Moderno Love: Sexual Role-Based Identities and HIV/STI Prevention Among Men Who Have Sex with Men in Lima, Peru
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- Clark, J., Salvatierra, J., Segura, E. et al. AIDS Behav (2013) 17: 1313. doi:10.1007/s10461-012-0210-5
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Role-based sexual identities structure male same-sex partnerships and influence HIV/STI epidemiology among MSM in Latin America. We explored shifting relationships between sexual roles, identities and practices among MSM in Lima, Peru, and implications for HIV/STI prevention. Patterns of HIV/STI epidemiology reflected differential risks for transmission within role-based partnerships with relatively low prevalences of HIV, syphilis, and HSV-2 but higher prevalences of urethral gonorrhea/chlamydia among activo MSM compared with moderno and pasivo participants. Qualitative analysis of how MSM in Peru integrate sexual identities, roles, and practices identified four key themes: pasivo role as a gay approximation of cultural femininity; activo role as a heterosexual consolidation of masculinity; moderno role as a masculine reconceptualization of gay identity; and role-based identities as social determinants of partnership, network, and community formation. The concept of role-based sexual identities provides a framework for HIV prevention for Latin American MSM that integrates sexual identities, practices, partnerships, and networks.
Las identidades basadas en roles sexuales forman la estructura de las relaciones de pareja e influyen en la epidemiología del VIH/ITS entre HSH en América Latina. Se exploró la relación cambiante entre roles, identidades, y practicas sexuales en HSH en Lima, Perú y las implicaciones para la prevención del VIH. Los patrones epidemiológicos del VIH/ITS mostraron diferencias en riesgos de transmisión en parejas definidas por roles sexuales con una prevalencia relativamente baja de VIH, sífilis, y HSV-2, pero una prevalencia alta de gonorrea/clamidia uretral en HSH activos en comparación a modernos y pasivos. El análisis cualitativo de como los HSH en el Perú integran sus identidades, roles y practicas identificó cuatro ejes temáticos: El rol pasivo como una aproximación gay de la feminidad cultural; el rol activo como una consolidación heterosexual de la masculinidad; el rol moderno como una reconceptualización masculina de la identidad gay; y las identidades basadas en roles sexuales como determinantes de la formación de parejas, redes, y comunidades. El concepto de identidades sexuales basadas en roles sexuales ofrece un marco analítico para la prevención del VIH entre HSH Latinoamericanos que puede integrar las identidades, prácticas, parejas, y redes sexuales.
Sexual identities (e.g., homosexual, bisexual, heterosexual, and transgender), sexual roles (e.g., activo, pasivo, and moderno/internacional), and sexual practices [e.g., insertive and/or receptive anal intercourse (AI)] all contribute to the social construction of male same-sex sexual partnerships in Latin America and influence biological risks for HIV and sexually transmitted infections (STIs) during sexual contacts. The constructions of sexual identities and sexual roles that structure interactions between men who have sex with men (MSM) in Latin America have been well described by researchers in the fields of Anthropology and Sociology. However, efforts to understand the influence of these sexual roles on patterns of transmission for HIV and STIs among MSM, and to incorporate these role-based identities into context-specific HIV/STI prevention interventions, remain underdeveloped.1
The social construction of sexual identities among MSM, and the importance of sexual roles in defining these identities, has been well described in a range of different social contexts within Latin America. Groundbreaking work done primarily in Mexico and Central America delineated the classic activo–pasivo paradigm that has traditionally been considered to govern sexual interactions between men in Latin America [1–5]. These studies described gendered constructions of sexual identity where sexual penetration is aligned with masculine heterosexuality, and being penetrated with femininized homosexuality. In this construction, the activo, or insertive, partner during (primarily anal) intercourse is not necessarily understood by themself or others as gay or homosexual, and maintains their position of masculine dominance in society and within the partnership. In contrast, the pasivo, or receptive, partner is considered to play the feminine role during intercourse, is necessarily identified as gay or homosexual, and is subject to the attendant social stigma against homosexuality. This foundational understanding of the social structures that define sexual partnerships between men in Latin America has been invaluable for understanding risk behavior within Latin American and Latino MSM populations, and has provided the basis for research on issues of sexual identity and HIV transmission in the Americas.
Building on this original ethnographic work, subsequent “waves” of research have addressed social constructions of sexual identity among Latin American MSM, traditional as well as new paradigms for the interaction between sexual identities, roles, and practices, and implications for HIV/STI prevention [6–19]. Research with Latin American and U.S. Latino populations has illustrated a range of contexts in which the activo/pasivo dynamic has been maintained, modified, rejected, or temporarily suspended in partnership formations that both consolidate and disrupt traditionally defined concepts of gender and sexuality. Yet while the activo/pasivo paradigm remains an organizing principle for many MSM in Latin America, sexual identities, roles, and practices are also frequently differentiated and reassembled into new combinations, such as with men that publicly identify as (and/or are perceived as) activo or pasivo but privately engage in “role-discordant” sexual practices [9, 20]. At the same time, specifically versatile sexual roles (identified as moderno in Peru and internacional in Mexico and other areas of Latin America) articulate role-based sexual identities for Latin American MSM outside of the masculine/feminine binary system of activo and pasivo roles [1, 21]. Yet although the versatile moderno sexual role avoids segregation into activo or pasivo, many moderno MSM rely on traditional concepts of gender and sexuality to define their sexual identities and practices. For example, research with Latino MSM in New York City has outlined how traditional social and physical characteristics of masculine sexuality were often used to determine which partner would engage in insertive or receptive intercourse (or both) during a specific sexual contact . To address the emerging complexity of sexual identities, roles, and practices, researchers have incorporated the influence of factors including homophobia, structural economic conditions, migration, acculturation, and gay community involvement into analyses of sexual identity formations, role definitions, and sexual practices [23–31]. These studies have illuminated ways in which traditional role-based definitions of gender, sexuality, and sexual practice among Latin American MSM have been maintained as well as reimagined, and have developed a critical theoretical space for understanding the social and cultural dimensions of HIV prevention in Latin America.
