HIV diagnoses among Black women in the U.S. have declined in the past 10 years, although questions remain as to what factors caused the drop. According to a 2019 study published in AIDS and Behavior, changes in behaviors among Black gay and bisexual cisgender men may be a potential contributor to the decline, highlighting their “bridging potential” for HIV transmission to heterosexual women.
Yet, experts say viewing bisexual men as “bridges” contributes to stigma, or biphobia, and obscures our understanding of bisexual men’s unique sexual health needs. Addressing the social and structural context of Black bisexual lives, by addressing the role of biphobia, can relieve barriers to care and reduce HIV and sexually transmitted infection (STI) vulnerability.
With HIV rates among Black women being on the decline in recent years, researchers at the Centers for Disease Control and Prevention (CDC) wanted to investigate whether changes in risk-related behaviors and access to HIV care and treatment from 2008 to 2014 among Black men who have sex with men and women (MSMW) was a factor, said Wade Ivy, Ph.D., study lead and epidemiologist.
Ivy and his colleagues at the CDC used the National HIV Behavioral Surveillance System to review surveys of Black MSMW in 2008, 2011, and 2014 to investigate whether changes in the sexual and HIV testing and treatment behaviors of Black MSMW would explain the decline in HIV among Black women. There were 1,299 Black MSMW in the sample, from 19 U.S. cities, and all reported having sex with at least one woman in the past 12 months. Over the three-year time intervals, they found increasing numbers of MSMW who’d received an HIV test in the past year: 54%, 69%, and 68%, respectively. Among the men who were living with HIV, more of them were aware of their status over time: 26%, 35%, and 48%, respectively. And of those men who knew their status, they also increased their use of antiretroviral therapy at each interval, by 46%, 69%, and 72%, respectively. Because no differences in their sexual behavior were reported, researchers concluded that Black cisgender women may have also contracted HIV less as more bisexual men knew their status and began using antiretroviral therapy, resulting in increased viral suppression rates.
“Study findings suggest that declines in HIV transmission among African-American women who have sex with MSMW are more likely the result of increased access to HIV testing, treatment, and care, and less likely the result of changes in high-risk behaviors among these men,” Ivy told TheBodyPro via email.
The study only investigated behaviors of Black MSMW who attended venues that MSM attend, including but not limited to clubs, bars, restaurants, organization meetings, and events, Ivy pointed out, so the sample does not represent the general population of Black gay and bisexual men. Still, Ivy pointed to the importance of expanding HIV testing and treatment for MSM, “regardless of the secondary effects.”
“The primary benefits of reduced morbidity and mortality and improved quality of life for men who have sex with men (MSM) only and MSMW warrant expanding access to HIV care and treatment for MSM,” Ivy said.
Bisexual Black Men and the Stigma of “Bridging Potential”
The study authors also pointed to “the bridging potential of African-American MSMW for HIV transmission to women” as motivation for the study. Yet, sexual health experts say that this very characterization of bisexual men is stigmatizing, an impediment to the very thing that the study’s authors recommend—HIV testing and treatment—and that tackling the still very-present societal biphobia is critical to expanding access to health care for this group.
“Don’t get me wrong, bridging is a possibility regardless of gender,” said Brian Dodge, Ph.D., professor with the Indiana University School of Public Health in Bloomington, when asked about bisexual men’s “bridging potential.”
Experts like Dodge say that viewing Black bisexual men as “bridges” or “vectors” of HIV for women contributes to biphobia and misinformation about bisexual men.
Biphobia refers to the stigma that bisexual persons experience, including beliefs that bisexual people are confused, promiscuous, incapable of being faithful, and, for men, spread HIV and STIs to women. Biphobia contributes to psychological distress and isolation, as well as reluctance to get screened for HIV.
“Biphobia can discourage bisexual men from being forthcoming with others and their partners about their sexual orientation, as well as their HIV status, for fear that others will mistreat them or perceive them negatively,” said William L. Jeffries, Ph.D., health scientist at the CDC, via email.
Jeffries investigates sexual health among gay and bisexual men in Black communities, and himself published a paper in 2014 about how the focus on the “bisexual bridge” contributes to the misinformation about bisexual men and their sexual health needs. In his study, Jeffries found that:
MSMW are more likely to be HIV positive than men who have sex with women only—but are more likely to have an undiagnosed HIV-positive status than MSM only.
MSMW are more likely to report injection drug use, exchange sex, and drug and alcohol use during sex, as well as having female partners who are at increased risk for HIV as well.
Biphobia, poverty, masculine ideologies, and sexual identity contribute to acquiring HIV and STIs.
