Diverse expressions of same-sex sexuality in black south African men who have sex with men (MSM): Implications for public health

Background/Purpose: Same-sex sexuality is expressed in a variety of ways that are concealed by the use of the label “MSM”. This diversity of expression is likely to be related to men's health and has consequences for how these men can be reached. Methodology: In-depth interviews were conducted with 81 purposively sampled Black MSM from four South African townships; interview transcripts were processed using ATLAS.ti. In addition, 480 Black MSM (aged 18 – 44) from the same area participated in a survey including HIV testing. Using qualitative and quantitative data, we explored participants' understandings of their sexual and gender identities, and sexual practices, and how these relate to health status, including HIV infection. Findings: Qualitative data showed five intersecting dimensions that distinguish MSM expressions: (1) exclusiveness of same-sex attraction and self-labeling; (2) gender identification and performance; (3) visibility and openness; (4) preference for partner type and sexual role; and (5) sexual interaction strategies. Gender identification turned out to be a key factor in explaining HIV status: feminine men were more likely to be HIV positive (most, however, were unaware of their status). Feminine men also experienced more discrimination, but were, at the same time, more open about their sexual orientation and experienced less identity confusion and internalized homophobia. Conclusions: There are critical differences among MSM which are of crucial importance in guiding development of prevention and care programs that meet their diverse needs. It is also necessary to address prejudices that may prevent MSM from accessing HIV testing and care.