Within Peru, studies of sexual identity and behavior among MSM have highlighted the range of identities and practices articulated by MSM, the importance of social contexts of homophobia and machismo in defining gender and sexuality, and the function of structural economic factors in defining sexual partnerships [21, 32–35]. While these analyses have documented the centrality of traditional norms of gender and sexuality in organizing sexual contacts between MSM in urban Peru, they have also identified ways in which these norms are often subverted, and the importance of social and cultural contexts in constructing the meanings of male sexuality [20, 36]. Recent research has also emphasized the blurring of boundaries between gender and sexuality through the production of “transgender” as a unique category of gendered sexual identity similar to but entirely distinct from male-identified MSM . These studies have been critical to understanding the social and cultural background of identities, roles and practices through which sexual partnerships between Peruvian MSM are developed and risk behaviors enacted. However, they have not specifically addressed how and why the social construction of role-based identities influences epidemiologic patterns of HIV/STI prevalence among MSM in Peru.
Previous epidemiologic and socio-behavioral analyses have advanced an understanding of sexual interactions and patterns of HIV/STI transmission among men and transgender persons in Latin America that moves beyond the concept of a uniform, homogenous “MSM” population. Epidemiologic surveys have identified dramatic differences in HIV/STI prevalence between subpopulations of MSM in the US and Latin America defined by sexual and/or gender identities [38–45]. Within Peru, surveillance studies of MSM have documented significantly higher rates of HIV, syphilis, and HSV-2 in gay-identified and transgender MSM as compared with heterosexual- and bisexual-identified MSM [43, 44]. Models of HIV transmission among Peruvian MSM have also addressed the potential impact of sexual role versatility in projecting the spread of HIV through the population [46, 47]. However, the existing epidemiologic literature on HIV/STIs in Peru does not unify the analysis of variations in disease prevalence between different MSM subpopulations with an understanding of how individual behavior, interpersonal partnership dynamics, and social contexts frame the biological mechanics of disease transmission.
Our research addresses the specific function of sexual role in defining concepts of gender and sexual identity and influencing sexual practices and epidemiologic patterns of HIV/STIs among MSM in Lima, Peru. The concept of sexual role provides a critical structure for understanding how individual constructions of gender and sexual identity, sexual behavior, and social patterns of partnership and network interaction collectively influence the spread of HIV and STIs. Within this framework, we present a detailed analysis of the social and behavioral factors that structure sexual identities, roles, and practices and how these factors influence patterns of HIV/STI prevalence among subgroups of MSM in Latin America.
Study Design and Population
We used quantitative and qualitative methods to study HIV/STI prevalence and associated risk behaviors in convenience samples of MSM recruited from the Centro de Referencia de ITS Alberto Barton (Barton STI Clinic) and surrounding neighborhoods in Lima/Callao, Peru. The Barton STI Clinic is located in Lima’s port city of Callao in the Ventanilla district, an urban area classified as “Poor” according to Peru’s Unmet Basic Needs Index . The Barton STI Clinic is a specialty STI clinic providing HIV/STI services as well as general health care to visitors from throughout Lima and Callao as well as residents of the local neighborhood. Data for this study was collected in three distinct stages: an initial behavioral survey and HIV/STI screening protocol completed between May and December, 2007, a complementary series of qualitative in-depth interviews and focus groups completed in May, 2008 to explore issues addressed in the behavioral/biomedical survey, and an additional series of individual interviews conducted between February and June, 2011 to follow-up key themes identified during the initial qualitative research.
As in previous epidemiologic surveys of MSM in Peru, participants for the quantitative protocol were selected through convenience sampling of MSM presenting for care at a municipal STI clinic or at one of several neighborhood outreach HIV/STI testing sites in the local community. The majority of participants (n = 438) were recruited from the Barton STI Clinic. An additional 122 participants were recruited in a series of community outreach visits conducted in evening hours by clinic staff in local neighborhoods which were programmed to increase the availability of services for MSM unable or unwilling to attend the clinic venue. Male and m-f transgender patients who presented for care at the Barton STI Clinic or one of the community outreach sites were provided with a flyer providing basic information about the study and instructing the recipient to inform the staff if they were interested in participating. Patients who expressed interest were screened for eligibility by study counselors. Enrollment was limited to persons born anatomically male who reported oral and/or anal sexual contact with a male or m-f transgender person in the preceding 12 months. All participants provided written informed consent prior to the initiation of any study procedures.
Participants completed the study survey using either a computer-assisted self-interviewing (CASI) system (for participants recruited from the clinic), or a paper survey (for participants recruited from community venues) which was subsequently transferred by study staff to a computerized database. Participants were instructed to complete the survey independently and in private, though counselors were available to provide assistance as needed. Individuals responded to questions in Spanish about their socio-demographic characteristics, sexual identity, sexual role, and sexual behavior generally during the last 6 months and specifically during their last sexual contact, as well as their history of STIs, substance use, and exchange of sex for money or other goods. After completing the survey, blood and urine specimens were collected from all participants by laboratory technicians, and urethral swabs were collected by the clinic physician only from men with urethral discharge. Participants were asked to return to the site approximately 2 weeks later to receive results and post-test counseling. Participants diagnosed with an STI were given appropriate antibiotic therapy and advised of the importance of partner notification. Participants newly diagnosed with HIV infection were provided with post-test counseling and referred to a designated Ministry of Health treatment site for ongoing care.
All biological samples were tested at the U.S. Naval Medical Research Center Detachment laboratory in Lima, Peru. Blood samples were screened for syphilis infection by RPR assay (RPRnosticon, Biomérieux; Marcy l’Étoile, France) and confirmed by Treponema Pallidum Particle Agglutination (TPPA) assay (Serodia, Fujirebio; Tokyo, Japan). TPPA-reactive specimens were serially diluted to measure the RPR titer, with active syphilis infection defined as an RPR titer >1:8. HIV-1 EIA (Vironostika, Biomérieux; Marcy l’Étoile, France) was used to screen for HIV antibodies in all participants and positive samples were confirmed by Western Blot (Genetic Systems, Biorad; Hercules, CA). HSV-2 ELISA (HerpeSelect, Focus Technologies; Cypress, CA) was used for serologic detection of genital herpes with an index value of ≥3.50 used to define seropositivity. (Index values <0.90 were defined as seronegative and values between 0.91 and 3.49 were classified as indeterminate.) Urine and urethral swab samples were analyzed using nucleic acid amplification testing (Roche Amplicor, Roche Diagnostics; Alameda, CA) for the detection of Neisseria gonorrhoeae and/or Chlamydia trachomatis.
