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Exploring Contextual Differences for Sexual Role Strain Among Transgender Women and Men Who Have Sex with Men in Lima, Peru

Abstract

Sexual and gender politics inform relational expectations surrounding sexual experiences of Peruvian transgender women (TW) and men who have sex with men (MSM). We used the framework of sexual role strain, or incongruence between preferred sexual role and actual sexual practices, to explore potential conflicts between personally articulated identities and externally defined norms of gender and sexuality and its potential to increase HIV/STI risk. Cross-sectional individual- and dyad-level data from 766 TW and MSM in Lima, Peru were used to assess the partnership contexts within which insertive anal intercourse was practiced despite receptive role preference (receptive role strain), and receptive anal intercourse practiced despite insertive role preference (insertive role strain). Sexual role strain for TW was more common with non-primary partners, while for MSM it occurred more frequently in the context of a primary partnership. Receptive role strain was more prevalent for TW with unknown HIV status (reference: without HIV) or pre-sex drug use (reference: no pre-sex drug use). For homosexual MSM, receptive role strain was more prevalent during condomless anal intercourse (reference: condom-protected) and with receptive or versatile partners (reference: insertive). Among heterosexual or bisexual MSM, insertive role strain was more prevalent with insertive or versatile partners (reference: receptive), and less prevalent with casual partners (reference: primary). Our findings suggest TW and MSM experience different vulnerabilities during sexual role negotiation with different partner-types. Future studies should explore the impact of sexual role strain on condom use agency, HIV/STI risk, and discordances between public and private presentations of gender and sexual orientation.

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Availability of Data and Material

Access to data is subject to review and approval by the UCLA Institutional Review Board, as well as the discretion and permission of the principal investigator (Jesse L. Clark, M.D., M.Sc.) of the parent study, from which the data for this manuscript were sourced.

References

  • Babor, T., Higgins-Biddle, J. C., Saunders, J. B., & Monteiro, M. G. (2001). The alcohol use disorders identification test (AUDIT): Guidelines for use in primary care (2nd ed.). Retrieved from World Health Organization website: http://apps.who.int/iris/handle/10665/67205.

  • Barros, A. J. D., & Hirakata, V. N. (2003). Alternatives for logistic regression in cross-sectional studies: An empirical comparison of models that directly estimate the prevalence ratio. BMC Medical Research Methodology, 3, 21. https://doi.org/10.1186/1471-2288-3-21

    Article  PubMed  PubMed Central  Google Scholar 

  • Beyrer, C., Trapence, G., Motimedi, F., Umar, E., Iipinge, S., Dausab, F., & Baral, S. (2010). Bisexual concurrency, bisexual partnerships, and HIV among Southern African men who have sex with men. Sexually Transmitted Infections, 86(4), 323–327. https://doi.org/10.1136/sti.2009.040162

    Article  PubMed  Google Scholar 

  • Blair, C. S., Segura, E. R., Perez-Brumer, A. G., Sanchez, J., Lama, J. R., & Clark, J. L. (2016). Sexual orientation, gender identity and perceived source of infection among men who have sex with men (MSM) and transgender women (TW) recently diagnosed with HIV and/or STI in Lima, Peru. AIDS and Behavior, 20(10), 2178–2185. https://doi.org/10.1007/s10461-015-1276-7

    Article  PubMed  PubMed Central  Google Scholar 

  • Bockting, W. O., Robinson, B. E., & Rosser, B. R. (1998). Transgender HIV prevention: A qualitative needs assessment. AIDS Care, 10(4), 505–525. https://doi.org/10.1080/09540129850124028

    Article  PubMed  Google Scholar 

  • Bowers, J. R., Branson, C. M., Fletcher, J. B., & Reback, C. J. (2012). Predictors of HIV sexual risk behavior among men who have sex with men, men who have sex with men and women, and transgender women. International Journal of Sexual Health, 24(4), 290–302. https://doi.org/10.1080/19317611.2012.715120

