The Trouble With “MSM” and “WSW”: Erasure of the Sexual-Minority Person in Public Health Discourse

WHAT’S IN A NAME?

In their naming practices, scientists reflect the attitudes and constructions of their culture and also advance and promote such attitudes.6 The history of scientific nomenclature referring to sexual minorities is a good example. Richard von Krafft-Ebing’s Psychopathia Sexualis introduced the notion of “antipathic sexual instinct,” used interchangeably with “homo-sexual instinct” and referred to as “anomaly,” “abnormal,” “tainted,” “neuropathic,” “degenerate,” “inverted,” and “injurious.”7 Later terms, which similarly advanced a disease model, included “sexual psychopaths” and, indeed, “homosexuals.”

Sexual-minority people—like other oppressed groups—have fought pitched battles over the right to determine the names by which they will be known in public discourse. As stated by Epstein: “Power inheres in the ability to name . . . what we call ourselves has implications for political practice.”8^(p241) In the 20th century, many sexual-minority men and women fiercely rejected homosexual in favor of self-chosen terms such as homophile, gay, lesbian, and more recently DL (down low), two-spirited, and transgender, among others. Even disparaging terms, for example, queer, have been reworked, redefined, and reclaimed.

It is important to recognize that people vary in regard to self-identity labels historically and cross-culturally and that, at any time or place, self-identities vary according to gender, culture, social class, ethnicity, and cohort, among other factors.9^–12 Cutting-edge work on identity, such as Crenshaw’s theory of intersectionality,13 challenges the implication that individuals have one central identity and that identities are fixed. In contrast to the notions that identities are hierarchically ordered and that a salient identity could potentially suppress or displace other identities, intersectionality suggests that identities are mutually constitutive. The central tenets of this approach are as follows: (1) no social group is homogenous, (2) people must be located in terms of social structures that capture the power relations implied by those structures, and (3) there are unique, nonadditive effects of identifying with more than one social group.14 Combined with social construction theory, an intersectional understanding of sexual identity suggests that sexual identities, while incorporating diversity, can be meaningful, powerful forces for group affiliation and political action.15

Any term applied generally obscures important distinctions. However, terms such as sexual minorities and gay, lesbian, and LGBT (lesbian, gay, bisexual, transgender) have acquired global resonance and political and cultural meanings. The diffusion of these terms has led not to homogenization but to a multiplication of identities, as Western and non-Western categories and practices mix and reconfigure.16^–18 Despite their limitations, there is ample evidence that the terms gay, lesbian, and LGBT are widely used alongside local terms, signifying liberationist ideologies for sexual-minority people in many cultures.9^–11 These terms have been used by such organizations as Amnesty International, Human Rights Watch, and the International Lesbian and Gay Association. The latter is a federation of national and local community-based groups with representatives from 90 countries, “dedicated to achieving equal rights for lesbian, gay, bisexual and transgendered (LGBT) people everywhere.”19

UNDERMINING SELF-DETERMINED SEXUAL IDENTITIES

Gay men, lesbians, queers, two-spirited people, and men on the DL prefer to use their own identity terms, but many contemporary public health writers prefer the terms MSM and WSW, ostensibly because these terms avoid assumptions about a singular, misleadingly coherent gay identity. In practice, however, MSM and WSW often signify not a neutral stance on the question of identity but a decided lack of sexual-minority identity. More important, by implication, MSM and WSW imply absence of community, social networks, and relationships in which same-gender pairing is shared and supported.

We are also concerned with the ways the terms have been racialized. As historian Allan Berube observed, “In the United States today, the dominant image of the typical gay man is a white man who is financially better off than most everyone else.”20^(p234) Just as gay and lesbian are often coded as “White,” WSW and MSM often implicitly refer to people of color, poor people, or racially and ethnically diverse groups outside the perceived mainstream gay and lesbian communities.

