Crosby, Richard PhD*†; DiClemente, Ralph J. PhD*†‡§; Mettey, Aaron MPH*
IN THE UNITED STATES, men who have sex with men (MSM) continue to experience a substantial and disproportionate risk of infection with the human immunodeficiency virus (HIV). 1–4 Moreover, strong evidence suggests that MSM are disproportionately at risk of acquiring and transmitting bacterial sexually transmitted diseases (STDs). 5–10 Clearly, empiric investigations that identify important correlates of engaging in unprotected anal sex (UAS) among MSM are urgently needed. These studies need to recognize that MSM are a diverse population; thus, assessment across a spectrum of venues is warranted.
Based on their recent resurgence, bathhouses and sex clubs are potential venues for investigating correlates of UAS among MSM. Unfortunately, few observational studies of men attending bathhouses or sex clubs have been reported. 11 A recent study of MSM attending a bathhouse in Portland, Oregon, compared men having risky sex with those having safer sex (the comparison was limited to sex while attending a bathhouse). Men reporting they were seropositive for HIV and those reporting they had 5 or more sex partners in the past 30 days were significantly more likely to report risky sex. Variables such as age, race, and education did not distinguish between men having risky and safer sex. 12 Other studies of MSM attending bathhouses and sex clubs have addressed HIV testing 13 and frequency of unprotected sex among men attending bathhouses. 14,15 Studies specifically investigating the correlates of engaging in unprotected sex among MSM attending sex resorts/clubs (as opposed to bathhouses) have not been reported.
The purpose of this exploratory study was to identify demographic and behavioral correlates of recently engaging in UAS among MSM attending a popular sex resort in the southern United States. As opposed to the bathhouse study conducted in Portland, 12 we chose to examine recent sexual practices of MSM regardless of whether these practices occurred at the study location. Also in contrast to the Portland study, we surveyed men attending a large sex resort rather than a bathhouse. Previously, researchers have used the term bathhouse to describe places where MSM can have sex in a private or semiprivate place, whereas the same is not true for sex clubs. 12 One extension of the bathhouse concept is a place where MSM congregate for extended stays (ie, staying all day or all night or for several days and nights in private rooms) within the context of an environment that supports cruising. Thus, we have used the term “sex resort” to denote this type of venue.
During Saturdays from May through November of 2002, 164 men attending a sex resort located in northeast Georgia were randomly approached by trained male research staff and asked to participate in a brief survey about men's sexual health. Of these men, 150 completed a self-administered questionnaire (yielding a response rate of 91%). Incentives for participation were not provided. The Emory University Institutional Review Board approved the study protocol before study implementation.
The sex resort is a 65-room complex enclosed by a privacy fence and a gated entrance. The resort provided men with a steam room, hot tub, maze, dungeon, and an outdoor pool and patio area. Patrons were 18 years of age or older and were admitted to the resort based on membership requirements. Men had the option of renting a room or buying a “day pass” (most patrons rented rooms). The environment was designed to facilitate the process of men meeting men for the purpose of having sex. Clothing is optional in specified areas.
Men were recruited for study participation only during their leisure time spent on the patio or near the pool area. Men providing informed consent were provided with a 10-page (single-sided and double-spaced) questionnaire. Men completed the questionnaire at tables within the patio area or near the pool; a few men chose to complete the questionnaire in the privacy of their rented rooms. Men were specifically instructed to skip any questions they felt were too personal and not to place their name on the questionnaire. Before filling out the questionnaire, men were also provided with a large manila envelope and instructed to seal the completed questionnaire in this envelope before returning it to the researchers.
Measurement of Risky Sex
Although research clearly shows that unprotected anal-receptive sex (UARS) poses greater risk for acquisition of STD/HIV than unprotected anal-insertive sex (UAIS), the latter clearly poses greater risk for STD/HIV transmission. 16 Given our intent to look at overall HIV risk (ie, acquisition and transmission behaviors), we created a measure based on frequency of men's engagement in both UARS and UAIS in the past 3 months (termed simply UAS). Previous research supports the use of a 3-month recall period for assessing unprotected sex. 17 To assess UARS, men were asked, “How many times have you been a BOTTOM during anal sex (another man's penis in your rectum) WITHOUT a condom being used?” To assess UAIS, the same question was provided with the word “TOP” replacing the word “BOTTOM.”
