There were 120 articles included in this scoping review. The majority of studies utilized a quantitative descriptive design (n = 79, 65.83%). Other studies adopted a qualitative design (n = 35, 29.17%). Few studies used mixed methods (n = 5, 4.17%). One study (.83%) used an intervention design. Zero studies were randomized, controlled trials.
The MMAT was used to appraise the quality of evidence of each article. Most studies were given a score of at least 60% (n = 114). More specifically, 46 studies were scored 100%, 48 studies were given a score of 80%, 20 studies were scored 60%, 5 studies were given a score of 40%, 1 study scored of 20%, and 0 studies scored of 0%. Out of the 79 quantitative descriptive studies, 18 scored 100%, 40 scored 80%, 18 scored 60% and three scored 40%. Qualitative studies were mostly appraised at 100% (n = 27). Five qualitative studies were appraised at 80%. The other three studies were appraised at 60%, 40%, and 20%, respectively. One mixed methods study received 100% and two others received 80%, one received 60%, and one received 40%. Finally, the intervention study was appraised at 80%.
Themes were organized into a priori categories based upon the three constructs: Identity Development, Attraction, and Behaviour. Under identity development, themes included hypermasculinity, uncertainty/silence, and compartmentalization. Themes related to attraction included lack of emotion with men and negative emotional responses. Behaviour-related themes consisted of sexually transmitted and blood borne infections (STBBI)/HIV risks, substance use and transactional sex, and types of sexual acts. See Fig. 2 for a model of these findings.
Identity Development
Identity development consists of three themes: hypermasculinity, uncertainty/silence, and compartmentalization.
Hypermasculinity
Twenty-nine articles discuss the roles of hypermasculinity and internalized homophobia. Findings from 28 of the 29 articles suggest there is a high prevalence of hypermasculinity and internalized homophobia among H-MSM. Social norms around gender, for instance, are rooted in masculinity and discourage men from identifying as non-heterosexual (Perez-Brumer et al., 2019). Accordingly, H-MSM tend to reject gay culture and have high degrees of hypermasculinity/machismo and internalized homophobia (Dillon et al., 2019; Phillips et al., 2020; Rutledge et al., 2018; Shoptaw et al., 2009; Silva, 2017). Conversely, Silva (2018, 2022) report most sampled H-MSM (56.09% and 62.88%, respectively) display low overt homophobia and conservative masculinity. Nevertheless, a considerable proportion of the participants have moderate or high levels of overt homophobia and/or conservative masculinity. Silva and Fetner (2022) also found that most H-MSM are moderately supportive of LGBTQ + rights; though, religiousity and homophobia remain associated with identity-behaviour discordance.
Vrangalova and Savin-Williams (2012) argue some degree of discordance is due to stigma toward male same-sex sexuality, resulting in H-MSM maintaining heterosexual identities. Indeed, Duffin (2016) shows that H-MSM equate identifying as gay with being weak and vulnerable and that they associate bisexuality with confusion and pedophilia (Duffin, 2016). Two studies find that H-MSM believe they could not obtain happiness or emotional security if they did not have children (Silva and Whaley, 2018; Williams et al., 2004), indicating some H-MSM may be maintaining heterosexual identities to comply with traditional norms around constructing families. Three other studies highlight how H-MSM uphold hypermasculine personas to avoid being perceived as gay within their Black and Latino communities (Miller et al., 2005; Phillips et al., 2020; Shoptaw et al., 2009). Two studies add that disclosing same-sex sexuality would harm their reputations, especially within their culture and religion (Benoit and Koken, 2012; Schrimshaw et al., 2018). Cardoso (2009), though, concluds H-MSM fisherman in Brazil are not concerned about how disclosure of same-sex behaviours could affect their reputations as macho heterosexual men. Relatedly, three studies suggest some H-MSM do not view homosexuality negatively, but they have negative attitudes towards feminine men and transgender individuals (Anderson, 2008; Cardoso, 2002, 2009).
