A Scoping Review of the Identity Development, Attraction, and Behaviors of Heterosexual Men Who Have Sex with Men

Background and Purpose: Approximately 8% of the North American heterosexual, cisgender male population experience discordance between their sexual identity and behaviors. Heterosexual men who have sex with men (HMSM) have worsened levels of physical and mental health and engage in more behaviors that elevate their risks for HIV/AIDS and other sexually transmitted and blood borne infections compared with concordant heterosexual men. Compared to sexual minority men (e.g., gay, bisexual), HMSM may have heightened levels of guilt and shame and poorer coping and communication skills. Awareness and acceptance of the discordance HMSM experience may be necessary for culturally competent social work practice. A knowledge synthesis of the available literature will help social workers become more prepared for engaging with HMSM. Thus, the purpose of this scoping review was to collate the literature related to the identity development, attraction, and behaviours of HMSM.

Methods: Articles published from January 1, 2000 onwards were retrieved from 13 databases (e.g., APA PsychInfo, SocINDEX with Full Text) using key search terms such as “heterosexual men who have sex with men,” “straight men who have sex with men,” and “sexual identity-behavior discordance.” Two independent reviewers used Covidence software to screen 3,617 titles and abstracts. The same two reviewers continued to use Covidence software to screen the 269 articles that passed the title and abstract screening, resulting in 164 articles for inclusion. Upon further review, four more articles were excluded. The remaining 160 articles were separated into those that only provided a number or percentage of HMSM in their sample (n = 37) and those that required full-team review (n = 123). Ten independent reviewers extracted the data from the 123 articles. Thematic content analysis was used to identify themes and subthemes.

Results: Under identity development, reviewer-identified themes included uncertainty and compartmentalization. Many HMSM experienced uncertainty, largely related to fear of discrimination/stigma and lack of social support. Meanwhile, other HMSM compartmentalized and dismissed sex with men as infrequent, recreational, and/or transactional (i.e., exchanging sex for drugs and/or money). Themes related to attraction included lack of attraction and negative emotional responses to same-gender partners. Same-gender attraction also was related to guilt, shame, disgust, and other negative emotional responses among HMSM. Finally, behaviour-related themes were STI/HIV risks, substance use, and hypermasculinity. HMSM engaged in several behaviours that increased risks for HIV/STI infections and delayed testing. Some HMSM stated sex with men was a result of substance use, suggesting they would not engage in same-sex sexual behaviours while sober. Further, HMSM frequently demonstrated hypermasculine values and norms, believing they were more of a man by being the insertive sexual partner, avoiding gay venues, and sharing poor attitudes toward homosexuality.

Conclusions and Implications: Findings show HMSM may be a distinct group from both concordant heterosexual men and from gay, bisexual, and other non-heterosexual MSM. Further, the population of HMSM is complex and intersecting areas of marginalization can cause unique contexts for these men. This presentation will discuss implications for distinct social work research and practice with HMSM.