    Article  PubMed  PubMed Central  Google Scholar 

  • Brown, S. E., Vagenas, P., Konda, K. A., Clark, J. L., Lama, J. R., Gonzales, P., Sanchez, J., Duerr, A. C., & Altice, F. L. (2015). Men who have sex with men in Peru acceptability of medication-assisted therapy for treating alcohol use disorders. American Journal of Men’s Health, 11(4), 1269–1278. https://doi.org/10.1177/1557988315576775

    Article  PubMed  PubMed Central  Google Scholar 

  • Cambou, M, C., Perez-Brumer A. G., Segura E. R., Salvatierra J., Lama J. R., Sanchez J., & Clark J. L. (2014). The risk of stable partnerships: associations between partnership characteristics and unprotected anal intercourse among men who have sex with men and transgender women recently diagnosed with HIV and/or STI in Lima, Peru. PloS One, 9(7). https://doi.org/10.1371/journal.pone.0102894.

  • Carballo-Diéguez, A., & Bauermeister, J. (2004). "Barebacking": Intentional condomless anal sex in HIV-risk contexts. Reasons for and against it. Journal of Homosexuality, 47(1), 1–16. https://doi.org/10.1300/J082v47n01_01.

  • Clark, J., Reisner, S., Perez-Brumer, A., Huerta, L., Sanchez, H., Moriarty, K., Mamani Luque, M., Okochi, H., Salazar, X., Mimiaga, M., Sanchez, J., Gandhi, M., Mayer, K. H., & Lama, J. (2021). TransPrEP: Results from the pilot study of a social network-based intervention to support PrEP adherence among transgender women in Lima, Peru. AIDS and Behavior, 25(6), 1873–1883. https://doi.org/10.1007/s10461-020-03117-4

    Article  PubMed  PubMed Central  Google Scholar 

  • Clark, J., Salvatierra, J., Segura, E., Salazar, X., Konda, K., Perez-Brumer, A., Hall, E., Klausner, J., Caceres, C., & Coates, T. (2013). Moderno love: Sexual role-based identities and HIV/STI prevention among men who have sex with men in Lima. Peru. AIDS and Behavior, 17(4), 1313–1328. https://doi.org/10.1007/s10461-012-0210-5

    Article  PubMed  Google Scholar 

  • Davidovich, U., de Wit, J. B. F., & Stroebe, W. (2004). Behavioral and Cognitive barriers to safer sex between men in steady relationships: Implications for prevention strategies. AIDS Education and Prevention, 16(4), 304–314. https://doi.org/10.1521/aeap.16.4.304.40398

    Article  PubMed  Google Scholar 

  • Degtyar, A., George, P. E., Mallma, P., Diaz, D. A., Carcamo, C., Garcia, P. J., Gorbach, P. M., & Bayer, A. M. (2018). Sexual risk, behavior, and HIV testing and status among male and transgender women sex workers and their clients in Lima, Peru. International Journal of Sexual Health, 30(1), 81–91. https://doi.org/10.1080/19317611.2018.1429514

    Article  PubMed  PubMed Central  Google Scholar 

  • Deiss, R. G., Clark, J. L., Konda, K. A., Leon, S. R., Klausner, J. D., Caceres, C. F., & Coates, T. J. (2013). problem drinking is associated with increased prevalence of sexual risk behaviors among men who have sex with men (MSM) in Lima, Peru. Drug and Alcohol Dependence, 132(1–2), 134–139. https://doi.org/10.1016/j.drugalcdep.2013.01.011

    Article  PubMed  PubMed Central  Google Scholar 

  • Delgado, J. R., Segura, E. R., Lake, J. E., Sanchez, J., Lama, J. R., & Clark, J. L. (2017). Event-level analysis of alcohol consumption and condom use in partnership contexts among men who have sex with men and transgender women in Lima, Peru. Drug and Alcohol Dependence, 170(1), 17–24. https://doi.org/10.1016/j.drugalcdep.2016.10.033

    Article  PubMed  Google Scholar 

  • Fox, J., White, P. J., Macdonald, N., Weber, J., McClure, M., Fidler, S., & Ward, H. (2009). Reductions in HIV transmission risk behavior following diagnosis of primary HIV infection: A cohort of high-risk men who have sex with men. HIV Medicine, 10(7), 432–438. https://doi.org/10.1111/j.1468-1293.2009.00708.x