Maintaining a hypermasculine persona and heterosexual identity may be harming the mental health and well-being of H-MSM. Carrillo and Hoffman (2016) state some participants experience stress from the societal pressures to be masculine and that allowing another man to be in charge of them during sex relieved some stress. Schrimshaw et al. (2013) similarly denote that concealment of same-sex sexuality is associated with heterosexual identification and internalized homophobia. In turn, internalized homophobia predicts heightened depressive and anxiety symptoms.
Uncertainty/Silence
Many HMSM experience uncertainty, largely related to fear of discrimination, stigma, and lack of social support. Dillon et al. (2019), for instance, finds H-MSM have high sexual identity uncertainty. This could be due to a lack of understanding of sexuality as reported in two studies. Duffin (2016) finds participants believed attraction was a dichotomy and bisexuality equated to sexual confusion. In another study, many men indicate they never had to define their sexuality until being interviewed for the study (Carrillo and Hoffman, 2016). These authors argue participants may have adopted flexible definitions of heterosexuality, in part, due to lack of understanding about heterosexuality and other sexual identities (Carrillo and Hoffman, 2016). Relatedly, the majority of H-MSM are at lower stages of homosexual identity acceptance, especially if they are still married to women (Malcolm, 2008).
Findings also show straight identification and concealment about same-sex behaviours among MSM and men who have sex with men and women (MSMW) is associated with political conservatism, marriage, high school or below education, full-time employment, living with a female partner, and frequent sex with women (Schrimshaw et al., 2013; Silva, 2017). MSMW are also more likely to identify as heterosexual than gay (Mayer et al., 2021), but are most likely to identify as bisexual (Reilly et al., 2016). Scholars also find anywhere from 24–63% of H-MSM never tell others about their same-sex attractions and behaviours (Schrimshaw et al., 2013, 2018; Zule et al., 2009). Schrimshaw et al. (2018) finds H-MSM have various reasons for not disclosing their same-sex behaviours, such as concerns related to negative emotional reactions and relationship changes (e.g., being disowned), prior negative experiences with disclosure, fear that someone will tell others, and cultural and religious rejection. Schrimshaw et al. (2013) also reports that greater concealment is related to higher levels of depressive and anxiety symptoms and lower positive affect.
Compartmentalization
According to four studies, some H-MSM compartmentalize sexual behaviours as unrelated to and not representative of their sexual identity (Operario et al., 2008). Reback and Larkins (2010), for example, find H-MSM describe their same-sex behaviours as unrelated to their heterosexuality because such experiences are infrequent and sometimes accidental and serve recreational and/or economic purposes. That is, substance use is often involved, leading many to dismiss same-sex behaviours as uncharacteristic of their sober selves. For others, same-sex behaviours are viewed as ‘sport’—something that is fun but does not require intimacy—which allows them to avoid adopting non-heterosexual identities. Many others engage in transactional sex with other men to exchange substances and/or money. Both substance use and transactional sex are further described under the Behaviours category.
Attraction
Two themes emerge under attraction: lack of emotion and negative emotional responses. Notably, attraction is the smallest category as few reports examine attraction among H-MSM.
Lack of Emotion
H-MSM experience different types of attraction toward men compared to women. Eight studies, for instance, indicate H-MSM experience no romantic attraction to men (e.g., Martinez and Hosek, 2005; Silva, 2017). Men in these studies only experience romantic attraction with women and use sex with men as a form of stress relief. Relatedly, Harawa et al. (2008) mentions some participants preferred male over female sexual partners when they were intoxicated because sex with other males required less emotional commitment. Morandini et al. (2019) finds the visual attention of mostly heterosexual men is fixated more heavily on sexually explicit features (i.e., genitals) rather than on other areas of the body (e.g., face, chest) due to increased sexual attraction. Other H-MSM deny any attraction to men (Duffin, 2016) or emphasize they are primarily attracted to women—not men (Carrillo and Hoffman, 2016)—allowing them to maintain their heterosexual identity. Overall, H-MSM's attraction toward other men is primarily sexual.
