Correlates of anal sex roles among Malay and Chinese MSM in Kuala Lumpur,Malaysia

Abstract

Identifying roles for anal sex is an important issue for populations of MSM. We describe the prevalence of identifying as being ‘top’, ‘bottom’, ‘versatile’, or ‘don’t know/not applicable’ among Malay and Chinese MSM in Kuala Lumpur, Malaysia, and behavioural outcomes according to these labels for sexual role identity. Data analysis was conducted on a survey administered during weekly outreach throughout Kuala Lumpur in 2012. Pearson’s Chi square tests were used to compare demographic and behavioural characteristics of MSM who reported roles for anal sex. Binary logistic regression was used to explore the odds of behavioural outcomes among MSM who identified as ‘bottom’, ‘versatile,’ and ‘don't know' compared to MSM who reported that ‘top' was their sexual role. Labels for anal sex roles were significantly associated with condom use for last anal sex. Among MSM who used labels for anal sex roles, MSM who identified as ‘bottom’ had highest level of not using condoms for last anal sex (24.1%, p = .045). In binary logistic regression model, identifying as ‘top’ was significantly associated with reporting using a condom during last anal sex and reported consistent condom use for anal sex in the past six months (p = .039 and .017, respectively). With regard to sexual role identity, some MSM may be a part of a special subgroup of at-risk men to be targeted. Future research should evaluate the origins, meanings, and perceptions of these labels, and the developmental process of how these MSM identify with any of these categories. Research should also uncover condom use decision making with regard to these labels for sexual positioning.

Keywords

HIV AIDS sexually transmitted infections sexual behaviour men homosexual men who have sex with men MSM sexual role anal sex anal sex positioning Malaysia culture

Introduction

Identifying roles for anal sex is an important issue for populations of MSM; however, this issue has received little discussion in the MSM and HIV literature, considering the risks for HIV and sexually transmitted infections (STIs) via condomless anal intercourse vary according to sexual positioning. Specifically, men who participate in receptive anal intercourse (RAI) are more likely to acquire HIV and rectal STIs compared to men who only participate in insertive anal intercourse (IAI).^1,2 RAI creates high risk for HIV acquisition among MSM because the lining of the rectum is thin and may allow HIV greater access to the blood stream during receptive anal sex, although IAI also allows for HIV enter through the opening of the penis.^1–4 Additionally, men who practice both insertive and receptive roles for anal sex may be at high risk for HIV infection via RAI and may also potentiate risk for HIV infection to others through IAI.^5–7 Versatility of anal sexual positioning thus increases the chance of infection and transmission to others in this group.^8,9

Anal sex positioning refers to sexual behaviours relating to anal sex practice, and sexual role generally refers to self-ascribed identities extending from anal sex positioning and/or preference. Although studies have suggested that there is no static or general dichotomous sexual role identity among MSM,^10,11 in Western populations, men who prefer IAI have generally been referred to as ‘tops’, men who prefer RAI have been referred to as ‘bottoms’, and men who prefer both are referred to as ‘versatile’ or ‘vers’.^12–15 Research also shows that sexual role identity and practice varies by age and may be dependent upon cultural context.^16–18

Studies from the United States show that the proportion of MSM who identify in each of these role identities is not equally distributed.^12,15,17,19 Among a sample of HIV-positive MSM in San Francisco and New York, data showed that 18% of identified as a ‘top’, 23% identified as ‘bottom’, 47% identified as ‘versatile’, and 12% of MSM responded that these labels were not applicable to them.¹⁹ Comparatively, Moskowitz et al. found that 19% identified as a ‘top’, 47% identified as ‘versatile’, and 34% of MSM identified as ‘bottom’.¹² In American samples, sexual self-labels among MSM correlated with anal sexual behaviours. Previous work on MSM and anal sex practice suggested that MSM who identified as ‘top’ had higher frequency and likelihood of IAI compared to those who identified as either ‘versatile’ or ‘bottom’. Conversely, MSM who identified as ‘bottom’ had higher frequency and likelihood of RAI compared to MSM who identified as ‘top’ or ‘versatile’.^14,15,19 MSM who identified as ‘versatile’ had varying frequencies of insertive and receptive anal sex.^12,19

