Condom use during anal intercourse is widely promoted among men who have sex with men (MSM) for the prevention of sexually transmitted infections (STIs), including HIV.1,2 However, some MSM may not always make regular condom use as their primary strategy of risk reduction,3,4 resulting in the potential for increased HIV incidence linked to unprotected anal intercourse (UAI) in this population.5,6 Recent research consistently demonstrates the importance of examining the relational, physical, or emotional contexts in which decisions about UAI are made.7 For example, condom use may be eschewed with main or long-term partners,8,9 or when the benefits of UAI (e.g., increased emotional intimacy or physical pleasure) are perceived to outweigh the risks (e.g., infection).9,10 Other research suggests that condom use decreases with depressed or negative mood,11 closeness with partner,12 higher frequency of oral-genital or manual-genital activities before or in conjunction with anal sex,13 lubricant use,14 greater age difference between partners,15 erection difficulty,10 enema use or rectal douching before sex,16 location of sexual event,17 and recent condom nonuse.18
Much of this contextual understanding, however, remains limited. Reliance on retrospective and/or single event measures (e.g., “How many times in the past 90 days did you have unprotected anal intercourse” or “At your last anal sex event, did you use a condom?”) may mean that current studies over- or under-estimate actual behavior prevalence,19 preventing accurate assessment of how the relationship of contextual factors with condom use differs from one sexual event to another. Alternatively, daily diaries allow researchers to capture, as close to the event's occurrence as possible, information about the characteristics of a given sexual event, thereby reducing the recall bias common with other methods. Additionally, diaries also facilitate repeated measurements across a large volume of anal intercourse and condom use events. This volume is requisite to not only examine the variability of condom use and nonuse across different anal intercourse event but also to better describe which factors specific to a given sex event increase the likelihood of condom use. This approach has been used extensively by researchers examining the link between sexual behaviors and alcohol use, and more recently in HIV prevention research among MSM.20–22 Studies that have focused on the circumstances surrounding sexual acts highlight the importance of contextual correlates. For example, partner characteristics, such as the duration of relationship with a sex partner, have been implicated as factors for unprotected anal sex.21 Finally, diaries have been shown to produce reliable estimates of behaviors, and are associated with high levels of completion and relatively low levels of missing data.23
The aim of this study was to explore affective, behavioral, partner, subjective, and situational factors related to HIV-negative MSM's condom use during both insertive and receptive anal intercourse over a recent period of time using diary data. This study extends current understanding of condom use by comparing how different sexual characteristics change the likelihood of condom use from one anal intercourse event to the other.
MATERIALS AND METHODS
Participant Recruitment and Data Collection
Since 2009, the Men's National Sex Study has recruited participants from online Web sites that facilitate social and sexual interactions with other men to examine the sexual attitudes and sexual behaviors of MSM. In October 2010, an electronic recruitment e-mail was sent to registered US users of these sites with a description of the study and a link to the study Web site, where individuals could read a detailed description of the study and, if interested, proceed to the study consent form. Those who consented to participate in the study were directed to the study baseline questionnaire, which assessed sociodemographics, health, and sexual history, and took approximately 20 minutes. A total of 55,452 men visited the study Web site, and 32,831 (59.2%) consented to and subsequently participated in the baseline study.
Following the baseline questionnaire, participants were given the opportunity to enroll in a second phase of the study in which they were e-mailed instructions on how to complete 30-day sexual diaries. Participants were informed that they would receive a daily e-mail reminder that asked them to return to the study Web site each day and complete a short survey about their sexual behaviors during the course of 4 weeks. Embedded in the daily e-mail reminder was a Web link that directed participants to the daily survey, which took approximately 5 minutes to complete each day. Pertinent to the current project, these diaries measured daily occurrence of manual, oral, and insertive or receptive anal sex behaviors, the external characteristics associated with these events, as well as condom use during these events.
Of the 32,831 men completing the baseline survey instrument, 4439 (13.5%) subsequently enrolled and completed some portion of the 30 expected daily diaries (mean: 11 days, SD = 15 days; range: 2–30 days). From this group, we then selected a subset of men (n = 3877; 90.0%) who were HIV negative at the time of recruitment (Table 1). This HIV-negative subsample did not differ from the larger sample in terms of age (P = 0.131), ethnicity (P = 0.076), education (P = 0.207), health status (P = 0.152), sexual activity history (manual, oral, and anal sex; all P > 0.05), and recency of any STI (gonorrhea, herpes, human papilloma virus, or chlamydia; all P > 0.05). This subsample had similar levels of diary completion (mean: 13 days, SD = 10 days; range: 2–30 days). Approximately one quarter of the HIV-negative subset completed all 30 days; an additional 30% completed more than half of the expected days. Additionally, sensitivity analyses was conducted to assess the impact on model estimates with and without respondents who completed 20% or less of diary days, and found no differences (data not shown, available from first author). Therefore, the entire HIV-negative sub-sample was retained using statistical methods (described in more detail later in the text), which adjusted model standard errors for difference in diaries submitted across individuals. All study protocols were reviewed and approved by the Institutional Review Board at Indiana University, and additional details on the larger study are available elsewhere.24
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Table 1: Participant (N = 4170) Sociodemographics
Measures
Main Outcome Measures.
