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2 tables omitted
To avoid social isolation, discrimination, or verbal or physical abuse,
many men who have sex with men (MSM), especially young and minority MSM, do
not disclose their sexual orientation.1-3 Young
MSM who do not disclose their sexual orientation (nondisclosers) are thought
to be at particularly high risk for human immunodeficiency virus (HIV) infection
because of low self-esteem, depression, or lack of peer support and prevention
services that are available to MSM who are more open about their sexuality
the risks for HIV infection and other sexually transmitted diseases (STDs)
are unknown for nondisclosers. To better understand the prevention needs of
young MSM, CDC analyzed data from the Young Men's Survey (YMS) to compare
HIV/STD risk differences between nondisclosers and disclosers. This report
summarizes the results of that analysis, which indicate that 8% of 637 nondisclosers
were infected with HIV compared with 11% of 4,952 disclosers. Among blacks,
the prevalence of HIV infection was 14% among 199 nondisclosers compared with
24% among 910 disclosers. Compared with disclosers, nondisclosers had similar
high risks for other STDs, reported less sexual behavior with men and more
sexual behavior with women, reported less use of HIV testing services, and,
among those who were HIV infected, were less likely to be aware of their infection.
To reduce HIV/STD transmission among young MSM and their female sex partners,
comprehensive HIV/STD testing and prevention programs for young nondisclosers,
especially for those who are black, should be developed or expanded.
YMS was a cross-sectional survey conducted during 1994-2000 of men aged
15-29 years who attended MSM-identified venues in six U.S. metropolitan areas
(Baltimore, Maryland; Dallas, Texas; Los Angeles, California; Miami, Florida;
New York, New York; and Seattle, Washington).4,5 Participants
were interviewed with a standard questionnaire, had blood drawn for testing,
and were provided HIV/STD prevention counseling and referral for care. Specimens
were tested for HIV and hepatitis B virus (HBV) with standard assays. HBV
infection was defined as the presence of HBV surface antigen or antibodies
to HBV core antigen.
Disclosure was assessed with the following measure: "Using this card,
choose the number that best describes how ′out' you currently are about
having sex with men. By ′out,' we mean you let others know that you
are sexually attracted to men." Responses were measured on a 7-point scale
(e.g., 1, "Not out to anyone;" 4, "Out to half the people I know;" 7, "Out
to everyone"). Participants who answered 1 or 2 were defined as nondisclosers,
and participants who answered 3-7 were defined as disclosers. Participants
who answered 1 or 2 were grouped together because of similarities in their
demographic characteristics, reported risk behaviors, and prevalence of HIV
infection. Differences between nondisclosers and disclosers were evaluated
by using the Cochran-Mantel-Haenszel chi-square test controlling for city,
age group, and race/ethnicity (if applicable). Analyses were stratified by
race/ethnicity for those groups that had ≥50 nondisclosers. Some analyses
were restricted to men aged 15-22 years because YMS was conducted in two different
phases, and some questions were not repeated in the second phase, which was
conducted among men aged 23-29 years.
In the six cities, 5,589 MSM participated in YMS (range by city: 815-1,060).
The participation rate among eligible men was 59% (range: 54%-66%). A total
of 637 (11%) MSM were defined as nondisclosers (range: 7%-14%); of these,
349 (55%) were aged 15-22 years (median: 22 years; interquartile range: 19-25
years). Black (18%), mixed-race (14%), Hispanic (13%), and Asian/Pacific Islander
(10%) MSM were more likely to be nondisclosers than were white MSM (8%) (p<0.05).
Among racial/ethnic minorities, age was not associated with nondisclosure.
However, among white MSM, the proportion of nondisclosers decreased with age:
12% among those aged 15-19 years, 8% among those aged 20-24 years, and 5%
among those aged 25-29 years (p<0.01).
Nondisclosers were less likely than disclosers to identify themselves
as homosexual and to attend homosexually identified bars and dance clubs (p<0.05),
although 64% of nondisclosers attended these venues at least monthly. Among
MSM aged 15-22 years, nondisclosers were more likely to report that being
homosexual or bisexual or having homosexual or bisexual friends was not important,
that they sometimes disliked themselves for being homosexual or bisexual,
that they felt isolated from others, and that the majority of persons in their
racial/ethnic group disapproved of homosexuals (p<0.05).
The 637 nondisclosing MSM reported a median of five male (interquartile
range: 2-13) and three female (interquartile range: 1-12) sex partners during
their lifetime. During the preceding 6 months, 212 (33%) reported having unprotected
anal intercourse (UAI) with men, and 169 (27%) reported having unprotected
vaginal or anal intercourse (UI) with women. For all racial/ethnic groups,
nondisclosers reported less sexual behavior with men and more sexual behavior
with women (p<0.05). Similar high proportions of disclosers and nondisclosers
reported perceiving themselves to be at low risk for HIV infection and using
a regular source of health care; however, proportionally fewer (p<0.05)
nondisclosers had ever or repeatedly (≥3 times) tested for HIV. Nondisclosers
reported a median of only one previous HIV test (interquartile range: 0-2);
60% had either never tested previously or had not tested in >1 year.
