Sexual behavior among HIV-positive men who have sex with men: what's in a label?

Journal of Sex Research, May, 2003 by Trevor A. Hart, Richard J. Wolitski, David W. Purcell, Cynthia Gomez, Perry Halkitis

The Seropositive Urban Men's Study Team

The sexual practices of men who have sex with men (MSM) have been the subject of many studies since the emergence of the human immunodeficiency virus (HIV) epidemic (Stall, Hays, Waldo, Ekstrand, & McFarland, 2000; Wolitski, Valdisseri, Denning, & Levine, 2001). These studies extensively document the prevalence of specific sexual practices but provide little insight into MSM's identification with, and preference for, specific roles during sexual intercourse. Among MSM, distinctions are commonly made regarding preferences for insertive or receptive intercourse (Wegesin & Meyer-Bahlburg, 2000). Three major self-labels are typically specified: "top," meaning one who prefers the insertive role, "bottom," meaning one who prefers the receptive role (Sanderson, 1994), and "versatile," meaning one who engages in both behaviors without strong preferences for one or the other. Despite the potential utility for those who design HIV prevention programs of knowing how MSM self-label regarding their typical sexual behavior, the use of such self-labels and their relation to HIV transmission behavior and psychological adjustment have received little attention in the literature.

A recent study was among the first to explore self-labels regarding sexual behavior in a sample of gay and bisexually identified men of mixed serostatus (Wegesin & Meyer-Bahlburg, 2000). Men were asked to indicate whether they identified themselves as a top, bottom, or other, or to indicate that they did not practice insertive anal intercourse (IAI) or receptive anal intercourse (RAI). Results suggested some degree of consistency between self-label and sexual behavior, with tops engaging in a higher frequency of IAI than bottoms and bottoms engaging in a higher frequency of RAI than tops. Degree of pleasure experienced during IAI or RAI was in the expected direction, with tops rating IAI as more pleasurable than bottoms, and bottoms rating RAI as more pleasurable than tops.

Research regarding preferred roles during sexual intercourse suggests that self-labels regarding sexual behavior among MSM may vary by culture. Carrier (1977) argues that interchangeability of insertive and receptive roles found among American MSM (e.g., Hooker, 1965) may be specific to middle- and upper-class non-Latino Caucasian Americans and may not be generally found among MSM of other ethnicities or working-class backgrounds. For example, among Mexicans and Mexican Americans who are less acculturated into the dominant American culture, it is normative to select either the insertive or receptive role but not both roles. Further, in Mexican, Greek, and Turkish culture, only those who engage in RAI are considered to be homosexual (Carrier, 1985, 1989; Magana & Carrier, 1991). Despite greater stigma in many communities against engaging in the receptive sexual role, there appear to be no ethnic differences among Latino American, African American, and Caucasian American MSM in proportion of men engaging in RAI versus IAI during a 1-year period (Doll et al., 1992). Given that self-labels may not reflect actual roles during intercourse, it is unknown if there are ethnic differences in self-labeling and its relation to self-identified sexual orientation.

Self-labels also appear to be associated with medical and psychological variables. Bottoms may be more likely to be HIV-seropositive than tops because of their preference for RAI versus IAI (Caceres & van Griensven, 1994; Vittinghoff et al., 1999; Wegesin & Meyer-Bahlburg, 2000). Sexual roles also have been associated with masculinity and femininity; one study showed that adults who preferred RAI recalled more childhood gender nonconformity (Weinrich et al., 1992). Mixed evidence exists regarding an association between top or bottom self-labels and femininity in adulthood (Wegesin & Meyer-Bahlburg, 2000).

Although Wegesin and Meyer-Bahlburg's (2000) study is remarkable for systematically examining self-labeling among MSM, the study did not examine the sexual behavior of those who identified as "other" or "not applicable." Many of the men in the "other" category may have identified as "versatile" if given the opportunity, as most men who engage in anal intercourse with other men engage in both insertive and receptive intercourse (Doll et al., 1992). Further, data are needed on those who do not identify with a self-label. Although Wegesin and Meyer-Bahlburg report that the "not applicable" group consisted of those who did not practice insertive or receptive anal sex, it is unknown to what extent this group was celibate or simply preferred other forms of sexual activity.

The current study attempted to answer three primary research questions. First, consistent with a shift in resources toward understanding the HIV risk behaviors of HIV-positive persons (e.g., Janssen et al., 2001), the study attempted to extend the findings of previous self-label research by examining (a) the relationship between self-labeling and sexual behavior in a multiethnic sample of HIV-positive MSM and (b) the use of the versatile label and its relationship to sexual behavior. We hypothesized that self-label would predict overall patterns of sexual behavior, with tops engaging in more IAI than RAI, bottoms engaging in more RAI than IAI, and versatiles engaging in intermediate rates of both IAI and RAI. In addition, we examined the sexual behavior of those who do not identify with a self-label and explored differences in oral intercourse to see if patterns found for oral intercourse were similar or different among self-label groups.