Background: The pervasive use of the term “MSM” in public health discourse provokes an illusion of homogeneity among men at high risk of sexually transmitted infections (STIs). Research suggests that several local sexual identities exist within MSM in India, including “panthis” (predominantly masculine, insertive anal sex), “kothis” (predominantly feminine, receptive anal sex), and “double-deckers” [DDs] (both receptive and insertive sex). Large-scale studies examining the association between these identities and sexually transmitted infections are lacking.
Methods: Respondent driven sampling was used to recruit MSM across 12 Indian cities between 09/2012-07/2013. Participants selected from a list of locally recognized identities, including panthi, kothi, DDand bisexual. HSV-2 infection was diagnosed using ELISA-based IgG assays. The association between sexual identity and HSV-2 infection was examined using random-effects logistic regression adjusting for potential confounders such as age, education, marital status, injection drug use, intercourse type, STI history, sex work, number of partners and circumcision.
Results: Among 12,022 men, median age was 26 years and 33.1% were married. Median age at first intercourse with a man was 18 years. Panthis represented the largest subgroup (32.7%), followed by kothis (23.5%), DDs (23.3%) and bisexuals (12.6%). The overall HSV-2 prevalence was 22.4% (range across sites: 10.8%-37%). Compared to panthis, the odds ratio [OR] for HSV-2 infection was 3.82 (95% confidence interval [CI]: 3.38-4.32) among kothis, 1.94 (95% CI: 1.70-2.21) for DDs and 1.51 (95% CI: 1.28-1.78) for bisexuals. In multivariate analysis, kothis remained more than twice as likely to demonstrate IgG to HSV-2 (OR: 2.11; 95% CI: 1.73–2.58) compared to panthis. All other subgroups showed no differences.
Conclusions: Indiscriminate labeling of Indian male sexual minorities as “MSM” overlooks the heterogeneity of locally recognized subgroups. Kothis and DDs appear to be at elevated risk for HSV-2 infection compared to panthis. The factors placing these identities at higher risk of STI require additional consideration.