The 2 main outcome measures were condom use during anal intercourse with participant as receptive partner, and condom use during anal intercourse with participant as insertive partner (both: yes/no). Each outcome was examined in a separate model.
Predictors.
Affective and behavioral event characteristics included the following: negative mood (additive index; 6, 4-point Likert-type items; e.g., “not at all” to “a lot”; α = 0.93), within-day noncoital sexual repertoire (additive index: any kissing, solo- or partnered masturbation, oral-genital contact or oral-anal contact; all (yes/no); α = 0.94), and any condom nonuse during [insertive/receptive] anal intercourse in past week (yes/no). Partner characteristics were partner type (main/casual) and partner age difference (older, same age, younger). Situational characteristics included lubricant use (yes/no), partner used an enema before sex (yes/no), participant used an enema before sex (yes/no), sexual event location (other/participant or partner's residence), participant ejaculated (yes/no), partner ejaculated (yes/no), and duration of penetration (single, 5-point Likert-type item; e.g., “less than 2 minutes” to “longer than 30 minutes”). Subjective characteristics were as follows: participant erection difficulty (yes/no), perceived sexual pleasure (single, 5-point Likert-type item; “extremely pleasurable” to “not at all pleasurable”), perceived sexual arousal (single, 5-point Likert-type item; “extremely aroused” to “not at all aroused”), and satisfaction with partner (single, 5-point Likert-type item; “very satisfied” to “very dissatisfied”).
Procedure
Multivariate logistic regression was used to assess a predictor variable's influence on the likelihood of condom use during each insertive or receptive anal intercourse event. A generalized estimating equation approach adjusted estimates for multiple sexual events reported within the same participant and differing number of diaries submitted across participants. All analyses were conducted using SUDAAN, Version 9.01 (Research Triangle Park, NC).25
RESULTS
Sample Characteristics
Table 1 provides an overview of the descriptive characteristics of men in this study (n = 4170). The participants ranged in age from 18 years to 79 years (mean = 35.92, SD = 12.39); the majority were white (82.7%, n = 3206), self-identified as gay (82.0%, n = 3206) and more than half of men indicated that they were not currently in a romantic relationship (64.1%, n = 2484). Most men (71.0%, n = 2764) described their health as being very good or better, and nearly all men reported having engaged in a variety of sexual behaviors in the course of their lifetime, with the most common sexual behavior being solo masturbation (99.9%, n = 3875), followed by receiving oral-genital sex (98.3%, n = 3810) and performing oral-genital sex (98.1%, n = 3804).
Enrollment Characteristics and Condom Use
We examined the bivariate relationship between socio-demographic characteristics and overall prevalence of condom use during the diary study, using one-way analysis of variance and independent means t tests.
As shown in Table 2, age, race/ethnicity, education level, employment status, STI history, solo or partnered masturbation, history of insertive anal intercourse, and history of giving oral-genital sex were not related to the total proportion of condom use for either insertive or receptive anal intercourse. Relationship status was significantly related to condom use (insertive anal intercourse: F[6356] = 7.709, P < 0.001; receptive anal intercourse: F[6356] = 8.145, P < 0.001), with men in longer relationships reporting significantly less overall condom use compared with those men not currently dating or those in more recently established relationships. Those in better general health (F[3356] = 2.28, P < 0.001) had marginally higher condom use during insertive anal intercourse, and those men with a recent diagnosis of syphilis (t[14.51] = 2.93, P < 0.01) had significantly higher condom use during insertive anal intercourse than those without syphilis (mean = 0.09, SD = 0.36). Condom use during receptive anal intercourse was less frequent among men who had ever received oral-genital sex (t[329] = −10.88., P < 0.001) compared with men who had never received oral-genital sex (mean = 0.01, SD = 0.01), and was also less frequent among men with prior receptive anal intercourse experience (t[329] = 32.98., P < 0.001) as compared with men who had not engaged in anal intercourse as the receptive partner before the study (mean = 1.00, SD = 0.01). Finally, significantly less condom use was noted during both insertive anal intercourse (t[206.24] = 3.50, P < 0.001) and receptive anal intercourse (t[116.19] = 2.77, P = 0.006) among men with a history of enema use compared with men who had never used enemas (insertive: mean = 0.45, SD = 0.48; receptive: mean = 0.37, SD = 0.47).
Table 2: Demographic Characteristics and Relationship to Condom Use
Event-Level Condom Use Distribution
HIV-negative MSM contributed 25,149 diary days, 2.9% (n = 730) of which were associated with the participant being the insertive partner during anal intercourse and 2.6% (n = 662) of which were associated with the participant being the receptive partner in anal intercourse. About one quarter (25.2%: 184/730) of insertive anal intercourse events were condom protected, whereas less than a fifth (18.8%: 125/662) of receptive anal intercourse events were condom protected.
