Sexual identity and risk behavior among men who have sex with men (MSM) in Accra, Ghana and Lomẻ, Togo

Abstract Objectives: We examined sexual identity and its relationship with risky sexual behavior among 60 men who have sex with men in Accra, Ghana and Lomé, Togo. Methods: We used mixed-methods to investigate this relationship. Results: Quantitative results show that negative sexual identity leads to risky sexual behavior. For example, exchanging sex for valued resources is, positively associated with identity confusion. But as revealed by the qualitative findings, the relationship between sexual identity and risky sexual behavior may stem from homophobic perception. Conclusions: More research is needed to disentangle the complex issues of sexual identity and sexual risk behavior.


Introduction
In 2015, there were 25.6 million people living with HIV/AIDS (PLWHA) in sub-Saharan Africa. This represents 67% of the total number of PLWHA in the world (World Health Organization, 2017), yet Africa contains only 15% of the world's population. Additionally, the majority of new infections also occur in this region. Certain population groups such as injection drug users, sex workers and their clients, and men who have sex with men have been identified as people at higher risk of HIV. In fact, studies report high levels of HIV infection (15-20% of new HIV infections) among men who have sex with men in many African countries (Lowndes et al., 2008;Smith, Tapsoba, Peshu, Sanders, & Jaffe,

PUBLIC INTEREST STATEMENT
HIV is a global public health phenomenon. Men who have sex with men (MSM) represent one of the population groups with a higher risk of contracting the HIV virus. Hence, it is important to understand factors that put MSM at risk of HIV. This study examined the impact of homonegativity on risky sexual behavior among MSM in Ghana and Togo (West Africa) using a mixed method approach. Findings show that risky sexual behaviors among MSM are associated with sexual identity dimensions (negative identity, identity confusion, feeling of superiority) and some demographic and sexual history characteristics. It is important for stakeholders and interest groups to understand the need for improving the lives of MSM in order to reduce/break possible bridges between this group and the general population.
2009). Beyrer et al. (2010) estimated that men who have sex with men in Africa were 3.8 times more likely to be HIV positive than men in the general population. Factors such as unprotected anal intercourse, social stigma, absence of human rights protection, and limited HIV infection prevention services may explain the high HIV rates (Mayer & Beyrer, 2007).
The limited preventive measures taken to control HIV among men who have sex with men in Africa is due to the fact that the existence of same-sex sexual relationships has, until very recently, been denied or shrouded in mystery (Dankwa, 2009;Essien & Aderinto, 2009;Owusu, Anarfi, & Tenkorang, 2013). Also, cultural, moral and religious rejection, social stigmatization, and/or criminalization are other reasons for the reluctance of authorities to adequately tackle the sexual health needs of this population (Lane, Shade, McIntyre, & Morin, 2008;Mc Kenna, 1996;Niang et al., 2003).

The concept of homonegativity
The term homonegativity or homophobia has been in the sexual identity literature for some time now. It has been used by authors such as Stokes and Peterson (1998), Williamson (2000), and Shoptaw et al. (2009). Mayfield (2001) suggested that internalized homonegativity (or homophobia) is a reflection of negative beliefs about being gay, perceptions of the larger gay community and the morality of being gay. Shoptaw et al. (2009) defined homonegativity using 11 items involving anxiety, feelings of shame, and resentment over being homosexual. Williamson (2000) suggested that the concept of internalized homonegativity involved two aspects: individual pathology and institutional or societal oppression. In Kenya, Midoun et al. (2016) found that homonegative tensions influenced self-sexual identity constructions which further affected sexual decision-making. Zea, Reisen, and Díaz (2003) posit that experiences with internalized homophobia are particularly strong and involve the incorporation of disapproval of homosexual orientation and behavior from both dominant and minority cultures. Stokes and Peterson (1998), for example, mention that internalized homonegativity and sexual risk behaviors are two factors that may be strongly correlated in communities of men who have sex with men and bisexual people of color. Furthermore, Shoptaw et al. (2009) state that negative perceptions about homosexual identity is a barrier to HIV testing and associated HIV prevention and control efforts. This paper investigates the relationship between sexual identity (the impact of homonegativity) and risky sexual behaviors among sixty men who have sex with men in two West African capital cities: Accra, Ghana and Lomé, Togo. Our previous HIV-related research and literature show that men who have sex with men in Africa are not socially accepted. Social stigma and discrimination are driving them underground. Family and friends do not accept them. Also, although these two countries have different national languages (English in Ghana and French in Togo), they have a lot of similarities. For example, the eastern part of Togo was joined to Ghana and divided only during the historical partitioning of Africa by European colonialists in the 1880s, during which families and people with the same cultures and indigenous languages were simply divided geographically. Consequently, a Ghanaian and a Togolese who are both from the same ethnic group (Ewe for example) are culturally similar than two Ghanaians who are from two different ethnic groups. Due to this, even to date, some families in Ghana have their farms and other landed property in Togo and vice versa, and families cross either side of the border to visit their extended family members routinely.

