In recent years, sexual risk behavior and sexually transmitted disease (STD) rates have been rising among men who have sex with men (MSM) [1–4], and increasing HIV incidence may follow . During approximately the same period, a sociocultural phenomenon called ‘barebacking’ emerged among MSM [6–9]. Barebacking has been described as a phenomenon whereby some men intentionally engage in unprotected anal sex for various reasons or motivations [9–11], although the specific conceptualization of barebacking varies [12,13]. For example, some have applied the concept primarily to HIV-positive men  or partners with the same HIV serostatus .
We propose that, from a sociocultural perspective, the term ‘barebacking’ (for both HIV-negative and HIV-positive MSM) be reserved for intentional anal sex without a condom with men who are not a primary partner (i.e. not someone the individual lives with or sees often and with whom the individual feels a special emotional commitment) among men who had heard of the term. A key aspect of this definition is intent; the individual consciously seeks unprotected anal sex. Intentionality distinguishes barebacking from poor planning or spontaneous decisions about condom use. Another key element of the definition is that the sexual partner is a non-primary partner and, therefore, the behavior is not in the context of ‘negotiated safety’ . The proposed definition thus refers to behavior that is a decided transgression from public health guidelines [16,17].
The study reported here assessed the extent to which MSM had heard of the term ‘barebacking’ and thus were likely to be familiar with the sociocultural context of the behavior. If men had not heard of the term, they were not part of the particular sociocultural phenomenon. Among MSM aware of the term and among the full sample, we examined the prevalence of barebacking in HIV-positive and HIV-negative MSM, the perceived HIV serostatus of their barebacking partners, and the specific sexual behaviors that occurred during their most recent bareback encounter. We assessed reasons for barebacking and where men met their partners. Finally, we examined whether men who barebacked had a higher general sexual risk behavioral and attitudinal profile compared with other men.
Materials and methods
Recruitment and data collection
Data were collected from July 2000 to February 2001. A convenience sample of men were recruited at or outside various venues (e.g. 13 bars, 15 dance clubs, 20 community service agencies), at street locations in the San Francisco Bay Area, including locations in the City of San Francisco (Tenderloin, Mission and Castro Districts) and East Bay (Oakland), and through snowball sampling. High-density recruitment locations were identified through focus groups in formative research, pilot testing, and previous research projects. Five trained peer staff worked a variety of day and evening hours to recruit participants. African-American and Latino MSM were over-sampled to increase their representativeness in the study; venues with a high density of HIV-positive men were also over-sampled.
To be eligible for the survey, men had to be at least 18 years old, live or work in the San Francisco Bay Area, and either identify as gay/bisexual or report having had sex with a man in the previous 12 months. All men were approached for eligibility screening (a brief set of closed-ended questions) as they walked towards recruitment venues; several staff worked together at the recruitment locations. A total of 2278 men were approached for recruitment, of which 62% agreed to be screened on site. Of the 1413 men screened, 1061 were eligible, and 842 agreed to complete the full survey. The reasons for the ineligibility of those screened included: did not live or work in the San Francisco Bay Area (20%); did not identify as gay or bisexual and had not had sex with a man in the previous 12 months (7%); and younger than 18 years (< 1%). Of the 842 candidates who were fully eligible and agreed to participate, 66% completed the survey.
After recruitment, participants were scheduled for interviews at one of four locations (San Francisco Health Department or community agencies in surrounding areas). Participants gave informed consent, completed a 1 h interviewer-administered questionnaire, and received a US$25 stipend.
Participants were first asked if they had ever heard of ‘barebacking’ in order to assess the prevalence of the awareness of the term. At this point, barebacking was intentionally undefined. Because of its various conceptualizations, we wanted to include every man for whom the sociocultural phenomenon of barebacking could possibly be pertinent. Men who were aware of the term were asked if they had been involved in a barebacking encounter in the previous 2 years. At this juncture, the operational definition of barebacking was presented as they had ‘intentionally set out to have unprotected anal sex with someone other than a primary partner (a primary partner is someone who you live with or have seen a lot and to whom you feel a special emotional commitment)'. Those men who said they had barebacked reported the number of such partners in the previous year, and provided specific information on their most recent bareback encounter (e.g. perceived HIV status of partner, specific behaviors). They were asked about where they met bareback partners and about their primary reasons for barebacking.
