to the national media, in particular the television, as their main source of information about HIV. It seems reasonable, therefore, to use these media as vectors for health promotion. Given the demographic profile of this group of men, it is probably best to avoid the sort of drama productions common a few years ago that charted the impact of an HIV diagnosis on a middle-class family and to avoid the usual earnest discussion programmes that would not be the natural fare of this group of men. (This is not to suggest that they are incapable of following such discussions, only that they may feel that simply to be watching such a programme is to give a message that they may want not to send.) Rather there is here a challenge for health promotion specialists to encourage the use of advertisements and storylines in drama series that reflect the realities of life for this group of men, alongside those of other groups with different priorities and needs. This approach involves pitfalls similar to those surrounding print advertising: it needs to be non-judgemental and bear a convincing resemblance to the lives of these men; it needs to avoid suggesting that this is a group of irresponsible, feckless or inadequate men; and it needs to avoid appearing heavy-handed and paternalistic.
The men in this sample met a significant proportion of their sexual partners in 'ordinary', – that is, not gay – pubs and clubs. The centrality of pubs and clubs to the gay scenes in most Western cities makes them an obvious and, on the whole, productive vector for health promotion, and managements have, on the whole, been receptive to displaying material, hosting events and undertaking fund-raising. The same will not be the case for the majority of 'straight' pubs and clubs which will, no doubt, see that to mention sexual health and/or HIV would be to accept that their premises were used for sexual purposes: an admission few would publicly make. It seems practically unlikely, therefore, that the licensed trade can be used productively in this fashion.
A small number of the men in this study used gay pubs and clubs or the gay media. The received wisdom within health promotion has been that the gay community would act as a 'natural' vector of health promotion for bisexual men since they would, presumably, be having sex with gay men at some time. The demographic make-up of this group, their sexual identities (or lack thereof), and their lack of identification with, and use of, the gay community make this an increasingly untenable proposal. For the same reasons, the widely held view that groups catering for bisexually identified men and/or women could be a sufficient resource to meet the needs of this community should be critically assessed in the light of the evidence in this report.
In summary, it is clear that there exists a sophisticated and widespread network of men (and women) who have sex with men and women. This network is articulated around a range of publications and, to a lesser degree, public spaces where sexual exchange takes place. The challenge for health promotion is to utilise this network for promulgating safer sexual practice without destroying the network itself (by focusing on it the attention of moral zealots) or by producing inappropriate, heavy-handed or patronising material that is ignored by the population or, worse still, alienates them from the task of protecting their health.
On the other hand there is also strong presumptive evidence that this group of men does not identify itself as a group, either by taking on a sexual identity or by organising itself for purposes other than sexual exchange. In the long term, therefore, it may be appropriate to encourage community development: to facilitate the exchange of information and experience and the formation of interest groups. In the short and medium term, however, it is probable that campaigns which address the concerns of this disparate group of men in national print and broadcast media will have the greatest chance of success hut, to maximise that success, they need to be both accessible and acceptable to their target audience.
9.4 THE CONTENT OF HEALTH PROMOTION
We have shown that in this population levels of knowledge about HIV and AIDS, while not as sophisticated as among gay men, are probably adequate. There is clearly a need to broaden and deepen basic knowledge, so that individuals are confident in the accuracy and extent of their knowledge. On the other hand, it is probably inappropriate to provide for this group of men skills workshops or safer sex days, since such unavoidably public events would not attract a significant audience, at least at this stage. A reactive service which provided specific and personalised advice on specific matters would seem to be the most effective way forward. It is important that such a service should not be restricted to matters of HIV or even of sexual health, but should have a broader remit of psychological and relational matters as well.
The main problem when addressing this group of men is that they will not identify with material produced for 'out' gay men. They also may feel themselves not well served by the material prepared for conventionally straight men, because of their greater perceived sexual sophistication and/or specialised tastes. The most challenging task for those charged with the delivery of health promotion is the provision of information which is applicable to this group of men without alienating other men.
Within HIV prevention over the past five years at least, the tendency has been towards more refined targeting, partly in response to critics within the gay community, and it may now be time to re-evaluate the efficacy of targeting as a universal strategy. It seems to us that there is a difficult balance to be achieved along a continuum between 'targeting' and what we might term 'broadcasting'. At either extreme, it is clear that ineffective and inefficient programmes are prone to emerge. On the one hand, campaigns which focus on ever smaller groups, often of dubious epidemiological or social cohesion, run the risk of seeking to access a vanishingly small population with increasingly lower marginal utility in terms of contact and increased levels of safer sex. On the other hand, it is equally clear that a single campaign which does not differentiate between different groups of men, is hardly likely to address or be acceptable to the very different experiences and needs of gay men and, say, heterosexual men in monogamous relationships. The challenge for health promotion is to find ways of generating gender- and sexuality-neutral campaigns which make themselves relevant to as wide a range of men as possible, while accepting the inescapable specificity of the experiences of particular groups.
