In the United States, men who have sex with men (MSM) experience a substantial and disproportionate risk of infection with HIV.1,2 Based on their recent resurgence, bathhouses and sex clubs are potential venues for programs that promote safer sex practices among MSM at risk of either acquiring or transmitting HIV; yet, few studies of men attending bathhouses have been reported.3 A notable exception is a recent study of MSM attending a bathhouse in Portland Oregon.4 Unfortunately, studies of MSM specifically attending sex resorts (as opposed to bathhouses) have not been reported.
Sex resorts are an extension of the bathhouse concept. Sex resorts, unlike bathhouses, are designed for couples and groups as well as singles. MSM congregate for extended stays (staying in private rooms for 1 or several days and nights) within the context of a self-contained environment that supports cruising (ie, a physical and social environment that is highly conducive to meeting sex partners). This study assessed the prevalence of various HIV-associated risk behaviors among MSM attending a popular sex resort in the southern United States.
During Saturdays from May through November of 2002, 164 men attending a sex resort located in the Southeast were randomly approached by trained male research staff and asked to participate in a brief survey about men’s sexual health. Of these, 150 completed a self-administered questionnaire (91% response rate). Incentives were not provided. The Emory University Institutional Review Board approved the study protocol.
The sex resort selected for this study was one of the largest in the southeastern United States. The resort was a 65-room complex enclosed by a privacy fence and a gated entrance. Depending on the season, between 50 and 100 men typically registered at the resort each week. Cost was comparable to that of a hotel room. The resort provided men with a steam room, hot tub, maze, dungeon, and outdoor pool and patio area. Patrons were 18 years of age or older and were admitted to the resort based on membership requirements. Most patrons stayed at the resort for at least 2 days. The social environment supported the meeting of men for the purpose of having sex. Clothing was optional in specified areas.
Men were recruited during their leisure time spent on the patio or near the pool area. Men providing informed consent subsequently completed a brief questionnaire. Men were free to complete the questionnaire in a semiprivate area (eg, at tables within the patio area or near the pool) or a private area (eg, in their rented rooms). Men were also provided with manila envelopes and instructed to seal the completed questionnaire in these on completion.
Two sets of measures were used. The first asked men to provide responses to questions that specifically assessed behaviors that occurred while attending the sex resort. The second set of measures assessed the prevalence of HIV-associated risk behaviors during the past 3 months.
Characteristics of the Sample
Men residing in 14 states comprised the sample; 30% reported residence in the same state where the sex resort was located. The average age of the men was 40.7 years (SD = 9.4, median = 40 years, range: 19-64 years). Most (93%) self-identified as white. The median income annual interval was $25,000 to $50,000. Thirty-eight percent indicated that they were raised in a small town (not close to a city) or a rural area.
Most men identified as gay (82%) or bisexual (16%). One sixth (16.7%) reported they were HIV-positive; 77% of these men reported taking antiretroviral therapy. Of those indicating a negative serostatus, 26 (21.7%) reported they had not been tested in the past year. Significant differences relative to unprotected anal sex (UAS) in the past 3 months between these 26 men (60.0% reported UAS) and the remaining men (46.7% reported UAS) were not found (P = 0.23). Similarly, significant differences in the mean number of recent (past 3 months) male sex partners between these 26 men (mean = 5.6) and the remaining men (mean = 11.0) were not found (P = 0.55).
Men reported having sex with a mean of 29.1 male partners in the past 12 months (SD = 88.4, median = 10.0). The distribution had a strong positive skew caused by 12 men reporting sex with 100 or more male partners. Fourteen percent of the men reported having sex with a female partner in past 12 months. Just greater than one half (51.4%) of the men reported they were currently involved in a primary relationship. The median length of these relationships was 3 to 5 years. Most (88%) partners were male. Men with a primary partner reported a mean of 30.8 male sex partners in the past 12 months. This mean was not significantly different than the mean (27.3) for men without a primary partner (t = 0.23, df = 137, P = 0.82).