Sexual role, sexual identity, and sexual practices were all defined according to participant self-report. Participants were asked to describe their sexual identity either by choosing from a list of possible options to describe their identity or by writing in their own term. Participants were asked to describe their sexual role as: activo, pasivo, moderno, or “Other/Does Not Apply.” Participants who defined their role as “Other/Does Not Apply” were excluded from further analyses. Finally, participants were asked to describe their general sexual practices within the previous 6 months as well as their specific sexual practices with their last partner, including oral (insertive and/or receptive), anal (insertive and/or receptive), and/or vaginal intercourse (for participants who reported a female partner) with and/or without a condom.
Prevalence estimates were calculated as percentages with 95 % confidence intervals (CI). The association of sexual role with socio-demographic variables, sexual identity, sexual practices with the last partner, sexual risk behavior, and HIV/STI prevalence were analyzed using contingency tables and Chi-square or Fisher’s exact tests, as needed.
Due to the high prevalence of disease in the study population and the subsequent likelihood of overestimating differences between subpopulations when calculating odds ratios in a logistic regression model, we used Poisson regression with a robust variance estimator to estimate the association of HIV, syphilis, and HSV-2 with sexual role . Using activo MSM as the reference category, we estimated the prevalence ratios and 95 % CI of HIV, HSV-2, syphilis, and urethral gonococcal and/or chlamydial infection with sexual role. Adjusted prevalence ratios were calculated by controlling for age, number of male sex partners in the past 6 months, and recent involvement in compensated sex in a multivariate Poisson regression model. All statistical analyses were two-tailed, with a p value of <0.05 considered statistically significant. Individuals with missing data were excluded from the affected analysis only. Stata 11.0 software was used for all analyses (Stata Corporation, College Station, TX).
The quantitative study protocol was approved by the institutional review boards of the University of California, Los Angeles, the Universidad Peruana Cayetano Heredia, and the U.S. Naval Medical Research Center in compliance with all U.S. Federal regulations regarding the protection of human subjects and conducted with the agreement of the Peruvian Ministry of Health, Dirección de Salud I-Callao.
In order to explore questions raised during analysis of the behavioral/biomedical survey concerning how role-based identities influence HIV/STI epidemiology, we used qualitative methods to assess the interaction of social constructions of sexual identities and roles with sexual practices and risks for HIV/STI acquisition among MSM in Peru. The initial qualitative analysis used focus group discussions to explore popular opinions and dominant social norms of sexual identities, roles, and practices while interviews were used to explore individual understandings of the interaction between sexual identity, role, and practice. As part of a separate study on partner notification among MSM patients of the Barton STI Clinic, we conducted a final series of interviews to further explore specific questions of sexual role-based identities and partnership structures that emerged during analysis of the earlier research.
The first stage of qualitative research was completed in May, 2008. In order to mimic the recruitment strategy of the behavioral/biomedical survey, participants were recruited from the Barton STI Clinic and surrounding neighborhoods by community-based outreach workers to participate in a study on sexual identity and risk behavior among men who have sex with men. Four community-based outreach workers purposively sampled MSM from clinic and community venues to obtain a study population that reflected the diversity of sexual identities in their local community. Enrollment was limited to persons born anatomically male who reported oral or anal sexual contact with a male or m–f transgender partner in the preceding 12 months. A total of 36 MSM participated in individual interviews (n = 8) or in one of four focus group discussions (n = 28). Interviewers used a semi-structured interview guide to discuss issues of sexual identity, sexual role, sexual behavior, and risks for HIV and STIs.
Based on findings from the initial qualitative analysis, additional information on sexual roles and identities within MSM partnerships in Peru was collected during a series of interviews conducted for a study on partner notification among MSM between February and June, 2011. A total of 126 participants were recruited from the Barton STI clinic for a study of partner notification following STI diagnosis. Enrollment for the partner notification study was limited to patients who were born anatomically male, reported oral or anal sexual contact with a male or m–f transgender partner in the preceding 12 months, and had recently been diagnosed with HIV, syphilis, or another STI. After completing a behavioral survey addressing issues of sexual identity, sexual role, sexual practices, HIV/STI history, and attitudes and practices related to partner notification (to be reported separately) a stratified sample of 27 individuals was invited to participate in a supplementary interview. Recruitment was stratified according to participants’ self-described sexual role and identity as reported in the behavioral survey. Spanish-speaking interviewers with extensive experience in HIV/STI prevention among MSM used a semi-structured questionnaire to address issues including the interaction of sexual identities and sexual roles, the function of these concepts in structuring partnerships between men, and their impact on partner notification decisions. Data on sexual identities, roles, and practices of MSM provided during these interviews was abstracted for use in the current analysis.
For both sets of interviews and focus groups, all participants provided verbal informed consent prior to the initiation of interviews and focus group discussions. Interviews and focus groups were conducted in a private office in the Barton STI Clinic. Interviews and focus groups were recorded, transcribed verbatim, and analyzed in Spanish. Quoted excerpts from transcripts were translated into English by the first author for the purpose of publication.
Transcripts were reviewed in Spanish by two readers and coded for thematic content using a grounded theory approach . Open interpretive coding was used to identify key themes that were organized into categories unique to one topic area or cutting across several areas. Discrepancies between the two readers were discussed to ensure consistency in coding and assess inter-reader reliability (87 % concordance based on a random selection of coded interview and focus group transcripts). Axial coding was then used to organize themes in relation to a central category of role-based sexual identity in order to develop a theoretical framework for understanding the qualitative data. Throughout the qualitative analysis period, members of the research team met regularly to identify and discuss emergent themes in order to refine the theoretical framework.
No personal identifying information was collected in either the qualitative or quantitative analysis. Participants in individual interviews are identified by a pseudonym and the specific word(s) they used to describe their sexual identity. Participants in focus groups are identified by the sexual identity most commonly reported by all members of the group.
The qualitative protocols were approved by the institutional review boards of the University of California at Los Angeles and the Universidad Peruana Cayetano Heredia in compliance with all U.S. Federal regulations regarding the protection of human subjects.
