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Discordance between Sexual Behavior and Self-Reported Sexual Identity: A Population-Based Survey of New York City Men FREE

Preeti Pathela, DrPH; Anjum Hajat, MPH; Julia Schillinger, MD; Susan Blank, MD; Randall Sell, ScD; and Farzad Mostashari, MD
[+] Article and Author Information

From New York City Department of Health and Mental Hygiene and Mailman School of Public Health, Columbia University, New York, New York; University of North Carolina School of Public Health, Chapel Hill, North Carolina; and Centers for Disease Control and Prevention, Division of Sexually Transmitted Disease Prevention, Atlanta, Georgia.


Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Acknowledgments: The authors thank Bonnie Kerker, PhD, Director, Community Epidemiology, Division of Epidemiology, New York City Department of Health and Mental Hygiene, for providing the background and detailed review of survey procedures, and Lorna Thorpe, PhD, Deputy Director, Division of Epidemiology, New York City Department of Health and Mental Hygiene, and Stuart Berman, MD, Chief, Epidemiology and Surveillance Branch, Division of STD Prevention, Centers for Disease Control and Prevention, for their insightful reviews of the manuscript.

Grant Support: None.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Preeti Pathela, DrPH, New York City Department of Health and Mental Hygiene, 125 Worth Street, Room 207, CN73, New York, NY 10013.


Ann Intern Med. 2006;145(6):416-425. doi:10.7326/0003-4819-145-6-200609190-00005
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Context

  • Self-identification of sexual orientation may not accurately reflect actual sexual practices.

Contribution

  • These investigators performed a population-based health survey of men living in New York City and found that almost 10% who self-identified as straight had at least 1 sexual encounter with another man during the previous year. These men were less likely than self-identified gay men to have been tested for HIV infection or to have used a condom during their most recent sexual encounter.

Implications

  • Physicians cannot rely on self-identification of sexual orientation to assess the likelihood of risky behavior. They must ask specific questions about sexual practices.

—The Editors

Men who have sex with men account for 45% of incident cases of HIV infection in the United States annually (1). Despite earlier declines in incidence rates of HIV infection among men who have sex with men (23), recent data show increases in high-risk sexual behaviors (45), sexually transmitted diseases (STDs) (69), and HIV diagnoses (10) among these men.

Previous research has found discordance between self-reported sexual identity and sexual behavior in men (1113). Several reports (1422) have focused on risk behaviors among men who have sex with men and acknowledge having male sexual partners but do not report a gay identity. Compared with gay-identified men who have sex with men, these men were less likely to use condoms during anal intercourse with other men (21) and less likely to have been recently tested for HIV infection (17). Because of secrecy about their sexual identity, these men may be distanced from the gay community, where most activities that focus on HIV prevention in men who have sex with men occur; therefore, they may have an increased risk for acquiring HIV infection and other STDs.

Current understanding of behavior and risk among non–gay-identified men who have sex with men has been largely gleaned from studies that used convenience samples, such as men at locations frequented for sexual encounters (1617, 20). Although numerous population-based surveys have measured sexual behaviors, such as the sex and number of partners (2324), few have simultaneously measured adult respondents' self-reported sexual identities (11, 25). The aims of this study were to use concurrent measures of sexual identity and behavior to characterize the demographic characteristics and sexual behavior profiles of specific identity–behavior groups in a large, representative sample of New York City men.

Survey Design

Between March and August 2003, the New York City Department of Health and Mental Hygiene conducted a survey to collect information on health status and risk behaviors among New York City residents. The Community Health Survey (CHS) is an annual cross-sectional survey based on the Centers for Disease Control and Prevention's (CDC) Behavioral Risk Factor Surveillance System. The survey includes about 130 questions on numerous health topics, such as health care access, physical activity, diabetes, immunizations, tobacco exposure, demographic characteristics, mental health, and sexual risk behaviors. The institutional review board at the New York City Department of Health and Mental Hygiene approved the survey.

The CHS sampled New York residents (≥18 years of age) using a stratified sample design to allow neighborhood estimation. The sampling frame was constructed by using residential telephone numbers provided by a commercial vendor. Households were selected by using a random digit–dialing method, and after all household members were enumerated, 1 adult was randomly selected to be interviewed. Interviews were conducted in English, Spanish, Chinese, and Russian, and a telephone translation service was used for survey participants who spoke only Greek, Korean, Yiddish, Polish, or Haitian Creole. Sample weights were constructed, accounting for the respondent's probability of selection within the household and a poststratification factor (created by weighting each record up to the neighborhood population while accounting for the respondent's age, sex, and ethnicity) (26). In 2003, 9802 New York residents participated in the survey (59% cooperation rate), of whom 4193 (42.8%) were men and are the focus of this analysis.

Ascertainment of Sexual Identity and Sexual Behavior

Figure 1 shows the wording of key sexual identity and behavior questions. The sexual identity question, introduced in 2003, used the same wording as a question included in the Massachusetts Youth Risk Behavior Survey since 1995 (27), and response choices were read by the interviewer. Within the CHS instrument, this question was placed in the demographic characteristics section in the middle of the survey, deliberately separated from questions regarding sexual behavior, which were placed at the end. Consistent with the U.S. National Health and Nutrition Examination Survey (NHANES), sex was defined as oral, vaginal, or anal intercourse for questions regarding the number of male and female sexual partners and condom use. All respondents, regardless of sex, were asked about the number of male sex partners before they were asked about female sex partners. This ordering of questions differs from methodology in other large in-person surveys (for example, NHANES) and audio computer-assisted self-interviewing surveys (for example, National Survey of Family Growth), in which participants are questioned first about opposite-sex partners or in which other formats and ordering of questions are used. Questions about history of testing for HIV infection and condom use were also asked (Figure 2). There were 4 questions to ascertain history of STDs (Figure 2); for our analysis, a person who answered yes to any of these 4 questions was considered to have a history of STDs.

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Figure 1.
Sexual Identity and Sexual Behavior Questions in the 2003 Community Health Survey
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Figure 2.
Sexual Risk Behavior Questions in the 2003 Community Health Survey
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Construction of Sexual Identity–Behavior Groups

For participants who reported sexual activity in the past year and answered the question regarding sexual identity, information regarding sex of the participant, sex of sex partner or partners, and self-reported sexual identity was used to construct identity–behavior groups. Groups included straight-identified men who have sex only with women, gay-identified men who have sex only with men, and straight-identified men who have sex only with men. The term non–gay identified was not used to describe the last group because most reports of non–gay-identified men who have sex with men include bisexual men, who were excluded from our analysis.