To understand how MSM is read, it is important to examine how explicit and implicit boundaries are drawn around the category gay. Consider, for example, a passage from Paul Farmer in which he claims that, in recent years, there have been fewer HIV cases than predicted among gay men in the United States, a category he implicitly racializes as White via the contrast with “injection drug users, inner-city people of color, and persons originally from poor countries in sub-Saharan Africa or the Caribbean.”21^(p47) He further excludes gay from poor and suggests that “males involved in prostitution are almost universally poor, and it may be their poverty, rather than their sexual preference, that puts them at risk of HIV infection. Many men involved in homosexual prostitution, particularly minority adolescents, do not necessarily identify as gay.”21^(p47) With this juxtaposition, Farmer seems to suggest that same-gender behavior among poor men of color (especially youth) is sex work rather than sex for pleasure and is devoid of identity and community; same-gender behavior among White men is read as synonymous with gay identity.

Compare these assumptions with a recent ethnographic report on men at risk for HIV in Dakar, Senegal.22 While many of these “men who have sex with men” are poor and engage in sex work, the authors found that they have indigenous sexual-minority identities that are differentiated and socially meaningful. Senegalese sexual-minority identities serve as a basis for social organization, including, but not limited to, sexual roles. The authors describe ibbi as men who “tend to adopt feminine mannerism[s] and to be less dominant in sexual interactions,”22^(p505) whereas yoos are men who “are generally the insertive partner.” They also stress that the categories have “more to do with social identity and status than with sexual practices.”22^(p506)

Despite their careful attention to local sexual identities of men in Senegal, the authors referred to them in the title and elsewhere as “men who have sex with men.” With this usage, the rich information on identity is lost, with MSM conveying transactional, decontextualized same-gender acts. Ironically, applying MSM in this way universalizes a culturally specific phenomenon in much the same way that critics say does the term gay.

The same is true of depictions of non-White populations within the United States. For example, Malebranche et al. studied Black men, recruited primarily from Black gay organizations, to assess the impact of a social environment characterized by prejudice on health services provided to these men.23 In qualitative interviews, the respondents talked about the challenges of being Black and gay men. They reported that conflicts among and displacement from communities are important aspects of their lives. Regarding health services, one respondent poignantly said: “When I go to a physician’s office, and when I identify myself as a gay person, part of that is looking for acceptance from them, because I haven’t gotten it from my family, you know?”23^(p100)

In this context, where communities and identities explain the substance of the concerns raised by the article, especially in a qualitative piece that purports to explore meanings, it is important to be vigilant in regard to named identities and communities. Yet, here too the authors referred to their respondents as BMSM (Black men who have sex with men). This seems especially amiss because so many of the respondents belonged to Black gay organizations—for example, the explicitly named “New York State Black Gay Network”—and because most reported that they used an identity term to describe themselves (53% gay, 12% bisexual, 12% same-gender-loving, 12% homosexual). It is an ironic commentary on the pervasiveness of men who have sex with men and MSM that the authors of the Senegalese and BMSM articles provided a nuanced cultural analysis but resorted to a deliberately anticultural term in describing the groups of men they studied.

In contrast, Munoz-Laboy24 observed complex sociosexual identities and meanings among US Latino men, noting that some adopt and others reject sexuality as an important feature of their identity. We concur with the author’s conclusion that “Latino MSM is far from being a homogeneous sexual category, and, as a framework, [the category MSM] is insufficient to capture the multidimensional aspects of Latino male bisexuality.”24^(p75)

Is MSM a useful term for describing groups that eschew prominent LGB categories? Much has been made of the fact that men on the DL lead secret lives and do not consider themselves gay.25^,26 But DL is not a behavioral category that can be conveyed as MSM. As Frank Leon Roberts has put it, “DL is . . . about performing a new identity and embracing a hip-hop sensibility [italics added].”27 DL functions not as a nonidentity but as an alternative sexual identity and community denoting same-gender interest, masculine gender roles distinct from the feminized sissy or faggot, Black racial/ethnic identity, and a dissociation from both White and Black middle-class gay cultures.26^–28

Certainly not all individuals experience sexual identity as salient. This is as true of White men and women as it is of people of color. Our point is that discourse on sexual minorities should attend to identity. To label as MSM and WSW people who describe themselves as gay or lesbian or use another identity term is to deny their self-labeling and, by extension, their self-determination. We believe that this is ethically indefensible. As stated by Battle et al.: “Debates about identity are not insignificant since they determine not only the public identity of the group, but also help to build and solidify feelings of pride, empowerment, and political purpose among group members. Thus, the politics of identity are an essential component of the politics of recognition and distribution.”11