Although societal attitudes towards gay and lesbian people have substantially improved over the years, data suggest a lack of positive attitudes towards bisexual people. What may be surprising to some is that biphobia is also found among people who are not heterosexual.
“There’s a lot of stigma from both sides, from heterosexual and from gay and lesbian people,” said Dodge, adding that biphobia encompasses beliefs that bisexual men are closeted gay men, or “down low,” therefore deceitful.
Dodge led the only recent nationally representative survey of attitudes towards bisexual men and women among a probability sample of gay, lesbian, heterosexual, and other-identified adults in the U.S.
“We found an interesting shift. We went from being sort of rock-bottom to ambivalent,” said Dodge. His study, published in 2016, finds that attitudes towards bisexual people are ambivalent, with most respondents most likely to “neither agree or disagree” with attitudinal statements. He compared these findings to those from a previous nationally representative study of attitudes towards bisexual people, conducted in 1999 (and published in 2002). Respondents in that survey ranked bisexual people lower than people who injected drugs, whereas gay and lesbian people were ranked much higher.
Dodge’s 2016 survey found 34% of adults agreed that bisexual men are confused about their sexuality, 44% agreed that people should be afraid to have sex with bisexual men because of STIs and HIV, and a quarter agreed that bisexual men would have sex with “just about anyone.”
Stigma, “Disclosure,” and Health Care Access
Biphobia hinders MSMW from being open about their same-sex behaviors with sexual partners who are women.
Biphobia may be amplified in some Black communities in which “racism, limited access to quality health care, high unemployment, mass incarceration of black men, and poverty already place many men and women at high risk for HIV infection,” Jeffries wrote.
Yet, Dodge questions the notion of disclosure by questioning the heteronormative assumptions that undergird it: “What is disclosure anyway? How many times do you have to disclose to someone? Do we expect every heterosexual person to talk about every sexual partner they’ve ever had? And why is there this pressure on Black bisexual men to just disclose?”
Dodge conducted a study on disclosure among 30 Black bisexual men in New York City and found that awareness of societal biphobia was the primary reason many did not disclose to their women partners.
“They knew that attitudes toward Black bisexual men were very negative, that they were seen as vectors of HIV, that if they were to disclose, particularly to their female partners, that the relationship would end, most likely,” he said.
“Like a partner saying, ‘If I ever found out you were messing around like this, I would get my brothers to come and kill you.’ So that’s a pretty valid reason not to disclose your bisexuality.”
Dodge’s study highlights the impact of stereotypes about bisexual men and HIV: “They’re not clueless,” he said, adding that bisexual men figure that, after disclosure, one of the first things a female partner may ask is, “Did you give me AIDS?”
The vast majority of participants in Dodge’s study found disclosure of their bisexuality to be much easier with male partners, compared to heterosexual women partners. Participants said they were afraid of disappointing or hurting women partners and did not disclose out of protection. Some feared repercussions from women partners, particularly public humiliation and scorn. Participants found exceptions in women who were bisexual themselves.
Men who did not have a problem telling their women partners were also more open with their sexuality, in general. Serious relationships marked by comfort and commitment facilitated disclosure to heterosexual women partners.
Support for Bisexual Men
Increasing HIV testing, awareness, and linkage to care are certainly important for promoting the sexual health and well-being Black gay and bisexual men, but reducing biphobia, as well as poverty, racism, and norms of masculinity may be more effective in improving sexual health for Black men and women, Jeffries wrote.
Dodge said that access to appropriate health care resources and services is critical to addressing the health of bisexual men. “Some of them have no knowledge because they’re not being reached by the gay community health clinics,” he said.
He stresses that community clinics for gay men must make room for bisexual men by acknowledging women as potential sexual partners, not trivializing bisexual behaviors, and recognizing that there are various types of bisexual men, that “a lot falls under the umbrella of bisexual.”
Self-identified bisexual men, those who are more open with their sexuality, compared to those who are not, are more likely to be engaged with their provider and seek HIV care and treatment, said Dodge. Reducing societal biphobia creates an environment in which men are affirmed in their bisexuality and seek appropriate health care. Social marketing campaigns can reduce community homophobia, like the Acceptance Journeys campaign, which was found to be associated with improved attitudes towards gay men.
Dodge says that there will always be a subset of men who are not comfortable with engaging openly with services and resources geared towards MSMW. “There’s always going to be that contingency, but I think there’s a newer and younger contingency that could be reached.” Dodge says that younger groups of MSMW can be better reached through cultural references that affirm their bisexuality early on.