Gay-identified men who reported having sex with women only were excluded from the analysis, because few men belonged to that group. Behaviorally bisexual persons have been found to differ in behavior and risk from those who exhibit exclusively homosexual behavior (28). Persons who reported bisexual identity or behavior were enumerated but were excluded from the main analysis. Therefore, the identity–behavior groups that we examined consisted of men who exhibited purely heterosexual behavior or purely homosexual behavior in the year before the survey.

Validity and Reliability of Key Survey Questions

To determine the reliability of answers to the questions regarding sexual behavior, we compared the 2003 and 2002 surveys. For both surveys, questions regarding the sex and number of sexual partners were placed at the end; however, the wording of the questions was different. In 2002, survey participants were asked, “During the past 12 months, with how many people have you had sex, including oral sex?” and were then asked, “During the past 12 months, have you had sex with only males, only females, or with both males and females?”

We hypothesized that the language in which the interview was conducted could have influenced respondents' answers regarding sexual identity. To examine this influence, we compared responses to the identity question for foreign-born and U.S.-born men and compared those surveyed in English with those surveyed in Spanish.

Statistical Analysis

The number, weighted number, and weighted percentage of sexually active men in each of the sexual identity–behavior categories were calculated. Demographic and risk characteristics were described for 3 analytic subgroups: straight-identified men who have sex with women, straight-identified men who have sex only with men, and gay-identified men who have sex only with men. In the univariate analysis, nonoverlapping 95% CIs indicated statistically significant differences for prevalence estimates between groups. An estimate was considered unstable if its relative standard error was greater than 30%, in other words, if the standard error of the survey estimate divided by the estimate itself was greater than 0.3 (29). To determine whether straight-identified men who have sex with men reported riskier behaviors than gay-identified men who have sex with men, we used gay-identified men who have sex with men as the referent group and examined 4 outcomes of interest: history of STDs, testing for HIV infection in the past year, no condom use during last sexual encounter, and risky sexual behavior. Risky sexual behavior was defined as a combination of 2 response categories: 2 or more sexual partners in the previous year and no condom use during the last sexual encounter. The nonrisky group consisted of men who had more than 1 sexual partner and used condoms and those who had exactly 1 sexual partner, regardless of condom use.

Multivariate models assessed associations between these outcomes and the 2 identity–behavior groups among men who have sex with men, while including other demographic and behavioral covariates found to be statistically significant in the univariate analysis or relevant based on a priori knowledge. Homogeneity tests were conducted to assess effect measure modification. Adjusted prevalence ratios and 95% CIs were calculated by using predicted marginal proportions (30). Analyses were conducted by using SUDAAN software (Research Triangle Institute, Research Triangle Park, North Carolina) to obtain appropriate standard errors for point estimates.

Role of the Funding Source

This study was not funded.

Male Survey Participants

Among men, 91.3% reported straight or heterosexual identity, 3.7% reported gay identity, 1.2% reported bisexual identity, 1.7% responded “not sure or don't know,” and 2.1% declined to answer the question. Of men who answered the questions regarding the number and sex of their sex partners, 70.6% reported having sex with only women, 9.3% reported having sex with only men, 0.8% reported having sex with men and women, and 19.3% reported no sexual activity during the past year. The final sample for which identity–behavior groups were constructed consisted of men reporting sexual partners in the previous year who also reported a straight, gay, or bisexual sexual identity; this included approximately 69% of 4193 surveyed men. Demographic characteristics of the 2898 men who were included and the 1295 men who were excluded were largely similar; however, the men who were not included were more likely to be older (>65 years of age) and to report a divorced, separated, or widowed marital status. Table 1 details the number of men in the sexual identity–behavior groups.

Table Jump PlaceholderTable 1.  Self-Reported Sexual Identity and Sexual Behavior, 2003 Community Health Survey, New York City

The remaining analysis focused on straight-identified men who have sex with women (concordant identity–behavior), straight-identified men who have sex with men (discordant identity–behavior), and gay-identified men who have sex with men (concordant identity–behavior). Of the men in these 3 weighted groups, 96.6% identified as straight and 3.4% identified as gay. Of the straight-identified men, 9.4% reported having sexual intercourse with at least 1 man (and no women) in the year before the survey. Thus, 87.5% of men in the 3 groups exhibited exclusively heterosexual behavior and 12.5% demonstrated exclusively homosexual behavior. Among men who have sex with men, 72.8% identified as straight.

Key Analytic Subgroups

There were no substantial age differences between straight-identified men who have sex with women, gay-identified men who have sex with men, and straight-identified men who have sex with men; approximately half of the men in each group were between 25 and 44 years of age. Straight-identified men who have sex with men were more likely than gay-identified men who have sex with men (62% vs. 28%) to report belonging to minority racial or ethnic groups (Table 2). Straight-identified men who have sex with men were also more likely than gay-identified men who have sex with men to have been born in a foreign country. Among foreign-born, straight-identified men who have sex with men, 33% were from Latin America; 30% were from the Caribbean; and 32% were from Europe, Asia, or Africa.

Table Jump PlaceholderTable 2.  Age-Adjusted Weighted Percentages of Selected Demographic Characteristics for Concordant and Discordant Identity–Behavior Groups*

Approximately 70% of straight-identified men who have sex with men reported being married, which was substantially more than any other identity–behavior group: 54% of straight-identified men who have sex with women and only 0.2% of gay-identified men who have sex with men reported being married. Gay-identified men who have sex with men were more likely than the men in the other groups to report a higher educational level, a higher annual income, and residence in Manhattan.

Table 3 shows the differences in behaviors and health status among straight-identified men who have sex with women, gay-identified men who have sex with men, and straight-identified men who have sex with men. Straight-identified men who have sex with women and straight-identified men who have sex with men reported having fewer sexual partners than gay-identified men who have sex with men; 15% of straight-identified men who have sex with women, 2% of straight-identified men who have sex with men, and 33% of gay-identified men who have sex with men reported having 3 or more partners in the previous year. Almost 96% of straight-identified men who have sex with men reported having only 1 sex partner in the past year.

Table Jump PlaceholderTable 3.  Age-Adjusted Weighted Percentages of Sexual Behaviors of Concordant and Discordant Identity–Behavior Groups*

The overall prevalence of previous STDs among men in the 2003 CHS was low (5%). Straight-identified men who have sex with women (4%) and straight-identified men who have sex with men (7%) were less likely than gay-identified men who have sex with men (20%) to report a previous STD. However, straight-identified men who have sex with women and straight-identified men who have sex with men were less likely than gay-identified men who have sex with men, particularly those with only 1 sexual partner in the past year, to report using a condom during their last sexual encounter. More than half of gay-identified men who have sex with men reported using a condom during their last sexual encounter, a rate substantially higher than the overall rates of condom use among straight-identified men who have sex with women and straight-identified men who have sex with men.