    Article  PubMed  Google Scholar 

  • Golub, S. A., Starks, T. J., Payton, G., & Parsons, J. T. (2012). The critical role of intimacy in the sexual risk behaviors of gay and bisexual men. AIDS and Behavior, 16(3), 626–632. https://doi.org/10.1007/s10461-011-9972-4

    Article  PubMed  PubMed Central  Google Scholar 

  • Goode, W. J. (1960). A Theory of role strain. American Sociological Review, 25(4), 483–496. https://doi.org/10.2307/2092933

    Article  Google Scholar 

  • Goodreau, S. M., Carnegie, N. B., Vittinghoff, E., Lama, J. R., Sanchez, J., Grinsztejn, B., Koblin, B. A., Mayer, K. H., & Buchbinder, S. P. (2012). What drives the US and Peruvian HIV epidemics in men who have sex with men (MSM)? PLoS ONE, 7(11), e50522. https://doi.org/10.1371/journal.pone.0050522

    Article  PubMed  PubMed Central  Google Scholar 

  • Goodreau, S. M., Goicochea, L. P., & Sanchez, J. (2005). Sexual role and transmission of HIV Type 1 among men who have mex with, in Peru. Journal of Infectious Diseases, 191(Suppl 1), S147-158. https://doi.org/10.1086/425268

    Article  PubMed  Google Scholar 

  • Hanley, J. A., Negassa, A., Edwardes, M. D. B., & Forrester, J. E. (2003). Statistical analysis of correlated data using generalized estimating equations: An orientation. American Journal of Epidemiology, 157(4), 364–375. https://doi.org/10.1093/aje/kwf215

    Article  PubMed  Google Scholar 

  • Herrera, M. C., Konda, K. A., Leon, S. R., Deiss, R., Brown, B., Calvo, G. M., Salvatierra, H. J., Caceres, C. F., & Klausner, J. D. (2016). Impact of alcohol use on sexual behavior among men who have sex with men and transgender women in Lima, Peru. Drug and Alcohol Dependence, 161, 147–154. https://doi.org/10.1016/j.drugalcdep.2016.01.030

    Article  PubMed  PubMed Central  Google Scholar 

  • Lama, J. R., Lucchetti, A., Suarez, L., Laguna-Torres, V. A., Guanira, J. V., Pun, M., Montano, S., M., Celum, C. L., Carr, J. K., Sanchez, J., Bautista, C. T., Sanchez, J. L., & Peruvian HIV Sentinel Surveillance Working Group. (2006). Association of herpes simplex virus type 2 infection and syphilis with human immunodeficiency virus infection among men who have sex with men in Peru. Journal of Infectious Diseases, 194(10), 1459–1466. https://doi.org/10.1086/508548.

  • Ludford, K. T., Vagenas, P., Lama, J. R., Peinado, J., Gonzales, P., Leiva, R., Pun, M., Sanchez, J., Altice, F. L., & Peruvian HIV Sentinel Surveillance Working Group. (2013). Screening for drug and alcohol use disorders and their association with HIV-related sexual risk behaviors among men who have sex with men in Peru. PloS ONE, 8(8), e69966. https://doi.org/10.1371/journal.pone.0069966.

  • Marks, G., Crepaz, N., Senterfitt, J. W., & Janssen, R. S. (2005). Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: Implications for HIV prevention programs. Journal of Acquired Immune Deficiency Syndromes, 39(4), 446–453.

  • Marshall, N., & Barnett, R. (1993). Work–family strains and gains among two-earner couples. Journal of Community Psychology, 21, 64–78.