Measurement of Correlates
In addition to assessing 3 demographic correlates (age, race, and income level), we assessed a broad range of behavioral correlates. Based on the Portland study, 12 we assessed men's HIV serostatus (by self-report) and whether they reported recent sex with 5 or more partners. In addition, men's self-reported history of STD infection was assessed as well as their recent engagement (past 3 months) in practices such as rimming (oral–anal contact), fisting (insertion of the hand into the rectum), and group sex. We anticipated that engaging in these practices might be associated with an increased proclivity for sexual adventurism, which in turn could predispose men to engaging in UAS. Based on previous research suggesting a relationship between risky sex among MSM and meeting sex partners through specific venues, 18–20 we also asked men if they used venues such as the Internet, bathhouses, public restrooms, or circuit parties as a way to meet potential sex partners. Also, we were interested in looking for an association between hepatitis B vaccination status and UAS. Thus, we included a question assessing whether men had been vaccinated against hepatitis B. We were also interested in learning whether men who take nonprescription viagra might be more likely to engage in UAS. Finally, we assessed whether men were currently involved with a primary partner by a question asking men, “Do you currently have a primary partner (a romantic relationship)?” Men indicating an affirmative response were asked how long the relationship had lasted.
Associations between dichotomous correlates and UAS were assessed by the use of contingency table analyses. Specifically, prevalence ratios, their 95% confidence intervals, and respective P values were calculated. Associations between correlates measured on a continuous level and UAS were assessed by independent-group t tests. Significance was defined by an alpha level of 0.05 or less.
Variables testing significant (P <0.05) at the bivariate level were entered into a forward stepwise multiple logistic regression model with the criteria for model entry and exit set at P = 0.10. Because our study was exploratory in nature, the small sample size precluded a fair test of the correlates using 95% confidence intervals. Therefore, the logistic regression model was used to calculate adjusted odds ratios (AOR) and their 90% confidence intervals for the correlates that were retained in the final model.
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 (Georgia). Average age of the men was 40.7 years (standard deviation [SD], 9.4 y; median, 40 y). Most (93%) men self-identified as white. The median income interval was $25,000 to $50,000 per year.
One sixth (16.7%) reported they were HIV-positive. Of those indicating a negative serostatus, 26 (21.7%) reported they had not been tested in the past year and 8 (5.3%) indicated they had never been tested for HIV. Thirty-nine percent of the men reported ever having an STD other than HIV. Men reported having sex with a mean of 10.0 partners in the past 3 months (SD, 42.0; median, 4). Just over 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. The majority (88%) of men reporting primary relationships indicated the partner was male. More complete descriptive information about the men is provided in Table 1.
UARS (in the past 3 months) 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). 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). Overall, 51% of the men reported consistent condom use for anal sex during the recall period. Thus, 49% of the men reported UAS during the recall period.
Table 1 displays the percent of men reporting UAS stratified by their responses (ie, yes versus no) to the assessed measures. Table 1 also provides prevalence ratios, their 95% confidence intervals, and respective P values. As shown, race, HIV serostatus, STD history, having a primary partner, fisting, meeting sex partners through the Internet, and use of nonprescription viagra did not achieve significance with the outcome measure.
Alternatively, several behavioral practices did achieve significance. For example, men recently engaging in rimming or group sex were approximately 1.7 and 2.0 times more likely, respectively, than those not engaging in these practices to report UAS. Men reporting recent sex with 5 or more partners were approximately 1.6 times more likely to report UAS compared with those reporting fewer partners. Men using bathhouses, public restrooms, and circuit parties as a way of meeting sex partners were approximately 1.6, 1.5, and 1.7 times more likely, respectively, to report UAS. Finally, men who had been vaccinated against hepatitis B were approximately 1.5 times more likely to report UAS.
Table 1 does not show the bivariate associations corresponding to 2 correlates that were continuous rather than dichotomous measures: age and income. Men's age was not associated with UAS (P = 0.66). Likewise, men's income was not associated with UAS (P = 0.39).
Of the correlates achieving bivariate significance, 4 remained significant in the multivariate model (Table 2). The model was significant (χ2 with 4 degrees of freedom [df] = 22.8; P <0.0001) and achieved an excellent fit with the data (goodness-of-fit χ2 with 7 df = 3.2; P = 0.87). The strongest multivariate correlate of UAS was recently engaging in group sex. Men engaging in group sex were 3 times more likely to report UAS compared with those not reporting recent engagement in this practice. Similarly, men who reported they had recently engaged in rimming were twice as likely to report UAS compared with those not having reporting recent engagement in this practice. Men who reported meeting potential sex partners in public restrooms were 2.6 times more likely to report UAS. Finally, men who reported they had been vaccinated against hepatitis B were approximately 1.9 times more likely to report UAS compared with those not reporting hepatitis B vaccination.
