Men who have sex with other men (MSM) comprise the largest proportion of Americans who have been diagnosed with HIV or AIDS, accounting for 57% of all reported cases of AIDS with a known source of transmission and 57% of all HIV-positive persons who believed that they knew how they became HIV-infected [1
]. Despite the so-called “changing face of AIDS in America,” these percentages for MSM have declined very little during the past ten years [2
In light of this, numerous studies have been conducted to identify why, 25+ years into the HIV/AIDS epidemic, so many men continue to place themselves at risk for contracting HIV and/or other sexually transmitted infections. Many factors have been identified, including the belief that engaging in unprotected sex is an expression of individual choice [4
], the belief that engaging in unprotected sex is an expression of masculinity [6
], the perception that AIDS antiretroviral drugs have made HIV/AIDS less of a health concern now than in prior years [9
], a fear of being rejected sexually by partners who dislike condoms [10
], the belief that sex is more pleasurable when condoms are not used [11
], feeling “burned out” by worrying about becoming HIV-infected [9
], and feeling a greater sense of emotional connectedness to sexual partners with whom one had unprotected rather than protected sex [13
How men who wish to have high-risk sex with other men locate potential sex partners has been the subject of relatively little research, however. For many men, “traditional” avenues of meeting other men–e.g., gay bars, gay/bisexual-oriented social activities, personal ads–remain popular ways of meeting potential sex partners. Another common way for men who wish to have unprotected sex with other men to locate potential partners is by frequenting public venues (e.g., parks, rest areas, rest rooms) where male-to-male cruising is known to take place. In recent years, with the proliferation of the internet, many men who wish to find other men specifically for engaging in unprotected sex appear to be turning to MSM-oriented websites for this purpose. For example, in a sample of gay men who were recruited into a health promotion study via gay-oriented internet websites [15
], Bolding and colleagues’ multivariate analysis revealed that the amount of risky sex in which men engaged was a significant predictor of their use of internet websites to locate sex partners. In another study [16
], among men actively using the internet as a means of locating potential sex partners, 97% reported actually having met someone online for sex, and 86% said that they used internet MSM sex sites at least once a week to identify possible partners. Another study examining the role that internet usage plays with regard to HIV risk taking found that persons who had a history of meeting sex partners via the internet reported more frequent involvement in risky sexual behaviors than persons who had not met sex partners online [17
]. Comparable findings were reported by Benotsch, Kalichman and Cage [18
], whose study of Atlanta area gay men found a greater likelihood of methamphetamine use, a larger number of sex partners, and a greater proportion of unprotected sex among men who used the internet to find sex partners. Similarly, in an online survey of men who engage in sex with other men, Berg [19
] reported that those who use the internet to find sex partners were more likely than those who did not to engage in unprotected anal sex. Based on a multi-site internet study of MSM, Mutanski [17
] found that a history of online sex-seeking was associated with a greater number of past-year sex partners, a larger number of one-time sex partners, more unprotected sex, and a lack of discussing sex partners’ sexual histories. Clearly, there has been mounting evidence of the importance of the role that the internet plays in fostering sexual encounters between men who specifically wish to have unprotected sex with other men.
Not as well understood, however, is the role that the internet plays in fostering drug use/abuse among MSM who meet for sex. This is, in part, the focus of the present paper. Research that has
been done on this subject indicates a tendency for drug use to be greater or more problematic among men who use the internet to find sex partners. For example, Taylor, Aynalem, Smith, Montoya and Kerndt [20
] reported that methamphetamine use was greater among men in their sample who used the internet to identify partners for sex. As another example, based on a comparison of men recruited from the internet and those recruited from a local Miami-area community, Fernandez and colleagues [21
] found that club drug use was higher among MSM from their internet sample. They also noted that the club drug use in their internet sample was associated with a greater propensity to engage in unprotected sex–a finding that was not replicated among their non-internet-recruited study participants. Compounding the preceding problems, some research has shown that drug users are less inclined than those who do not use illegal drugs to participate in internet-based HIV risk reduction intervention programs [22
]. As a general rule, however, more needs to be learned about the role that the internet plays in fostering drug use encounters and/or drug-related problems among MSM using websites to identify potential sex partners.