HIV Risk Occurring at the Resort
Men reported a median of 3.0 stays at the resort during a typical year (range: 1-56 stays). The typical length of stay reported ranged from 1 to 5 days (median = 2.0). About 38% of the men reported they typically attended the resort alone; however, 34% reported attending with a lover, 19% reported attending with a friend, and the remainder reported attending in groups of 3 or more. During a typical visit to the resort, men reported having sex with an average of 4.2 partners (SD = 6.1, median = 3.0, range: 0-56 partners).
Sex was clearly defined in the questionnaire as including anal-genital or oral-genital contact. About two thirds (65.3%) of the men indicated engaging in anal sex during a typical visit to the resort. Of these, 41% reported using condoms for every act of anal sex, 19% for at least 75% of the acts, 11% for at least 50%, 8% for at least 25%, and 21% reported never using condoms while engaging in anal sex at the resort. HIV-positive men (64.7%) were as likely as HIV-negative men (58.0%) to report inconsistent (less than 100%) condom use while staying at the resort (P = 0.61).
HIV Risk During the Past 3 Months
Men reported having sex with a mean of 10.0 partners in the past 3 months (SD = 42.0, median = 4). Based on previous research suggesting a relation between risky sex among MSM and meeting sex partners through specific venues,5-7 we also asked men if they recently used specific venues as a way to meet potential sex partners. Use of the Internet was common (57.3%), followed by bathhouses-excluding sex resorts-(40%), public rest rooms (16.7%), and circuit parties (9.3%). Sixty-two percent of the men reported recently engaging in group sex.
To assess frequency of engaging in unprotected anal receptive sex (UARS), men were asked (using a 3-month recall period): “How many times have you been a BOTTOM during anal sex (another man’s penis in your rectum) WITHOUT a condom being used?” UARS was reported by 26.6% of the men. Among these men, UARS occurred a mean of 18.1 times (SD = 81.6; median = 3.0; range: 1-500 times). UARS was more likely among HIV-positive men (47.6%) than among HIV-negative men (22.9%; P = 0.02). To assess recent frequency of unprotected anal insertive sex (UAIS), the same question was provided with the word “TOP” replacing the word “BOTTOM.” UAIS was reported by 42.3% of the men. Among these men, UAIS occurred a mean of 12.3 times (SD = 51.0, median = 2.5, range: 1-400 times). UAIS was equally likely among HIV-positive men (52.2%) and HIV-negative men (40.3%; P = 0.29).
Forty-nine percent of the men reported engaging in any UAS (receptive or insertive) during the recall period. Significant differences in recent frequency of UAS between HIV-positive and HIV-negative men were not found (P = 0.74).
Problems With Condom Use
About two thirds of the men (69%) reported discussing condom use with sex partners before sex. Sixteen percent of the men indicated that they had recently attempted to persuade a partner to use condoms but the partner had refused. When asked specifically about times when they had used condoms as an insertive partner, 20% of the men indicated not using condoms from start to finish of penetrative sex, 7% reported breakage, and 6% reported slippage. Despite these problems, most men (81%) indicated they were “highly confident” in their ability to use condoms correctly. Associations between “confidence” and incomplete use, breakage, and slippage were not significant (P = 0.80, 0.11, and 0.54, respectively).
Risky Sexual Practices
Twenty-three percent of the men recently engaged in anal sex without using any form of lubrication (a practice that may promote condom breakage and slippage or, if condoms are not used, may facilitate HIV transmission through penile or rectal abrasions8,9). Of interest, 48% of the HIV-positive men reported not using lubrication compared with 19% of HIV-negative men (P = 0.002). Similarly, fisting (reported by 15%) may promote rectal abrasions that enhance probabilities of HIV transmission. We were also interested in learning whether men used Viagra for recreational purposes (because increased erection size and longer duration of intercourse could also damage penile and rectal tissue). Fifteen percent of the men reported they had recently used “nonprescription” Viagra. Finally, men reported using a variety of substances during sexual encounters. Poppers were used by 48.0% of the men, ecstasy by 13.3%, “Whip-Its” by 5.3%, and cocaine by 12.7%.
