Migration, bisexuality and HIV

Author of “Bisexual Latino Men and HIV”, Miguel Muñoz-Laboy, Doctor of Public Health and professor at Columbia University (USA), has been focusing on the relation between bisexuality and Aids. Despite the scarcity of studies on bisexuality and HIV prevention, if we compare to the amount of research on homosexuality and Aids, bisexual people are always labeled the “bridge” population, spreading HIV from male homosexual networks to heterosexual networks.

“The extent to which HIV is spread in this way is difficult to measure partly because bisexuality encompasses a wide range of behaviors. Rather than blaming bisexuals for spreading HIV it is more useful to examine the different types of bisexual experiences, the HIV risks involved, and their relevance to public health,” says Muñoz in the following interview. He was recently in Brazil to participate in the Latin American Dialogue on Sexuality and Geopolitics, organized and promoted by the Sexuality Policy Watch (SPW).

Bisexuality is rarely addressed with regard to HIV. What was the role of bisexuality in your research on Latino men and Aids? If there are different ways of being bisexual or bisexual behaviors, would there also be differences in the risk of transmission of the Aids vírus and other STDs?

Bisexuality is often referred to as the sexual expression of individuals who are emotionally and/or sexually attracted to both genders. Since the AIDS epidemic began, bisexuals were singled out as the “bridge” population, spreading HIV from male homosexual networks to heterosexual networks. The extent to which HIV is spread in this way is difficult to measure partly because bisexuality encompasses a wide range of behaviors and because other transmission routes such as injection drug use complicate the picture. Rather than blaming bisexuals for spreading HIV it is more useful to examine the different types of bisexual experiences, the HIV risks involved, and their relevance to public health.

Estimates of the bisexual population in the US depend on how it is defined. For example, if we define bisexuality as ever having had a sexual experience to the point of orgasm with both a male and a female partner, the size of the bisexual population would be several times higher than if we define it as those individuals who are in sexual relationships with both males and female partners during the same time period.

In terms of lifetime bisexual experience measured in sexual relations with both genders, the US bisexual population is estimated to be around 28 percent. If defined by sexual experiences with both genders since puberty or substantial adult bisexual experience, the estimates are 12 percent and 3 percent, respectively. To our knowledge there are no studies that document the prevalence of bisexuality among Latinos in the US. More research with this important population is needed to better understand bisexuality in relation to HIV prevention.

It is important to note that sexuality and gender expression exist as entire spectrums and are not limited to straight or gay, male or female. If we define bisexuality as ever having had an emotional or sexual attraction to both males and females, regardless of whether it led to a sexual relationship, the estimates would certainly be considerably higher. With this in mind, providers can broaden their HIV prevention services to overcome many of the stereotypes that may result in excluding vulnerable segments of the population.

Studies on bisexuality have moved from models that classify individuals as either homosexual or heterosexual to a model that includes bisexuality as its own sexual orientation. Many researchers see bisexuality as an intricate phenomenon with manifestations that are linked by complex psychosocial and cultural factors. Researchers have found that bisexual individuals have a high self-esteem, self-confidence, independence from social norms and a high assertiveness, which is in contrast with the common belief that bisexuals are psychologically maladjusted and that individuals who identify as bisexual are in denial of their homosexuality. The way society often views sexuality in terms of either straight or gay can make it difficult for individuals to recognize or maintain their identity as bisexuals. Again, it is important for providers to go beyond these common stereotypes as they plan and implement their HIV prevention programs.

What’s the situation of the Latino bisexuals?

Bisexual HIV risk behavior has mostly been studied by lumping bisexuals into one group. In actuality, there are a number of distinct groups that make up the broad spectrum of bisexuality. Providers considering prevention for Latino bisexuals must take into account the important differences that exist among these various groups if they are to succeed. In this section we focus on the various bisexual groups with highest HIV vulnerability and provide insights that will assist in planning and implementing prevention programs for them.