The overall prevalence of risky sexual behavior (≥2 sexual partners and no condom use during last sexual encounter) was low (7%). Straight-identified men who have sex with women (7%) and straight-identified men who have sex with men (1%) were less likely than gay-identified men who have sex with men (14%) to report risky behavior. The 3 groups were not statistically significantly different regarding testing for HIV infection in the past year.

Influence of Identity–Behavior Group on Risk Behaviors among Men Who Have Sex with Men

Multivariate models (Table 4) show independent risk factors related to testing for HIV infection, condom use, risky behavior, and history of STDs among men who have sex with men, including the influence of identity-behavior group on these outcomes. Recent testing for HIV infection among men who have sex with men was associated with younger age, minority race or ethnicity, and gay identity. Straight-identified men who have sex with men were approximately 40% less likely than gay-identified men who have sex with men to have had such testing.

Table Jump PlaceholderTable 4.  Multivariate Logistic Regression Analysis of Factors Associated with Reported History for Testing for HIV Infection, Reported Condom Use during Last Sexual Encounter, Reported Risky Behavior, and Reported History of Sexually Transmitted Disease among Men Who Have Sex with Men Only*

Condom use during the last sexual encounter was associated with younger age, higher number of sexual partners, and gay identity. Straight-identified men who have sex with men were half as likely as gay-identified men who have sex with men to have used a condom during their last sexual encounter. Gay identity was positively associated with risky behavior; straight-identified men who have sex with men were approximately half as likely to have reported risky behavior. History of STDs was not associated with sexual identity among men who have sex with men.

Validity and Reliability of Key Survey Questions

The weighted estimate of the rate of same-sex behavior among all sexually active men in New York City (12.2%) was similar to that in the 2002 CHS (9.5%), despite the use of a different sequence of questions to determine the status of sexual partners.

A total of 90% of men completed the English-language survey, 8% completed the Spanish-language version, and the remaining 2% completed the survey in other languages. Of U.S.-born men, 99% completed the English-language survey and almost 1% completed the Spanish-language survey. Of foreign-born men, 76% completed the English-language survey, 19% completed the Spanish-language survey, and the remaining 5% completed the survey in other languages. Foreign-born men surveyed in English or Spanish were less likely than U.S.-born men surveyed in English to be classified as gay-identified men who have sex with men (1% and 2% vs. 6%). Similar proportions of foreign-born men surveyed in Spanish (7%), foreign-born men surveyed in English (8%), and U.S.-born men surveyed in English (7%) were classified as straight-identified men who have sex with men.

We believe our study describes the largest U.S. population-based survey to report concurrent measures of sexual identity and sexual health behaviors to date. Our findings show a considerable discordance between self-reported sexual behavior and self-reported sexual identity among men. Straight-identified men who have sex with men differed demographically and behaviorally from gay-identified men who have sex with men and were in some respects more similar to straight-identified men who have sex with women than to other men who have sex with men.

Although some discordance between sexual identity and sexual behavior is to be expected in any population and has been described in the context of nonrandom samples (13, 16, 18), our analysis suggests a larger discrepancy than has been noted previously in population-based studies. The Urban Men's Health Study (UMHS) (25) included a large probability sample of men who have sex with men, of whom only 3% perceived themselves as heterosexual. The UMHS, however, included households in neighborhoods known to be predominantly gay and probably does not provide an accurate measure of sexual identity among all men from the general population who have sex with men. Data from representative samples suggest that approximately 98% of men and women describe their sexual identity as heterosexual. The remaining 2% describe themselves as bisexual, homosexual, or undecided; however, substantially more than 2% report same-sex attraction, same-sex experience, or both (11). In their landmark population-based surveys of sexual behavior, Laumann and colleagues (12) found that although 9% of 18- to 59-year old men living in the largest U.S. cities identified as gay or bisexual in 1 study, a higher proportion of men (14.3%) surveyed in the same cities reported having male sexual partners in the past 5 years, 10.2% in the previous year. We report more marked differences using a single sample: In New York City, among sexually active men who also reported a sexual identity, 4% reported a gay identity but 12% reported same-sex sexual behavior in the past year. Despite the differences in phrasing of the question regarding sexual partners, the 2003 estimate of same-sex behavior in men was similar to that in the 2002 CHS.

We found that straight-identified men who have sex with men were much more likely than gay-identified men who have sex with men to report being foreign-born (43% vs. 15%). This led us to consider whether miscomprehension of survey questions could have resulted in misclassification of sexual identity. Foreign-born men who have sex with men, whether interviewed in English or Spanish, were less likely than U.S.-born men to identify as gay, suggesting that rather than misunderstanding the question regarding identity, foreign-born men in New York City who have sex with men were reluctant to associate their behavior with a gay identity. Although reasons for discordance could not be ascertained in our survey, the interaction of identity and behavior is probably influenced by social and cultural factors. Foreign-born men who have sex with men may be subject to the social and cultural contexts of the countries in which they were born and thus may be reluctant to acknowledge homosexuality or tend to use a more narrow definition of what homosexuality constitutes. For example, the phenomenon of men who have sex with men but identify as heterosexual has been well-documented in Mexico (31) and in upper-class settings in Latin America (32). These straight-identified men who have sex with men, most of whom also have sex with women, will exchange sex with “gay” men and transvestites but only in the role of the insertive (anal or oral) partner. Of note, New York City has experienced a rapid growth in foreign-born population, which is expected to continue. In 2000, 36% of the population of New York City was born in countries other than the United States. Approximately one third emigrated from Latin America, and another one quarter emigrated from Asia (33).

There were several unexpected findings in our study. First, we found that 70% of straight-identified men who have sex with men reported that they were married, substantially more than the 54% of men who have sex with women who reported being married. Previous research, including that of Fay and colleagues (34) and Kinsey and colleagues (35), showed that a small percentage of married U.S. men had engaged in homosexual activities during the preceding year. In our sample, 10% of married men reported same-sex behavior during the preceding year. Some of these men, particularly those from socially conservative foreign countries, may have felt pressured to marry or to have children. It is not known how many of these straight-identified men who have sex with men reside with their spouses and engage in homosexual practices; these findings warrant further investigation.