This descriptive study of MSM attending a large sex resort revealed a substantial degree of HIV risk behavior among the patrons during their stay at the resort as well as in the past 3 months. Perhaps most striking was that one sixth of the men knew they were HIV-positive and continued to practice risky behavior in this sociosexual milieu. Given that men reported having an average of 10 sex partners in the past 3 months, the potential for HIV to be acquired from the resort and to spread to a home community (in any of 14 states) is apparent. This potential is particularly emphasized by findings relevant to men having sex with partners they meet via the Internet, bathhouses, public rest rooms, and circuit parties. A substantial portion of the men may also be placing their female sex partners at risk for HIV infection.
Notably, more than one fifth of the men indicated they were HIV-negative despite lack of recent testing and ongoing risk behaviors. Clearly, in the absence of more frequent testing, self-identifying as HIV-negative is problematic among men involved in this high-risk environment. With cautions against negotiated safety, HIV prevention efforts could be designed to increase men’s motivation to learn their serostatus and to make HIV testing easily available to men attending sex resorts. These efforts may lay the foundation for subsequent HIV prevention education and corresponding safer practices. Our findings, like those of other studies,10 suggest that prevention education should target men attending sex resorts.
About 4 of every 10 men reported consistent condom use while attending the resort; however, our findings suggest that men attending the resort commonly do not wear condoms from start to finish of penetrative sex. Condom breakage and slippage were also relatively common. Thus, in addition to promoting consistent condom use among men attending sex resorts, programs may also benefit men by teaching skills designed to promote the correct use of condoms.
The findings also suggest that men attending the sex resort may commonly engage in practices that facilitate HIV transmission (ie, anal sex without lubrication, fisting, use of Viagra). Thus, HIV prevention programs might also benefit men by means of education promoting the maintenance of abrasion-free penile and rectal tissues. Consistent and correct use of latex condoms should be strongly promoted among men who nonetheless engage in behaviors that lead to abrasions.
Findings are limited by several factors, including the inherent limitations of a cross-sectional study design and the use of a convenience sample. Clearly, the use of a nonprobability sample precludes generalization of the findings. An important limitation is reliance on the validity of men’s responses to the interview questions. More extensive research is needed with other samples of men attending similar resorts.
This descriptive study found that MSM attending a sex resort engaged in multiple HIV-associated risk behaviors at the resort and during the past few months. The evidence suggests that sex resorts may be a point source of HIV infection and that transmission to communities in multiple states may result. Therefore, HIV prevention programs that seek to promote safer sex behaviors among men attending these resorts (during their stay and when they return to their home community) may be a beneficial response to the ongoing HIV epidemic among MSM.
1. Centers for Disease Control and Prevention. Need for sustained HIV prevention among men who have sex with men. Available at: www.cdc.gov/hiv/pubs/facts/msm.htm.
Accessed November 19, 2001.
2. Sullivan PS, Chu SY, Fleming PL, et al. Changes in AIDS incidence for men who have sex with men, United States 1990-1995. AIDS
3. Woods WJ, Binson DK, Mayne TJ, et al. HIV/sexually transmitted disease education and prevention in US bathhouse and sex club environments. AIDS
4. Van Beneden CA, O’Brien K, Modesitt S, et al. Sexual behaviors in an urban bathhouse 15 years into the HIV epidemic. J Acquir Immune Defic Syndr
5. Coates TJ, Acree M, Stall R, et al. Men who have sex with men in public places are more likely to have unprotected anal intercourse. Presented at the XIth International Conference on AIDS, Vancouver, July 1996.
6. Church J, Green J, Vearnals S, et al. Investigation of motivational and behavioural factors influencing men who have sex with men in public toilets (cottaging). AIDS Care
7. McFarlane M, Bull SS, Rietmeijer CA. The Internet as a newly emerging risk environment for sexually transmitted diseases. JAMA
8. Warner DL, Hatcher RA. Male condoms. In: Hatcher RA, Trussell J, Stewart F, Cates W, et al, eds. Contraceptive Technology
. 17th ed. New York: Irvington Publishers; 1999:325-352.
9. Royce RA, Sena A, Cates W, et al. Sexual transmission of HIV. N Engl J Med
10. DiClemente RJ, Wingood GM, del Rio C, et al. Prevention interventions for HIV positive individuals: a public health priority. Sex Transm Infect