Notably, three studies report on the types of men that H-MSM were attracted to when they do acknowledge they are attracted to other men. Findings reveal the types of men H-MSM are attracted to may vary. Fontdevila (2020), for example, concluds participants desire masculine cisgender men. Meanwhile, other H-MSM report same-sex attractions and behaviours by being attracted to feminine men (Siegel and Meunier, 2019) and transgender women (Duffin, 2016), occasionally justifying their identity-behaviour discordance through these attractions.
Negative Emotional Responses
Findings from seven studies suggest H-MSM experience negative emotional responses following sexual encounters with other men. In particular, many H-MSM feel shame about their same-sex behaviours (e.g., Miller, 2008). Reback and Larkins (2010) report H-MSM feel shameful, guilty, disgusted, and unclean after having sex with other men. According to participants, these negative feelings suggest H-MSM cannot be LGBTQ + as if positive emotional responses would indicate an individual may be LGBTQ+ (Reback and Larkins, 2010). In addition, feelings of shame and guilt are associated with greater anxiety and depression (Mendelsohn et al., 2022) and likelihood of engaging in transactional sex or having a history of substance abuse (Senreich, 2015).
Behaviours
Behaviours is the largest category and consists of three themes: STBBI/HIV risks, substance use and transactional sex, and types of sexual acts.
STBBI/HIV Risks
Forty-four studies included findings relate to behavioural risks, testing, stigma, treatment, and health services/help seeking. These studies mostly showe H-MSM have elevated risks for HIV and other sexually transmitted and blood borne infections (STBBIs) in comparison to heterosexual or other MSM. Three studies, though, find H-MSM are less likely than other heterosexual men or MSM to report being diagnosed with HIV (Everett, 2013; Mendoza et al., 2015; Pathela et al., 2006). One other study found H-MSM are not significantly more likely to test positive for HIV despite having significantly higher odds of engaging in condomless sex (Baytop et al., 2014). However, these lower odds of reporting past or current STBBIs/HIV may be related to lack of testing. Indeed, six studies conclud H-MSM have low rates of HIV testing (Margolis et al., 2012; McCree et al., 2016). In fact, one study of Black MSM in Washington, DC finds 82% of participants who had never tested for HIV were heterosexual and 19% of the full sample identified as heterosexual (McCree et al., 2016). Another study of MSM in the United Kingdom shows 83% of H-MSM have not been tested for HIV in the past 12 months and 70% never received an HIV test result (Witzel et al., 2016). Perhaps related to the lack of testing, Lert et al. (2010) and MacCarthy et al. (2014) find H-MSM have higher odds of delayed diagnosis and treatment for HIV compared to other MSM.
H-MSM report several reasons for not testing, including thinking they did not have HIV; fearing being diagnosed with HIV, being outed to others, and/or being deported; not knowing where to get tested; not having the time or resources; and not believing they did anything to contract HIV (Boyce et al., 2012; Margolis et al., 2012; Wirtz et al., 2014). Importantly, men who had never tested before preferred self-administered testing, genitourinary medicine clinics, and testing in general practice (Witzel et al., 2016). H-MSM also often prefer free, public health clinics as they provide greater anonymity and allow them to blend in without bringing attention to their same-sex sexual behaviours (Boyce et al., 2012). These services may be especially important as H-MSM are less likely than gay and bisexual men to have a primary healthcare provider (Merighi et al., 2011) and less likely than gay men to disclose their same-sex sexual behaviours to providers (Stults et al., 2020). A lack of knowledge of HIV may also pose a barrier to testing and prevention. Ortiz-Sánchez et al. (2017) and Tang et al. (2014) each report H-MSM lack adequate knowledge of HIV.