Second, our analysis shows that straight-identified and gay-identified men who have sex with men are engaging in different patterns of sexual behavior: Gay-identified men who have sex with men report a higher average number of sexual partners, and the majority of straight-identified men who have sex with men (96%) report 1 sexual partner (a man) in the previous year. This contrasts with findings from a convenience sample of men in Denver, Colorado, who frequented venues for anonymous sex; that study found that married men who reported having sex with men reported more partners per month than gay-identified or bisexually-identified men (22).

Third, after we controlled for number of partners, straight-identified men who have sex with men were less likely than gay-identified men who have sex with men to have used condoms during their last sexual encounter and less likely to have been recently tested for HIV infection. Other investigators (17) have found that non–gay-identified men who have sex with men (that is, straight-identified or bisexual-identified men who have sex with men) had similar rates of condom use and lower rates of testing for HIV infection compared with gay-identified men who have sex with men; however, differences in study frames and sampled populations make direct comparison difficult.

Our findings suggest that in the general population, straight-identified men who have sex with men, with fewer sexual partners on average, may consider themselves to be at lower risk for HIV infection and STDs. In fact, compared with men who have sex with men and report concurrent sexual partners or such activities as “bare backing” (intentional unprotected anal intercourse) or those with diagnoses of recurrent or concurrent STDs, straight-identified men who have sex with men may not play a substantial role in fueling the current STD and HIV epidemics among men who have sex with men. However, compared with men who have sex with women, the risk for acquiring infections may be elevated in straight-identified men who have sex with men, because their single male sexual partners may themselves have had multiple sex partners in the previous year. The male sexual partners of straight-identified men who have sex with men may be other straight-identified men who have sex with men or gay-identified men who have sex with men. In our survey, gay-identified men who have sex with men were found to exhibit risky behavior; 33% of gay-identified men who have sex with men reported having 3 or more sexual partners in the previous year, and 20% reported having a previous STD. Gay-identified men who have sex with men were also much more likely than straight-identified men who have sex with men to report both having 2 or more sexual partners and not using a condom during their last sexual encounter.

Our analysis has limitations. There are few data on the validity and reliability of sexual identity questions and the importance of how such questions are ordered within a survey. Sensitive items that are presented too early may lead to greater measurement error (36); it is possible that if identity were ascertained later, when a greater rapport had been established with the interviewer, more men who have sex with men would have self-identified as gay. However, an initial reluctance to self-identify as gay on an anonymous health survey may accurately reflect a propensity not to identify oneself as gay in other social or health care settings. Second, measures of sexual behavior may be affected by the manner in which the sex of sexual partners is ascertained and the placement of such questions in a survey. We ascertained the sex of partners by asking all survey participants first about male partners and then about female partners. It is possible that this unique method, in which men were asked about same-sex partners first and the accompanying definition of sex included vaginal intercourse, resulted in misunderstanding of the question and misclassification of heterosexual men as homosexual. It is possible that asking participants about opposite-sex sexual partners first (that is, asking male participants about female sex partners first and asking female participants about male sex partners first) may change the proportion of men who report male partners, although such ordering may also be more likely to introduce a bias toward a socially desirable answer (36). Preliminary data from the 2005 CHS, which ascertained sex of partners by asking about opposite-sex partners first, suggest that doing so resulted in a much lower self-reported prevalence of men who report sex with other men (New York City Department of Health and Mental Hygiene, unpublished data). Additional study of different methods of ascertaining sex of partners will help to ensure accurate and reliable means of estimating same-sex behavior and may shed light on some of the large discrepancies we observed between behavior and identity.

The incidence of a previous STD may have been underestimated for all survey participants, but this may have been especially true for straight-identified men who have sex with men. Although primary care providers and sexual health centers serving a patient population predominantly of men who have sex with men are probably familiar with relevant national guidelines for STD screening, straight-identified men who have sex with men may be unlikely to obtain clinical services from such practices, particularly foreign-born men who may experience barriers to health care access. In the absence of a thorough sexual history including sex of partners and anatomic sites of sexual exposure (including the anorectum and oropharynx), providers, such as general practitioners caring for straight-identified men who have sex with men, may not recognize that their patients are at risk for STDs and HIV infection. Consequently, these providers may fail to offer appropriate screening or to attribute to sexual exposure infections that may be transmitted by other means (for example, such enteric pathogens as hepatitis A).

The CHS did not ask about unprotected anal intercourse, which could have been used to further elucidate risk. The question regarding condom use during the last sexual encounter is not a measure of the correct and consistent use of condoms that is required to effectively prevent transmission of HIV infection and STDs and therefore may have misclassified the risk of men's sexual behavior. Also, it is not known whether the men lived with their wives, information that could validate our surprising finding of the high proportion of straight-identified men who have sex with men who reported only 1 sexual partner—a man—in the year before the survey. The CHS is a comprehensive health survey rather than a focused sexual behavior survey, and survey length constraints did not permit inclusion of detailed questions on sexual behavior and living arrangements.

Finally, the CHS does not sample some groups that cannot be reached by using a basic telephone survey. Persons living in institutional settings and those in households without telephone service were excluded. Data are weighted to account for households without telephones; however, neighborhood-specific estimates of such households are available only once every 10 years.

The 2005 New York City HIV/AIDS surveillance data show that 68% of incident cases of HIV infection in men with an identified risk factor occur in men who have sex with men (37). Data regarding sexual identity are not routinely available for persons with HIV infection in New York City; however, because sexual risk profiles in men seem to be associated with identity, insights could be gained from routine collection of these data. The observation that a few gay-identified men reported having sex with women in the past year indicates the need for longitudinal research to better understand how the social construct of sexual identity evolves on an individual level.

Gay-identified men who have sex with men in New York City were found to exhibit sexual behaviors that put them at higher risk than other men for HIV infection and STD acquisition, and public health prevention messages should continue to address the need for behavior modification to reduce risk in men who have sex with men. However, because men who have sex with men do not necessarily identify as gay, prevention messages should focus on the activities that pose risk (for example, unprotected receptive anal sex) and should not be framed to appeal solely to gay-identified men. Although most straight-identified men who have sex with men in New York City reported having sexual encounters with only 1 partner, it is likely that this does not eliminate risk, and it is troubling that a portion of this group seems to overlook key strategies for HIV and STD prevention. To ensure appropriate care and to reduce the burden of STDs and HIV infection among men who have sex with men, it is of utmost importance for providers to take a sexual history that ascertains the sex of partner or partners. Given our data, asking about a patient's sexual identity will not adequately assess his risk. Because there are different screening guidelines for men who have sex with men (38) and because certain STDs currently are appearing almost exclusively among men who have sex with men (69), a medical provider's knowledge that a male patient has sex with other men could result in a material change in clinical management. Such a change could contribute to improved diagnosis, prevention, education, and decision making about sexual health.