Other correlates of sexual positioning practices have included masculinity stereotypes, partner type, and HIV status. Data show that some MSM who engaged in IAI may have been less likely to consider themselves ‘woman-like’ compared to MSM who engaged in RAI.^16,20,21 Additionally, qualitative research suggests that the context of a ‘hookup’ or casual partner versus a committed relationship influenced sexual positioning decision making; within the context of a hookup or causal sexual encounter, gender roles aided in the decision making. However, within a romantic long-term relationship, gender roles were not inherent to the negotiation of anal sex behaviours.^20,22 Data also show that individual and partner HIV status may have affected sexual positioning decision making. In Australia, Van de Ven found that most HIV-negative MSM who had unprotected anal intercourse in serodiscordant relationships were insertive and most receptive MSM were HIV-positive.²¹ Labelling for sexual role preferences also differed in gay self-identification, internalised homophobia, sexual sensation seeking, and anxiety. For example, tops were less likely than versatiles or bottoms to identify as gay and reported higher internalised homophobia than versatiles.¹⁹ These groups also differed in socio-demographic characteristics. For example, Asian/Pacific Islander men, men with a lower educational level, and men born in Asia or the Philippines were more likely than were other MSM to prefer being a ‘bottom’.¹⁵

Of the 84,630 total reported cases of HIV infection in Malaysia from 1986 to 2008, the Ministry of Health reported that 1.9% were infected through homosexual or bisexual activity.²³ However, these data are based on a person’s voluntary declaration of a history of male-to-male sex. In Malaysia, homosexuality is heavily stigmatised, anal sex is explicitly or implicitly prohibited by law, and data considering the profiles of MSM may be underrepresented.^24,25 Still, HIV in Malaysia is concentrated among Malay and Chinese men.^23,26,27 Studies in Kuala Lumpur, the capital of Malaysia, have observed HIV prevalence among MSM between 3.9 and 9.4% between 2011 and 2014.^24,28 The profiles of Malay and Chinese MSM with regards to HIV infection and risks are limited, and the relationship between sexual role identity and sexual behaviours has never been studied. Previous research highlighted that MSM in Kuala Lumpur had low levels of perceived HIV knowledge and considerable misinformation about the routes of HIV transmission among MSM in Kuala Lumpur. Studies also showed that roughly 63% of MSM in Kuala Lumpur reported that they ‘don’t have’ or have ‘average’ HIV knowledge and 20.1% of MSM believed that HIV cannot be transmitted through RAI or IAI.^24,29 It becomes important, then, to begin understanding the behaviours of these men with regard to these sexual role identities and preferences.

Little attention has been paid to associated socio-demographics or behavioural risk factors for HIV and STIs with regard to these sexual role identities. Due to the limited quantitative data describing MSMs' sexual roles, this study examined the prevalence of identifying as being ‘top’, ‘bottom’, ‘versatile’, or ‘don’t know/not applicable’ among a sample of Malay and Chinese MSM in Kuala Lumpur, Malaysia, and behavioural outcomes including condom use, drugs use for sex, exchanging money for sex, and multiple sexual partners according to these labels for sexual role identity.

Methods

Analysis was conducted using data collected during weekly outreach sessions of the PT Foundation, a long established AIDS community-based organisation in Kuala Lumpur, from March to December 2012. PT Foundation volunteers approached men at parks and saunas throughout Kuala Lumpur to complete a short written questionnaire. Upon survey completion, participants received a safe sex kit and were encouraged to take part in voluntary HIV testing and counselling at PT Foundation. A total of 671 men completed the survey. This study limited data analysis to Malay and Chinese MSM who reported having at least one male partner for anal sex and no female partners within the past six months. Analysis was limited to MSM with no female sexual partners due to extant literature describing behavioural differences between groups of MSM and MSM who also have sex with women (MSMW) that may impact the discussion provided about sexual role identity and behaviours among MSM who only have sex with men.^30–35 Analysis resulted in a total of 372 MSM included in this study. This research was reviewed and approved by the University of Southern California Health Sciences Internal Review Board.

Measures

Sexual role identity

All participants were asked to identify their preferred sexual role for anal sex as ‘top’, ‘bottom’, ‘versatile’, or ‘don’t know/not applicable’.

HIV knowledge

Participants were asked one question to identify their perceived knowledge of HIV information: ‘What is your HIV knowledge?’ Participants were asked to respond using one of three options as either ‘don’t know’, ‘average’, or ‘good’. Due to low responses of individuals reporting that they ‘don’t know’ much information about HIV, responses of ‘don’t know’ and ‘average’ were combined in the analysis to indicate having a lower level of perceived HIV knowledge in relation to individuals who report having ‘good’ perceived knowledge.

Statistical analysis

Pearson’s Chi square tests were used to compare demographic and behavioural characteristics of participants who indicated a sexual role. Fisher’s exact tests were conducted in analysis of drugs and condoms for group sex in the past six months to account for small sample sizes.