To assess general sexual risk behavior, all participants reported whether or not they had engaged in unprotected anal sex (separately for receptive and insertive) with male partners (separately for HIV-positive, HIV-negative and HIV-unknown partners) in the previous 3 months. The men were asked whether or not they used alcohol or other drugs (i.e. cocaine, crack, ecstasy, γ-hydroxybutyrate/γ-butyrolactone, heroin, ketamine, crystal methamphetamine, hallucinogens, marijuana, poppers) and if they had experienced a substance ‘over-use’ instance (i.e. passed out, needed medical assistance or could not take care of self) in the past 3 months. Participants self-reported their HIV status and 12 month history of STD infections (chlamydia, gonorrhea, syphilis and non-specific urethritis). The men were asked about their level of agreement with statements that knowing: (i) about improved treatments, and (ii) that fewer individuals are developing AIDS, had caused them to have more unprotected sex (agreement was a rating of 4 or 5 on a 5-point Likert scale). Participants were also asked about the percentage of time they would be willing to use a future microbicide lubricant during anal sex (without a condom) that was 50% effective in preventing HIV transmission.
Bivariate analyses used chi-square tests to assess differences (P < 0.05) in awareness of barebacking and bareback behavior by demographic and other descriptive variables. Multivariate logistic regression analysis on barebacking awareness was conducted for highly correlated demographic variables (white versus other race/ethnicity, income, education, gay versus bisexual identification) that were associated with univariate differences in awareness.
Chi-square tests were used to compare HIV-positive and -negative participants who barebacked with regards to specific risk behaviors during their most recent bareback encounter (e.g. unprotected insertive or receptive anal sex), venues or approaches used to meet partners, and primary reasons for barebacking. Men who had barebacked in the past 2 years were compared with men who had not barebacked in terms of general 3 month unprotected anal sex, 12 month STD rates, substance use and over-use, beliefs about HIV disease, and attitudes about rectal microbicides using chi-square tests. For general 3 month risk behavior, unprotected anal sex with a serodiscordant partner (i.e. partner's serostatus known to be different from the respondent's serostatus) or with a partner of unknown serostatus were examined as the riskiest sexual behaviors.
Of the 554 participants, 28% were African-American, 27% Latino, 31% white, and the remainder were another race/ethnicity or a combination. Median age was 35 years (range 18–67). Thirty-five per cent of the sample reported being HIV-positive, 61% reported being HIV-negative, and 4% did not know their serostatus. Their annual income ranged from less than US$10 000 (30% of the sample), to US$10 000–29 999 (35%), to US$30 000 or above (35%). Regarding education, 30% had a high school diploma or less, 34% had some post-high school training (but less than a Bachelor's degree), and 36% had a Bachelor's degree or higher. Most men identified as gay (79%), 19% identified as bisexual and 2% identified their sexual orientation as something other than gay or bisexual. This sample of MSM is more diverse in terms of ethnicity, income, sexual orientation identification and self-reported HIV serostatus compared with other recent studies based on convenience [18,19] and probability  samples of MSM in San Francisco and other US cities.
More than two-thirds of the participants had heard of barebacking (Table 1). A greater proportion of white men than Latino or African-American men were aware of the term. Increasing levels of education and income were associated with having heard of barebacking. A greater percentage of MSM who identified as being gay, compared with bisexual, had heard of the term. These differences (with the exception of income) persisted in multivariate logistic regression analysis in that white race/ethnicity [odds ratio (OR) 2.2; 95% confidence interval (CI) 1.4–3.6], increasing education (OR 1.8; CI 1.4–2.4), and gay identification (OR 2.2; CI 1.4–3.5) were associated with having heard of barebacking.