Sociodemographic and behavioral characteristics of MSM according to self-defined sexual role; Lima, Peru 2007
Activo (n = 170)
Pasivo (n = 179)
Moderno (n = 183)
Total (n = 532)
Age (median ± IQR)
Education (HS Diploma or Higher)
78.8 % (72.1–84.2 %)
73.2 % (66.2–79.1 %)
81.4 % (75.1–86.4 %)
78.2 % (74.6–81.4 %)
18.2 % (13.1–24.7 %)
8.4 % (5.2–13.4 %)
9.8 % (6.3–15.0 %)
11.7 % (9.3–14.6 %)
Compensated sex (6 months)
18.9 % (13.8–25.5 %)
38.1 % (31.2–45.4 %)
36.3 % (29.6–43.5 %)
30.8 % (27.1–34.8 %)
Self-identify as sex worker
8.3 % (5.0–13.4 %)
34.3 % (27.7–41.5 %)
30.8 % (24.5–37.8%)
24.4 % (21.0–28.2 %)
Median number of male partners (6 months) + IQR
Median number of female partners (6 months) ± IQR
Unprotected anal intercourse (6 months)
Any unprotected receptive AI
6.4 % (3.2–12.6 %)
55.6 % (47.9–63.1 %)
60.5 % (52.3–67.7 %)
44.1 % (39.6–48.8 %)
Any unprotected insertive AI
55.3 % (45.7–64.6 %)
6.7 % (3.8–11.6 %)
59.6 % (51.2–66.9 %)
37.8 % (33.3–42.4 %)
Any unprotected AI
52.2 % (43.0–61.3 %)
58.4 % (50.8–65.7 %)
71.8 % (64.4–78.1 %)
60.9 % (56.3–65.3 %)
Gender of last sex partner
25.3 % (19.4–32.3 %)
98.3 % (95.2–99.4 %)
96.2 % (92.3–98.1 %)
72.9 % (69.1–76.4 %)
67.6 % (60.3–74.2 %)
1.7 % (0.6–4.8 %)
2.2 % (0.9–5.5 %)
24.3 % (20.9–28.1 %)
7.0 % (4.1–11.9 %)
0 % (0–2.0 %)
1.6 % (0.6–4.7 %)
2.7 % (1.7–4.5 %)
Sexual practices with last partner (male partners only)
Only insertive AI
29.4 % (23.1–36.7 %)
0.6 % (0.1–3.0 %)
16.4 % (11.7–22.4 %)
14.9 % (12.2–18.1 %)
Only receptive AI
1.2 % (0.4–4.2 %)
94.4 % (90.0–96.9 %)
41.0 % (34.1–48.2 %)
45.2 % (78.0–84.5 %)
Both insertive and receptive AI
1.2 % (0.4–4.2 %)
1.1 % (0.3–4.0 %)
36.6 % (30.0–43.8 %)
12.9 % (10.3–15.9 %)
No AI or female partner
68.2 % (60.9–74.8 %)
3.9 % (1.9–7.8 %)
6.0 % (3.4–10.4 %)
27.0 % (23.5–30.9 %)
77.0 % (70.0–82.7 %)
1.1 % (0.3–4.0 %)
0.6 % (0.1–3.1 %)
24.8 % (21.3–28.7 %)
4.2 % (2.1–8.5 %)
1.7 % (0.6–4.8 %)
5.0 % (2.6–9.2 %)
3.6 % (2.3–5.6 %)
10.3 % (6.5–15.9 %)
43.3 % (36.2–50.6 %)
56.9 % (49.6–63.9 %)
37.6 % (33.6–41.8 %)
0 % (0–2.3 %)
40.1 % (33.3–47.2 %)
17.1 % (12.3–23.3 %)
19.5 % (16.3–23.1 %)
8.5 % (5.1–13.7 %)
14.0 % (9.7–19.9 %)
20.4 % (15.2–26.9 %)
14.2 % (11.5–17.4 %)
Few or no friends identify as Gay/Bi/Trans
84.1 % (77.8–88.9 %)
19.6 % (14.4–26.2 %)
35.2 % (28.6–42.4 %)
47.2 % (43.0–51.4 %)
Few or no friends know participant is MSM
85.4 % (79.1–89.9 %)
16.9 % (12.2–23.2 %)
18.9 % (13.8–25.2 %)
45.9 % (41.7–50.1 %)
No attendance at MSM venues
24.7 % (18.8–31.7 %)
5.0 % (2.7–9.3 %)
2.2 % (0.9–5.5 %)
12.5 % (10.0–15.6 %)
Correlations of sexual role with sexual identity and sexual practices generally followed expected patterns. The majority of men who identified as heterosexual reported an activo sex role (97.7 %; 127/130), while most transgender participants reported a pasivo role (69.6 %; 71/102), and none described themselves as activo. Gay or homosexual-identified MSM most commonly described their sex role as moderno (52.3 %; 103/197), though 39.1 % (77/197) described themselves as pasivo. Sexual roles generally correlated with self-reported sexual practices as 61.7 % (50/81) of men who engaged in exclusively insertive AI with their last partner identified as activo [and 1.2 % (1/81) as pasivo], 68.7 % (169/246) of participants who had engaged in exclusively receptive AI identified as pasivo [0.8 % (2/246) as activo], and 95.6 % (66/69) of participants who engaged in both insertive and receptive AI with their last partner identified their role as moderno. Sexual risk behavior followed a similar pattern with 55.3 % of activo MSM reporting unprotected insertive AI in the previous 6 months, and 55.6 % of pasivo MSM reporting unprotected receptive AI in the same time period. In contrast, 6.4 % of activo MSM reported unprotected receptive AI and 6.7 % of pasivo MSM reported unprotected insertive AI in the same time frame. Of note, the greatest frequencies of both insertive and receptive unprotected AI were reported by moderno MSM, with 71.8 % recently engaging in unprotected insertive and/or receptive AI.
