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Authors’ reply: Discordance between male sexual identity and behavior
Letter to the Editor
Do many straight-identified men have sex with men?
Questions on NY Study
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Preeti Pathela, DrPH, MPH New York City Department of Health and Mental Hygiene, Julia A. Schillinger, Bonnie Kerker
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ppathela{at}health.nyc.gov Preeti Pathela, et al.
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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 |
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Gary E Langer ABC News
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Gary.E. Langer{at}abc.com Gary E Langer
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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 |
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Qiang Xia, MD, MPH California Department of Health Services, Office of AIDS, Joel Moskowitz, Assunta Ritieni, Matthew Facer, and Fred Molitor
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qxia{at}dhs.ca.gov Qiang Xia, et al.
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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
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 |
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Steven Ml Frankhouser, English University of Delaware
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stevef{at}udel.edu Steven Ml Frankhouser
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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 |
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