Missing from this discussion, of course, is the perspective of the women who have sex with partners of both genders. The image of the dutiful and faithful wife betrayed by the base desires and deceitful behaviour of her 'bisexual' husband is central to the discourse – or mythology – of bisexuality and AIDS. While it would be facile to deny that such a figure exists in reality, it is equally clear that many of the women involved with these men are themselves sexually sophisticated and adventurous. Very little is known of these women, but it is likely that their participation in this market will be informed by different imperatives and circumstances than those that drive the men's participation, and they will also perceive their activities differently.
This study set out to answer a number of questions about men who have sex with both men and women. Those questions arose from a presumptive perception based partly on experience but also largely on prejudice and pejorative assumptions backed up by scientific and behavioural research that has, on the whole, failed to ask questions which challenge those assumptions. While providing some answers to some of these questions, this study has also posed a new set of questions which future research will have to address. In the meantime, there is sufficient information here for a judgement to be made concerning the need to target behavioural bisexuals with HIV prevention initiatives, and the ways in which this could be done.
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Index
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ACSF Investigators
advertising methodology
advice services
age
AIDS see HIV/AIDS
AIDS organisations
anal intercourse:
disclosure and
new partners and
risk perception and
see also following entriesanal intercourse, female:
condoms and
past yearanal intercourse, male:
condoms and
first
past yearAustralia, studies in
background to study
bars
behaviourally bisexual men:
activity high
as homogenous group
bisexuals and
contacting
'dangers' posed by
definition
HIV prevalence among
HIV prevention campaign and
HIV spread and
prevalence of
term
women's image and
see also following entry and sexual partnersbisexuality:
dismissal of
identity and
patterns of
self-identified
stigma and
surveys
taxonomies of
see also previous entryBlumstein & Schwarz
Boulton (1991)
Boulton & Weatherburn
Boulton et al.
Boulton, Hart & Fitzpatrick
clubs
condoms see under gay men; vaginal intercourse
contact advertisements
Cox report
Davies et al.
Day, Professor
demography
disclosure:
to female partners
to male partnerseducational qualifications
ethnicity
Fay et al.
female partners:
casual
new
numbers in past year
regularForman & Chivers
gay bars
gay men
bisexual men and
condom use
center ads
education
GUM/STD clinics and
health promotion and
HIV/AIDS and
partners, number of
sexual identity and
survey methodology and
see also anal intercourse, female; anal intercourse, malegay pubs
GPs
GUM/STD clinics
Hansen & Evans
heath promotion
HEA research programme
helpline services
HIV/AIDS:
contact with
condom use and
differences between
infection, identifying
information sources
knowledge about
partner selection and
prevention campaign
questionnaire and
report on
sexual practices and
testing
transmission, knowledge about
transmission rates
see also behaviourally bisexual menhomosexual behaviour: incidence of
homosexual men see under gay men
Hood et al.
Hunt et al.
interviews
Johnson et al.
Kinsey, Pomeroy & Martin
Kippax, Redden & Crawford
Klein, Sepekoff & Wolf
leaflets
Lever et al.
literature survey
living arrangements
London Lesbian and Gay Switchboard
MacDonald (1981)
McQueen et al.
male partners:
casual
new
number in past year
regularmarital status
methodology
Morrow (1989)
National Study of Sexual Attitudes and Lifestyles (Johnson et al.)
new partners:
encounters, location of
encounters, number of
initiating contact
meeting, circumstances of
previous relationship with
sexual practices with
times elapsed sincenightclubs
Orton & Samuels
parks
Paul (1984)
posters
press
public toilets
pubs
questionnaire
report: nature of
residence, area of
Rogers & Turner
Ross (1988)
Ross (1991)
saunas
sex, paid for
sex acts, risky
sexual experience, first
sexual identity
sexual partners:
absence of
HIV/AIDS and
last 5 years
last year
sources
see also female partners; male partners; new partnerssexual strategies: HIV/AIDS and
social class
STD/GUM clinics
Sunder et al.
telephone interviews
telephone sex lines
television
threesomes
vaginal intercourse:
condoms and
last year
new partners
Weatherburn & Davies
Weatherburn et al.
Wolf (1987)
workplace
Zinic (1985)