Sexual identity theory and risky sexual behavior
In general, sexual identity has been studied less compared to other aspects of identity (Archer & Grey, 2009). Usually occurring during youth or early adulthood, the development of sexual identity is a process that takes place when individuals recognize their sexual attractions and begin to incorporate them into their self-identity (Mohr & Fassinger, 2000). Formerly thought of as a series of stages, development of sexual identity is now seen as a multi-dimensional, non-linear process, as individuals experience it in different ways (Mohr & Fassinger, 2000). Sexual identity among sexual minority groups (gay, lesbians, bisexuals, etc.) may be a challenging process because of heteronormativity, discrimination, stigma, and rejection.
Sexual identity may be important to the prevention of HIV/AIDS among African men who have sex with men in that studies have shown links between sexual identity issues and risky sexual behaviors in non-African settings. For example, psychological distress and lack of social support for one's identity increase one's likelihood to use condoms inconsistently, have multiple sexual partners, have sex under the influence of drugs or alcohol, or have sex in exchange for money among African American men (Midoun et al., 2016;Myers, Javanbakht, Martinez, & Obediah, 2003). Rosser, Bockting, Ross, Miner, and Coleman (2008) also found a negative correlation between levels of internalized homophobia and the process of publicly acknowledging one's sex-same attractions among American men who have sex with men. Additionally, males who conceal their sexual orientation because of internalized homonegativity tend to exhibit risky sexual behavior (Ross et al., 2001). Ross, Rosser, and Neumaier (2008) also found that internalized homonegativity was related to higher rates of unprotected sex and lower condom self-efficacy.

HIV infection rates in African regions and countries
High HIV prevalence among men who have sex with men has also been reported in other African countries (Baral et al., 2011;Legrand, Yomb, Bourrelly, & Lorente, 2010;McDaid & Hart, 2010;Millett et al., 2012;Okonofua, 2012;Smith et al., 2009). Yet, across the African region, there are great disparities in the prevalence of HIV among this subgroup. Figures from UNAIDS' Global AIDS Response Progress Reporting (2014a) indicate a range from less than 4% in Egypt to 52% in Mauritania, and less than 5% for Burkina Faso to about 55% in Guinea. UNAIDS's Gap Report (UNAIDS, 2014b), cites a median HIV prevalence of 19% among gay men and men who have sex with men in western and central Africa, 13% in eastern and southern Africa, and 7% in Northern Africa. However, UNAIDS's Global AIDS Response Progress Reporting (2014a) gives the highest median HIV prevalence among this population as 15% in western and central Africa, 14% in eastern and southern Africa.
In an environment where homosexuals are ostracized and their health and sexual needs overlooked in HIV planning and prevention programs, we examine the hypothesis that a sexual identity based on homonegativity has a correlation with risky sexual behavior among men who have sex with men. We examine these relationships in the context of Mohr's and Fassinger's lesbian, gay, and bisexual identity scale (LGBIS) (Mohr & Fassinger, 2000). Three main questions guide this research, namely: (1) What are the risky sexual behaviors in which men who have sex with men engage?
(2) Is there a correlation between the risky sexual behavior and sexual identity among men who have sex with men?
(3) What kind of environments do men who have sex with men in Accra and Lomé experience that influence their sexual identity and risk behaviors?