Event-Level Condom Use
Table 3 presents the likelihood of condom use when men were either the insertive or receptive partner during anal intercourse. Condom use during insertive anal intercourse was more likely when the sexual event occurred with a casual partner (OR = 4.24) and higher insertive partner perceived sexual pleasure (OR = 1.84), but was less likely with a sexual partner using an enema before sex (OR = 0.98) and higher insertive partner sexual arousal (OR = 0.59). Condom nonuse was marginally associated with a wider within-day noncoital sexual repertoire (OR = 0.82). Using a condom during receptive anal intercourse was more likely when the sexual event occurred with a casual partner (OR = 6.59), but was less likely with condom nonuse during receptive anal intercourse in the past week (OR = 0.04) and higher receptive partner sexual pleasure (OR = 0.26).
Table 3: Sexual Event Characteristics Associated With Condom Use During Insertive and Receptive Anal Intercourse
DISCUSSION
Condom use is an effective means of preventing the transmission and acquisition of many sexually transmitted infections, including HIV; however, when warranted, their effectiveness decreases when not used consistently. These data extend current understandings of condom use among MSM during insertive and receptive anal intercourse, providing insight into how characteristics associated with a specific sexual event influence the likelihood that condoms are used. Our findings suggest that routine condom use is infrequent for both types of anal intercourse, but at rates comparable with national estimates of men's condom use during last vaginal sexual event.26
Patterns of condom use varied across sexual events, orchestrated in concert with different affective, behavioral, partner, situational, and subjective event characteristics. Men who indicated that anal intercourse (regardless of sexual position) occurred with a nonrelational partner were significantly more likely to report a condom being used. This finding highlights an increased use of condoms during sexual situations in which higher risk of STI acquisition may be present, demonstrating men's capacity to engage in protective risk reduction measures with new or more casual sexual partners. Although condom nonuse may in fact be appropriate for MSM who are engaging in anal intercourse with an HIV sero-concordant sexual partner who is STI negative, extrarelational sexual contacts can result in the introduction of HIV and other STI into an exclusive sexual relationship, demonstrating the importance of condom messaging that encourages open dialogue and communication between sexual partners, for perceived risk to be accurate. Moreover, positive ratings of sexual pleasure were associated with condom use among men who were insertive partners during anal intercourse, whereas condom nonuse was significantly related to higher ratings of pleasure among men who were receptive partners. This finding is consistent with recent nationally representative studies of condom use27 in which men who used a condom were more likely to report higher ratings of sexual pleasure. Although the relationship between condom use and pleasure has been previously linked with the reduction of anxiety associated with unintended pregnancy among men engaging in penile-vaginal intercourse, these data suggest the possibility that disease prevention may serve as a similar impetus for men engaging in same-sex intercourse. Alternatively, these differences may be a function of varying physiological responses to a condom's physical properties between different anatomical sites (i.e., on the penis vs. inside the rectum).
In support of other research,12 we did not find an association of negative mood with condom use, perhaps because negative effect may influence sexual risk as a moderator of other influences such as relationship conflict. Also parallel to prior work,18 regular patterns of condom nonuse during receptive anal intercourse strongly predicted current condom nonuse during receptive anal intercourse. Contrary to previous literature, however, we did not find an association of condom use with partner age difference, enema use before sex, lubricant use, sexual event location, erection difficulty, or sexual satisfaction. Commensurate with more recent qualitative work suggesting that sexual risk is often defined or negotiated within the dynamics of a specific sexual encounter,7,28,29 this may mean that factors traditionally labeled as “high risk” from the public health perspective (e.g., age discordance) may need to be reexamined within different contexts, particularly if those relationships change from one sexual event to another.
Finally, a strength of this study is the inclusion of data points designed to capture elements associated with a sexual encounter that are not traditionally measured (e.g., enema use). In this regard, condom use was less likely with a sexual partner using an enema before sex, and significantly less condom use was noted during both insertive anal intercourse and receptive anal intercourse among men with a history of enema use compared with men who had never used enemas. Although enema use is considered a mechanism for men engaging in anal intercourse to feel “clean,” this finding raises the possibility that for some men condoms may be used as a protective barrier from possible exposure to feces. Because of the biologic mechanisms of enema use in the rectum and increased risk for STI acquisition, further research examining the relationships between enemas and condom use is warranted.
The current work should be viewed within the context of its limitations. The sample was not representative of the general population, and participants were recruited through Web sites geared toward individuals who may be more sexually conscious; however, challenges exist with establishing nationally representative samples of MSM. Although this sample was entirely Internet-based, and as such, may not be generalizable to all MSM in the United States, this same limitation provides a strength in that previous studies have demonstrated the potential of online data collection to result in more accurate and honest responses from study participants.30
CONCLUSIONS
This study provides a longitudinal examination of condom use during anal intercourse among MSM in the United States. Findings from this study highlight that event-level relational and sexual-situational factors predict condom use differently during insertive and receptive anal sex among MSM. These data identify points on which clinicians and health educators can engage MSM in a dialogue about increasing condom use in situations where it is warranted.
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