This exploratory study of MSM attending a large sex resort in the South revealed a substantial degree of STD/HIV-risk behavior among the patrons regardless of their age, income, race, HIV serostatus, or whether than had a primary partner. The prevalence of UAS practices among these men, coupled with their rather high prevalence of HIV infection, suggests the possibility that sex resorts (much like bathhouses and sex clubs) could also be important HIV prevention venues for MSM. Moreover, the findings suggest that sex resorts could also be an important venue for the spread of STDs among MSM.
At a multivariate level, we found that men were more likely to report recent UAS if they had been vaccinated against hepatitis B. In the context of a cross-sectional study such as this one, this finding cannot address whether being vaccinated against hepatitis B is an antecedent of risky sex or (conversely) whether men who engage in risky sex are more likely to be vaccinated against hepatitis B. The observed association deserves further investigation in the context of prospective studies.
At a multivariate level, we also identified 2 behaviors that could serve as markers for sexual adventurism (ie, engaging in group sex and rimming) and thus were strongly associated with UAS. The multivariate findings also supported a previous observation, reported by Coates and colleagues, 18 that men who use public restrooms to meet sex partners were more likely to report UAS.
The findings have implications on several levels. First, the findings suggest that a substantial portion of HIV-positive MSM attending sex resorts could be engaging in UAS. Thus, sex resorts could constitute an important venue for promoting consistent condom use among MSM to prevent STD and HIV acquisition and transmission.
Second, the findings suggest that at least 2 forms of sexual adventurism could serve as markers of a tendency to engage in UAS. The concept of co-occurring risk behaviors appropriately describes the observed relationships. In particular, group sex can exacerbate STD/HIV risk through 2 mechanisms: 1) a potential increase in the number of sex partners and 2) a potential increase in the odds of rectal and penile tissue damage as a result of prolonged intercourse, thereby facilitating the transfer of STD/HIV. We found that 60% of the men reporting UAS also reported recently engaging in group sex.
Third, the findings suggest that meeting sex partners in public restrooms could also be a behavior that co-occurs with UAS. Of course, seeking sex partners from restrooms could simply be a marker for men's preference toward casual or recreational sex. Thus, the specific measure (ie, meeting partners in public restrooms) could be less important than the notion that men seeking recreational sex could be quite focused on the physically gratifying aspects of sex and that condom use could be perceived as antithetical to this goal. Nonetheless, this finding warrants further investigation with larger samples of MSM.
Findings from this study are unique because they add another dimension to the literature addressing sexual risk among MSM. Binson and colleagues previously noted the importance of understanding sexual risk behavior among MSM within well-defined venues such as bathhouses and public cruising areas. 14 Our study suggests that in addition to bathhouses, sex resorts (ie, places where men meet to have sex with men and stay as registered guests in a hotel-type atmosphere) could be an important meeting place for men at high risk of transmitting or acquiring STDs, including HIV infection.
Several of the null findings are also noteworthy. For example, contrary to what might be expected based on recent reports, 1,2,4 UAS was not more likely among young MSM compared with their older counterparts. Similarly, despite potential expectations to the contrary, having a primary partner and reporting an HIV-positive serostatus were not associated with UAS. One important reason for the observed lack of differences could be that MSM attending the sex resort are not representative of other MSM in the United States. Indeed, these findings suggest the possibility that these men are quite unique.
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 findings cannot be generalized to other populations of MSM in the United States. An important limitation is reliance on the validity of men's responses to the interview questions. Furthermore, the use of our bivariate and multivariate findings is limited by the low statistical power that is inevitable given a small sample size (nonetheless, the use of a small sample provides assurance that significant effects represent substantially large effect sizes given that medium and small effect sizes could not be detected). Also, although the level of missing data in this study was minimal (see Table 1), it is nonetheless important to note that nonresponse could have biased the findings. It should also be noted that we did not assess a comprehensive range of measures that might distinguish between men engaging in risky and safer sex behaviors. More extensive research is needed with other samples of men attending similar resorts.
Sex resorts could be an important venue for STD and HIV prevention among MSM. Although much more extensive research is needed, the findings suggest that STD/HIV prevention programs can benefit MSM by tailoring protective messages to men having group sex, those recently engaging in rimming, and men who meet partners in public restrooms. Tailored prevention messages designed for men who report being vaccinated against hepatitis B could also be appropriate.
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