Pre-exposure prophylaxis (PrEP) use is another preventative tool against HIV. However, only one study examines PrEP use, finding H-MSM were significantly less willing to use PrEP than gay MSM (Lim et al., 2017). Condom use is also important to prevent HIV and other STBBIs. Findings are mixed on whether H-MSM have lower or higher condom use than other MSM. Four studies report H-MSM have lower condom use than other MSM (Denning and Campsmith, 2005; Rutledge et al., 2018). Zellner et al. (2009) similarly report that 91.7% of H-MSM who engage in sex with female and male partners during the past 60 days did not use condoms and only 21% of H-MSM, compared to 53.1% of gay MSM, were carrying condoms at the time of the survey. McCree et al. (2016) also acknowledge those who had never tested for HIV are more likely to be heterosexual and less likely to use condoms with male partners. Meanwhile, two studies found H-MSM have less condomless episodes than gay, bisexual, and other MSM (Carballo-Diéguez et al., 2011; Joseph et al., 2018). Another four studies found no significant differences in condomless anal intercourse between H-MSM and other MSM (Ayer et al., 2021; Bond et al., 2009). Additionally, eight studies show H-MSM are more likely to use condoms with male partners than female partners (Martinez and Hosek, 2005). Shen et al. (2016) suggested social and cultural norms around married life create expectations for men to engage in condomless sex with their wives, which may help explain the different rates of condom use with male and female partners. Further, Rosenberger et al. (2012) and Williams et al. (2004) report that location, physical urges, and religious beliefs impact condom use. Condoms are not always readily available in venues for anonymous sex, cars, parks, and other locations where H-MSM engage in sex. Condoms are more readily available when H-MSM engage in sex in a hotel or at a partner’s home. Miller et al (2005) add that substance use can make H-MSM incapable of discussing condom use.
Moreover, HIV stigma impacts how H-MSM engage in preventative measures and treatment. Philibin et al. (2018), for example, note H-MSM often delayed treatment of HIV and other STBBIs due to fear of discrimination and stigma. HIV-related stigma and associating HIV with identifying as gay or bisexual also prevented many H-MSM from getting tested (Boyce et al., 2012; Williams et al., 2004). Stigma about HIV also may affect disclosure of HIV. Reback et al. (2015) find some H-MSM refuse to disclose their HIV serostatus to female sexual partners. The authors also share that those H-MSM who did disclose having HIV did so in ways to protect their heterosexual identity. Alternatively, Ayer et al. (2021) find H-MSM were more likely than gay or bisexual men to communicate about HIV. Relatedly, HIV programming is often geared toward gay and bisexual and younger MSM and not heterosexual and/or older MSM (Martinez-Donate et al., 2010; Philibin et al., 2018).
Substance Use and Transactional Sex
Substance use and/or transactional sex among H-MSM is discussed in 27 studies. Among these articles, 11 examine substance use, 10 examine transactional sex, and six examine both substance use and transactional sex. Generally, results show H-MSM often use various substances (Reback and Larkins, 2010). However, research on substance use disparities between H-MSM and other heterosexual men and MSM is mixed. Findings from five studies suggest H-MSM have elevated levels of recent substance use and substance use during sex compared to other heterosexual men and MSM (Dillon et al., 2019; Zellner et al., 2009). Deren et al. (2001) also argue that H-MSM have larger drug networks than other MSM. In addition, Brewer et al. (2014) find Black H-MSM are more likely than other Black MSM to have a history of incarceration and incarceration history was associated with drug and alcohol use in the last six months. Results from three other studies, though, indicate H-MSM may abuse substances less than others. First, Lert et al. (2010) find HIV + H-MSM were less likely to use poppers or cocaine but more likely to smoke tobacco compared to other HIV + MSM. The authors found no significant differences in heavy alcohol use. Second, McCabe et al. (2019) similarly found that past-year prevalence of alcohol use disorder did not differ significantly between H-MSM and other heterosexual men without same-sex attraction. Notably, though, H-MSM have a lower prevalence of alcohol use disorder than gay, bisexual, and men who are unsure of their identity. Third, Gattis et al. (2012) find H-MSM have lower rates of alcohol dependence than other heterosexual or gay men. Gattis et al. (2012) also share H-MSM have higher usage rates of depressants, stimulants, cannabis, hallucinogens, and inhalants than other heterosexual men but lower usage rates than gay men.
Results from four studies reveal H-MSM use substances to lower inhibitions and make them more comfortable engaging in sex with another man (Benoit and Koken, 2012; Operario et al., 2008). According to Harawa et al. (2008), drug use not only increases comfort with engaging in sex with other men, but drugs also help Black H-MSM cope with their same-sex behaviours. That is, some H-MSM may use intoxication from drugs to excuse their same-sex behaviours and maintain their heterosexual identity. Harawa et al. (2008) also mentioned that drugs and alcohol are often located in many areas where Black H-MSM and other non-gay-identified Black MSM pick up other men for sex.
