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Try out PMC Labs and tell us what you think. Learn More. Understanding the diversity that this label comprises is critical for the development of health interventions that effectively reach the various populations subsumed under this label. We found ificant differences between these two groups in terms of sexual attraction, sexual identity, sexual preferences, sexual histories, and current sexual practices. MSMW were more likely to be confused about their same-sex attraction, to experience internalized homophobia, and to have paid for sex in the year, while MSME were more gender nonconforming and more likely to have been forced to have sex in the year.

These findings underscore that the MSM label compromises a diverse population and that exclusive sexual engagement with other men is a critical distinction to take into in understanding this diversity and fully grasping the lived experiences of men who have sex with men.

Sexual behaviors among heterosexual partners are widely considered to be the driving force in the transmission of HIV in this region. The stigmatization and criminalization of same-sex experiences have likely contributed to this neglect Poteat et al. It is estimated that MSM in Africa are 3. MSM who also have sex with women seemed likely to believe that it is safer to have sex with men than with women, which has implications for condom use and transmission of HIV and other STDs Lockhart, ; Lorway, ; Musinguzi et al.

There also seem to be differences in sexual behaviors, sexual risk, and sexual identities between men who have sex exclusively with men MSME and men who have sex with both men and women MSMW. Understanding of differences between these two groups might critically contribute to our comprehension of human sexuality. Findings will also have consequences for HIV prevention programming, because they will allow tailoring of such efforts. Eligibility criteria included: 1 male sex ased at birth; 2 being over 18 years of age; 3 spending a considerable amount of time in the Tshwane metropolitan area; 4 proficiency in English, isiZulu, or Sepedi Northern Sotho ; 5 having engaged in masturbatory, oral, or anal sex with a man within the 12 months; and 6 willingness to take a rapid HIV test.

These seeds, all of Black ethnicity, were purposively selected, taking into sexual orientation, gender identity, geographic residence, age, and having a large social networks and the ability to recruit other men. Seeds were identified in formative work through the involvement of key informants see Sandfort et al. The same procedure was followed with study participants who were referred to the study by the seeds.

The coupons had identification s that were used to link participants. As an incentive for participation, each participant was given a voucher to be redeemed at a local supermarket. Recruitment of further participants was also incentivized. Participants were recruited in 18 waves between August and January Data were collected through minute interviewer-administered computer-assisted personal interviews.

The questionnaire captured demographic information i. To assess gender and sexual identity-related concepts, we used identical or similar scales that have been used successfully in this population e. Would you call yourself gay, bisexual, or straight, or would you use another word? Cronbach alpha was 0. Sexual identity confusion was measured using a 4-item scale i. The Cronbach alpha in this study was 0. Sexual preferences were assessed by evaluating the degree of pleasure associated with various sexual acts i.

Sexual history was assessed by examining the lifetime of male and female sexual partners and participation in risky sexual behaviors, such as transactional sex, as well as forced sex. Sexual experiences were assessed by examining whether or not men had engaged in certain sexual behaviors throughout their lifetime i. Frequency of sexual behaviors were assessed by asking the participants how many times they had engaged in particular sexual behaviors in the year i. Sexual risk behavior was assessed by asking participants about condomless anal sex with men, separate for receptive and insertive roles, and about condomless vaginal or anal intercourse with women.

This was done to give greater weight to MSM who had considerably smaller social networks or personal network size PNS , because these participants would likely have a lower probability of being recruited into this study. The Ns produced in different analyses varied slightly due to this adjustment; hence, they may not always have totals of Both approaches resulted in similar patterns of differences. We chose to report on lifetime sexual behavior to define MSMW and MSME so that experiences that occurred over a year ago would not be left uned for.

Chi square tests and t-tests were used to compare sexual attraction and identity, sexual preferences, sexual histories, sexual experiences, and sexual risk between MSMW and MSME, with an alpha a priori set at 0. In total, men who met the inclusion criteria participated in the study Table 1.

The mean age for this sample was Among the participants, In terms of sexual identity, Moreover, Ns produced in different analyses vary slightly due to the adjustment of the sample for RDS. There were also differences regarding sexual identity. MSMW were more likely to be secretive about their sexual attraction to men and experienced ificantly higher levels of identity confusion and internalized homophobia, while MSME were much more likely to be more gender nonconforming Table 1.

For instance, MSMW were more likely to find engaging in vaginal and anal sex with a woman, and receiving oral sex and performing insertive anal sex with a man pleasurable compared to MSME Table 1. However, there was no ificant difference in terms of being given something in exchange for sex by a man in the year.