OBSCURING THE SOCIAL MEANING OF SEXUALITY

We agree that sexual identity is not sufficient for understanding the epidemiology and prevention of HIV/AIDS or other health problems, but it is far from irrelevant. In modern social studies of sexuality, distinctions have been made among sexual identities, desires, and behaviors.29^,30 Indeed, understanding that these dimensions of sexuality do not always travel together in predictable ways was one impetus for introducing the terms MSM and WSW. But WSW and MSM can obscure critical inquiry into the social meaning of sexuality. Thinking in flat behavioral terms may lead us to ignore affiliation networks and communities that are important sources of information, norms, and values and that provide resources for health promotion efforts.

A striking case in point is the study of elevated HIV rates among sexual-minority female injection drug users relative to other injection drug users.3^,31 Many such women are typically thought of as situational WSW, in reference to same-gender behavior that is purportedly engaged in purely for material or social gain rather than for erotic or romantic purposes. Such women are considered the most appropriate subjects for an identity-free label such as WSW. To the contrary, however, Young and colleagues found that female injection drug users in New York City described complex social situations that included emotionally and erotically invested relationships with their female partners; most identified themselves as gay, a term often preferred by these women over lesbian.32

To understand the consistently elevated rates of HIV among these women, it is important to consider precisely the sort of shared social experiences that WSW obscures. In fact, we believe that WSW may thwart understanding of risk for HIV among these women because it focuses attention on purely behavioral factors. But HIV risk among WSW injectors cannot be explained as a direct result of woman-to-woman sexual behavior. The pattern only makes sense when we understand that WSW injectors also share a sexual-minority status that involves exposure to discrimination and exclusion, relationship patterns, and subcultural norms. These insights can be extended to other health disparities, such as smoking or obesity, that also differ between sexual-minority and other women but that are not connected directly to, and cannot be explained by, sexual behavior.

For men, too, the narrow focus on sexual behavior reflected in the use of MSM clouds understanding of HIV (and other health concerns). We use as one example the EXPLORE project, an HIV prevention trial aimed at MSM.33^,34 A majority of the 4295 men who participated in EXPLORE were apparently recruited from predominantly gay venues, and many enrolled in the study for altruistic reasons such as “helping stop the AIDS epidemic” and “giving to their community.”33^(p928) The authors suggested that attention to sexual self-identification, affiliation with the gay communities, and perceived community norms are important factors in HIV prevention. Despite this recommendation, the authors referred to respondents as MSM and provided no information on self-identification or sociosexual affiliations. This exemplifies a missed opportunity for public health research to more fully describe sociocultural factors related to HIV prevention.

BEHAVIORAL TERMS THAT SAY LITTLE ABOUT BEHAVIOR

Purportedly, one of the greatest advantages of WSW and MSM is that unlike lesbian and gay, they are anchored in concrete behaviors that are more relevant than identity terms to epidemiological investigations. MSM and WSW have often been understood as stand-ins for presumed risk behaviors. With this usage, researchers ignore the important task of describing actual sexual behaviors, even though this information has greater relevance to public health.

For example, reports about the risks of sexually transmitted infections involved in woman-to-woman sex typically fail to provide any information regarding specific sexual practices between women.35^,36 While important knowledge has been gained about the risk of sexually transmitted infections (including HIV) among sexual-minority women from analyses of data collected for other purposes, specific same-gender practices are rarely assessed and reported.31^,37 Studies on the specific sexual practices of women are critical if models are to be built that combine biological plausibility with empirical information on associations between sexual practices and incidence rates of sexually transmitted infections. Without such data, public health professionals cannot provide sexual-minority women with meaningful harm reduction information.