In some situations individuals are bisexual by necessity or because there is no heterosexual outlet. Bisexual behavior is observed among men and women who have sex primarily for money, drugs, or other economic benefit. Prisons and jails are other prime examples. Most of the people participating in sexual economies or imprisoned are likely to be Latino or African American due to class inequities and economic exclusion in the US.

It is important for providers to consider the unique challenges confronted by bisexual sex workers in their intimate (not sex work) relationships. HIV prevention efforts often focus on reducing risk with clients and overlook the risk to intimate partners. Further research and efforts to reach intimate partners of sex workers is an important area for HIV prevention.

Sex and forced sex (rape) between incarcerated women, men, and with guards is common. HIV prevention providers are often challenged by institutional barriers in correctional facilities with regard to condom access and health education. Social justice and human rights issues in correctional facilities are beyond the scope of this prevention guide for providers. However, these issues are critical to the overall health of society and will need to be addressed before an ideal situation is reached.

The stigma associated with prison sex prevents many formerly incarcerated Latinos from speaking about it, even if they continue to be bisexually active after they leave the correctional facilities. This population has high general mortality as well as high probabilities of having contracted HIV, STI and hepatitis C (associated with drug use). This makes them extremely challenging with regard to HIV prevention and early treatment. Providers who are successfully able to support this population will be acting where prevention is most needed.

How is bisexuality dealt among bisexual Latino youth?

Central values for most Latino teenagers in the US include respect, family reputation, and emotional connectedness with family. Being bisexual represents an attack to the family value system and challenges gender norms. Often bisexuality is viewed by family members as temporary, a flaw or sign of insecurity, and a form of rebellion. Encouragingly, a few Latino parents accept and even celebrate their child’s bisexuality. Acceptance is frequently the outcome of an older relative or parent being lesbian or gay.

Studies indicate that most bisexual youth have not told their families. Some struggle with “having to lie.” They wish they could share their emotional struggles as well as moments of happiness with their family. These youth describe living “a double life,” hoping that their emotional and sexual attraction toward either females or males will end at some point. Intent on reducing conflict, their internalized struggle is accompanied by a sense of self-blame and mental distress. Research shows that psychological distress is a predictor of health risk behaviors including risk for HIV. Providers may want to address issues of disclosure as part of their prevention programs for this group in order to help relieve this distress. For bisexual youth who have been “outed” to parents or guardians, their main concern is to meet family expectations in spite of negative views toward bisexuality.

Some bisexual Latina teens report living in a “low impact war” with parents or grandparents. They are constantly reminded of their bisexuality openly but also through avoidance as in not talking about sexual issues at all, encouraging relationships with the opposite sex or not acknowledging same sex intimate partnerships. Latina teens tend to blame themselves. Feelings of social isolation decrease self-esteem and self-efficacy, increasing the likelihood of unprotected sex and other self-destructive behavior. In some cases, these negative feelings are compounded by other traumatic events like child abuse or sexual abuse within the family. Often, binge drinking and drugs are used to cope with the situation at home.

There are Latino youth who show resilience while maintaining their bisexuality outside their family environment. Resilience is related to support from friends and same-age siblings or cousins, and involvement in gay-straight school alliances. Providers can build on these sources of strength in designing and implementing their prevention efforts.

In dealing with bisexual youth HIV prevention, families are often overlooked. Given the importance of family as a cultural value, education for families is a necessary aspect of supporting healthy outcomes for self-identified bisexual Latino youth. With greater family understanding and acceptance, these youth will be better prepared to make safer choices and avoid risk on many levels including HIV.

How about the non self-identified bisexual Latino youth?

There are straight, lesbian and gay Latino youth who have sex with both male and female partners but who do not identify as bisexual. Among these, straight-identified behaviorally bisexual youth are a particularly vulnerable and hard group for HIV prevention providers to reach.

In most instances lesbian and gay Latino youth who are bisexually active have sex more often with someone of their same gender and occasionally with the opposite gender. This bisexuality is expressed through friendships that become sexually intimate, exploration, and as part of having a good time with friends. Alcohol and other substances are often used to help these individuals relax, engage in and enjoy same sex behaviors. This adds a further challenge to providers as substance use can make it difficult for even the well informed to follow safer sex practices.