    Article  Google Scholar 

  • Mauk, D., Perry, A., & Muñoz-Laboy, M. (2013). Exploring the desires and sexual culture of men who have sex with male-to-female transgender women. Archives of Sexual Behavior, 42(5), 793–803. https://doi.org/10.1007/s10508-013-0079-z

    Article  PubMed  Google Scholar 

  • Milkie, M. A., & Peltola, P. (1999). Playing All the roles: Gender and the work-family balancing act. Journal of Marriage and Family, 61(2), 476–490. https://doi.org/10.2307/353763

    Article  Google Scholar 

  • Ministerio de Salud del Peru. (2012). Informe nacional sobre los progresos realizados en el pais Peru, period enero 2010—diciembre 2011. Retrieved from Issuu website: https://issuu.com/comite_vigilancia-coremusa-ll/docs/informe_de_progresos_peru_2012

  • Moen, P., & Dempster-McClain, D. I. (1987). Employed parents: Role strain, work time, and preferences for working less. Journal of Marriage and Family, 49(3), 579–590. https://doi.org/10.2307/352203

    Article  Google Scholar 

  • Moriarty, K. E., Segura, E. R., Gonzales, W., Lake, J. E., Cabello, R., & Clark, J. L. (2019). Assessing sexually transmitted infections and HIV risk among transgender women in lima, Peru: Beyond Behavior. LGBT Health, 6(7), 370–376.

    Article  Google Scholar 

  • Nagaraj, S., Segura E. R., Peinado J., Konda, K. A., Segura P., Casapia M., Ortiz, A., Montano, S. M., Clark, J. L., Sanchez, J., Lama J. R., & Peruvian HIV Sentinel Surveillance Working Group. (2013). A cross-sectional study of knowledge of sex partner serostatus among high-risk peruvian men who have sex with men and transgender women: Implications for HIV prevention. BMC Public Health, 13, 181. https://doi.org/10.1186/1471-2458-13-181.

  • Nemoto, T., Bödeker, B., Iwamoto, M., & Sakata, M. (2014). Practices of receptive and insertive anal sex among transgender women in relation to partner types, sociocultural factors, and background variables. AIDS Care, 26(4), 434–440. https://doi.org/10.1080/09540121.2013.841832

    Article  PubMed  Google Scholar 

  • Nemoto, T., Operario, D., Keatley, J., & Villegas, D. (2004). Social context of HIV risk behaviors among male-to-female transgenders of colour. AIDS Care, 16(6), 724–735. https://doi.org/10.1080/09540120413331269567

    Article  PubMed  Google Scholar 

  • Nureña, C. R., Zúñiga, M., Zunt, J., Mejía, C., Montano, S. M., & Sánchez, J. L. (2011). Diversity of commercial sex among men and male-born trans people in three Peruvian cities. Culture, Health & Sexuality, 13(10), 1207–1221. https://doi.org/10.1080/13691058.2011.609908

    Article  Google Scholar 

  • Nuttbrock, L., Hwahng, S., Bockting, W., Rosenblum, A., Mason, M., Macri, M., & Becker, J. (2009). Lifetime risk factors for HIV/STI infections among male-to-female transgender persons. Journal of Acquired Immune Deficiency Syndromes, 52(3), 417–421. https://doi.org/10.1097/QAI.0b013e3181ab6ed8

  • Operario, D., & Yang, M. F. (2014). Stigma and the syndemic of HIV-related health risk behaviors in a diverse sample of transgender women. Journal of Community Psychology, 42(5), 554–557.

    Article  Google Scholar 

  • Passaro, R. C., Castañeda-Huaripata, A., Gonzales-Saavedra, W., Chavez-Gomez, S., Segura, E. R., Lake, J. E., Cabello, R., & Clark, J. L. (2019). Contextualizing condoms: A Cross-sectional study mapping intersections of locations of sexual contact, partner type, and substance use as contexts for sexual risk behavior among MSM in Peru. BMC Infectious Disease, 19(1), 958. https://doi.org/10.1186/s12879-019-4517-y

    Article  Google Scholar 

  • Passaro, R. C., Segura, E. R., Lama, J. R., Sanchez, J., Lake, J. E., & Clark, J. L. (2020). High-risk, but hidden: binge drinking among men who have sex with men and transgender women in Lima, Peru, 2012–2014. Substance Use & Misuse, 55(3), 399–404.

