A history of forced or coerced sex was associated with significantly increased levels of risk for all 4 outcomes.
In contrast, school AIDS education appeared to act as a protective factor, predicting decreased risks in regard to 3 of the 4 outcomes just mentioned. Similarly, school condom instruction was related to a significantly increased probability of condom use after general AIDS education and other variables had been controlled. The most important findings of this study concern the differential risk rates among adolescent males with opposite-sex, same-sex, and both-sex partners. We had anticipated elevated risks among YMSM, and our data suggest the possible presence of 2 distinct profiles of risk taking in this group.
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Consistently, youths with only male partners reported behavioral risk levels no higher than those of youths with only female partners. Relatively low behavioral risk does not, of course, equal low risk of infection. In contrast to young men with only female or only male sexual partners, the bisexually active males who took part in this study present an extremely high-risk profile. This difference between homosexually exclusive and bisexually active youths is consistent with the results of some earlier studies of AIDS risk in adult males. At this point, we can say little about why this pattern appears in our findings.
Perhaps bisexually active adolescents, as members of neither the heterosexual majority nor any visible gay community, function outside the normative constraints of either group. Alternatively, initial differences in temperament, impulse control, or sensation seeking may contribute both to high-risk behavior and to sexual experimentation with partners of both sexes. Whatever the causes, bisexually active males constitute a group at high risk for AIDS and other STDs, and their male and female partners are at high risk as well.
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The issue of sexual identity is also complicated. As has been the case with other research on adolescents, our study showed discordance between sexual behavior and self-defined sexual identity. These findings are not unusual, given the stigma attached to nonheterosexual identities. However, the 2 groups of YMSM differed in sexual identity; most of the youths reporting same-sex-only partners labeled themselves heterosexual, whereas bisexually active youths varied widely in regard to selfdefinition. It may be that males with only male partners are more likely than bisexually active youths to view their behavior as anomalous or as simply youthful experimentation.
Unfortunately, because of the small cell sizes in the present study, we were not able to determine the effect of different identities within separate behavioral groups. The critical implication of the identity—behavior discordance observed here, however, is that few YMSM are likely to be reached by prevention messages based on self-labeled identity.
Consistent with previous studies, our study found a strong association between sexual abuse or coercion and high levels of risk behavior.
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Also consistent with earlier research, a history of sexual abuse or coercion was more frequently reported by males with same-sex partners than by other young men. While some of this abuse may have occurred in childhood, some may be more current. YMSM have few safe venues for socializing and dating, and they may be at risk if their search for companionship leads them to adult-only settings e. School AIDS education and condom use instruction appear to exert strong protective effects on the risk behavior of sexually active adolescents.
AIDS education was associated with lower rates of multiple partners, unprotected sex, and injection drug use. It is also encouraging that sexually active males who had been taught how to use a condom properly were less likely to have unprotected sex, even after control for AIDS education in general. The discrepancy in AIDS education between heterosexually exclusive males and those with same-sex partners is disturbing. The YMSM in this study attended the same schools with the same educational requirements as other youths; thus, their educational experiences should have been similar.
One significant contributor to youths' lack of AIDS education was their having skipped school in the previous month as a result of feeling unsafe, an experience far more common among both groups of YMSM than among other males. Extensive research documents that victimization of sexual minority youths is common. Failure to attend school is not the whole picture, however; males with any male partners had lower rates of AIDS education, even after school absence due to fear had been controlled.
One plausible explanation may be that standard classroom instruction does not address the concerns and questions of many YMSM and is therefore dismissed, discounted as irrelevant, or entirely forgotten. Although some community-based AIDS prevention interventions targeted toward sexual minority youths have demonstrated effectiveness, 12, 28, 29 these approaches have not been used in school settings. One promising recent study indicates that mainstream school instruction that includes gay-appropriate curricula and materials may reduce sexual risk taking among gay, lesbian, and bisexual adolescents 46 ; at present, however, we know little about the details of such instruction.