Binary logistic regression was used to evaluate the odds of selected behavioural outcomes including reported condom use for last anal sex, reported consistent condom use for anal sex in the past six months, drug or alcohol use for sex, group sex, exchanging money for sex, and multiple male partners in the past six months among MSM who identify as ‘bottom’, ‘versatile’, and for MSM who ‘don’t know’ their label or for whom these labels are ‘not applicable’ compared to MSM who identified as ‘top’ for sexual positioning. Logistic regression models were adjusted to control for differences in age and ethnicity given the variability of sexual practices by age, ethnicity, and culture.

Results

A total of 372 MSM were included in this analysis from outreach data and socio-demographic profile information is summarised in Table 1. Of Malay and Chinese MSM surveyed, 18.8% were between the ages 15 and 19, 51.7% were between the ages 20 and 29, and 29.6% were 30 years or older. A total of 200 (53.8%) MSM were Malay and 46.2% were Chinese. With regard to sexual role identity, 31.4% of MSM in this sample identified as ‘top’, 15.7% identified as ‘bottom’, 49.5% identified as ‘versatile’, and 3.5% responded that they ‘don’t know’ or that these roles are ‘not applicable’ to them. Table 1 also shows that 14.8% of MSM in this study reported not using a condom last anal sex, and 44.9% reported using condoms sometimes or most of the time in the past six months. Among this sample of MSM, 13.7% reported using drugs or alcohol for sex at least once in the past six months, and 16.4% reported having group sex in the past six months. Additionally, 11% of MSM reported having ever paid for sex in the past six months, and 6.5% reported having been paid for sex in the past six months (Table 1).

Table 1.

Demographics and behavioural characteristics among Malay and Chinese MSM.

	N = 372 (%)
Age N = 362
15–19	68 (18.8)
20–29	187 (51.7)
30 or older	107 (29.6)
Ethnicity N = 372
Malay	200 (53.8)
Chinese	172 (46.2)
Venues N = 372
Parks	145 (40.1)
Saunas	223 (59.9)
Self-reported HIV Knowledge N = 372
Don’t know/Average	233 (62.6)
Good	139 (37.4)
Sexual Role N = 370
Don’t know	13 (3.5)
Top	116 (31.4)
Bottom	58 (15.7)
Versatile	183 (49.5)
Last anal sex among MSM who reported having anal sex N = 372
<3 months	313 (84.1)
3–6 months	59 (15.9)
Condom use last anal sex among MSM who reported having anal sex N = 372
No	55 (14.8)
Yes	317 (85.2)
Condom use for anal sex in the past six months N = 372
Never	12 (3.2)
Sometimes/Most	167 (44.9)
Always	193 (51.9)
Drugs or alcohol for sex in the past six months N = 372
No	321 (86.3)
Yes	51 (13.7)
Group sex in the past six months N = 371
No	310 (83.6)
Yes	61 (16.4)
Drugs for group sex among MSM who have had group sex in the past six months N = 61
No	42 (68.9)
Yes	19 (31.1)
Condoms for group sex among people who have had group sex in the past six months N = 61
No	45 (73.8)
Yes	16 (26.2)
Ever paid for sex in the past six months N = 372
No	331 (89.0)
Yes	41 (11.0)
Ever been paid for sex in the past six months N = 372
No	348 (93.5)
Yes	24 (6.5)
Number of male sexual partners in the past six months N = 372
One	82 (22.0)
Two or more	290 (78.0).

Table 2 reports the univariate associations between social and behavioural characteristics among MSM and labels for sexual role identity. Pearson’s Chi square tests showed that age was significantly associated with sexual role labels. MSM in age groups 15–19 and 20–29 reported significantly higher proportion of labelling as ‘versatile’ (55.2 and 54.2%, respectively), while older MSM (30 years or older) had a higher proportion of reporting ‘top’ as preferred sexual role (46.2%, X²= 21.56, p = .001). Reported condom use during the last anal sex was also significantly associated with these sexual role labels. Among MSM who indicated a preferred label within ‘top’, ‘bottom’, and ‘versatile’, MSM who identified as ‘bottom’ had the highest level of reporting not using condoms during last anal sex (24.1%, respectively, p = .045). Additionally, 30.8% of MSM who indicated that they ‘don’t know’ or that these labels ‘don’t apply to them’ reported not using a condom during their last anal sex (X²= 8.05, p = .045).

Table 2.

Characteristics of Malay and Chinese MSM with regard to sexual role self-labelling.