In line with how to two groups were composed, only MSMW had a regular female sex partner, either exclusively or in combination with a regular male sexual partner Table 1. However, the two groups did not differ ificantly regarding having a male regular sexual partner: In terms of lifetime sexual behaviors, MSMW were more likely to ever have received oral sex from a man and to have ever engaged in insertive anal sex with a man.

MSME were more likely to have ever performed oral sex on a man and to have ever engaged in receptive anal sex. Only MSMW had ever engaged in anal intercourse with a woman. In terms of sexual behaviors in the year, MSMW were more likely to have received oral sex from men and to have engaged in insertive anal sex with a man, while MSME were more likely to have engaged in receptive anal sex with men. However, there was no ificant difference in terms of having performed oral sex on a man.

Only MSMW had participated in vaginal sex with women in the year. About one in four MSMW had had vaginal intercourse without using a condom in the preceding year; the proportion of MSMW who had engaged in condomless anal sex with women in substantially smaller 4. When the information across sexual activities is combined, MSME were not more likely than MSMW to have engaged in condomless sex in the preceding year. This study is the first to investigate differences in sexual expression and sexual experiences between behaviorally bisexual and behaviorally homosexual men in South Africa.

Some of the observed differences seem self-evident and have been reported by others. However, as others did, we also found that some men who identified as exclusively homosexual ever had female sexual partners Larmarange et al. We also found that a few men who have sex exclusively with men identified as straight or bisexual Sheehy et al. Again, these differences were to some extent to be expected: substantially larger proportions of MSMW said that vaginal and anal sex with women was very pleasurable, compared to MSME. Parallel differences were observed when we compared the groups in terms of lifetime sexual behavior and the frequency of specific sexual acts in the preceding year.

Others have observed similar differences in sexual practices Lamarange et al. MSME were not more likely than MSMW to have engaged in condomless sex in the preceding year, but there were differences related to specific sexual activities.

This is only a crude indicator of sexual risk because it leaves out of the frequency with which the various acts occurred as well as the of partners with whom these acts have been practices; Smith et al. That these two groups differed in preferences for specific sexual activities, as well as actual behavior, can help with the tailoring of HIV prevention messages. Furthermore, because some men might engage in insertive anal sex with men because they believe — as has been shown among African MSM in different contexts Musinguzi et al.

Whether MSM also had sex with women seems to be associated with how they relate to their same-sex attraction. MSMW seemed to be more confused and feel more negative about their same-sex attraction, and were more secretive about it, compared to MSME. Mental health interventions focused on dealing with negative feelings of same-sex attraction, regardless of whether that occurs in the context of a gay or bisexual identity seem of specific importance. In terms of transactional sex, MSMW were more likely to have paid or exchanged items for sex in the year compared to MSME; this difference has also been observed in the African context by others Sanders et al.

A better understanding of transactional sex among MSM would have to take into the context in which it occurs e. A similar finding has been reported by Micheni et al. Other studies examining this in Africa have not found such differences Lamarange et al. The association between gender nonconformity and preferences for specific sexual practices seems complex: do these preferences result from being more feminine or does the identification with femininity result from a preference for and engaging in specific sexual practices?

This study has a few limitations. Because our study is based on self-reported data, they may be affected by recall bias and social desirability bias. It is quite possible that the MSMW group comprises men who had sex with a woman early in their sexual career, while, subsequently, they only had sex with men. We would like to point out, though, that when we used behavior in the year to group men, we found a similar pattern of differences.

Furthermore, study participants were on average very young, indicating that they were still in the early stages of their sexual career and that any heterosexual engagement was not likely to have been in a distant past. Another limitation concerns our operationalization of sexual risk by not including the of partners and the frequency of unprotected sex.

Whether MSM only have sex with men or also engage in sex with women seems to be a meaningful distinction. The observed differences suggest variability in sexual developmental processes, behaviors, experiences and modes of expression among MSM in South Africa, which is essential to a comprehensive understanding of their sexual and gender diversity. Understanding these differences contributes to our comprehension of sexuality in general.

However, these differences are also critical to tailor interventions aimed at improving health and well-being among the population of men who have sex with men. We thank OUT Well-being, the communities that partnered with us in conducting this research, and the study participants for their contributions.

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Mental Health or the National Institutes of Health. National Center for Biotechnology Information , U.

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