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Goldbaum G, Perdue TR, Higgins D.  Non-gay-identifying men who have sex with men: formative research results from Seattle, Washington. Public Health Rep. 1996; 111:Suppl 136-40. PubMed
 
 Condom use and sexual identity among men who have sex with men—Dallas, 1991. MMWR Morb Mortal Wkly Rep. 1993; 42:7, 13-14. PubMed
 
Earl WL.  Married men and same sex activity: a field study on HIV risk among men who do not identify as gay or bisexual. J Sex Marital Ther. 1990; 16:251-7. PubMed
 
Blumberg SJ, Cynamon ML, Osborn L, Olson L.  The impact of touch-tone data entry on reports of HIV and STD risk behaviors in telephone interviews. J Sex Res. 2003; 40:121-8. PubMed
 
Lau JT, Kim JH, Lau M, Tsui HY.  HIV related behaviours and attitudes among Chinese men who have sex with men in Hong Kong: a population based study. Sex Transm Infect. 2004; 80:459-65. PubMed
 
Catania JA, Osmond D, Stall RD, Pollack L, Paul JP, Blower S. et al.  The continuing HIV epidemic among men who have sex with men. Am J Public Health. 2001; 91:907-14. PubMed
 
Behavioral Risk Factor Surveillance System. Operational and User's Guide. Version 3.0. March 4, 2005. Accessed athttp://www.cdc.gov/brfss/pdf/userguide.pdfon 31 March 2006.
 
Garofalo R, Wolf RC, Kessel S, Palfrey SJ, DuRant RH.  The association between health risk behaviors and sexual orientation among a school-based sample of adolescents. Pediatrics. 1998; 101:895-902. PubMed
 
Agronick G, O'Donnell L, Stueve A, Doval AS, Duran R, Vargo S.  Sexual behaviors and risks among bisexually- and gay-identified young Latino men. AIDS Behav. 2004; 8:185-97. PubMed
 
National Center for Health Statistics.  Data definitions—relative standard errors. Accessed athttp://www.cdc.gov/nchs/datawh/nchsdefs/relativestandarderror.htmon 31 March 2006.
 
 SUDAAN User's Manual, Release 8.0. Research Triangle Park, NC: Research Triangle Institute; 2001.
 
Carrier JM.  Mexican male bisexuality. Klein F, Wolf TJ Bisexualities: Theory and Research. New York: Haworth Pr; 1985; 75-85.
 
Cáceres CF.  HIV among gay and other men who have sex with men in Latin America and the Caribbean: a hidden epidemic? AIDS. 2002; 16:Suppl 3S23-33. PubMed
 
The newest New Yorkers 2000: immigrant New York in the new millennium. Accessed athttp://www.nyc.gov/html/dcp/pdf/census/nny_briefing_booklet.pdfon 20 April 2006.
 
Fay RE, Turner CF, Klassen AD, Gagnon JH.  Prevalence and patterns of same-gender sexual contact among men. Science. 1989; 243:338-48. PubMed
 
Kinsey AC, Pomery WB, Martin CE.  Sexual Behavior in the Human Male. Philadelphia: WB Saunders; 1948.
 
Catania JA, Binson D, van der Straten A, Stone V.  Methodological research on sexual behavior in the AIDS era. Rosen R, Davis C, Ruppel H Annual Review of Sex Research. Mt. Vernon, IA: Society for the Scientific Study of Sexuality; 1995; 77-125.
 
HIV surveillance and epidemiology 2006 first semiannual report. Accessed athttp://www.nyc.gov/html/doh/html/dires/epi_reports.shtmlon 20 July 2006.
 
Sexually transmitted diseases treatment guidelines 2002. MMWR Recomm Rep. 2002:51(No. RR-6):7-10. [PMID: 12184549]
 

Figures

Grahic Jump Location
Figure 1.
Sexual Identity and Sexual Behavior Questions in the 2003 Community Health Survey
Grahic Jump Location
Grahic Jump Location
Figure 2.
Sexual Risk Behavior Questions in the 2003 Community Health Survey
Grahic Jump Location

Tables

Table Jump PlaceholderTable 1.  Self-Reported Sexual Identity and Sexual Behavior, 2003 Community Health Survey, New York City
Table Jump PlaceholderTable 2.  Age-Adjusted Weighted Percentages of Selected Demographic Characteristics for Concordant and Discordant Identity–Behavior Groups*
Table Jump PlaceholderTable 3.  Age-Adjusted Weighted Percentages of Sexual Behaviors of Concordant and Discordant Identity–Behavior Groups*
Table Jump PlaceholderTable 4.  Multivariate Logistic Regression Analysis of Factors Associated with Reported History for Testing for HIV Infection, Reported Condom Use during Last Sexual Encounter, Reported Risky Behavior, and Reported History of Sexually Transmitted Disease among Men Who Have Sex with Men Only*

References

Centers for Disease Control and Prevention.  HIV/AIDS Surveillance Report, 2003. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2004; 10.
 
Quan VM, Steketee RW, Valleroy L, Weinstock H, Karon J, Janssen R.  HIV incidence patterns, trends, and association with HIV prevalence in the United States, 1978–1999 [Abstract]. In: Program and Abstracts of the XIII International Conference on AIDS, Durban, South Africa, 9–14 July 2000. Abstract no. MoPeC2450.
 
Institute of Medicine.  No Time to Lose: Getting More from HIV Prevention. Washington, DC: National Academy Pr; 2000.
 
