Homophobia and heteronormativity as dimensions of stigma that influence sexual risk behaviors among men who have sex with men (MSM) and women (MSMW) in Lima, Peru: a mixed-methods analysis
RESEARCH ARTICLE Open Access
Homophobia and heteronormativity as
dimensions of stigma that influence sexual
isk behaviors among men who have sex
with men (MSM) and women (MSMW) in
Lima, Peru: a mixed-methods analysis
Amaya G. Perez-Brumer1*† , Ryan C. Passaro2,3†, Catherine E. Oldenburg4, Jonathan Garcia5, Jorge Sanchez7,
H. Javier Salvatie
a6, Javier R. Lama6 and Jesse L. Clark3
Abstract
Background: Stigma differentially influences HIV and STI care among MSM, especially regarding partner notification
practices. Recognizing the heterogeneous behaviors/identities within the category “MSM,” we used mixed-methods to
assess sexual risk behaviors among men who have sex with men only (MSMO) and behaviorally bisexual MSM (MSMW)
with HIV and/or other STIs.
Methods: MSMO/MSMW recently diagnosed (< 30 days) with HIV, syphilis, urethritis, or proctitis completed a cross-
sectional survey assessing sexual risk behaviors, anticipated disclosure, and sexual partnership characteristics (n = 332).
Multivariable generalized estimating equation models assessed characteristics associated with female compared to
male partners in the last three partnerships. Follow-up qualitative interviews (n = 30) probed
partner-specific experiences (e.g., acts and disclosure).
Results: Among all participants, 13.9% (n = 46) described at least one of their last three sex partners as female
(MSMW). MSMW (mean age of 31.8) reported a mean of 3.5 partners (SD = 4.5) in the past 3 months and
MSMO (mean age 30.6) reported a mean of 4.6 partners (SD = 9.7) in the past 3 months. MSMW were more
likely to report unprotected insertive anal sex (77.9%) than MSMO (43.1%; p < XXXXXXXXXXCisgender female partners
were associated with condomless insertive sex in the last 3 months (aPR: 3.97, 95%CI: 1.98–8.00) and
classification as a “primary” partnership (2.10, 1.34–3.31), and with lower prevalence of recent HIV diagnosis (0.
26, 0.11–0.61). Planned notification of HIV/STI diagnoses was less common for female than for male partners
(0.52, 0.31–0.85). Na
atives illustrate internal (e.g., women as ‘true’ partners) and community-level processes (e.
g., discrimination due to exposure of same-sex behavior) that position homosexual behavior and bisexual
identity as divergent processes of deviance and generate vulnerability within sexual networks.
(Continued on next page)
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* Co
espondence: XXXXXXXXXX
†Amaya G. Perez-Brumer and Ryan C. Passaro are co-first authors.
1Columbia Mailman School of Public Health, Department of Sociomedical
Sciences, 722 West 168th St., New York, NY 10032, USA
Full list of author information is available at the end of the article
Perez-Brumer et al. BMC Public Health XXXXXXXXXX:617
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(Continued from previous page)
Conclusions: MSMW recently diagnosed with HIV/STI in Peru report varying partnership characteristics, with
different partner-specific risk contexts and prevention needs. Descriptions highlight how behaviorally bisexual
partnerships cut across traditional risk group boundaries and suggest that HIV/STI prevention strategies must
address diverse,
partnership-specific risks.
Keywords: Men who have sex with men and women (MSMW), Sexually transmitted infections (STIs), Human
immunodeficiency virus (HIV), Partner notification, Social determinants of health
Background
Men who have sex with men (MSM) have 50 times the
odds of HIV infection compared to the general popula-
tion in Peru [1]. “MSM,” however, are a heterogeneous
population and research in multiple international set-
tings suggests that programs targeting gay-identified
MSM may not be effective at reaching men who have
sex with men and women (MSMW) [2–4]. While HIV
prevalence among MSMW has been reported to be less
than that among men who have sex with men only
(MSMO), recent research shows that MSMW are less
likely than their MSMO counterparts to access HIV
prevention and testing services [2, 5]. They are also at
higher risk for other sexually transmitted infections
(STIs) than both MSMO and men who have sex with
women only [4, 6–8].
Previous global studies have identified substantial
heterogeneity within the category of “MSM,” docu-
menting increased substance use, partner concu
ency,
and transactional sex in MSMW compared to MSMO
[4–6, 9]. However, behavioral risk factors only tell a
part of the story about how these men are exposed to
STIs and HIV. Stigma has been described as a central
mechanism increasing HIV vulnerability among gay, bi-
sexual, and other men who have sex with men, all of
whom violate societal expectations of gender roles and
sexual behaviors, and often experience homoprejudice
[10]. In heteronormative societies, where social, cul-
tural, and institutional processes elevate heterosexuality
as natural and normal and devalue other sexual orienta-
tions, non-gay identifying MSM may experience psy-
chosocial stress over the prospect of being “outed” [11–
13]. Similarly, as Peruvian sexual and gender norms are
derived from social standards of machismo, heteronorma-
tivity may intersect with other forms of marginalization
and stigma experienced by sexual/gender minorities to
discourage disclosure of same-sex behavior by MSMW to
their female partners [14, 15]. Accordingly, an in-depth
understanding of sexual and gender politics, and how they
inform partner expectations and disclosure practices, is
critical to the development of successful interventions to
promote sexual health among MSMW [15–18].
