This literature review adds key points to the dialogue about men on the down-low. First, black MSM are more likely than MSM of other races and ethnicities to identify as bisexual and to be bisexually active. Second, heterosexual identity and corresponding sexual behavior among black men are sometimes incon-gruent, but this discordance is not exclusive to nor greatest among black men. Third, black MSM are less likely than other MSM to disclose their homosexual behavior or identity, but nondisclosing black MSM may engage in fewer sexual risks with male sex partners than disclosing black MSM. Last, a large multi-site study found that more gay- or bisexually identified HIV-positive black MSM reported sex with women than heterosexually identified HIV-positive black MSM.
The available data suggest that the behaviors associated with being on the down-low are not specific to black men. Nongay-identified men of other races and ethnicities also engage in homosexual sex and do not disclose their homosexual behavior to female partners. However, two crucial factors make bisexual behavior among men a more pressing issue in African-American communities than in other communities: the high background prevalence of HIV and the greater odds of bisexual activity among black men. These two factors generally increase the risk for HIV infection (еreating HIV infection when used along with other medicines) among black women with bisexual male partners compared with women from other racial or ethnic groups with bisexual male partners.
Nonetheless, having sex with a bisexual man is not the only HIV risk (еreating HIV infection when used in combination with other medicines) factor for heterosexual black women. Surveillance data on HIV infections reported between 1999 and 2002 show that proportionally more HIV-positive black women reported having had sex with a male injection drug user (IDU) than with a bisexual man (Figure l). But these data are likely underestimates, since the available literature clearly establish that black MSM are less likely to disclose their sexual behavior than MSM of other ethnicities. Figure 1 also shows that the largest category of black women heterosexually infected with HIV between 1999 and 2002 was that of women with no identified risk. It has been anecdotally suggested that the high estimates of unknown risk represent women who contracted HIV from bisexual men. What has not been explored is whether the large percentage of unknown risk among black women reflects high-risk behavior among exclusively heterosexual adults. A population-based estimate from the National AIDS Behavioral Survey found that high-risk black heterosexuals accounted for 20% of the black population, and proportionally more black heterosexuals reported ongoing HIV risk (treating HIV infection) behaviors than white heterosexuals (73% versus 56%, respectively).
Figure 1. Heterosexual Transmission of HIV among Black Women, 1999-2002
The HIV risk behavior data on black heterosexuals is compelling. Rates of condom use by black heterosexuals is low, even among couples in serodiscor-dant partnerships. Moreover, compared with other racial or ethnic groups, black heterosexuals report having more sex partners, more involvement in concurrent and mutually nonmonogamous sexual relationships, more trading of sex for drugs or money, and a greater likelihood of having ever had a sexually transmitted infection or reinfection. Studies have also documented anal sex among subpopulations of black heterosexuals. Black heterosexuals are less likely to use condoms during anal sex than during vaginal sex, and anal intercourse is a more efficient route for HIV transmission than vaginal sex. Last, black women are significantly more likely than women of other races or ethnicities to report vaginal douch-ing, which may increase their chances of STD acquisition and susceptibility to HTV infection. All of these risk behaviors have been absent from the discourse surrounding men on the down-low and the increasing HTV infection rates among black women.
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Additionally, the social context of sexual decision-making by black women has not been adequately considered in the collective discussion of men on the down-low. There is evidence that even when armed with the knowledge of a male partner’s sexual infidelity (with men or women) or intravenous drug abuse, some black women not only remain in the relationship but continue to engage in unprotected sex with their main male partner. This may be a particularly important aspect of the current debate about men on the down-low, which addresses why black women may consciously choose to engage in unprotected sex with their male sex partners despite knowledge of increased risk for HIV infection. These findings support existing scientific research that suggests that gender roles, power dynamics in relationships, socioeconomic status, and perceptions of few suitable male partners influence black as well as other women’s sexual decisionmaking choices.
Finally, there needs to be clarification around whether the primary source of HIV infection among black women is black men who are bisexually active or black men who are heterosexually active. The best poulation-based estimate of black MSM show that only 3% of all black men ages 18-49 years were homosexu-ally or bisexually active. In contrast, a population estimate of high-risk black heterosexuals found that 29.7% of exclusively heterosexual black men ages 18^49 engaged in high-risk sexual activities. Assuming that 97% of all black men in the United States are exclusively heterosexual and that 30% of these men engage in high-risk activity, a central issue emerges: Are heterosexually transmitted cases of HIV in black women driven by a small percentage of MSM/W who have a high HIV prevalence and unknown HIV risk behavior, or by a much larger population of exclusively heterosexual black men who have comparatively lower HIV prevalence but high HIV risk behavior?
This review has several limitations. First, the data presented in this review are from studies that did not seek to answer research questions about men on the down-low. Data from these studies provide limited insight into a population for which there are no scientific data. Second, the data are limited to specific searches from studies indexed in three online databases. Searching additional databases or using different search criteria may have yielded additional data. Third, the population-based statistics of bisexuality among black men are only generalizable to metropolitan areas with high HIV prevalence.
More quantitative investigations comparing HIV risks among populations of black men who are exclusively heterosexual, homosexual or bisexually active should be undertaken. Additionally, future studies of HIV-positive black MSM/W must address bisexual men’s sexual risk behaviors. Existing studies of HIV-positive bisexual black men use inadequate measures of HIV risk behavior (e.g., pooling unprotected anal or vaginal sex or not reporting prevalence of unprotected sex), do not control for the serostatus of sex partners or fail to assess bisexually active men’s HIV risk behavior altogether.
The role of bisexually active black men in HIV transmission is a more complex issue than depictions of black men on the down-low as sexual predators and black women as uninformed victims. Future HIV research and programmatic activities must reflect this level of complexity by focusing on the sexual behaviors and sociocultural processes that facilitate HIV transmission between black men and women.