Moreover, every article mentioning transactional sex acknowledged that many H-MSM have sex with other men to obtain drugs and/or money (Fernández-Dávila et al., 2008; Finlinson et al., 2006). Similarly, many H-MSM engage in survival sex where they have sex with another man as a means towards obtaining food, money, clothes, and/or shelter (Fontdevila, 2020; Wirtz et al., 2014). In fact, H-MSM have increased odds of engaging in transactional sex (Boyce et al., 2012) and transactional sex is the most common HIV risk behaviour among H-MSM (Abdallah et al., 2020). In addition, transactional sex is associated with crack and injection drug use (Newman et al., 2004) and shame, guilt, and a need for secrecy (Senreich, 2015). H-MSM sex workers also are less knowledgeable of HIV, report more unprotected vaginal sex, and experienc symptoms of STBBIs (Tang et al., 2014).
Types of Sexual Acts
Finally, 22 studies explore the types of sexual acts performed by H-MSM. Twelve studies report on the position or role H-MSM take during sex with other men. Nine of these articles find H-MSM only accept roles as the insertive partner during anal intercourse (Duffin, 2016; Cardoso, 2009). This likely relates to cultural beliefs about sexuality and gender roles. Indeed, many studies highlight how certain cultures and communities (e.g., South and East Asians, Turkish, Latino, and Black cultures and communities) associate an insertive role with manhood and masculinity (Cardoso, 2009; Clark et al., 2013; Huysamen, 2018). Thus, H-MSM often insist they can maintain their manhood and identity as heterosexual as long as they are the insertive partner and not the receiving partner during anal intercourse with other men (Duffin, 2016). Relatedly, some H-MSM avoid kissing (Li et al., 2010) or anal sex (Carrillo and Hoffman, 2016) to maintain their heterosexual identities.
Another unique aspect of sex with men related to discretion. Six studies explicitly reported discretion was valued among H-MSM. Silva (2017) found H-MSM prefer regular and discrete partners with no strings attached versus one-night stands. One study mentions discretion is arousing and exciting for H-MSM (Carrillo and Hoffman, 2016). Similarly, another study mentioned that young H-MSM enjoy Internet cruising because it is erotic and promises greater anonymity over public venues (Robinson and Moskowitz, 2013). Meanwhile, two studies shared that discretion is important to avoid others learning about their same-sex behaviours (Schrimshaw et al., 2018; Williams et al., 2004). Findings from one other study simply stated H-MSM prefer discretion because sex is a personal and private topic (Schrimshaw et al., 2014).
Four other studies describe the type of sex H-MSM enjoy with men versus with women. Results indicate H-MSM perceive male partners as sexually adventurous and have rougher and more aggressive sex with them compared to female partners (Fernández-Dávila et al., 2008; Fontdevila, 2020; Siegel and Meunier, 2019). In addition, H-MSM report that male partners are more capable of pleasing them than female partners (Fontdevila, 2020; Siegel and Meunier, 2019). Sex with men is viewed by H-MSM as a way to feel free and achieve sexual relief (Fernández-Dávila et al., 2008; Fontdevila, 2020; Martinez and Hosek, 2005) while sex with women is viewed as morally superior (Fontdevila, 2020). In three other studies, H-MSM recognize that other men are more readily available for sex and securing a sexual relationship is easier with men than with women (Fernández-Dávila et al., 2008; Martinez and Hosek, 2005; Reback et al., 2019). Additionally, findings from three studies suggest H-MSM sometimes engage in opportune or situational sex with other men. That is, H-MSM had sex with other men because the opportunity was available and other options were limited in their given situation. For instance, Muñoz-Laboy (2004) show H-MSM engage in opportunity sex with other men while in prison for drug-related offenses. Finally, two studies report that H-MSM may have sex with other men because female partners wanted them to have a threesome with another man (Carrillo and Hoffman, 2016; Thompson et al., 2022).