Similarly, gay and bisexual men organize sexual behavior in a variety of ways that MSM does not convey. As noted by Ayala:

HIV prevention has become synonymous with condom use and condom use has become solely about anal sex. . . . This focus on anal sex and condom use is reductionist; it narrows the sexual possibilities for gay and bisexual men of color. It also limits HIV prevention messages in the media, as well as the individual- and group-level interventions conducted by [community-based organizations]. Within this rubric there is little room for discussing, understanding, or promoting other sexual options and choices apart from anal sex and condom use.38^(p8)

Ignoring identity in HIV prevention efforts can be perilous, because sexual identities may provide important clues for public health prevention efforts. In his study of Latino sexuality, Munoz-Laboy noted: “The problem with the MSM category is that many men do not identify with the label, which leads to their increased alienation from HIV prevention strategies.”24^(p58) This led Munoz-Laboy24^(p59) to advocate that “we . . . move beyond MSM ” so that we gain a more nuanced understanding of sexuality. With such attention to identity and labels, for example, Black men who identify as gay, DL, or who claim no sexual identity would require different HIV prevention approaches.

Similarly, “top” and “bottom,” to denote sexual roles, and “bareback,” to denote sex without condoms, are part of a sex culture and connote meanings as well as behaviors that are associated with HIV risk and are relevant to HIV prevention.39^,40 These terms and others could be more useful than MSM in public health research and intervention in that they reveal more nuanced information about sexuality, identity, and risk for HIV infection.

CONCLUSIONS

MSM and WSW have become ubiquitous terms in public health discourse but have failed to live up to their promise. We do not advocate the demise of MSM and WSW, but we believe that, a decade after their introduction, the terms have become institutionalized and risk inattentive usage.

Readers of an earlier version of this article—having been convinced by arguments against MSM and WSW—were frustrated that we did not provide a list of acceptable terms and usages. We continue to balk at that task. We believe that the solution resides not in discovering better terminology but in adopting a more critical and reflective stance in selecting the appropriate terms for particular populations and contexts.

Rather than offer a menu of terms, our aim here is to open a discussion among colleagues. In our analysis of current usages of MSM and WSW, we hope it is clear that the task of naming is challenging and is thoroughly engulfed in the substantive context of the text. It is the intellectual responsibility of writers to disentangle meanings within contexts and to carefully choose the terms that best fit their purpose. Despite our reluctance to offer solutions to the labeling question, our article reveals at least 4 principles: (1) we view MSM and WSW as lowest denominator terms that tell us little about risks for HIV/AIDS or any other disease; (2) at the most general level, we prefer terms, such as sexual minorities, that allow for sociocultural and political contexts; (3) in more specific contexts, we prefer local terms that respect the self-identifications of the populations in question; and (4) when relevant to the research question, we would report the full range of identity terms represented in samples, and, when discussing individuals, we would use the terms they use.

It has also been suggested to us that some investigators might prefer MSM or WSW because the terms allow important but potentially controversial research to fly under the radar of social conservatives who want to block research on sexual minorities. We disagree. First, the strategy does not work. Many grants on the infamous list of the National Institutes of Health–funded studies that were targeted by the Traditional Values Coalition as a “waste of tax-payer’s money”41 used WSW or MSM, not the identity terms that are supposedly risky. Second, even if this strategy did keep our work from being attacked, it is perilous because the terms we use are not merely a matter of semantics but are referents for important constructs. Using inappropriate constructs can compromise the integrity of our work.

We recognize that MSM and WSW may also have strategic appeal for international work, especially in instances in which “gay and lesbian” work may be blocked. Here, too, we caution that this strategy is risky because it may reinforce the position of local conservatives who portray minority sexualities as Western, foreign, and corrupt. Contemporary work on sexuality and human rights shows that local struggles over the meaning and legitimacy of particular sexual forms are often cloaked in the language of “tradition” versus “modern corruption” or “local” versus “Western” sexual norms and behaviors.42 In such a context, MSM and WSW may inadvertently undermine local struggles for sexual rights.

We have argued that use of reductive labels is unethical because it denies the right of identity to members of sexual-minority groups whose marginalization and mistreatment in medical settings have been amply documented and to whom we have the responsibility of heightened sensitivity.43^,44 Sensitivity in discussing the health needs of members of sexual-minority groups requires neither avoiding identity simply because it is complex nor retreating to yet another generic term. Instead, researchers should aim for a deeper understanding of variations in the meaning of sexual identity and community.