Prevalence, crude and adjusted prevalence ratios for HIV, syphilis, HSV-2, and urethral gonorrhea/chlamydia infection according to MSM sexual role; Lima, Peru, 2007
Adjusted prevalence ratioa
Activo (N = 170)
11.8 % (7.8–17.5 %)
Pasivo (N = 179)
26.8 % (20.9–33.8 %)
2.26 (1.40, 3.65)
2.36 (1.46, 3.82)
Moderno (N = 183)
28.4 % (22.4–35.3 %)
2.40 (1.50, 3.85)
2.49 (1.55, 4.01)
Syphilis (any RPR titer)
Activo (N = 170)
5.9 % (3.2–10.5 %
Pasivo (N = 179)
35.8 % (29.1–43.0 %)
6.08 (3.23, 11.44)
5.85 (3.10, 11.07)
Moderno (N = 183)
29.0 % (22.9–35.9 %)
4.92 (2.59, 9.36)
4.75 (2.49, 9.06)
Syphilis (RPR ≥ 1:8)
Activo (N = 170)
0.6 % (0.1–3.2 %)
Pasivo (N = 179)
15.1 % (10.6–21.1 %)
25.64 (3.52, 186.63)
24.71 (3.38, 180.33)
Moderno (N = 183)
15.3 % (10.8–21.2 %)
26.94 (3.71, 195.61)
25.78 (3.54, 187.73)
Activo (N = 170)
28.8 % (22.5–36.0 %)
Pasivo (N = 179)
74.3 % (67.4–80.1 %)
2.58 (2.00, 3.31)
2.52 (1.96, 3.25)
Moderno (N = 183)
66.7 % (59.5–73.1 %)
2.31 (1.79, 2.99)
2.31 (1.79, 2.98)
Activo (N = 169)
10.0 % (6.4–15.5 %)
Pasivo (N = 179)
1.7 % (0.6–4.8 %)
0.17 (0.05, 0.56)
0.19 (0.06, 0.64)
Moderno (N = 183)
6.0 % (3.4–10.4 %)
0.60 (0.29, 1.64)
0.66 (0.32, 1.39)
Measures of involvement in communities and social networks of MSM also showed significant variations according to sexual role. In contrast to pasivo and moderno participants, 24.7 % of activo men reported never having visited a community venue associated with MSM including a bar, disco, sauna, social club, or party, 84.1 % reported not having any friends who identified as gay, bisexual, or transgender, and 85.4 % reported that few or none of their friends knew that they have sex with men.
Content analysis of the interview and focus group transcripts identified four central themes related to the interaction of sexual roles, identities and practices, their influence on partnership and network structures, and vulnerability to HIV/STIs among MSM in Peru: (1) pasivo role as a gay or transgender approximation of cultural femininity; (2) activo role as a heterosexual or bisexual consolidation of unquestioned masculinity; (3) moderno role as a gay reconceptualization of masculine sexual identity; and (4) role-based sexual identities as structural determinants of sexual partnerships, social and sexual networks, and community formation.
Pasivo Role and Feminine Homosexuality
Some pasivo MSM reported engaging in penetrative intercourse with male partners, though usually described these episodes as isolated commercial sexual transactions, “activa when it has to do with work” (Focus Group Participant, Trans), distinct from the intimate sexual behavior they engaged in with romantic partners.
I think that what it is to be pasivo is that they penetrate you. It is to play the role of the woman, in any case. Or, rather, pasivo because I can penetrate him, because I can do it to him, but not the role of the woman. Because definitely, not for nothing, the role of the woman is totally different. (Eduardo, Bisexual)
The concept of pasivo sexual role as an approximation of feminine sexuality was often seen as governing partnerships and sexual contacts between MSM, with pasivo partners considered to be submissive or dependent in their interaction with their male partner(s). Pasivo MSM described their, “role of being weaker than the man, of not feeling like I am the one who manages the situation” (Susana, Trans). Others described the pasivo partner as literally passive, as someone who is acted upon by their partner but does not act, “the tranquil person, the one who is with the other person and is penetrated” (Jésica, Travesti)
Sometimes your [female] partner doesn’t accommodate you. For example, if you want anal sex with your partner, she doesn’t accommodate you. Sometimes men want to get oral sex and sometimes women refuse. That’s why men don’t just get their feet off the floor [se sacan los pies del piso] with women, but also with travestis or gays, because the woman doesn’t accommodate the man. (Focus Group Participant, Bisexual)
Activo Role and Masculine Heterosexuality
Many activo participants refused to question the impact of their sexual practices on their sexual identity, “Since I have relations with men, women, I play my soccer, I know what I am” (Focus Group Participant, Bisexual).
I feel that I am normal like that, you know? To have relations with a gay, it doesn’t change the… my way of being [mi forma de ser], no? Because there are those who, yes, I believe that they feel themselves different, no? (Luis, Bisexual)
Has the situation ever presented itself where they ask to penetrate you?
If it did occur, what would you do?
I’d put a stop to it. I would say, ‘You know what? I don’t like that stuff and it’s up to here and no more. It’s over.’
A passing thing, no? We went to the bathroom and the guy gave me oral sex. He told me to penetrate him, and I said, ‘But how?’ since I was like that with alcohol. So, okay, to see, to try it out, no? I did it like that a little, but I lost interest quickly. (Carlos, Heterosexual)
In this case, I would be homosexual, because I have a travesti partner, so I would be homosexual. It wouldn’t be—it’s not that I don’t have heterosexual preferences, I do have heterosexual preferences, I prefer a woman 100 percent. But in this case, at this moment, I am pigeon-holed [encasillado] into a homosexual behavior. Definitely, I am not in agreement with my preference, definitely, definitely, to say that I am homosexual makes me uncomfortable. I prefer to say that I am… or, I don’t like it… I don’t like the term. But those are the preferences that I am having now, so that is what I am. But I don’t like the term. (Jaime, Homosexual)
Moderno Role as Masculine Homosexuality
At the same time as they emphasized their masculine gender, many moderno MSM unified their presentation of masculinity with their versatile sexual practices and gay identity:
Sex, more than anything, is how I make another guy feel the same sensation of having sex with an equal man, with a man. To show him to himself, to demonstrate his strength in his embrace, in his kisses, in passion, that is what I consider part of modernismo, that’s what you don’t get in a pasivo. In the pasivo its more feminine, more womanly. In modernismo, no. Modernismo is to have relations between two men demonstrating their force [midiendo fuerzas] sexually, I consider it like that.” (Focus Group Participant, Gay)
In a word, you could say that we both enjoy what we desire to do, or what we want to do, without pretexts. There is no shame in what he can do, or in what I can do to him, there is no shame. In contrast, with an activo who is looking for a pasivo, let’s say criollamente,2 he considers himself a man and nothing happens, although in reality he’s gay. (Alan, Moderno)
In my case, because there are a lot of guys who don’t like penetration—because moderno means that you give and receive—they preface the moderno, they do sex “light”, which are kisses, caresses, or oral sex that the activo performs on the other person. I am a moderno activo, that is, someone who is still activo, who doesn’t let themselves be penetrated, or doesn’t like it. I don’t like to be penetrated, but I can perform oral sex, I can do sex “light,” as they say, with kisses and caresses and all those things. (Juan, Bisexual)
These participants considered the moderno sexual role, or their modification of it, to be the only way to adequately signify the complex intersection of masculine gender, insertive and receptive sexual practices, and non-heterosexual identity that defined their sexuality:
Versátil, I accommodate the situation. That is, a versátil can screw with a man and a woman at the same time. Instead, a moderno plays the man’s role, or rather is activo and pasivo, but only with men, not with a woman, because they only like men. In contrast, a versátil can be activo and pasivo and can penetrate a woman as well, understand? (Diego, Versátil)
Homosexual, I consider like effeminate, gay, heading towards what you call ‘trans’ and all those things. And to say, ‘moderno activo’ I consider more masculine, to exist among people without saying that I am gay, that I am homosexual, and so to maintain my identity… as a man. (Cesar, Moderno Activo)
In contrast, both activo and pasivo participants considered the masculine homosexuality of the moderno role to be a disruption of traditional norms of gender and sexuality. Pasivo participants described the versatile practices of moderno MSM as a violation of masculine sexuality, describing a moderno as someone who, “appears to be a masculine person, that is you don’t recognize it, you see him and it’s like you were looking at a man. But in private, they let themselves be penetrated” (Focus Group Participant, Gay). Similarly, activo participants described moderno MSM as a potential threat to their masculine role within the traditional activo/pasivo order, “transforming themselves and no longer—that is, they like men, but the really macho guys. But not so that they can be penetrated by them, but so that they can penetrate the men. Those are the modernos” (Armando, Heterosexual).