Study design and procedures
We conducted cross-sectional surveys and qualitative interviews with 60 men who have sex with men to investigate their sexual history and examine how risky sexual behavior is explained by aspects of their sexual identity. We derived three measures of sexual identity from Mohr's and Fassinger's (2000) lesbian, gay, and bisexual identity scale (LGBIS). We used these three measures of sexual identity as the main independent variables stemming from the idea that the near-repressive environment within which our respondents practice their sexual behavior in the two study cities, will be associated with a higher probability of engaging in risky sexual behavior. In the qualitative portion, we wanted to understand whether homonegativity, stigma, and discrimination are related to the lived experiences of these men and their sexual behavior based on their own words.
Sixty men who have sex with men (40 in Accra and 20 in Lomẻ) were recruited via convenience sampling from October 2012 to July 2013. We contacted a director/manager of the only HIV center that caters to the needs of men who have sex with men in Lomé, Togo, which is run by an international non-governmental organization (INGO). We explained the purpose of the study to him and asked for his help in recruiting potential participants. In Ghana, we contacted a man who identified himself as a person who has sex with men. This person managed programs that are related to men who have sex with men for an internationally funded NGO as part of the activities of an HIV and AIDS advocacy, treatment, and support initiative. He had responsibility for research and health education as part of the NGO's response to HIV & AIDS in the country. This person had openly declared his sexual preference to a research assistant and in relation to his official assignment, had previously mentioned his wish to facilitate studies related to men who have sex with men. We explained the purpose of the study to him and asked for his help in recruiting potential participants. His outfit then spoke with the potential respondents, and those who agreed to participate were interviewed.
To be included in the study, participants had to be at least 18 years old and a male who has sex with other males. The study protocol was approved by the University of North Texas Institutional Review Board. A consent form was signed by each participant prior to both survey and qualitative interview. Respondents were assured of confidentiality before the interview. Interviews lasted 50 min on average, with a range of 29-62 min. The modal time was about 34 min. The average time was the same in both Lomé and in Accra. The questions were interviewer administered in face-toface, paper-and-pencil sessions.
The first author collected both the qualitative and quantitative data in both Lomé and Accra. The first author is a native Ewe from Togo. She speaks French, English and Mina (a native language of Togo). All respondents in Togo chose to be interviewed in French, except two who were interviewed in Mina. However, all the Ghanaian participants were interviewed in English. Pretesting was done in each city using respondents who were not interviewed again in the main data collection exercises. In Lomé, five respondents were used for the pretesting, and in Accra, eight were used. The respondents used for the pretesting mostly pointed out that some of the questions were not too direct/focused, and suggested how best to reword them. For instance, it is not considered polite to mention the direct names of the sexual organs and sexual intercourse, thus euphemisms are often used in referring to them. However, they asked us to mention them specifically as they are called in the various languages and assured us that their colleagues will not be offended with that, which we found true during the interviews. The data collection instruments were finalized after the pretesting. A tape recording device was used from start to end for each interview session.
A semi-structured interview guide was used for qualitative data collection. Follow-up questions and probes such as "what do you mean when you stated that …" and "can you tell me more about that" were used to get to the depth of the answers. The data were transcribed verbatim by a professional who was not involved in the study. This professional works with a demographic research company in Lomė, and has worked on some of our past projects.

Quantitative data
The questionnaire for the survey included two parts. The first part asked demographic information and questions on sexual history that were used as dependent variables, including number of sexual partners in the past 3 months, condom use during sexual intercourse (vaginal and anal), and exchange of sex for valued resources. This section also included questions for control variables, including respondent's age, age at first sex, number of lifetime sexual partners, and level of education (in years). The second portion of the questionnaire used Mohr and Fassinger's (2000) Lesbian, Gay, and Bisexual Identity Scale (LGBIS), a 27-item measure that assesses six dimensions of sexual identity among sexual minorities: 1-internalized homonegativity, 2-need for privacy, 3-need for acceptance, 4-difficult process, 5-identity confusion, and 6-superiority. Mohr and Fassinger (2000) then regrouped the six dimensions into three because the first four dimensions (homonegativity, need for privacy, need for acceptance, and difficult process) loaded on a single, second order factor which they called "negative identity." Based on our hypothesis, we adopted these three dimensions for our key independent variables, and they are: A-negative identity, B-identity confusion, and C-superiority. Each of the 27 items has seven-point Likert type responses with 1 = disagree strongly to 7 = agree strongly (Table 2).