Strong, culturally competent AIDS prevention education relevant to adolescent males with male sexual partners needs to be developed, although targeted prevention may be politically difficult in public school settings. Several limitations of this study must be acknowledged. The MYRBS accurately represents public high school students residing in Massachusetts during the survey years, but we cannot guarantee that it is also representative of smaller subpopulations such as YMSM. Both adolescents in alternative school settings 47 and out-of-school youths have far higher rates of risk behavior than do high school youths in the general school population.
Another limitation concerns the wording of questions asking about sexual behavior. Finally, the cross-sectional nature of the surveys examined here does not permit inference of clear causal directionality. For example, absence of AIDS education and high risk rates may not be causally related but may both be part of an overall pattern of problem behavior that includes general disengagement from school. Despite the limitations just described, this study provides the best available population-based behavioral risk data on adolescent rather than young adult MSM.
Our findings have important implications for research and intervention. Clear differences between exclusively same-sex and bisexually active males indicate the importance of disaggregating these 2 groups of YMSM in future research and, possibly, in intervention efforts. High AIDS-related risk rates among bisexually active youths point to the urgent need for prevention programs addressing these youths' specific concerns.
Also, the discordance between sexual behavior and sexual identity in YMSM highlights the importance of finding ways to reach adolescents who engage in male—male sex but do not label themselves as gay, bisexual, or homosexual.
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Given the stigma attached to nonheterosexual identities, it would be unrealistic to assume that these young men or even many who do privately identify themselves as gay or bisexual will join gay support groups, apply for gay-related medical or social services, or participate openly in prevention activities aimed at gay—bisexual youths. It may be possible, however, to make mainstream classroom instruction more inclusive and more culturally appropriate for sexual minority adolescents. It is critical that such programs be strengthened and that their messages be clearly relevant to the needs and choices faced by all sexually active youths.
We acknowledge the Massachusetts Department of Education for sharing with us the data sets discussed in this research. Finally, we express our appreciation to Kim Westheimer, Eric Pliner, Margot Abels, and Tim Hack for their thoughtful comments about interpretation of the data. Goodenow and J. Netherland conceptualized the study. Goodenow planned and conducted initial data analyses and wrote the first draft of the paper.
Szalacha conducted final data analyses. All of the authors collaborated in interpreting results and planning revisions. Goodenow revised the paper. National Center for Biotechnology Information , U. Am J Public Health. Find articles by Carol Goodenow. Find articles by Julie Netherland. Find articles by Laura Szalacha. Author information Article notes Copyright and License information Disclaimer.
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Accepted September 28, This article has been cited by other articles in PMC. Abstract Objectives. Analytic Approach Data were weighted to adjust for school and student nonresponse. Open in a separate window. School AIDS Education Although AIDS education is a potentially protective factor, the 3 groups of young men differed significantly in terms of reporting having ever received such instruction.
Any sexual contact against will 2. Male-to-Male Sexual Activity The most important findings of this study concern the differential risk rates among adolescent males with opposite-sex, same-sex, and both-sex partners. Identity vs Behavior The issue of sexual identity is also complicated. Risk and Protective Factors Consistent with previous studies, our study found a strong association between sexual abuse or coercion and high levels of risk behavior.
Limitations Several limitations of this study must be acknowledged. Conclusions Despite the limitations just described, this study provides the best available population-based behavioral risk data on adolescent rather than young adult MSM. Acknowledgments We acknowledge the Massachusetts Department of Education for sharing with us the data sets discussed in this research. Notes C. Peer Reviewed. References 1. Vol Atlanta, Ga: Centers for Disease Control and Prevention; Prevention of HIV among adolescents. Prev Sci.
The Second Decade. Washington, DC: National Academy Press; Centers for Disease Control and Prevention. Youth risk behavior surveillance—United States, Trends in HIV-related sexual risk behaviors among high school students—selected US cities, — More young gay men report unsafe sex. Continuing high prevalence of HIV and risk behaviors among young men who have sex with men: HIV prevalence and associated risks in young men who have sex with men.
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