Ten per cent of the sample reported barebacking in the previous 2 years (16% of HIV-positive versus 7% of HIV-negative men, P < 0.001). More importantly, of the men who were aware of the term and thus potentially familiar with the sociocultural phenomenon of ‘barebacking', 14% had barebacked in the previous 2 years (Table 1). Twenty-two per cent of HIV-positive men who were aware of the term had barebacked, whereas 10% of HIV-negative men (P < 0.001) aware of the term had done so. There were no differences in the prevalence of barebacking by race/ethnicity, education, income or sexual orientation identification. The median number of barebacking partners for men who had barebacked was three partners during the past 12 months.
Behavior during the most recent bareback encounter is presented in Table 2. A strong pattern of serostatus-assortative behavior (i.e. HIV-positive men with HIV-positive partners, and HIV-negative men with HIV-negative partners) was found for receptive anal sex. In particular, a greater proportion of HIV-positive than HIV-negative barebackers reported unprotected receptive anal sex with an HIV-positive partner. Similarly, more HIV-negative than HIV-positive barebackers reported unprotected receptive anal sex with HIV-negative partners. There was no difference by participant serostatus in unprotected receptive anal sex with partners of unknown HIV serostatus. Many men who barebacked reported unprotected receptive and insertive anal sex with men of different or unknown HIV serostatus during their most recent bareback encounter. Half of the HIV-positive and more than half of the HIV-negative barebackers reported being drunk on alcohol or high on drugs during their last bareback encounter.
The most commonly reported venues or approaches used to meet bareback partners were bars and dance clubs, friends and acquaintances, and the internet (Table 2); however, a variety of venues were mentioned. The reason most frequently cited for barebacking was to experience greater physical stimulation; feeling emotionally connected with a partner was also a relatively common reason.
Men who had barebacked in the past 2 years had a higher general sexual risk profile than other men. In particular, in the previous 3 months, barebackers had a higher prevalence of any unprotected anal sex with men of unknown HIV serostatus or known serostatus different from their serostatus compared with all other men (53 versus 17%, respectively, P < 0.001). Men who barebacked also had a higher rate of self-reported STD in the previous 12 months compared with men who had not barebacked (21 versus 8%, P < 0.01). More barebackers than non-barebackers agreed that improved treatments had caused them to have more unprotected sex (19 versus 9%, P < 0.05), and knowing that fewer individuals are developing AIDS had led them to have more unsafe sexual behavior (15 versus 4%, P < 0.01). Finally, more barebackers than non-barebackers said they were willing to use, without a condom, a future rectal microbicide lubricant that was only 50% effective in preventing HIV infection (75 versus 43%, P < 0.001, for unprotected receptive anal sex; 79 versus 52%, P < 0.001, for unprotected insertive anal sex). Barebackers did not differ significantly from non-barebackers in whether or not they had had a drug overuse instance in the previous 3 months (11 and 9%, P > 0.05); nor did the two groups differ in the prevalence of individual substance use (alcohol, cocaine, crack, ecstasy, γ-hydroxybutyrate/γ-butyrolactone, heroin, ketamine, hallucinogens, marijuana, poppers) during the previous 3 months. The single exception was higher 3 month use of crystal methamphetamine among barebackers compared with non-barebackers (42 versus 23%, P < 0.01), similar to studies that have found methamphetamine use to be associated with unprotected anal sex in general [21,22].
Barebacking, strictly defined here as intentional unprotected anal sex with a non-primary partner and not unprotected anal sex in general, is a public health concern, not necessarily as a result of its prevalence but more because of its nature of intent. Bareback behavior is transgressive in that it is not in the context of ‘negotiated safety’ (i.e. a long-term, monogamous relationship; repeated testing to verify HIV-concordance; a verbal agreement in the context of a trustworthy, communicative relationship); prevention specialists and researchers have recognized negotiated safety as a reality and viable alternative for some men under specific circumstances [15,23–25]. Intentional unprotected anal sex with non-primary partners is a health concern for gay communities because of the risk of transmitting HIV or other STD to uninfected men, including treatment-resistant strains [26,27], and the potential risk of superinfection in HIV-positive men .