	Sex Role
	Don’t know	Top	Bottom	Versatile	p
Age N = 360
15–19	3 (4.5)	11 (16.4)	16 (23.9)	37 (55.2)	.001
20–29	6 (3.2)	53 (28.3)	26 (13.9)	102 (54.5)
30 or older	4 (3.8)	49 (46.2)	14 (13.2)	39 (36.8)
Ethnicity N = 370
Malay	7 (3.5)	54 (27.1)	36 (18.1)	102 (51.3)	.229
Chinese	6 (3.5)	62 (36.3)	22 (12.9)	81 (47.4)
Venues N = 370
Parks	6 (46.2)	48 (41.4)	27 (46.6)	67 (36.6)	.530
Saunas	7 (53.8)	68 (58.6)	31 (53.4)	116 (63.4)
Self-reported HIV Knowledge N = 370
Don’t know/Average	8 (61.5)	70 (60.3)	33 (56.9)	121 (66.1)	.566
Good	5 (38.5)	46 (39.7)	25 (43.1)	62 (33.9)
Last anal sex among MSM who reported having anal sex N = 370
<3 months	11 (84.6)	102 (87.9)	48 (82.8)	150 (82.0)	.578
3–6 months	2 (15.4)	14 (12.1)	10 (17.2)	33 (18.0)
Condoms last anal sex among MSM who reported having anal sex N = 370
No	4 (30.8)	15 (12.9)	14 (24.1)	22 (12.0)	.045
Yes	9 (69.2)	101 (87.1)	44 (75.9)	161 (88.0)
Condom use for anal sex in the past six months N = 370
Never	0 (0.0)	4 (3.4)	2 (3.4)	6 (3.3)	.092
Sometimes/Most	4 (30.8)	53 (45.7)	36 (62.1)	73 (39.9)
Always	9 (69.2)	59 (50.9)	20 (34.5)	104 (56.8)
Drugs and alcohol for sex in the past six months N = 370
No	13 (100.0)	95 (81.9)	49 (84.5)	163 (89.1)	.147
Yes	0 (0.0)	21 (18.1)	9 (15.5)	20 (10.9)
Group sex in the past six months N = 369
No	10 (83.3)	90 (77.6)	50 (86.2)	159 (86.9)	.186
Yes	2 (16.7)	26 (22.4)	8 (13.8)	24 (13.1)
Drugs for group sex among MSM who have had group sex in the past six months N = 60
No	2 (100.0)	16 (61.5)	5 (62.5)	18 (75.0)	.667
Yes	0 (0.0)	10 (38.5)	3 (37.5)	6 (25.0)
Condoms for group sex among people who have group sex in the past six months N = 60
No	2 (100.0)	16 (61.5)	8 (100.0)	18 (75.0)	.154
Yes	0 (0.0)	10 (38.5)	0 (0.0)	6 (25.0)
Ever paid for sex in the past six months N = 370
No	10 (76.9)	104 (89.7)	52 (89.7)	163 (89.1)	.617
Yes	3 (23.1)	12 (10.3)	6 (10.3)	20 (10.9)
Ever been paid for sex in the past six months N = 370
No	13 (100.0)	112 (96.6)	53 (91.4)	168 (91.8)	.250
Yes	0 (0.0)	4 (3.4)	5 (8.6)	15 (8.2)
Number of male sexual partners in the past six months N = 370
One	5 (38.5)	25 (21.6)	11 (19.0)	41 (22.4)	.500
Two or more	8 (61.5)	91 (78.4)	47 (81.0)	142 (77.6)

Table 3 summarises the odds of sexual behaviours among MSM with regard to sexual role identity after adjusting for age and ethnicity. The logistic regression model showed that MSM who identified as ‘top’ were significantly associated with reported condom use during their last anal sex and reporting always using condoms for anal sex in the past six months (p = .039 and .017, respectively).

Table 3.

Correlates of sexual behaviours among MSM with regard to sexual role identity after adjusting for age and ethnicity.

	‘Top’		‘Bottom’		‘Versatile’		‘Don’t Know’
	REF	P	OR (95% CI)	p	OR (95% CI)	p	OR (95% CI)	p
Condom use for last anal sex		.039	.43 (.18–1.00)	.052	1.05 (.49–2.22)	.899	.31 (.08–1.16)	.082
Always using condoms for anal sex past six months		.017	.52 (.26–1.04)	.066	1.38 (.84–2.27)	.206	2.11 (.601–7.31)	.240

Discussion

The present study examined the prevalence of identifying with roles for anal sex among Malay and Chinese MSM in Kuala Lumpur, Malaysia and associated behavioural differences among these groups. In the bivariate model, there were statistically significant differences in anal sex roles with regard to age and condom use for the last anal sex among MSM. In the multivariate binary logistic regression model, this study found that MSM who identified as ‘top’ were significantly associated with reported condom use for last anal sex and reporting always using condoms for anal sex in the past six months (p = .039 and .017, respectively).