Qualitative data
Participants were asked questions about their sexual history, such as circumstance of their first sexual encounter and gender of the person, risky sexual behavior such as condom use/non-use, whether one has ever exchanged sex for a valued resource, and reasons for each of the sexual behaviors. Each participants were also asked to describe life as a men who has sex with men, including the daily challenges that they encountered and ways they overcame them. Finally, participants were asked if they had disclosed their sexual orientation to their family members and the reasons for disclosure/non-disclosure. In cases of disclosure, they were asked to describe the reaction of family members, to reveal discrimination or stigma that they experienced. In this paper, we report findings related to homonegativity and ways this influences sexual identity and risky sexual behavior. Table 1 shows demographic characteristics of the respondents. The mean age of the sample was about 22 years. They had a mean of about 11 years of education. All respondents were single, but about 7% had children. The mean age at which they had their first sexual intercourse was 14 years. The mean number of the people they had had sex with in their lifetime was 22. Also, in the last three months prior to the study, the respondents had sex with a mean number of 5 people. The respondents reported being mostly HIV negative (about 82%). Most of them consistently used condoms (69%) in the past three months prior to the study. Seventeen percent reported they had ever had a sexually transmitted infection, and about 32% had ever exchanged sex for money or a valuable resource. While 48% were employed, 40% were still attending school, and almost 12% were unemployed.

Data analysis
We examined the relationship between each of the three risky sexual behaviors ((a) exchanging sex for a valued resource; (b) inconsistent condom use [during vaginal and/or anal intercourse]; and (c) having more than one sexual partner in the past 3 months) and sexual identity. We used a binary logistic regression model that included each of the three dimensions of the LGBIS scale and also controlled for age at first sexual intercourse, total number of sexual partners, age, and number of years of education.
The analysis of the qualitative data followed a grounded theory approach (Corbin & Strauss, 2008). First, the data were open-coded line by line, whereby each author independently broke the interviewees' comments into different codes. Second, through axial coding, categories and relationships among them were explored. Also, ideas, events, and experiences that were relevant to sexual identity of the respondents were examined. Third, selective coding generated a grounded theory of homonegativity among study participants. Homonegativity was a process that loved ones, society, and even participants were all involved in, and which ultimately impacted both sexual identity and behavior of participants. Saturation was achieved when we established relationships among categories and we could no longer found new concept.

Quantitative results
Results of the univariate analyses are found in Table 2. Means, standard deviations, ranges, and internal-consistency reliabilities were calculated for the three scales (Table 2). Negative identity scores ranged from 2.40 to 5.90, with higher scores indicating greater feelings of negative identity. On average, respondents felt fairly negative about their status (mean = 4.34; SD = 0.77). The reliability of this scale in this sample was α = .60 indicating moderate reliability. Scores for the identity confusion scale ranged from 1 to 7, with higher scores indicating more confusion about one's sexual identity. The reliability coefficient for this sample was α = 0.70, a relatively strong indication of internal consistency for the items in this scale. The average score on this scale (mean = 3.2; SD = 1.77) suggests only moderate identity confusion among the sample. Scores on the superiority scale ranged from 1 to 7 with higher scores meaning one feels superior toward heterosexuals. The reliability in this sample was α = 0.68. The mean for this scale is a low 2.71 (SD = 1.97) indicating that on average, respondents did not feel very superior to heterosexuals.
Three models were constructed, each using a dependent variable that measures a risky sexual behavior ((a) exchanging sex for a valued resource; (b) inconsistent condom use; and (c) having more than one sexual partner in the past 3 months). Table 3 shows the variation in the odds of exchanging sex for a valued resource. Negative identity, identity confusion, and number of lifetime sexual partners, were each significantly associated with exchanging sex for valuable resources. In fact, respondents experienced nearly a 90% reduction in the odds of exchanging sex for valued resources (odds ratio = 0.095), for every unit increase in negative identity. However, for each unit increase in identity confusion, the odds of exchanging sex for valued resources are more than 3 times as large, while the odds of exchanging sex increases by 15% with each additional lifetime sexual partner. Table 4 shows the results for the second dependent variable. Age at first sexual intercourse (odds ratio = 0.58) is negatively associated with inconsistent condom use. The odds of engaging in an inconsistent use of condoms reduces by 42% with each additional year of delay in initiation of sexual intercourse. However, the odds of inconsistent condom use is also positively related to the number of lifetime sexual partners, meaning the higher the number of lifetime sexual partners, the greater the odds (odds ratio = 1.13) of inconsistent use of condoms.
Finally, Table 5 shows that having multiple sexual partners in the three months prior to the study (the third dependent variable) is positively associated with identity confusion, number of lifetime sexual partners, and number of years of education (Table 5). Each unit increase in the score of identity confusion increases the odds of having multiple sexual partners by more than 3 times (Odds ratio = 3.69). Also, an additional increase in the number of lifetime sexual partners increases the   odds of having had sex with more than one partner in the past three months (odds ratio = 1.13). Finally, a year's increase in education also increases the odds (odds ratio = 2.50) of having sex with more than one person in the past three months.