Straight-identified Latino male youth are at high risk for HIV through same gender unprotected receptive and insertive anal intercourse. Some have sex with other men out of curiosity or exploration and from bisexual interest and attraction. Latino male youth who have sex with other males are disproportionately affected by HIV. Reducing HIV/STI risk among Latino male youth who have sex with males regardless of their identity is a critical HIV prevention priority.

Keeping a heterosexual image is one of the major stressors for Latino straight-identified bisexually active youth. Maintaining their social gender identity can lead them to engage in risky behaviors to prove their masculinity and femininity. This is particularly relevant in some religious communities and urban communities with high street violence where actions are closely observed and same gender sex is stigmatized.

Research shows that religion is important to Latino youth regardless of sexual orientation or identity. The vast majority of Latinos grow up in religious environments where non heterosexual expressions are considered sinful and bring shame to the person and his or her family. Cultural values that combine religion and loyalty to family make protecting the family’s reputation a priority. The need for secrecy and the notion of deceitfulness increase the distress of Latino youth regarding their bisexual activity.

And how about those Latino men who identify themselves as bisexuals?

This group has been approached mostly through HIV prevention education in gay communities. They are likely to be involved in steady concurrent or serial monogamous relationships with male and female partners. In addition to regular partners, bisexual Latino men have casual male and female partners including acquaintances, one-night-stands, and partners met through the internet.

Their main risks for HIV and STI infections are unprotected receptive anal intercourse, insertive anal intercourse with male or female partners, and vaginal intercourse. HIV risk is typically perceived to come from male partners. Because of this, self-identified bisexual Latino men tend to use condoms infrequently and inconsistently with their female partners.

Latino men whether they are straight, bisexual or gay often experience increasing pressure from their communities and families to become fathers and to take their place in the family system. They may also have fears of growing old alone or want someone to take care of them when they do grow old. As a result, a number of Latino bisexual men are more likely to get their female partners pregnant or pressure them to become pregnant. A number of them get married to women due to these pressures.

Some bisexual Latino men express that ideally they would be married to both a woman and a man. Others hide their relationships with other men from their families to “protect them” or to protect themselves from stigma.

Reproductive sex and family planning are often overlooked in HIV prevention interventions with bisexual Latinos (as well as for gay and lesbian Latinos). Being tested for HIV/STI is critical for bisexual men interested in becoming fathers.

How vulnerable is the group of self-identified bisexual Latina woman?

This is probably one of the least understood and hardest to reach bisexual groups. The silence around Latina bisexualities is astonishing. There are almost no studies that have systematically examined this group’s levels of HIV behavioral risk and no information about their risk perceptions. Sexual identity for Latina bisexuals remains a deeply unexamined arena and is particularly relevant because of their apparent invisibility.

Bisexual Latinas have been excluded from the research agenda because they are considered not at risk for HIV. However, they have both steady and casual male and female partners with the same risks for HIV and STI infections as other bisexual groups. More research is necessary to determine appropriate and effective prevention messages and ways to reach this group.

What’s the importance of Latino bisexuals to global public health?

The global nature of the HIV/AIDS pandemic makes migrant populations important for HIV prevention. Documented and undocumented Mexican, Central American and Caribbean Latinos travel constantly to their country of origin for family visits, vacations and temporary relocation. This constant travel is often referred to as the “air bridge.”

Bisexually active individuals represent a sexual bridge between heterosexual and homosexual groups. Researchers found Latino men who have steady relationships with men in the US but who behave mostly heterosexual (including visits to female sex workers) when traveling to the other side of the “air bridge.”

Despite the central role that bisexuals play in connecting sexual networks, it was not until after almost two decades that studies were initiated to examine the HIV risk of bisexual men of color. It is important for providers to understand that bisexual men have similar concerns about transmission as the general population. However, their circumstances and the lines they walk between communities and identities make strategies for avoiding transmission harder to implement and talk about. More studies are required to better understand this population and to develop effective local and international HIV prevention strategies.