Wolitski R, Valdiserri R, Denning P, Levine W.  Are we headed for a resurgence of the HIV epidemic among men who have sex with men? Am J Public Health. 2001; 91:883-88. PubMed
 
Elford J, Hart G.  If HIV prevention works, why are rates of high-risk sexual behavior increasing among MSM? AIDS Educ Prev. 2003; 15:294-308. PubMed
 
 Trends in primary and secondary syphilis and HIV infections in men who have sex with men—San Francisco and Los Angeles, California, 1998-2002. MMWR Morb Mortal Wkly Rep. 2004; 53:575-8. PubMed
 
 Primary and secondary syphilis among men who have sex with men—New York City, 2001. MMWR Morb Mortal Wkly Rep. 2002; 51:853-6. PubMed
 
 Increases in unsafe sex and rectal gonorrhea among men who have sex with men—San Francisco, California, 1994-1997. MMWR Morb Mortal Wkly Rep. 1999; 48:45-8. PubMed
 
 Lymphogranuloma venereum among men who have sex with men—Netherlands, 2003-2004. MMWR Morb Mortal Wkly Rep. 2004; 53:985-8. PubMed
 
 Increases in HIV diagnoses—29 states, 1999-2002. MMWR Morb Mortal Wkly Rep. 2003; 52:1145-8. PubMed
 
Smith AM, Rissel CE, Richters J, Grulich AE, de Visser RO.  Sex in Australia: sexual identity, sexual attraction and sexual experience among a representative sample of adults. Aust N Z J Public Health. 2003; 27:138-45. PubMed
 
Laumann E, Gagnon J, Michael R, Michaels S.  The Social Organization of Sexuality: Sexual Practices in the United States. Chicago: Univ Chicago Pr; 1994.
 
Ross MW, Essien EJ, Williams ML, Fernandez-Esquer ME.  Concordance between sexual behavior and sexual identity in street outreach samples of four racial/ethnic groups. Sex Transm Dis. 2003; 30:110-3. PubMed
 
Kennamer JD, Honnold J, Bradford J, Hendricks M.  Differences in disclosure of sexuality among African American and white gay/bisexual men: implications for HIV/AIDS prevention. AIDS Educ Prev. 2000; 12:519-31. PubMed
 
 HIV/STD risks in young men who have sex with men who do not disclose their sexual orientation—six U.S. cities, 1994-2000. MMWR Morb Mortal Wkly Rep. 2003; 52:81-6. PubMed
 
Goldbaum G, Perdue T, Wolitski R, Rietmeijer C, Hedrich A, Wood R. et al.  Differences in risk behavior and sources of AIDS information among gay, bisexual, and straight-identified men who have sex with men. AIDS Behav. 1998; 2:13-21.
 
Rietmeijer CA, Wolitski RJ, Fishbein M, Corby NH, Cohn DL.  Sex hustling, injection drug use, and non-gay identification by men who have sex with men. Associations with high-risk sexual behaviors and condom use. Sex Transm Dis. 1998; 25:353-60. PubMed
 
Doll LS, Petersen LR, White CR, Johnson ES, Ward JW, the Blood Donor Group.  Homosexually and non-homosexually identified men who have sex with men: a behavioral comparison. J Sex Res. 1992; 29:1-14.
 
 HIV transmission among black college student and non-student men who have sex with men—North Carolina, 2003. MMWR Morb Mortal Wkly Rep. 2004; 53:731-4. PubMed
 
Goldbaum G, Perdue TR, Higgins D.  Non-gay-identifying men who have sex with men: formative research results from Seattle, Washington. Public Health Rep. 1996; 111:Suppl 136-40. PubMed
 
 Condom use and sexual identity among men who have sex with men—Dallas, 1991. MMWR Morb Mortal Wkly Rep. 1993; 42:7, 13-14. PubMed
 
Earl WL.  Married men and same sex activity: a field study on HIV risk among men who do not identify as gay or bisexual. J Sex Marital Ther. 1990; 16:251-7. PubMed
 
Blumberg SJ, Cynamon ML, Osborn L, Olson L.  The impact of touch-tone data entry on reports of HIV and STD risk behaviors in telephone interviews. J Sex Res. 2003; 40:121-8. PubMed
 
Lau JT, Kim JH, Lau M, Tsui HY.  HIV related behaviours and attitudes among Chinese men who have sex with men in Hong Kong: a population based study. Sex Transm Infect. 2004; 80:459-65. PubMed
 
Catania JA, Osmond D, Stall RD, Pollack L, Paul JP, Blower S. et al.  The continuing HIV epidemic among men who have sex with men. Am J Public Health. 2001; 91:907-14. PubMed
 
Behavioral Risk Factor Surveillance System. Operational and User's Guide. Version 3.0. March 4, 2005. Accessed athttp://www.cdc.gov/brfss/pdf/userguide.pdfon 31 March 2006.
 
Garofalo R, Wolf RC, Kessel S, Palfrey SJ, DuRant RH.  The association between health risk behaviors and sexual orientation among a school-based sample of adolescents. Pediatrics. 1998; 101:895-902. PubMed
 
Agronick G, O'Donnell L, Stueve A, Doval AS, Duran R, Vargo S.  Sexual behaviors and risks among bisexually- and gay-identified young Latino men. AIDS Behav. 2004; 8:185-97. PubMed
 
National Center for Health Statistics.  Data definitions—relative standard errors. Accessed athttp://www.cdc.gov/nchs/datawh/nchsdefs/relativestandarderror.htmon 31 March 2006.
 
 SUDAAN User's Manual, Release 8.0. Research Triangle Park, NC: Research Triangle Institute; 2001.
 
Carrier JM.  Mexican male bisexuality. Klein F, Wolf TJ Bisexualities: Theory and Research. New York: Haworth Pr; 1985; 75-85.
 
Cáceres CF.  HIV among gay and other men who have sex with men in Latin America and the Caribbean: a hidden epidemic? AIDS. 2002; 16:Suppl 3S23-33. PubMed
 
The newest New Yorkers 2000: immigrant New York in the new millennium. Accessed athttp://www.nyc.gov/html/dcp/pdf/census/nny_briefing_booklet.pdfon 20 April 2006.
 
Fay RE, Turner CF, Klassen AD, Gagnon JH.  Prevalence and patterns of same-gender sexual contact among men. Science. 1989; 243:338-48. PubMed
 
Kinsey AC, Pomery WB, Martin CE.  Sexual Behavior in the Human Male. Philadelphia: WB Saunders; 1948.
 
Catania JA, Binson D, van der Straten A, Stone V.  Methodological research on sexual behavior in the AIDS era. Rosen R, Davis C, Ruppel H Annual Review of Sex Research. Mt. Vernon, IA: Society for the Scientific Study of Sexuality; 1995; 77-125.
 
HIV surveillance and epidemiology 2006 first semiannual report. Accessed athttp://www.nyc.gov/html/doh/html/dires/epi_reports.shtmlon 20 July 2006.
 