Sexual Roles and the Formation of Sexual Partnerships, Networks, and Communities
In contrast, while moderno participants described a general tendency to form partnerships with other moderno MSM,
The activo is your partner, supposedly your man, and he penetrates you, nothing more, he doesn’t let you touch his buttocks, nothing. He penetrates you, you give him a blow job (tu le haces sus guauis) and nothing more. (Focus Group Participant, Gay)
It’s not, as they say, a requirement, no? That is, if I’m moderno and my partner is pasivo, it’s normal, but if I’m moderno and my partner’s moderno, I adjust to that, too, or if I’m moderno and my partner is activo and only wants to do the activo, then I do the pasivo. (Hugo, Gay)
In contrast, the activo men interviewed characterized their sexual contacts with gay and transgender partners as distinct from and less than their romantic partnerships with women, as, “A friend that I see sometimes, nothing else. Not like a partner (pareja), no? Because a partner would be there every day, give you a little kiss and such” (Eduardo, Bisexual). These distinct perspectives on the character of their relationships correlated with differences in risk-taking behavior within the partnerships, with activo MSM typically viewing male partners as potential sources of disease:
I would someday like to have a committed relationship with someone who offers me affection and to whom I, too, can give affection, without the need for incentives on either side, neither for me nor for the other person. Because it would be a way, a sacrifice by both of us, mutually, to move forward. (Pilar, Gay)
In contrast, both pasivo and moderno participants considered sex with known partners to be relatively safe, often neglecting condom use with anyone they considered a stable partner since, “In general, with a partner you don’t use it [a condom]” (Focus Group Participant, Gay).
A gay is not like the girls who sometimes do it with somebody but don’t have sex that regularly. I am of the opinion that the gays, they are mostly with one person and another and then another, and they can have any illness, AIDS, any disease. For that reason, I protect myself. (Fernando, Bisexual)
These social networks influenced access to health education and HIV/STI control efforts for MSM, with health education messages targeted towards gay- or transgender-identified MSM distributed to their non-gay identified partners only indirectly. Pasivo-identified MSM discussed telling their activo partners, “about the dangers of HIV and I tell them, ‘If you go out with another fag [maricona] or something like that, use your condom’” (Maria, Travesti). Similarly, activo men who were aware of public health education and services for MSM described indirect access to these interventions through their gay-identified partners where, “They taught him and he taught me” (Luis, Bisexual), about the need for condom use and routine HIV/STI screening:
One day, I went to a party and a guy took me out to dance a few times, and I didn’t realize that he was moderno. Then I saw him in the street with a lot of gays. So even before he told me ‘I’m moderno,’ I already knew the truth. (Maria, Travesti)
Before when I was young I didn’t have any clear idea about gay life (el ambiente), I was a stay-at-home kid, I hadn’t heard about condoms. Recently, when I met this partner, he taught me so much, he told me about infections, about AIDS. He taught me, I learned a ton. (Focus Group Participant, Bisexual)
Similarly, the activo role adhered to by many non-gay identified MSM was described in some focus groups as a thing of the past, “Whoever tells you that he’s activo, that’s already gone, it doesn’t exist, it’s over” (Focus Group Participant, Bisexual). One interview participant articulated his understanding of activo and pasivo roles that both recognized and questioned the traditional link between gender and sexuality:
Sometimes when I was pasivo, I found myself with moderno guys and when that situation occurred I left. I liked activo guys and if they were identical to me, nothing happened. It shocked me, but when you get to find out how it is, and you like it, you go on being moderno. (Focus Group Participant, Gay)
Although these perceptions of changes in role-based identities among MSM in Peru were not shared by all participants, they reflected a recognition of how traditional sexual role frameworks provide the structure for a larger social transformation of identities, roles, and practices that was echoed by all of the MSM in our study:
‘Hombre’ refers to gender, conduct is something else. Now yes, if we, with a clinical eye observe ten activos and ten pasivos, those ten pasivos are always going to have a more feminine conduct, from what I have seen. But the activo doesn’t necessarily have to be or to have characteristics of masculine conduct. (Antonio, Bisexual)
One time I went to a party and saw two beautiful men. They were kissing each other like crazy, the two of them equal to each other, with great, big bodies. But the gay world [el ambiente] is like that, you see normal guys giving each other crazy kisses. You have to be really good to be able to differentiate between them. (Focus Group Participant, Gay)
Discussion and Conclusions
Our findings provide important information about the relationship between the ongoing transformation of sexual identities, roles, and practices among MSM in Lima, Peru and subsequent implications for the dissemination and control of HIV and STIs in this population. Integrating social and epidemiologic analyses of sexual role-based identities provides a framework for analyzing multiple factors that influence the spread of HIV and STIs among MSM in Peru including: shifting meanings of gender, sexual identity, sexual roles, and sexual practices among Peruvian MSM; epidemiologic patterns of HIV/STIs and associated risk behavior that mirror role-based sexual practices within MSM partnerships; interpersonal contexts of sexual behavior and power dynamics within MSM relationships; and effects of role-based sexual identities on social and sexual network formation and access to HIV/STI prevention resources.