Qualitative findings
Data analysis generated a grounded theory of homonegativity among study participants. Homonegativity was a process that loved ones, society, and even participants were all involved in, and which ultimately impacted both sexual identity and behavior as indicated by these three main components: (a) loved ones' attitudes toward their sexual orientation and risky sexual behavior, (b) societal attitudes toward sexual orientation and sexual identity, and (c) respondents' attitudes toward themselves.

Loved ones' homonegativity, sexual identity, and risky sexual behavior
A minority of the respondents (8%) reported that their parents, especially mothers, accepted their sexual orientation. However, most of them reported significant difficulties such as discrimination, rejection, and regular insults from their loved ones, including their parents. Those who described these reactions often adopted a double sexual identity that impacted their risky sexual behavior. They concealed their homosexual or bisexual identity from people, including their female sexual partners. For instance, an 18-year old male who was caught having sex with another male when he was 15 years old and was severely beaten by his parents noted the following: R1: Whenever my parents asked me if I still continue that lifestyle (having sex with men), I tell them No. I even found a girlfriend and brought her to my house to prove to them (parents) that I am now straight.
By bringing a girlfriend to the house, this man was able to convince his parents that he was straight. Generally, the concealment of one's true sexual identity was not only limited to the parents but also the girlfriends. This practice was quite common among the males in our sample.
Another respondent who never disclosed his true sexual identity to any of his girlfriends explained: R2: To my girlfriends, I am a heterosexual. As a girlfriend, boyfriend, I cannot tell these women that I sleep with men too. If we ever break-up, then they will insult me and gossip about my sexual orientation. Then what will happen next? Some people may use this information and hurt me afterward.
As suggested by the comments above, concealing one's true sexual identity is a strategy of social survival in an environment that is very resentful of homosexuality. Such behavior is adamantly shunned by loved ones as well as the general public. It is an environment that is firmly homonegative and merciless toward people with homosexual and bisexual identity.

Societal homonegativity and sexual identity
The general populations in both Ghana and Togo express repugnance towards homosexuals. All of the respondents whose sexual orientation is known to the general public shared how people treat them badly. Some have been gang-beaten, others have been yelled at, insulted, and ridiculed. Still others have been evicted from their residence.
The comments below explained some of the problems that the men face from the general public and why they conceal their sexual identity: R3: We are often discriminated against. People ridicule us and at times want to hurt us. One day a man called me on my cell phone and gave me a rendezvous at night. When I arrived at the date, I saw four men. One acted as if he was going to court me. Suddenly, they all ganged up on me and began to beat me. I had a pair of scissors in my bag with me since I was back from work (he is a tailor). I was able to withdraw my pair of scissors and cut one person with it. When they saw their friend bleeding, they all ran away. I am not sure what would have happened to me that day if I had not had the scissors with me. . . . As men who have sex with men, we are very careful about identifying ourselves as such because people can hurt us.
Some of the respondents also shared the ways some people try to avoid them as if they had something contagious-(a damaged or tainted identity).
R4: Sometimes if a man and a woman are coming in the opposite direction, the woman usually grabs the man when they come close to you, they will move away from your path as if you will contaminate the man or something. It is a difficult life. You have to be brave to openly live it and share your sexual identity with people.
In both Ghana and Togo, people do not hide their disdain toward men who have sex with men. Some actively express their disdain by threatening and even harming these men. Others use milder cues to show their avoidance of this group. All of these behaviors, in fact, affect the lives of these men and their sexual identity.

Personal attitudes toward themselves
As the men that we studied go through all the challenges and difficulties associated with having sex with men, some wished they were straight and would not have to experience all the problems in their lives. Others became deeply affected by the ways they were treated by both their loved ones and society. They then, at times, questioned their sexual identity. As stated below, a few respondents asked God, why they have to be attracted to men or both men and women?
R5: I know that my Mom hates me. She loves all my siblings except me because of my sexual orientation. Sometimes, I cry and ask God why he made me this way. I want to stop having sex with men, but I can't. I will stop for a while, 6 months or so, but then I feel the urge again. I can't.
Another one simply explained: R6: Being a homosexual is a very difficult life. You are in disharmony with yourself, your God, your friends, and your parents. It is a life that is devoid of telling the truth.

