Male adolescents who have sexual contact with both males and females are more likely to report AIDS-related risk factors and a history of sexually transmitted disease (STD) than are males who have sexual contact only with females. Compared with young men who have only heterosexual contact, those who engage in bisexual behavior have three times the odds of having injected drugs and five times the odds of having had an STD. Among young men progressing to sexual intercourse, those with partners of both sexes have reduced odds of using a condom and elevated odds of having had multiple lifetime partners. In contrast, men who have exclusively homosexual relationships are no more likely than heterosexually active men to report these AIDS-related risk factors. These findings, based on an analysis of data from a Massachusetts survey of high school students,1 suggest that bisexually active young men deserve specific attention in prevention programs.
Past studies of AIDS-related risk behaviors among young men have yielded limited information, because they have grouped together homosexually and bisexually active males as "young men who have sex with men" and because they have not included adolescents. To gain detailed insight into AIDS-related risk among male adolescents, researchers compared the behaviors of youths who had engaged in bisexual, homosexual or heterosexual activity. The researchers studied data from the Massachusetts Youth Risk Behavior Survey, a population-based survey of students in randomly selected public high schools throughout the state, which was conducted in 1995, 1997 and 1999. The investigators combined information from all three surveys and examined responses from the 3,267 male students who reported any "sexual contact."
Of the study sample, 94% reported sexual contact with only females, 3% with only males and 3% with both males and females. The average student age was 16.4; the youngest male was about 12, and the oldest was about 18. Heterosexually active males were, on the whole, older than the males in the other two groups. Nearly half of heterosexually and homosexually active respondents attended urban schools (46-49%), whereas bisexually active youths were less likely to come from urban schools (30%) and more likely to attend suburban schools (50%). More than 60% of each study group reported white ethnicity.
Chi-square analyses showed that adolescents reporting bisexual activity were significantly more likely than the others ever to have injected drugs (39% vs. 4-6%), had sexual contact under coercion (59% vs. 8-21%), had an STD (35% vs. 3-4%) and missed school in the previous month for fear of safety (36% vs. 7-10%). Although these youths were less likely than others to have received AIDS education at school (67% vs. 83-93%), about one-half of all three groups had been taught how to use condoms.
More than 85% of all three study groups had had sexual intercourse. Among these respondents, a significantly higher proportion of bisexually active males than of others had had intercourse before they were 13 (54% vs. 15-17%). The trend was similar for the following risk behaviors: having had four or more lifetime partners (63% vs. 19-28%), having had four or more partners in the previous three months (43% vs. 6-7%) and having used drugs or alcohol at the most recent intercourse (60% vs. 26-27%). In addition, bisexually active males were the least likely group to have used a condom at most recent intercourse (33% vs. 61-66%).
Logistic regression analyses that controlled for ethnicity, age and school type revealed that bisexually active youths had significantly higher odds of having had an STD (odds ratio, 5.4), having used injectable drugs (3.1) and having had four or more lifetime partners (2.9) than youths reporting only heterosexual contact. They also had reduced odds of reporting condom use (0.4). Males who had only homosexual contact, however, were no more likely than those who engaged only in heterosexual behavior to report these risk factors.
Recipients of AIDS education or condom instruction had significantly higher odds of condom use at last intercourse than did nonrecipients (1.5 and 1.3, respectively), but homosexually and bisexually active males were less likely than heterosexually active males to have received AIDS education (0.2-0.4). Moreover, students who did not attend school for fear of safety--commonly males who had any same-sex contact, the researchers note--had reduced odds of receiving AIDS education (0.7). The investigators suggest that students who miss school for fear of victimization miss out on AIDS education and its protective benefits. Nevertheless, they do not rule out the possibility that the quality and content of AIDS education among schools varied so that some students with same-sex experience who did attend the classes may not have found them relevant.
Finally, the investigators found significant differences in how the three groups reported sexual identity: Bisexually active teenagers indicated a spread of identities (31% heterosexual, 11% homosexual, 35% bisexual and 23% unsure or none), whereas most other students indicated a heterosexual identity (96% and 69% of those reporting heterosexual and homosexual experience, respectively). The authors comment that the low proportion of homosexually active males with a homosexual identity (12%) is "not unusual, given the stigma attached to nonheterosexual identities."
Although the researchers acknowledge that the terms "sexual contact" and "sexual intercourse" were not defined in the survey and that the study was limited to a public high school setting, they conclude that male adolescents who are bisexually active display higher levels of AIDS-related risk behavior than do other adolescents. According to the investigators, bisexually active young men place themselves and their partners at high risk of AIDS and other STDs, thus creating an "urgent need for prevention programs addressing these youths' specific concerns." Given the different identity profiles between bisexually and homosexually active young men and the tendency of both groups to label themselves heterosexual, the authors suggest that future intervention efforts are unlikely to be successful if they target self-defined "gay" or "bisexual" youths. One possibility, they propose, is "to make mainstream classroom instruction more inclusive and more culturally appropriate for sexual minority adolescents."-- T. Lane
1. Goodenow C, Netherland J and Szalacha L, AIDS-related risk among adolescent males who have sex with males, females, or both: evidence from a statewide survey, American Journal of Public Health, 2002, 92(2): 203-210.