No differences were observed in the high prevalence of HBV infection
and self-reported previous STDs between disclosers and nondisclosers; however,
the prevalence of HIV infection was lower among nondisclosers than disclosers
(adjusted odds ratio [AOR] = 0.5; confidence interval [CI] = 0.4-0.7). Among
nondisclosers, the prevalence of HIV infection was higher among blacks than
all other racial/ethnic groups combined (14% versus 5% [AOR = 2.9; CI = 1.5-5.6]).
However, black nondisclosers were more likely to perceive themselves to be
at low risk for ever acquiring HIV compared with all other nondisclosers (68%
versus 56%; p<0.01). Similar proportions of HIV-infected nondisclosers
(n = 51) and disclosers (n = 522) reported engaging in UAI with male partners
during the preceding 6 months (51% versus 50%) and injecting drugs during
their lifetime (8% versus 12%). HIV-infected nondisclosers were more likely
than disclosers to report being unaware of their infection (98% versus 75%;
p<0.01), and during the preceding 6 months, having one or more female sex
partners (35% versus 10%; p<0.01) and engaging in UI with female sex partners
(20% versus 5%; p = 0.01).
DA Shehan, Univ of Texas Southwestern Medical Center at Dallas, Texas.
M LaLota, MPH, Florida Dept of Health. DF Johnson, MPH, Los Angeles County
Dept of Health Svcs, California. DD Celentano, ScD, Johns Hopkins Univ School
of Hygiene and Public Health, Baltimore, Maryland. BA Koblin, PhD, New York
Blood Center, New York; LV Torian, PhD, New York City Dept of Health, New
York. H Thiede, DVM, Public Health–Seattle and King County, Seattle,
Washington. DA MacKellar, MPH, GS Secura, MPH, S Behel, LA Valleroy, PhD,
GW Roberts, PhD, Div of HIV/AIDS Prevention, National Center for HIV, STD,
and TB Prevention, CDC.
The findings in this report are consistent with previous research suggesting
that among MSM, nondisclosure of sexual orientation is associated with being
a member of a racial/ethnic minority group, identifying as bisexual or heterosexual,
having greater perceived community and internalized homophobia, and being
less integrated socially within homosexual communities.1-3,6 Although
this study did not find that nondisclosing MSM were at higher risk for HIV
infection than MSM who are more open about their sexuality,1-3 the
data suggest that a substantial proportion of nondisclosers are infected with
HIV and other STDs and are at high risk for transmitting these infections
to their male and female sex partners.
The finding that more than one in three nondisclosers reported having
recent female sex partners suggests that nondisclosing MSM might have an important
role in HIV/STD transmission to women. This might be particularly true for
black nondisclosing MSM, of whom approximately one in five was infected with
HBV and one in seven was infected with HIV. To help prevent further HIV/STD
transmission among young MSM and their female sex partners, greater efforts
are needed to increase public awareness and to develop or expand HIV/STD testing
and prevention programs to meet the needs of nondisclosers, particularly those
who are black.
The findings in this report suggest that public-awareness and prevention
programs should be developed for nondisclosing MSM to reduce internalized
homophobia and other factors that influence nondisclosure, barriers to HIV/STD
testing and prevention services, low-risk perception, and high-risk behavior,
including the risk for transmission to male and female sex partners. Corresponding
efforts also should be developed for women to increase knowledge of HIV/STD
acquisition risks from partners who might be bisexual and of where to obtain
confidential testing and prevention services for themselves and their partners.
Prevention managers should intensify outreach efforts to provide HIV/STD
testing, risk reduction, and health-care referral services to nondisclosers
who avoid homosexually identified prevention organizations. Because this report
and others6 suggest that many nondisclosers
have regular male and female sex partners, prevention managers should consider
combining outreach efforts with partner counseling and referral services7 and community network development strategies8 to increase the availability of HIV/STD prevention
services to sex partners of nondisclosing MSM.
In accordance with recently revised guidelines, health-care providers
should routinely assess the HIV/STD risks of their patients and encourage
at-risk MSM to test annually for HIV, syphilis, gonorrhea, and chlamydia,
and to accept or seek vaccination against hepatitis A and B.9 To
facilitate risk disclosure from young MSM, health-care providers should create
discrete and nonjudgmental environments and ensure that patients are aware
of confidentiality safeguards and of the importance of disclosing accurate
The findings in this report are subject to at least three limitations.
First, information about the types of persons to whom disclosure was provided
or withheld was not collected routinely. Second, the percentage of young MSM
defined as nondisclosers in this report should be considered a minimum estimate
because young MSM who are reluctant to disclose their sexual orientation were
probably less likely to participate or report sexual behavior with men. Finally,
findings might not be applicable to nondisclosing MSM aged >29 years or to
MSM aged 15-29 years who do not attend MSM-identified venues or reside in
one of the six participating cities.
The finding that all but one HIV-infected nondiscloser were unaware
of their infection is consistent with a recent report suggesting that the
majority of young HIV-infected MSM do not know they are infected.10 For more young HIV-infected MSM to realize the
benefits of early diagnosis and care, and to help prevent further HIV transmission
among young MSM and their female partners, health-care providers and federal,
state, and local HIV-prevention managers should expand and improve HIV testing
and prevention practices to meet the needs of diverse MSM, including those
who do not disclose their sexual orientation.
HIV/STD Risks in Young Men Who Have Sex With Men Who Do Not Disclose Their Sexual Orientation—Six U.S. Cities, 1994-2000. JAMA. 2003;289(8):975–977. doi:10.1001/jama.289.8.975