|AIDS and Men Who Have Sex with Men (Best Practice - Technical Update) (Update, May 2000) (UNAIDS, 2000, 8 p.)|
Sex between men occurs in most societies. For cultural reasons, it is often stigmatized by society. The public visibility of male-to-male sex, therefore, varies considerably from one country to another. Sex between men frequently involves anal intercourse, which carries a very high risk of HIV transmission for the receptive partner, and a significant risk, though a lesser one, for the insertive partner. HIV prevention programmes addressing men who have sex with men (MSM) are therefore vitally important. However, they are often seriously neglected - because of the relative invisibility of MSM, stigmatization of male-to-male sex, or ignorance or lack of information.
Identity and behaviour
Sexual identity is different from sexual behaviour. Many men who have sex with other men do not regard themselves as homosexual. In a number of societies, the way such men view their own sexual identity is determined by whether they are the insertive or the receptive partner in anal sex. In these societies, many men who have sex with other men self-identify as completely heterosexual, on the grounds that they take an exclusively insertive role in such activities.
Worldwide, a large percentage of MSM are married or have sex with women as well. This bisexual behaviour is reported to be common in some societies, such as in Latin America (see Schifter J, et al, Bisexual communities and cultures in Costa Rica, and Parker RG, Bisexuality and HIV/AIDS in Brazil, both in Key Materials: Aggleton P (ed), 1996) and in North Africa (see Schmitt A, Different approaches to male-male sexuality/eroticism from Morocco to Uzbekistan in Key Materials: Schmitt and Sofer (eds), 1992).
A self-awareness among MSM has developed, and now exists to a considerable extent in industrialized countries - though even in these countries there are many men who have sex with other men who do not identify themselves as homosexual or gay. In some parts of the developing world the number of self-identified gay men has also grown - often through local initiatives - particularly in some Asian and Latin American countries. Along with this self-identification, gay meeting places have sprung up - organized social groups or campaigning groups, and gay bars, discos, gyms and saunas.
Even in places where most MSM are obliged to stay out of public view, some will choose to be visible. These include transvestite men and transsexuals. Because they are often the only visible ones, they frequently become stereotyped as typical of all MSM. In fact, such transgendered people usually represent only a very small percentage of all MSM.
Most same-sex behaviour is conducted out of natural preference. There are also, however, instances of institutions where men are obliged to spend long periods in all-male company, such as in the military, prisons, and male-only educational establishments, and in which male-to-male sex can be common. While such institutional male homosexual behaviour represents only a small part of all male-to-male sex, it can nonetheless be important from the point of view of the AIDS epidemic. Male prisons, for example, have been shown to make a significant contribution to some countries epidemics - both through drug injecting and male-to-male sex (see UNAIDS Technical Update, Prisons and AIDS).
Male-to-male sex, anal intercourse and HIV
Penetrative anal sex frequently occurs in sex between men. If HIV is present in the insertive partner, and if condoms are not used, then anal sex carries an especially high risk of HIV transmission for the receptive partner. The risk to a receptive partner in unprotected anal sex is several times higher than the next most risky category, that of a woman having unprotected vaginal intercourse with an HIV-infected man. The reason for this is that the lining of the rectum is thin and can easily tear - and even only small lesions in the lining are sufficient to allow the virus easy access. Even without lesions, it has been postulated that there might be a lower natural immunity in the cells of the rectal lining to resist HIV than there is, for instance, in the lining of the vagina. There is also a risk of HIV infection from unprotected anal intercourse, though a lesser one, for the insertive partner. (See Detels, R, The contributions of cohort studies to understanding the natural history of HIV infection, in Nicolosi A (ed), HIV epidemiology: models and methods, Raven Press, New York, 1994, p.239.)
The presence of other untreated sexually transmitted diseases (STDs) - such as syphilis, gonorrhoea and chlamydia - can further greatly increase the risk of HIV transmission, when HIV is present. STDs located in the anus and rectum can often be asymptomatic.
Oral (oro-penile) sex is also common among MSM. While HIV could be transmitted through such sex if not protected by a condom, the risk is generally considered low. (See Samuel, MC, et al. Factors associated with human immunodeficiency virus seroconversion in homosexual men in three San Francisco cohort studies, 1984-1989. Journal of Acquired Immune Deficiency Syndromes 1993 6(3):303-12.)
The AIDS epidemic and men who have sex with men
At least 5-10% of all HIV cases worldwide are due to sexual transmission between men, though this figure varies locally very considerably. In North America, Australia, New Zealand and most of Western Europe, UNAIDS believes the figures are closer to 70%.
In most developed countries and some developing ones (such as Indonesia, the Philippines and Mexico), the first detected cases of HIV and AIDS occurred in men who had sex with men. Later, although the absolute number of cases of male-to-male transmission in several of these countries often continued to rise, the proportion of such cases decreased while the proportion of cases among heterosexual men and women increased correspondingly. This can hide the scale of the problem for MSM.
Commercial sex between men
In most countries, a certain proportion of sex between men is in some way commercial, though this can cover a wide range of possibilities. Much sex work is highly informal, with the expectation perhaps of a small present for services rendered. Some of it is full-time and professional, though proportionally much less so than among female sex workers. Many male sex workers have a wife or regular female partner and would not self-identify as homosexual. Frequently, the clients of male sex workers are married men or behaviourally bisexual.
Male sex workers can often find themselves in a weak bargaining position in their power to insist on condom use. However, reports from some countries, including the Philippines, suggest that the female sex workers there face more difficult conditions, and that the male sex workers have at least some degree of bargaining power. While economic pressure is still an important reason for male sex workers not using condoms, they are usually more able than female sex workers to resist physical coercion, and can often be more selective in choosing clients.
Major social and political upheavals and emergency situations - especially those displacing people and creating refugees - can in certain circumstances act as a catalyst to push significant numbers of young men (as well as women) into prostitution.
Adolescent men frequently have sex with other males of their age group. They also sometimes have sex with older men - in some cases with men considerably older. This younger-older type of male-to-male relationship is common in certain cultures, where it is frequently within the family (with an uncle, for example). A younger-older male relationship may be more or less consensual, or it may be a violent and abusive one. In either case the younger man is likely to be relatively vulnerable, because of a lack of knowledge about HIV and a lack of negotiating skills - and also because the older partner, simply because he has probably had many more sexual encounters, is more likely to be infected than a partner of the same age.