Also not well-understood is the role that the internet plays in fostering sexual encounters and risky practices among men who do not self-identify as gay or bisexual, but who use the internet to find other men with whom they can have sex. This is the other main focal area of the present study. Although behaviorally men who have sex with other men can be classified as gay or bisexual, in terms of their self-identity, not all of these persons consider themselves to be gay or bisexual. Indeed, many men who have sex with other men think of themselves as heterosexual/straight, or choose to label themselves as “sexually curious” instead. Both in the mass media and in the scholarly literature, these men are sometimes referred to as “being on the down-low” [23
] or as engaging in “dude sex” [26
]. Research on their sexual and risk behavior practices is sparse, but what has
been published suggests that MSM who do not consider themselves to be gay or bisexual often engage in a variety of risky practices. For example, Siegel and colleagues [24
] found that unprotected sex was common in this population, with nearly one-quarter of their study participants reporting both unprotected vaginal and unprotected anal sex during the preceding three months. Generally speaking, however, little is known about this population–a lament that has been voiced by other scholars as well [27
Given: (1) the growing role that the internet appears to be playing in risky practices among MSM, (2) the general dearth of knowledge pertaining to drug use behaviors/problems, and (3) the dearth of information pertaining to risky practices among internet-using MSM who do not self-identify as gay or bisexual, the present study represents an effort to bridge part of this gap in knowledge. The emphasis in this paper is on sexual risk practices (both those entailing risk for HIV as well as those entailing risk for other sexually transmitted infections) and risk-related behavioral preferences sought by men who use the internet specifically to identify partners with whom they can engage in unprotected sex. Comparisons are made amongst four self-identified groups: gay/bisexual men who look online for partners with whom they can engage in sex while high, gay/bisexual men who look online for men with whom they can engage in sex while not being under the influence of alcohol or other drugs, heterosexual/“curious” men who use the internet to identify partners with whom they can engage in sex while high, and heterosexual/“curious” men who use the internet to find partners with whom they can engage in sex without being under the influence of alcohol or other drugs. Three main research questions are examined: First, are there differences in the extent to which men in these four groups seek risky behaviors in their online profiles? Second, do these four groups differ in terms of their risk-related preferences regarding how they want to have sex? Third, do the men in these four groups differ in terms of their sexual role preferences, their HIV serostatus, or the HIV serostatus they prefer in potential sex partners? Obtaining the answers to all of these questions is crucial if one wishes to understand how sexual orientation and drug use preference during sex mutually influence men’s behaviors, and then on that basis develop an informed prevention and/or intervention effort targeting the risk behaviors of men who use the internet to locate other men with whom they can engage in risky sex.
This research relies upon content analysis as the principal analytical tool. The data were collected between September 2006 and September 2007 using one of the largest MSM-oriented websites currently available on the internet. The website was chosen because it is free to the public, findable by virtually any internet search utilizing common key words like “bareback,” and because it boasts a large and steadily growing membership. At the time the data were collected, the site had more than 145,000 registered users (the large majority of whom resided in the United States) and it was growing at a rate of several hundred persons per month. This website allows members to post profiles (including photographs) describing themselves, and there are no length restrictions placed on profiles posted (see Endnote 1
). In addition, there are specific places in their profiles where members are instructed to indicate the type(s) of relationships they are seeking (long-term relationships, one-on-one sexual encounters, three-way sexual encounters, and so forth), specific sexual acts that they would like to practice with a willing partner, and a free-for-all field that can be used to provide supplemental information about one’s most-sought-after traits or behaviors. Essentially, the large, stable, and growing membership of this website, coupled with members’ ability to describe themselves as fully as they choose, made this particular website an ideal candidate for the present content analysis research.
The content analysis was based on a random sample of users’ profiles, randomly selected by ZIP code, which is a searchable feature on the site. To facilitate comparisons based on sexual orientation, a random oversampling of 118 men who self-identified as heterosexual or “curious” supplemented the initial random sample (which also contained some men who considered themselves to be heterosexual or “curious”). Men residing outside of the United States were excluded from this research, so as to keep it an America-focused study. Also excluded from analysis (n = 6) were profiles that had not been filled out completely (i.e., with the user not providing at least one piece of the required information on each profile page on the website). In order to be included in the analyses, a user’s profile had to remain active at the conclusion of the data collection period, to guard against “experimenters” or one-time-only visitors to the site being included in the study. This led to the exclusion of 67 cases (4.8%). In all, 1,434 profiles constitute the sample for this research.