The term barebacking is known by most MSM and not merely by a visible subgroup. Overall, awareness is somewhat more prevalent among white men and gay-identified men. These differences in awareness could stem from the fact that barebacking is discussed in the literature and media of largely white, gay-identified communities [9,10,29]. However, it is important to note that the actual practice of barebacking was not associated with race/ethnicity or sexual orientation identification among men who had heard of the term.
Several behavioral patterns were observed that further define public health concerns about barebacking. First, MSM who had barebacked in the past 2 years had a higher recent, general sexual risk behavior profile than MSM who had not barebacked during that time period; these men were having general unprotected anal sex in addition to barebacking. Second, bareback behavior was significantly more prevalent among MSM who reported that they were HIV-positive. Although these men tended to bareback with partners also believed to be seropositive during their most recent bareback encounter, a sizable percentage of the HIV-positive barebackers said they had receptive bareback partners who were HIV-negative or of unknown serostatus. Third, HIV-negative participants tended to bareback with partners reported to be HIV-negative. However, confidence in whether or not a reportedly HIV-negative partner was truly negative at that point in time depends on multiple factors (e.g. the length of time since the last HIV test for an individual who engages in high-risk behavior; the level of honesty and trust with the partner). Some of the HIV-negative participants said they barebacked with HIV-positive men who were the insertive partners, thus knowingly placing themselves at extremely high risk of contracting HIV.
Our findings must be interpreted within the methodological constraints of the study. The multiethnic sample of MSM who lived or worked in the San Francisco Bay Area may not represent behavioral patterns of MSM in other regions of North America or elsewhere; nor may the convenience sample be entirely representative of the MSM community in the Bay Area. Although the 14% prevalence estimate among those who were aware of the term may be relatively accurate regarding bareback behavior as a sociocultural phenomenon, it is not intended to be a prevalence estimate for all MSM. It is also important to keep in mind that the prevalence rates we observed may be underestimates because of the potential controversial nature of reporting bareback behavior. Finally, analyses of barebackers, particularly by participant serostatus, were conducted on relatively small subgroups, and thus true differences may not be detectable with limited statistical power [e.g. barebacking parties as a venue to meet bareback partners were reported by 17% (five out of 29) of HIV-positive men and 4% (one out of 23) of HIV-negative men, P > 0.05].
Despite these limitations, this is the first quantitative study strictly defining and describing the sociocultural phenomenon of barebacking in a diverse sample of MSM. New approaches are needed to reduce the prevalence of barebacking and to address, more generally, the increasing incidence of sexual risk behavior, STD and, potentially, HIV infection among MSM. Interventions must take into account that men who bareback are more likely to report that their recent sexual risk behavior in general has resulted partly from the availability of improved treatments and declining rates of AIDS diagnoses and deaths. Prevention messages should simultaneously address specific risk behaviors, perceptions of HIV disease in an era of largely successful drug therapy, and issues of treatment resistance, side-effects and failure.
Bareback behavior is a call for new health promotion paradigms for a subgroup of men. Some HIV-negative men are intentionally putting themselves at risk and some HIV-positive men are intentionally putting themselves and others at risk of HIV and STD infections in order to meet important human needs (e.g. physical stimulation, emotional connection) other than physical health. Unique programs that target men by their HIV serostatus are needed, such as CDC's Serostatus Approach to Fighting the HIV Epidemic (SAFE) initiative ; motivations for barebacking and sexual risk behavior in general may differ by whether individuals are primarily putting themselves or others at risk of infection. Researchers, practitioners and community members should work together and consider holistic health and wellness lifestyle approaches that take multiple human needs into account, particularly for men who bareback.
Finally, our data suggest that most men who bareback are likely to use a future rectal microbicide, even if such a product were protective only 50% of the time that it was used. An effective microbicidal product could provide protection without compromising physical stimulation and emotional connectedness. Partly effective microbicides would reduce the risk of HIV transmission among men who do not currently use condoms during anal sex; however, such products could increase the risk of transmission by the substitution of microbicides for condom use among men who currently use condoms with at least some of their anal sex partners [31,32]. More collaboration is needed in laboratory research, clinical trials and behavioral studies to identify safe, effective, and acceptable rectal microbicides.
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