    Article  Google Scholar 

  • Pearlin, L. I. (1989). The sociological study of stress. Journal of Health and Social Behavior, 30(3), 241–256. https://doi.org/10.2307/2136956

    Article  PubMed  Google Scholar 

  • Perez-Brumer, A. G., Konda, K. A., Salvatierra, H. J., Segura, E. R., Hall, E. R., Montano, S. M., Coates, T. J., Klausner, J. D., Caceres, C. F., & Clark, J. L. (2013). Prevalence of HIV, STIs, and risk behaviors in a cross-sectional community- and clinic-based sample of men who have sex with men (MSM) in Lima, Peru. PLoS ONE, 8(4). https://doi.org/10.1371/journal.pone.0059072.

  • Pollock, L., Silva-Santisteban, A., Sevelius, J., & Salazar, X. (2016). ‘You should build yourself up as a whole product’: Transgender female identity in Lima, Peru. Global Public Health, 11(7–8), 981–993. https://doi.org/10.1080/17441692.2016.1167932

    Article  PubMed  Google Scholar 

  • Poteat, T., Wirtz, A. L., Radix, A., Borquez, A., Silva-Santisteban, A., Deutsch, M. B., Khan, S. I., Winter, S., & Operario, D. (2015). HIV risk and preventive interventions in transgender women sex workers. The Lancet, 385(9964), 274–286. https://doi.org/10.1016/S0140-6736(14)60833-3

    Article  Google Scholar 

  • Reback, C. J., Lombardi, E. L., Simon, P. A., & Frye, D. M. (2005). HIV seroprevalence and risk behaviors among transgendered women who exchange sex in comparison with those who do not. Journal of Psychology & Human Sexuality, 17(1–2), 5–22. https://doi.org/10.1300/J056v17n01_02

    Article  Google Scholar 

  • Salazar, X., Villayzán, J., Silva-Santisteban, A., & Caceres, C. (2010). Las personas trans y la epidemia del VIH/SIDA en el Peru. Lima: IESSDEH, UPCH, ONUSIDA, amfAR.

  • Sanchez, J., Lama, J. R., Kusunoki, L., Manrique, H., Goicochea, P., Lucchetti, A., Rouillon, M., Pun, M., Suarez, L., Montano, S., Sanchez, J. L., Tabet, S., Hughes, J. P., & Celum, C. (2007). HIV-1, Sexually transmitted infections, and sexual behavior trends among men who have sex with men in Lima, Peru. Journal of Acquired Immune Deficiency Syndromes, 44(5), 578–585. https://doi.org/10.1097/QAI.0b013e318033ff82

    Article  PubMed  Google Scholar 

  • Satcher, M., Segura, E. R., Silva-Santisteban, A., Sanchez, J., Lama, J. R., & Clark, J. L. (2016). Partner-level factors associated with insertive and receptive condomless anal intercourse among transgender women in Lima, Peru. AIDS and Behavior, 21(8), 2439–2451. https://doi.org/10.1007/s10461-016-1503-x

    Article  Google Scholar 

  • Sausa, L. A., Keatley, J., & Operario, D. (2007). Perceived risks and benefits of sex work among transgender women of color in San Francisco. Archives of Sexual Behavior, 36(6), 768–777. https://doi.org/10.1007/s10508-007-9210-3

    Article  PubMed  Google Scholar 

  • Sevelius, J. M. (2013). Gender affirmation: A framework for conceptualizing risk behavior among transgender women of color. Sex Roles, 68(11–12), 675–689. https://doi.org/10.1007/s11199-012-0216-5

    Article  PubMed  Google Scholar 

  • Silva-Santisteban, A., Raymond, H., & Salazar, X. (2012). Understanding the HIV/AIDS epidemic in transgender women of Lima, Peru: Results from a sero-epidemiologic study using respondent driven sampling. AIDS and Behavior, 16, 872–881.