Discussion
This exploratory study used a mixed methods approach to examine sexual identity and risky sexual behavior among men who have sex with men in Ghana and Togo. It found some significant correlations between sexual identity and risky sexual behaviors in this group. Specifically, the quantitative findings suggest that negative sexual identity among men who have sex with men significantly reduces the odds of exchanging sex for a valued resource, contrary to our expectation of a positive association, but does not significantly change the odds of inconsistent condom use during a vaginal and/or anal intercourse, or the odds of having multiple partners. As negative sexual identity represents the overall difficulties related to sexual orientation identity (Mohr & Fassinger, 2000), a possible explanation for this association is that males with negative identity about their sexual orientation might have some difficulties accepting their sexual orientation and thus are less likely to exchange sex with other men for valued resources. It could also be that these men might be hesitant or fearful to self-identify as homosexual or gay because of the unwelcoming social environment and violence that they face. While our conclusion about this relationship is based on the regression results, we learn from the qualitative results that some participants go to great lengths to conceal their status.
Identity confusion, on the other hand, increases the chances of exchanging sex for valued resources as well as those of having multiple sexual partners, as indicated in the extant literature (Mustanski, Garofalo, Herrick, & Donenberg, 2007;Schwartz, Mason, Pantin, & Szapocznik, 2008). Moreover, the fact that family members and society objected to their sexual orientation may lead to conflict within oneself about one's sexual identity as found in Kenya (Midoun et al., 2016). As these men generally did not receive support from family, they might exchange sex for valuable resources in order to secure not only material goods but also emotional and psychological support from sexual partners. It is important to note from our qualitative findings that such an environment also led some respondents to have sex with women in order to conceal their homosexuality.
Furthermore, no identity factors significantly correlated with inconsistent use of condoms, contrary to findings by Myers et al. (2003). This may be explained by the high rate of condom use among participant (69%). However, the negative relationship between age at first sexual intercourse and the odds of inconsistent use of condoms may be due to the fact that young people tend to have less skill to negotiate their early sexual activities as they are inexperienced and less confident in themselves (Juarez & LeGrand, 2005). The control for number of lifetime sexual partners significantly increased the odds of engaging in all the three sexual risk behaviors (exchange of sex for valued resources, having sex with more than one person in past 3 months, and inconsistent use of condoms).
The qualitative findings show homonegativity and negative identity may be factors in HIV-related risky factors behavior. This homonegativity also means that some of the respondents were literally obliged to have multiple sexual partners by being bisexual, in their effort to make themselves and their sexual orientation (heterosexuality) more acceptable to their family members and society at large. Additionally, part of our quantitative findings support our qualitative findings and lends credence to our hypothesis that homonegativity has the potential to induce risky sexual behaviors with implications for higher risk of HIV infection for men who have sex with men, specifically that a higher number of sexual partners increases the odds of engaging in all three risky sexual behaviors ((a) exchanging sex for valued resources, (b) having multiple sexual partners within the last three months, and (c) using condoms inconsistently).
To our knowledge, this study is the first attempt to study identity dimensions among men who have sex with men in Ghana and Togo, a hard to reach population group. Results indicate to some extent identity problems among our study participants. However, several limitations should be considered in interpreting the study findings. First, because the data were cross sectional data, causality cannot be inferred. Also, our study may have not been sufficiently powered given the small sample size. Additionally, accounts of risky sexual behaviors and sexual identity were self-reported. Selfreport data have been shown to be biased by social desirability issues (Gordis, 2013). Furthermore, because the study used a small sample, data may not be representative of all men who have sex with men in both countries, hence, results must be interpreted with caution. Finally, the subscales had somewhat lower reliability coefficients. These may be due to the small size and the non-representativeness of the sample.
Despite these limitations, this exploratory study is an attempt to study a hard to reach population. The results give insight into risky sexual behavior and sexual identity in the lives of both Ghanaian and Togolese men who have sex with men. The findings show that risky sexual behavior among this subgroup correlate with sexual identity dimensions. More research is needed to disentangle the complex issues of sexual identity and sexual risk behavior. It is also important for stakeholders to devise ways to prepare the general population on issues affecting men who have sex with men and the importance of accepting these men in order to reduce/break possible bridges in HIV transmission between this group and the general population.