Stigma influences routine HIV care for all MSM, with
MSMW less likely to access STI and HIV prevention
programs targeted to MSM populations—usually due to
fear of being identified as gay or homosexual [2, 18, 19].
Historically, stigmatizing language describing MSMW as
a “
idge population” (i.e., responsible for transmitting
STIs/HIV to their female partners) [16, 17] has had the
unintended consequence of increasing psychosocial
stress [6] and limiting the acceptability among MSMW
of HIV prevention strategies targeted to gay men and
transgender women (TW) [6]. However, little work has
een done to address vulnerabilities particular to
MSMW, which is crucial to increasing their access to
prevention and treatment tools, and to reducing HIV
infection within their sexual networks [20].
To address this gap and to provide an improved under-
standing of HIV/STI risk factors, we used mixed quantita-
tive and qualitative methods to: 1) Describe similarities
and differences in risk behavior and HIV prevalence be-
tween MSMO and MSMW, and 2) Assess and describe
sex-specific partnership characteristics of sexual risk be-
havior among heterogeneous sexual identities and behav-
iors within the um
ella category of MSM recently
diagnosed with HIV and/or an STI.
Methods
Study sample and procedures
All participants were recruited by staff at the Asociación
Civil Impacta Salud y Educación [“Impact Health and
Education” Civil Association] in Lima and the Centro de
Referencia de ITS [STI Refe
al Center] “Alberto Barton”
in Callao as part of a 2012 study of MSM and TW re-
cently diagnosed with HIV and/or another STI. Partici-
pant recruitment, data collection methods, and data
instruments have been previously described [21, 22].
Briefly, enrollment was limited to individuals who: 1)
Were assigned male sex at birth, while some identified
as cisgender men (gender identity congruent with natal
sex) or as TW (assigned male sex at birth and reporting
gender identity on a transfeminine spectrum), 2) Re-
ported anal or oral intercourse with a male or TW part-
ner during the previous year, and 3) Had been diagnosed
Perez-Brumer et al. BMC Public Health XXXXXXXXXX:617 Page 2 of 8
within the previous 30 days with HIV, syphilis, genital
herpes, urethritis or proctitis. TW were not included in
the quantitative analytic sample for this manuscript due
to the small number of those reporting female partners
and partnerships.
Participants were invited to complete a survey about
partner notification (PN) after completing post-test coun-
seling, following Peruvian guidelines for standard PN rec-
ommendations. Participants were encouraged to complete
the survey immediately after post-test counseling, but
could return to complete the survey within a 30-day
period, in order to accommodate the potential emotional
distress su
ounding an HIV/STI diagnosis. Despite hav-
ing the option of returning at a later time, all subjects
completed the survey at the time of diagnosis.
Interview participants were sampled by convenience,
per participant and interviewer availability, and recruited
from the larger quantitative study until reaching a point
of qualitative data saturation. There were no statistically
significant differences between the subset of participants
interviewed and the larger study population. Interviews
lasted 15–20min and were audio-recorded, transcribed
ve
atim, and coded by two separate readers.
Written informed consent was obtained from all study
participants prior to enrollment. The study protocol was
eviewed and approved by the Ethics Review Board at
the University of California (G10–03–036-01), Los
Angeles (UCLA) and the Comite de Bioética [Bioethics
Committee] at Asociación Civil Impacta Salud y Educa-
ción (0104–2010-CE). Participants were compensated 10
Nuevos soles ($4 USD) for their transportation costs.
Measures
All participants completed an 82-item bio-behavioral,
computer-assisted self-interview (CASI) survey address-
ing demographics, attitudes related to PN, and sexual
practices with their three most recent sexual partners.
Participants reported key characteristics of each partner,
including relationship type and duration, their percep-
tion of the partner’s gender identity (male, female, trans-
gender) and sexual orientation, and their perception of
whether this partner was a likely source of their recently
diagnosed STI. Partner-specific sexual acts were elicited,
including type of intercourse (anal, vaginal, oral), sexual
ole during intercourse (insertive, receptive, both), and
condom use during each reported act. Questions about
likelihood of notifying their three most recent partners
were measured via a 4-point Likert scale (Very Likely
Somewhat Likely/Somewhat Unlikely/Very Unlikely).
Responses were re-categorized into binary (Likely/Un-
likely) outcomes for analyses. Qualitative interviews
followed a semi-structured script based on the main the-
matic groupings covered in the quantitative survey in-
cluding, understandings of PN and how attitudes related
to PN differed within the context of recent sexual prac-
tices and partnerships. Specifically, participants were
asked to provide pseudonyms for their last three part-
ners and to describe perceptions and rationale of antici-
pated PN. In-depth interviews were conducted with the
purpose of exploring relationships within the thematic
groupings in the cross-sectional survey in order to iden-
tify possible mechanisms to explore in future research.
Statistical analysis
Bivariate comparisons using Fisher’s exact and Chi-Square
tests for categorical variables (where appropriate) and
t-tests for continuous variables compared characteristics
etween participants who described one or more of thei
last three partners as female (i.e., MSMW) and partici-
pants