Despite a great deal of popular attention in recent years, the issue of black men keeping their bisexual behavior secretive from their main female sex partners, or "keeping it on-the-down-low," does not translate to high-risk sex with male partners, nor an increased risk of HIV transmission, according to David J. Malebranche, MD, MPH, assistant professor of medicine in the Division of General Medicine at the Emory University School of Medicine and internist at Grady Memorial Hospital.
Dr. Malebranche is the second author of a recent review article with Gregorio Millett, MPH, Byron Mason, BS, and Pilgrim Spikes, PhD, MSW, all of the Centers for Disease Control and Prevention (CDC). The authors did not receive external funding for the study.
The results of the review, entitled, "Focusing 'Down-Low': Bisexual Black Men, HIV Risk and Heterosexual Transmission," appear in the July issue of the "Journal of the National Medical Association." The journal article is the first of its kind to critically examine the "down-low" theory -- that secretive black bisexual men are the primary force behind the current high rates of HIV among black women in the United States.
Using statistical data compiled from 24 reference articles, two conference abstracts and literature about bisexually active men of all races and ethnic groups, the authors examined four key points: estimates of bisexuality among black men; identity versus behavior -- or what men call themselves versus how they behave sexually; rates of same-sex behavior disclosure among black men who have sex with men (MSM); and whether non-disclosure of same-sex activity translates to riskier sex or decreased condom use.
According to the article, the best available studies actually report a low prevalence of bisexual behavior (2 percent) among black men in the United States. The authors also found that when compared to white, Latino, and Asian MSM, black MSM were more likely to identify as bisexual or report being behaviorally bisexual, and were less likely to disclose their same-sex behavior.
In the article's conclusion, the authors look to the compelling HIV risk behavior data on black heterosexuals to help explain the high prevalence of HIV infection among black women. They found that rates of condom use by black heterosexuals are low, even among couples, where one partner is HIV positive and the other is HIV negative. And when compared with other racial or ethnic groups, black heterosexuals report having more sex partners, more involvement in concurrent and mutually non-monogamous sexual relationships, more trading of sex for drugs or money, and a greater likelihood of having ever had a sexually transmitted infection. Black women are also more likely than women of other races to report vaginal douching, which can irritate the vagina and may increase the risk of STD and HIV transmission.
The authors argue that the issue of high-risk sexual behavior among heterosexuals has been absent from the discussion involving men on the down-low and the high prevalence of HIV among black women. They also found studies reporting that black women are more likely than women of other ethnicities to remain in an unfaithful relationship and continue engaging in unprotected sex with their male partner even after learning of their partner's sexual infidelity with other men or women.
The authors hope future HIV research and intervention programs that focus on the black community will address high-risk sexual behaviors between all sexually active people, regardless of gender or claimed sexual orientation.