Quantitative and qualitative findings from our study demonstrate how traditional systems of gender-based sexual roles among MSM in Peru have been both reinforced and reinterpreted through new constructions of sexual identities, roles, and practices. The majority of MSM in our study affirmed the continued importance of the activo/pasivo system and adhered to traditional roles with corresponding sexual identities and practices. However, many participants located themselves outside of the activo/pasivo tradition and based their sexual identity and/or practices on a reconceptualization of gay and transgender roles within MSM partnerships. Participants in our study used the activo/pasivo/moderno system as a common frame of reference, using this system as a basic framework through which to develop their own personalized identity formations incorporating gender, sexual identity, sexual role, and sexual practices.
Research from other areas of Latin America has demonstrated a similar proliferation and transformation of traditional sexual identities and roles in relation to contextual factors including gay community involvement, international migration, socioeconomic status, and involvement in transactional sex [9–14, 27–31]. By reinterpreting how sexual identities and roles are formed and implemented as sexual practices, these studies have shifted the understanding of HIV/STI prevention from a focus on individual behavioral modification within fixed social frameworks to a dynamic process where the individual, the partnership, and the social context are all integral elements in defining HIV/STI transmission and prevention . In Peru, additional interdisciplinary research is needed to further explore factors underlining the development of traditional and non-traditional role-based sexual identities as well as their implications for partnership interactions, social and sexual network formation, and the spread of HIV and STIs.
The multidimensional reinterpretation of sexual identities, roles, and practices described in our qualitative findings was reflected in the complex patterns of HIV/STI prevalence observed between different subgroups of MSM. While the prevalence of HIV and STIs was high among all of the MSM surveyed, certain general patterns of role-based interaction can be discerned within the epidemiologic findings. High prevalences of HIV, syphilis, and HSV-2 among pasivo MSM were distinct from comparatively lower prevalences of disease among activo men. In contrast, the prevalence of urethral gonorrhea and chlamydia was significantly greater among activo as compared to pasivo MSM. These complementary HIV/STI prevalence patterns are most readily explained by known differences in risk for acquiring HIV and urethral bacterial STIs during receptive as opposed to insertive sexual intercourse [51, 52]. However, with ulcerative STIs like syphilis and genital herpes, transmission may occur through superficial contact with infected skin or mucosal surfaces and is not necessarily dependent on condom use during intercourse or related to an individual’s position during sexual contact. Accordingly, the greater prevalence of these STIs noted among pasivo compared with activo MSM is likely due to a combination of risk factors observed in this subpopulation, including frequently reported unprotected receptive AI, high median numbers of male sex partners, and an increased frequency of contact with MSM sexual networks that maintain a higher baseline prevalence of disease than primarily heterosexual networks.
Social and behavioral factors, specifically the ways in which sexual roles structure partnerships between MSM in Peru, may also impact the spread of HIV and STIs by influencing power dynamics, perceptions of romantic commitment, and trust within partnerships of MSM. Within activo–pasivo relationships, the activo partner was described as controlling both the specific sexual encounter and the general pattern of interaction within the partnership. While pasivo participants often hoped for love and intimacy in their relationships with activo partners, the activo MSM interviewed typically considered their sexual contacts with other men as incidental events without ties of intimacy or commitment. From our data, it is not clear what direct impact power differentials, control over sexual practices, and variations in romantic commitment within activo–pasivo partnerships have on risk for HIV/STI acquisition. However, recognition of how these partnership factors influence interpersonal interactions and control over sexual practices is important for understanding the context of HIV/STI prevention interventions introduced into partnerships structured by this dynamic.
In contrast to the complementary patterns of disease prevalence observed between activo and pasivo MSM, moderno men in our study were found to have high prevalences of all STIs, including HIV, syphilis, HSV-2, and urethral gonorrhea and chlamydia. Moderno MSM reported partnership structures that were generally equal in terms of sexual practices, power relations, and approaches to intimacy. However, despite the egalitarian power dynamics of their partnerships, moderno participants reported higher frequencies of insertive and receptive unprotected AI compared to both activo and pasivo MSM, suggesting the importance of social norms as well as interpersonal partnership factors in defining sexual risk behavior. Possible explanations for the high prevalence of infection observed among moderno MSM include the higher rates of dissemination of HIV and STIs through role-versatile sexual networks, and the corresponding increased likelihood of HIV/STI exposure during unprotected sexual contacts with other moderno MSM (as opposed to activo male or heterosexual female partners) . Additional factors underlying the high levels of sexual risk behavior and HIV/STIs observed among moderno MSM may include the crude nature of this category for capturing subtle distinctions in gender, sexuality, and sexual practices articulated by many participants in our qualitative study. While the moderno label is frequently adopted by gay or m-f transgender MSM who engage in both insertive and receptive sexual practices, our qualitative findings illustrate how the meanings of the moderno role extend beyond basic sexual practices and vary widely between individuals to include concepts of gender, sexuality, sexual behavior, and interpersonal partnership structures. Research specifically addressing the construction of moderno sexual roles among MSM in Peru, variations in these identities between MSM of different geographic, social, and economic communities in the region, and implications for sexual risk behavior and HIV/STI acquisition will be important for a detailed understanding of how new role-based identities are produced and defined, and their influence on interpersonal and community-based interactions between MSM.