Sexually transmitted diseases treatment guidelines 2002. MMWR Recomm Rep. 2002:51(No. RR-6):7-10. [PMID: 12184549]
 

Letters

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Comments

Submit a Comment
Questions on NY Study
Posted on September 29, 2006
Steven Ml Frankhouser
University of Delaware
Conflict of Interest: None Declared

I found your report quite interesting and informative. I have a few questions I would like to pose to the editors. Firstly, do you think the results of this survey would be different if conducted in a city other than New York? What does the fact that 70% of the men were married say about the stigma of homosexuality among minorities? Why did most of the men engaging in sexual intercourse with other men neglect to use condoms, and what does this say about sexual health education in this country? Also, why would doctors prefer to glean information about risky sexual behavior by asking sexual orientation? I understand that almost 50% of HIV cases reported are from homosexual sex, but it seems like doctors would know better by now than to just ask that question to assess risky behavior. Isn't any unprotected sex risky, despite sexual preference?

Conflict of Interest:

None declared

Do many straight-identified men have sex with men?
Posted on September 29, 2006
Qiang Xia
California Department of Health Services, Office of AIDS
Conflict of Interest: None Declared

To the Editor:

In the September 19 issue of the Journal, Pathela et al. reported that, of the heterosexual or straight-identified men from the five boroughs of New York City, "9.4% reported having sexual intercourse with at least 1 man (and no woman) in the year before the survey" (1). This statistic is atypical to those found in other general population studies (2, 3).

Using the data from the 2003 California Health Interview Survey (CHIS), we found a rate similar to those reported elsewhere. CHIS, the largest health survey in California and one of the largest health surveys in the United States, is a random-digit dial survey of adults, adolescents and children throughout California (4). Similar to the Community Health Survey (CHS) as reported by Pathela et al., the question on sexual orientation in the CHIS 2003 adult questionnaire was asked in the middle of the interview. CHIS 2003 participants between 18 and 70 years old were asked about their sexual orientation, and number and gender of sexual partners during the past 12 months.

A total of 17,476 men were interviewed in the CHIS 2003, and 13,026 reported having at least one sexual partner in the past 12 months. Table 1 presents weighted results for men who reported having sex with men and/or women in the past 12 months by self-reported sexual orientation. Among the straight-identified men, 0.4% reported having sexual intercourse with men (0.3% with men only, and 0.1% with both men and women). Little variation was observed across regions (Los Angeles: 0.4%; San Francisco: 0.5%; San Diego: 0.2%; and Sacramento: 0.2%) or by racial/ethnic groups (White: 0.4%; Latino: 0.2%; and African American: 0.3%).

Table 1. Gender of sexual partners by self-reported sexual orientation from a population-based sample of California men who were sexually active in the past 12 months, 2003

Table 1. Gender of sexual partners by self-reported sexual orientation from a population-based sample of California men who were sexually active in the past 12 months, 2003
Self-reported sexual orientationGender of sexual partner(s)
Male, % (95% CI)Female, % (95% CI)Both, % (95% CI)
Straight or heterosexual0.3 (0.2-04)99.6 (99.5-99.8)0.1 (0.0-0.1)
Gay or homosexual95.0 (91.8-98.2)3.2 (0.6-5.8)1.8 (0.0-3.7)
Bisexual17.7 (10.2-25.2)61.6 (50.6-72.7)20.7 (11.6-29.8)
Not sexual/celibate/none"”99.2 (97.6-100.0)"”
CI: confidence interval; ""”" indicates an estimate of less than 500 men throughout California.

The Urban Men's Health Study (UMHS) (2), one of the studies cited by Pathela et al., reported that 3% of men who have sex with men (MSM) in San Francisco were heterosexual. CHIS 2003 found that 20.8% of sexually active men in San Francisco were having sex with men (4). Assuming that the percentage (20.8%) hasn't changed since UMHS was conducted and no gay- identified men had sex with only women, we can surmise that about 0.8% of straight-identified men had sex with men in the past year (the percentage of straight-identified MSM among all sexually active men: 20.8% x 3% = 0.624%; the percentage of straight-identified men among all men: (100%- 20.8%) + 0.624% = 82.824%; the percentage of straight-identified MSM among all straight-identified sexually active men: 0.62%/82.824% = 0.8%).

Another study cited by Pathela et al. reported that 9% of men were gay or bisexual but 10.2% of men had sex with men in the past year (3). Again, if we assume that no gay-identified men had sex with only women, then we estimate about 1.3% of straight-identified men had sex with men in the past year (the percentage of straight-identified MSM among all sexually active men: 10.2%-9% = 1.2%; the percentage of straight- identified men among all men: 100%-9% = 91%; the percentage of straight- identified MSM among all straight-identified men: 1.2%/91% = 1.3%).

In the above-mentioned two studies, if we figure that indeed a few gay men only had sex with women, bisexual men had sex with both men and women, and straight-identified men might not be as sexually active as gay men, then we would arrive at slightly higher percentages. However, the percentages do not begin to approach the 9.4% reported by Pathela et al.

It is interesting to note that in Pathela et al.'s paper, almost all (96%) of straight-identified MSM reported having only one sexual partner (a man) in the past year. Moreover, almost 70% were married. This would suggest that virtually all straight-identified married MSM were sexually abstinent with their spouse for an entire year, but had one male sexual partner.

While the sexual identity question in the Pathela et al. survey was administered in the middle of the interview, the sexual behavior questions were located at the end of a long 130-question telephone interview. To their credit, Pathela et al. point out that their finding may be higher than the actual rate partly as a result of measurement error: "It is possible that this unique method, in which men were asked about same-sex partners first and the accompanying definition of sex included vaginal intercourse, resulted in misunderstanding of the question and misclassification of heterosexual men as homosexual. "¦ Preliminary data from the 2005 CHS, which ascertained sex of partners by asking about opposite-sex partners first, suggest that doing so resulted in a much lower self-reported prevalence of men who report sex with other men (New York City Department of Health and Mental Hygiene, unpublished data)."

Given the attention that this study received by the mass media, and the increasing public health concern surrounding the "down low" phenomenon, it is important to keep in mind that the Pathela et al.'s. finding is inconsistent with the rates reported by others, and may in fact be an artifact of the methods used in the survey.

Qiang Xia, MD, MPH, California Department of Health Services, Office of AIDS

Joel Moskowitz, PhD, University of California, Berkeley, Center for Family and Community Health

Assunta Ritieni, MHS, California Department of Health Services, Office of AIDS

Matthew Facer, PhD, California Department of Health Services, Office of AIDS

Fred Molitor, PhD, California Department of Health Services, Office of AIDS

References

1. Pathela P, Hajat A, Schillinger J, Blank S, Sell R, Mostashari F. Discordance between sexual behavior and self-reported sexual identity: A population-based survey of New York City men. Ann Intern Med 2006; 145:416 -425.