2.1. Data Collected
For each profile, the following information was collected: age; race/ethnicity (Caucasian, African American, Latino, Asian, Native American, or biracial/multiracial); self-identification as being a “top,” a versatile top, versatile, a versatile “bottom,” or a bottom (see Endnote 2
); self-reported HIV serostatus (negative, positive, or unknown); desired HIV serostatus in sex partners (must be negative, may be negative, must be positive, may be positive, do not care); self-identified sexual orientation (gay, bisexual, “curious,” heterosexual); willingness to give and receive ejaculatory fluid in the mouth and anus; type(s) of “relationships” sought (one-on-one sexual encounter, long-term relationship, three-person sexual encounter, multiple partner sexual encounter, activities partner); the user’s ZIP code (which was used to compute population density as a macro-level analytical variable); and whether or not the user had opted for an expanded, paid membership on the site.
In addition, data collection also entailed coding for a wide variety of specific sexual behaviors, including among others felching (eating ejaculatory fluid that has been inserted into one person’s anus and then feeding it back to that individual by mouth, usually with a kiss), rimming (oral stimulation of the anus), bukkake (ejaculating directly onto another person’s mouth and face), and double penetration (forcing two penises into the same anus simultaneously). Finally, a variety of risk-enhancing practices and attitudes (hereinafter referred to as “risk preferences”) were also coded, including a stated preference for engaging in rough sex, having sexual relations while high (known in the target community as PNP, or “partying and playing”), overtly stating that they will not use condoms and/or that they will not permit their partners to use condoms, actively trying to become HIV-infected (known in the target community as “bug chasing”), actively trying to infect partners with HIV (known as “gift giving”), refusing to withdraw the penis prior to ejaculation and/or refusing to allow a sex partner to withdraw his penis prior to ejaculation, an overt preference for anonymous sex (i.e., sexual encounters in which the name and/or face of the sexual partner(s) is/are unknown), a stated preference for having long-lasting sexual encounters, an expression of seeking sexual encounters that are “uninhibited” or “no holds barred,” and eroticizing ejaculation fluid (known in the target community as being a “cum whore” or a “cum freak” or a “cum lover”).
The principal independent variable used in these analyses is a categorical measure combining information pertaining to men’s sexual orientation (self-identified, as described above) and their preference for/against having sex while high. Four groups are compared: (1) gay/bisexual men who look online for partners with whom they can engage in sex while high (n = 722), (2) gay/bisexual men who look online for men with whom they can engage in sex while not being under the influence of alcohol or other drugs (n = 578), (3) heterosexual/“curious” men who use the internet to identify partners with whom they can engage in sex while high (n = 44), and (4) heterosexual/“curious” men who use the internet to find partners with whom they can engage in sex without being under the influence of alcohol or other drugs (n = 90).
2.2. Research Questions and Analysis
Research Question #1 is “Are there differences in the extent to which men in these four groups seek risky behaviors in their online profiles?” Analytically, this can be examined with chi-square tests, since the dependent variables in question (e.g., felching, insertive/receptive oral sex, insertive/receptive anal sex) are dichotomous in nature. Post hoc comparisons tests were performed for all statistically-significant main effects relationships, to “tease out” the specific nature of the findings regarding sexual orientation versus drug use preference during sex versus the interaction effects of both of these measures. These post hoc tests entailed the computation of odds ratios, because this particular statistical method enables direct comparison of one group (or combination of subgroups) with another. Research Question #2 is “Do these four groups differ in terms of their risk-related preferences regarding how they want to have sex?” This too can be answered with chi-square tests (and post hoc testing as just described, whenever appropriate) because, once again, the dependent variables are dichotomous measures (e.g., wanting rough sex, seeking anonymous sex, wanting long-lasting sex). Research Question #3 is “Do the men in these four groups differ in terms of their sexual role preferences, their HIV serostatus, or the HIV serostatus they prefer in potential sex partners?” Again, because these measures are dichotomous or categorical in nature, chi-square tests (and post hoc testing as just described, whenever appropriate) are appropriate analytically. Results are reported as statistically-significant whenever p < 0.05.