Building on the understanding of how sexual role-based identities influence individual behavior, partnership interactions, social network formation, and the spread of HIV/STIs presents an important challenge for prevention research. Knowledge of how sexual roles, identities, and partnerships are structured and their relationship with sexual behavior and risks for HIV/STI acquisition can contribute to comprehensive prevention interventions specifically tailored to the individual and the partnership context. Specific prevention tools including regular condom use, routine HIV/STI screening, pre-/post-exposure prophylaxis, topical microbicides, and initiation of antiretroviral therapy for HIV-positive MSM can be combined and optimized for use within specific social and behavioral contexts. Context-specific prevention approaches can be developed as individual, partner-level, or network-level interventions to address key issues including sexual behavior, interpersonal communication, power dynamics, social network formation, and access to structural health care resources. For example, given the combined disproportionate difference in HIV/STI prevalence and unequal power dynamics present in activo/pasivo partnerships, interventions such as pre-exposure prophylaxis, rectal condoms, and topical rectal microbicides that offer the receptive partner greater control in preventing disease transmission may provide an important prevention resource in this context. In contrast, HIV/STI control methods based on open communication between partners like serostatus disclosure, partner notification, and patient-delivered partner therapy may be more effective within communities where partnerships are considered equal but prevalences of HIV/STIs and associated high-risk behavior remain high, as with moderno MSM. Additional studies of how intimacy, communication, trust, and power dynamics influence sexual risk behavior and HIV/STI acquisition within different types of partnerships will help to develop and introduce context-specific, partner-based prevention interventions for MSM in Peru.
Similarly, improved understanding of how sexual identities and roles influence social and sexual network formation can also inform HIV prevention efforts in Peru. Network-based interventions provide a critical opportunity for disseminating health education and behavioral prevention interventions through peer-based social networks as well as for retracing patterns of disease transmission to deliver targeted HIV/STI screening and treatment through sexual networks. Both quantitative and qualitative data from our study suggest that sexual roles and identities contribute to the formation of participants’ social networks and influence their access to sexual health education and prevention resources. Gay and m–f transgender MSM, who typically identified as pasivo or moderno, were familiar with new concepts of sexual identity, integrated into social networks of MSM, and aware of ongoing HIV/STI prevention efforts in Peru, including access to free condoms, HIV/STI counseling and testing, and sexual health education. In contrast, activo MSM frequently denied knowledge of abstract concepts of sexual identity or practical HIV/STI prevention outreach measures directed to MSM. Activo MSM who reported access to HIV/STI prevention services described being educated about and connected to these resources by their pasivo partners. Acknowledging how existing networks distribute health education and HIV/STI prevention methods to different MSM subpopulations and developing new channels to provide information to underserved groups of MSM present critical challenges for preventing the spread of disease among all MSM. Given the ways in which health education information is currently distributed through male sexual partnerships and networks, public health efforts directed towards gay-identified men and transgender persons may be an effective starting point for disseminating HIV prevention interventions for all MSM. In these groups, interventions involving open discussions of sexuality, HIV/STIs, and sexual risk behavior based on diffusion of innovations or community-popular opinion leader models may be effective in disseminating information and modifying community behavioral norms. However, these efforts are likely to have only a tangential impact on non-gay identified activo MSM who are not integrated into traditional gay or transgender social networks. To effectively reach these MSM, prevention researchers must acknowledge and incorporate the ways that they understand and articulate their sexual identity and behavior as well as their specific patterns of socialization with both male and female sexual partners, as well as with their social peers. Detailed understanding of the social and sexual network patterns that exist among non-gay identified, activo MSM will help to address their specific needs both in the content of the message (e.g., the importance of risk behavior reduction with both male and female partners) and in the mechanism of delivery (e.g., distribution of information through connections with partners or with peers).
There are several issues that limit the generalizability of our findings. Since our study evaluated convenience samples of MSM from a specific cultural and socioeconomic context in Lima, Peru, the data is not representative of all MSM in Peru and cannot be directly superimposed onto other areas of Latin America. Recruitment of the majority of study participants from an STI clinic venue is likely to have overestimated the prevalence of HIV/STIs and sexual risk behavior in the population and potentially affected estimates of disease prevalence in different MSM subpopulations. As in any study of sexual behavior, use of self-reported data on recent sexual practices may have resulted in response bias due to both social desirability in reporting potentially stigmatizing information and participant recall concerning recent sexual practices. In addition, though we have outlined general patterns of interaction between HIV/STI prevalence and socially constructed sexual identities, roles, and partnerships, the crudeness of our system for classifying sexual roles and the complexity of role-based identities maintained by MSM in Peru complicate efforts to understand the relationship between epidemiologic and social factors and implications for HIV/STI prevention. Further research is needed to address how these identities are developed and defined, and how they influence the spread of HIV/STIs within networks of MSM in Peru and throughout Latin America. Finally, since our study was not designed to address network patterns of disease transmission at the partnership or population level, we can draw only limited conclusions concerning these topics and highlight them as important areas for future research. Despite these limitations, our findings make an important contribution to research on the interconnected nature of sexual identities, roles and practices and implications for HIV/STI prevention research with MSM in Latin America.
As MSM in Peru and throughout Latin America work to reinforce and redefine traditional meanings of sexual identities and roles, researchers and public health officials must make a parallel effort to understand how these shifting articulations of identity and role guide sexual practices and influence risks for transmission of HIV and STIs within sexual partnerships and sexual networks. The complexity of interactions between identities, roles, and practices, as well as the proliferation of new terms to capture these redefinitions, limit the development of universal approaches to HIV/STI prevention for “MSM.” Instead, specific details of the social and behavioral contexts of sexual partnerships and implications for the spread of HIV/STIs need to be incorporated into new prevention interventions that collectively address sexual identities, practices, partnerships, and networks in comprehensive approaches to HIV and STI prevention for MSM in Latin America.
A note on terminology: we have chosen to use the term “MSM” throughout this paper to describe all male and male-to-female (m–f) transgender persons who have sex with male and/or m–f transgender partners. We are aware of the problems inherent in collapsing differences of gender and sexual identity into a uniform category of “MSM.” However, we use the term provisionally for the purpose of analysis in order to consolidate a diverse population into a single, unified category. During the course of our discussion, we explore how the emerging diversity of sexual roles structures identities and subgroups, defines partnership interactions, influences the epidemiology of HIV and STIs, and redefines the meanings of “MSM” in Latin America.
Criollamente refers to the contemporary Peruvian cultural sensibility produced by a blend of European and indigenous American cultures.
We would like to thank Ms. Patricia Arana, Ms. Vicki Solari, Dr. Doris Chunga, and the staff of the CERITS Barton for their work in completing the study protocols; Dr. Silvia Montano and the staff of the Bacteriology and Virology laboratories of the U.S. Naval Medical Research Unit-6 in Lima, Peru for testing of biological specimens; and Dr. Angela Bayer for her assistance with qualitative analysis. We would like to thank all of the participants for sharing their lives with us.Funding support provided by NIH grants T32 MH 080634 (JLC and KAK) and K23 MH 084611 (JLC).
The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government.