Review and Special Articles
Beyond the Bisexual Bridge: Sexual Health Among U.S. Men Who Have Sex with Men and Women

https://doi.org/10.1016/j.amepre.2014.05.002Get rights and content

Context

Men who have sex with both men and women (MSMW) experience health problems in ways that distinguish them from men who only have sex with men (MSM) and men who only have sex with women (MSW). Historically, an undue focus on MSMW’s potential role in transmitting HIV to women has resulted in limited understanding of these men’s unique sexual health needs. This article discusses the sexual health of MSMW in the U.S.

Evidence acquisition

The author searched PubMed, Sociological Abstracts, PsycINFO, and GoogleScholar to acquire peer-reviewed studies pertaining to MSMW that were published during January 2008 and December 2013. Reference lists for these studies provided additional studies not acquired through this search.

Evidence synthesis

MSMW are more likely than MSW to be infected with HIV. MSMW may be at increased risk for some other sexually transmitted infections (STIs) compared with both MSW and MSM. Some factors that affect their sexual health include unprotected sex, early sexual debut, forced sexual encounters, increased numbers of sexual partners, substance use, exchange sex, risk behaviors of their male and female partners, and pregnancy-related considerations. These factors uniquely shape MSMW’s vulnerability to HIV/STIs and other sexual health problems. Anti-bisexual sentiment, socioeconomic marginalization, culturally specific masculine ideologies, and sexual identity can negatively influence their sexual partnerships and likelihood of disease acquisition.

Conclusions

Risk-reduction interventions alone are likely insufficient to improve MSMW’s sexual health. Efforts should also address the social contexts affecting MSMW in order to decrease HIV/STI vulnerability and mitigate other barriers to MSMW’s sexual health.

Introduction

Men who have sex with both men and women (MSMW) experience health conditions and factors that influence health in ways that critically distinguish them from men who only have sex with men (MSM) and men who only have sex with women (MSW).1 However, an undue focus on MSMW’s potential role in constituting a “bisexual bridge” for HIV transmission from MSM to women has limited the scientific community’s understanding of MSMW by diverting attention away from the specific health needs of these men.2 National surveillance data and survey-based mathematical models suggest that MSMW account for relatively few HIV transmissions to women in the U.S.3, 4, 5 Nevertheless, some recent investigations continue to improperly characterize MSMW’s overall role in “bridging” HIV to women.5, 6, 7, 8, 9 Fortunately, some researchers have attempted to better understand the unique social and sexual lives of MSMW by studying these men directly10, 11 or in comparison with other men.12, 13, 14, 15, 16 A more comprehensive understanding of MSMW relative to both MSM and MSW is needed.2

This article discusses the sexual health of MSMW. Sexual health is “a state of well-being in relation to sexuality across the life span that involves physical, emotional, mental, social, and spiritual dimensions.”17 Sexual health promotion includes HIV and sexually transmitted infection (STI) prevention and attention to sociocultural factors that support sexual safety and fulfilling sexual relationships. Although few (approximately 2%) sexually active men in the U.S. report being MSMW (based on past-year sexual behaviors),14 these men are disproportionately affected by HIV, other STIs, and social marginalization conducive to multiple sexual health challenges.6, 13, 14, 18 Greater knowledge of MSMW is critical for the improvement of these men’s sexual health.

For this article, the author searched PubMed, Sociological Abstracts, and PsycINFO to acquire peer-reviewed studies pertaining to MSMW that were published during January 2008 and December 2013. These searches cross-referenced terms pertaining to MSMW, such as men who have sex with men and women, MSMW, bisexual men, and male bisexuality, and sexual health, including sexual health, HIV, human immunodeficiency virus, sexually transmitted disease, STD, sexually transmitted infection, STI, and sexual behavior. After acquiring relevant studies, the author reviewed their references for additional studies relevant for understanding MSMW’s sexual health. Finally, the author searched GoogleScholar for sources illustrating how contextual factors (e.g., poverty) might influence MSMW’s sexual health.

Section snippets

Sexual Health Challenges for MSMW

MSMW’s disproportionate risk for HIV/STIs might be understood via their likelihood of engaging in unprotected sex. Other individual–level behavioral factors, and the behaviors of their partners, additionally contribute to these men’s risk for HIV/STIs. MSMW’s sexual health appears to be uniquely shaped by sexual encounters within partnerships including both men and women as well as their attitudes toward pregnancy.

Although studies9, 16, 18, 19 generally report that HIV prevalence is lower among

The Importance of Sociocultural Factors

In addition to individual-level behaviors, multiple sociocultural factors affect MSMW’s sexual health. Biphobia, socioeconomic marginalization, culturally specific masculine ideologies, and sexual identity notably influence their sexual partnerships and likelihood of disease acquisition.

Societal biphobia—negative attitudes and behaviors toward bisexual individuals—is more prevalent than anti-gay sentiment.46, 47 It is sometimes perpetrated by lesbians and gay men48, 49 and public health

Interventions to Promote MSMW’s Sexual Health

Interventions can improve MSMW’s sexual health. Four published interventions show some promise, but they almost exclusively focus on behavioral risk reduction among MSMW of color (Table 2). Nonetheless, increased use of these interventions alongside those addressing the social contexts of MSMW’s lives may improve behavioral and psychosocial outcomes conducive to MSMW’s sexual health.

Hombres Sanos (Healthy Men) uses social marketing principles to promote condom use among heterosexual-identified

Acknowledgments

The findings and conclusions in this report are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

No financial disclosures were reported by the author of this paper.

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