2. Catania JA, Osmond D, Stall RD, Pollack L, Paul JP, Blower S, et al. The continuing HIV epidemic among men who have sex with men. Am J Public Health. 2001; 91:907-914.

3. Laumann E, Gagnon J, Michael R, Michaels S. The Social Organization of Sexuality: Sexual Practices in the United States. Chicago: Univ Chicago Pr; 1994.

4. UCLA Center for Health Policy Research. California Health Interview Survey. Available at: www.chis.ucla.edu. Accessed September 28, 2006.

Appendix: Sexual behavior and orientation questions in the CHIS 2003:

Question: In the past 12 months, how many sexual partners have you had?

_______ Number of sexual partners

Refused

Don't know

Question: {Is that partner male or female?} In the past 12 months, have your sexual partners been male, female, or both male and female?

Male

Female

Both male and female

Refused

Don't know

Question: Do you think of yourself as straight or heterosexual, as gay {, lesbian} or homosexual, or bisexual?

[IF NEEDED, SAY: "Straight or Heterosexual people have sex with, or are primarily attracted to people of the opposite sex, Gay {and Lesbian} people have sex with or are primarily attracted to people of the same sex, and Bisexuals have sex with or are attracted to people of both sexes".]

Straight or heterosexual

Gay, lesbian, or homosexual

Bisexual

Not sexual/celibate/none

Other (specify): __________________

Refused

Don't know

Conflict of Interest:

None declared

Letter to the Editor
Posted on October 10, 2006
Gary E Langer
ABC News
Conflict of Interest: None Declared

To the Editor,

"Discordance between Sexual Behavior and Self-Reported Sexual Identity" (2006;145:416-425) underemphasized an apparent limitation in the data cited. Self-identified heterosexual male respondents were asked if they'd had sex with a man in the previous 12 months, then were read a definition of sex including vaginal sex. Respondents who said yes were disproportionately foreign-born, low-education and married; overwhelmingly reported a single sex partner in the previous year; and had a very low prevalence of risky sexual behavior. That profile suggests many may have misunderstood the question and were reporting sex with their wives, rather than "vaginal" sex with other men. Persuasive supporting evidence comes in the 30th of the report's 35th paragraphs, describing a repeat study, as yet unpublished, two years later, in which asking men about sex with women before asking them about sex with men produced "a much lower self-reported prevalence of men who report sex with other men." This marked difference in data, produced by a simple flipping of question order, deserved greater attention. Instead the only limitation prominently reported was that RDD samples exclude non-residential-telephone households "“ a triviality in light of the question-wording and question-order effects much less prominently disclosed. The news release1 associated with the report made no mention of these effects, and subsequent press reports2 described the finding as far more conclusive than the relevant data, in their entirety, suggest.

Gary Langer Director of Polling ABC News

1 American College of Physicians, 9/18/2006, "In new survey, men call themselves straight but have sex with men"

2 Philadelphia Inquirer, 9/18/2006, "Almost one in 10 straight men on the "˜down-low,' study finds"

Conflict of Interest:

None declared

Authors' reply: Discordance between male sexual identity and behavior
Posted on November 14, 2006
Preeti Pathela
New York City Department of Health and Mental Hygiene
Conflict of Interest: None Declared

We appreciate the comments of Gary Langer and Xia et al., as they highlight important issues regarding placement and phrasing of sexual behavior questions on population surveys, and contribute to the limited body of population-level data reflecting discordance between identity and sexual behavior.

Our 2003 New York City (NYC) Community Health Survey (CHS) used a definition of sex validated by other research and used by other large- scale surveys such as the National Health and Nutrition Examination Survey (NHANES) [1]. Like the NHANES, the CHS provided the definition once, and then asked about sex partners. Unlike the NHANES, the CHS asked both men and women first about male sex partners, and second about female sex partners. As discussed in our paper, we considered the possibility that asking male participants about male before female partners could have affected respondents' answers. Arguably, however, offering the opposite sex of partner first may introduce a bias toward a socially desirable answer [2].

Indeed, the ordering of partner questions was changed for the CHS conducted in 2005, such that male participants were asked first about female, and then about male partners. Preliminary data from the 2005 CHS suggests a lower estimate of male same-sex (MSM) behavior compared to that obtained from the 2003 survey, and a lower proportion of MSM who identify as straight. It is of note, however, that in 2005, fewer men overall identified as straight, and more were unsure of their sexual identity than in 2003, even though the sexual identity question did not change between the two years. The exclusion of these men from constructed identity- behavior groups affected the estimate of straight-identified MSM. To date, we do not have evidence of "true" prevalence; with additional data from 2005 and 2006, we will be uniquely poised to evaluate the reliability of answers using various ordering of questions.

Though the California and NYC surveys are not directly comparable (questions to ascertain number and sex of partners on the two surveys are not identical), we were interested to see the very low prevalence of straight-identified MSM in California. Even with the change in question order made to the 2005 CHS, the prevalence of straight-identified MSM in NYC in 2005 was still higher than that on the California survey. It is important to consider that observed differences between the California and NYC surveys may be related to true differences in the populations studied.

Whether the "true" proportion of MSM who identify as straight is 1% or 10%, our large city and other metropolitan areas have sizable (>10%) populations of MSM. There will always be a number of straight-identified MSM who will not benefit from public health messages targeting gay- identified men. Medical providers must learn to inquire about sexual behavior rather than identity to serve their patients well.

References

1. National Health and Nutrition Examination Survey: Survey Questionnaires, Examination Components and Laboratory Components 2003- 2004. Available at: http://www.cdc.gov/nchs/data/nhanes/nhanes_03_04/ai_sxq_c.pdf. Accessed November 12, 2006.

2. Catania JA, Binson D, van der Straten A, Stone V. Methodological research on sexual behavior in the AIDS era. In: Rosen R, Davis C, Ruppel H, eds. Annual Review of Sex Research. Mt Vernon, IA: Society for the Study of Sexuality; 1995:77-125.

Conflict of Interest:

None declared

Submit a Comment

Summary for Patients

Can Doctors Use Self-Reported Sexual Identity as a Reliable Indicator of Sexual Behavior?

The summary below is from the full report titled “Discordance between Sexual Behavior and Self-Reported Sexual Identity: A Population-Based Survey of New York City Men.” It is in the 19 September 2006 issue of Annals of Internal Medicine (volume 145, pages 416-425). The authors are P. Pathela, A. Hajat, J. Schillinger, S. Blank, R. Sell, and F. Mostashari.

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