This study observed a higher proportion of MSM identifying as ‘versatile’ among younger MSM. Specifically, MSM in age groups 15–19 and 20–29 reported significantly higher proportion of labelling as ‘versatile’ (55.2 and 54.2%, respectively, p = .001). This finding is similar to data found in other populations of MSM. One study among MSM in San Francisco reported the highest level of identifying within these labels being ‘versatile’ (47%).¹² Another study of MSM in Australia also showed that highest levels of labelling for sexual roles were ‘versatile’ (62%) and reported versatility during anal sex was most common among younger MSM in the sample.⁶ Perhaps younger MSM have higher levels of versatility during anal sex as part of a sexual development process along the life course. This may be important to highlight especially in Kuala Lumpur where explicit proclamation of homosexual desires or behaviours is discouraged. Versatility among the younger ages may also be a part of misconceptions about HIV transmission. One study among Australian MSM suggested that some MSM may be practicing insertive or receptive anal sex roles as a function of their own or their partners’ HIV status.²¹ That is, some MSM may be more likely to ‘top’ if their partner is HIV-positive and ‘bottom’ if their partner is HIV-negative. It is possible that a lack of knowledge of HIV transmission information among this group might also contribute to higher levels of sexual role versatility among this group, though this study found no statistically significant difference in HIV knowledge with regard to sexual positioning identity. Still, this study highlights this finding to encourage research that uncovers the motivations of sexual positioning versatility among MSM in this context.

This study also observed that sexual role identity was significantly associated with reported condom use during the last anal sex and reported consistent condom use in the past six months. Malay and Chinese MSM who identified as ‘bottom’ had highest level of reported condomless sex during last anal sex. The multivariate regression model showed that MSM who identified as ‘bottom’ also may have been less likely to use a condom compared to MSM who identified as ‘top’ during their last anal sex. Another sample of MSM found highest level of condomless anal intercourse among MSM who identified as ‘bottom’.¹⁵ Extant research on sexual positioning preferences has suggested that power plays an important role in the decision to practice RAI.^16,36,37 Perhaps condom negotiation is lost as ‘power’ is relinquished to the ‘top’ during experiences of anal sexual intercourse among this group. While extant research highlights gender role and power dynamics affects MSM sexual decision making, further information is needed to explore the extent to which condom negotiation is included in the decision making to practice RAI without a condom.

This research presents interesting and statistically significant findings, but this work is also limited. This research is cross sectional in nature and does not make any causal claims about self-labelling and sexual behaviours. This research did not correlate these self-labels with actual sexual positioning for anal sex among these MSM. This research also does not consider HIV status in sexual decision making among these MSM. Additionally, there are limitations with data collection as these secondary data were collected as part of a convenience sample during community-based outreach for which response rates are not known. However, this study is the first to describe the prevalence of these sexual role identities and does begin to shed light on an important and relevant issue among a community of MSM in Kuala Lumpur.

Future research should evaluate the origins, meanings, and perceptions of each of these labels and the developmental process of how MSM come to identify with any of these categories. Research on this issue should also consider the fluidity of these labels along the life course of these men and the relationship between these labels and behaviours over time. Additional research should also focus on this subgroup of MSM who ‘do not identify’ within these particular labels to uncover the meanings of and motivations for such identifications in addition to associated behaviours that may lead to HIV and STI risk and/or transmission. ‘Don’t know’ or ‘not applicable’ may involve more complex identifications of sexual positioning labels such as ‘versatile top’ or ‘versatile bottom’ that may require more fluid understandings of sexual positioning identity, or perhaps these are men who are still forming their identities within these labels. Future research should also uncover motivations for sexual positioning with sexual partners. Interventions should assess sexual positioning identity, preferences, and practices at all ages among MSM. This consideration during intervention should also include disseminating sexual health information specific to MSM who identify as ‘bottom’ or prefer RAI.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for this research was provided by the US Department of State Fulbright Program, the National Science Foundation Graduate Research Fellowship Program, the PT Foundation, the High Impact Research Grant of the University of Malaya (E000001-20001), and the UJMT Fogarty Global Health Fellows Training Program #5R25TW009340.

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