    Article  Google Scholar 

  • Silverstein, L. B., Auerbach, C. F., & Levant, R. F. (2002). Contemporary fathers reconstructing masculinity: Clinical implications of gender role strain. Professional Psychology: Research and Practice, 33(4), 361–369. https://doi.org/10.1037/0735-7028.33.4.361

    Article  Google Scholar 

  • Simpson, R. (2005). Men in non-traditional occupations: Career entry, career orientation and experience of role strain. Gender, Work & Organization, 12(4), 363–380. https://doi.org/10.1111/j.1468-0432.2005.00278.x

    Article  Google Scholar 

  • Smith, T. E., & Leaper, C. (2006). Self-perceived gender typicality and the peer context during adolescence. Journal of Research on Adolescence, 16(1), 91–104. https://doi.org/10.1111/j.1532-7795.2006.00123.x

    Article  Google Scholar 

  • Tabet, S., Sanchez, J., Lama, J., Goicochea, P., Campos, P., Rouillon, M., Cairo, J. L., Ueda, L., Watts, D., Celum, C., & Holmes, K. K. (2002). HIV, syphilis and heterosexual bridging among Peruvian men who have sex with men. AIDS, 16(9), 1271–1277.

    Article  Google Scholar 

  • Theodore, P. S., Durán, R. E. F., Antoni, M. H., & Fernandez, M. I. (2004). Intimacy and sexual behavior among HIV-positive men-who-have-sex-with-men in primary relationships. AIDS and Behavior, 8(3), 321–331. https://doi.org/10.1023/B:AIBE.0000044079.37158.a9

    Article  PubMed  Google Scholar 

  • UNAIDS. (2013). Global Report: UNAIDS Report on the Global AIDS Epidemic. Retrieved from UNAIDS website: http://unaids.org/en/resources/campaigns/globalreport2013/globalreport.

  • Verre, M., Peinado, J., Segura, E. R., Clark, J. C., Gonzales, P., Benites, C., Cabello, R., Sanchez, J., & Lama, J. R. (2014). Socialization patterns and their associations with unprotected anal intercourse, HIV, and syphilis among high-risk men who have sex with men and transgender women in Peru. AIDS and Behavior, 18(10), 2030–2039.

    Article  Google Scholar 

  • Wei, C., & Raymond, H. F. (2011). Preference for and maintenance of anal sex roles among men who have sex with men: sociodemographic and behavioral correlates. Archives of Sexual Behavior, 40(4), 829–834. https://doi.org/10.1007/s10508-010-9623-2

    Article  PubMed  Google Scholar 

  • Weinberg, M. S., & Williams, C. J. (2010). Men sexually interested in transwomen (MSTW): Gendered embodiment and the construction of sexual desire. Journal of Sex Research, 47(4), 374–383. https://doi.org/10.1080/00224490903050568

    Article  PubMed  Google Scholar 

  • Wilson, E. C., Garofalo, R., Harris, D. R., & Belzer, M. (2010). Sexual risk taking among transgender male-to-female youths with different partner types. American Journal of Public Health, 100(8), 1500–1505. https://doi.org/10.2105/AJPH.2009.160051

    Article  PubMed  PubMed Central  Google Scholar 

  • Young, R. M., & Meyer, I. H. (2005). The trouble with “MSM” and “WSW”: Erasure of the sexual-minority person in public health discourse. American Journal of Public Health, 95(7), 1144–1149. https://doi.org/10.2105/AJPH.2004.046714

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

We are deeply grateful to the study participants, peer recruiters, and staff of the Asociación Civil Impacta Salud y Educación for their contribution to this study. This study would not have been possible without their collaboration and support.

Funding

Milan F. Satcher received funding from the UCLA South American Program in HIV Prevention Research (SAPHIR; NIH R25 MH087222) and is supported by the Health Resources Services Administration postdoctoral fellowship grant (T32HP32520). The primary research for this secondary data analysis was funded by the NIH/NIMH (NIH R21 MH092232 and K23 MH084611).

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All study procedures were approved by the Institutional Review Boards of the University of California, Los Angeles and Asociación Civil Impacta Salud y Educación in Lima, Peru.

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Satcher, M.F., Segura, E.R., Silva-Santisteban, A. et al. Exploring Contextual Differences for Sexual Role Strain Among Transgender Women and Men Who Have Sex with Men in Lima, Peru. Arch Sex Behav 51, 1977–1991 (2022). https://doi.org/10.1007/s10508-021-02181-8

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Keywords

  • Transgender women
  • Men who have sex with men
  • Sexual role strain
  • Condom use
  • HIV
  • STI