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Faster and Riskier? Online Context of Sex Seeking Among Men Who Have Sex With Men in China

Cao, Bolin PhD; Liu, Chuncheng BA; Stein, Gabriella; Tang, Weiming MD, PhD; Best, John BA; Zhang, Ye MS; Yang, Bin PhD; Huang, Shujie MS; Wei, Chongyi DrPH; Tucker, Joseph D. MD, PhD

Sexually Transmitted Diseases: April 2017 - Volume 44 - Issue 4 - p 239–244
doi: 10.1097/OLQ.0000000000000575
Original Studies

Background Many men who have sex with men (MSM) seek sex partners online, creating barriers and opportunities for human immunodeficiency virus prevention. The purpose of this study was to examine the characteristics of MSM and the risks associated with seeking sex through websites, gay apps, and both platforms in China.

Methods Data were collected through a cross-sectional online survey from September through October 2014 from 3 large gay Web portals. Sociodemographic information, sexual behaviors, and online sex seeking behaviors were measured. Multinomial logistic regression was performed to compare sexual risk behaviors among website users, gay app users, and men who used both platforms.

Results Of the 1201 participants, 377 (31.4%) were website-only users, 487 (40.5%) were gay app-only users, and 337 (28.0%) were men who used both platforms. These 3 MSM subgroups have distinct sociodemographic characteristics. Overall, 57.6% of participants reported having engaged in condomless anal sex with their last male partner in the past 6 months, but there was no significant difference in condomless sex between the 3 groups. Men who used both platforms viewed more sexually transmitted disease-related messages than website-only users (adjusted odds ratio, 2.19; 95% confidence interval, 1.57–3.05).

Conclusions Condom usage behaviors were unaffected by the medium through which sexual partners were found. However, the high frequency of condomless sex suggests that websites and gay apps are both risk environments. This study suggests using multiple platforms for human immunodeficiency virus/sexually transmitted disease social media interventions may be useful.

A study of Chinese men who have sex with men found that online sex seeking platforms may be facilitators for meeting sex partners, but they are not necessarily related to risky sexual behaviors.

From the *University of North Carolina Project-China, Guangdong Provincial Centers for Skin Diseases and STI Control; †SESH (Social Entrepreneurship for Sexual Health) Global; ‡STD Control Department, Guangdong Provincial Centers for Skin Diseases and STI Control, Guangzhou, China; §College of Arts and Sciences, University of North Carolina at Chapel Hill, Chapel Hill, NC; and ¶Department of Neurology, University of Pennsylvania, PA

Acknowledgments: The authors thank all the study participants and staff members at SESH Global, Danlan, and the Guangdong Provincial Center for Skin Diseases and STI Control who contributed.

Conflict of interests: None declared.

Funding: US National Institute of Allergy and Infectious Diseases (NIAID; 1R01AI114310); University of North Carolina (UNC)-South China STD Research Training Centre (Fogarty International Centre 1D43TW009532); UNC Center for AIDS Research (NIAID; 5P30AI050410); UNC Chapel Hill, Johns Hopkins University, Morehead School of Medicine and Tulane University (UJMT) Fogarty Fellowship (FIC R25TW0093).

Correspondence: Joseph D. Tucker, MD, MPH, University of North Carolina Chapel Hill Project-China, No. 2 Lujing Road, Guangzhou, 510095, China. E-mail: jdtucker@med.unc.edu.

Received for publication September 29, 2016, and accepted December 1, 2016.

Online sex seeking is an increasingly common practice among men who have sex with men (MSM).1,2 The online environment provides MSM an alternative venue in which men can build social connections and find new sex partners.3 At the same time, there is concern that sex seeking online may increase the risk of acquiring and transmitting sexually transmitted diseases (STDs).4–7

Technological advances now provide MSM multiple platforms for online sex seeking. Such platforms include websites and gay mobile apps.8 Men who have sex with men are likely to seek sex through a wide range of websites (eg, gay-specific forums, chat rooms, and dating websites). These websites connect MSM from different places, and MSM often develop online relationships before meeting in person.9 Gay mobile apps are another increasingly popular approach to online sex seeking (Table 5, SDC, http://links.lww.com/OLQ/A153). Unlike websites, gay apps use geospatial technology to identify physically proximate men.10,11 Gay apps differ from websites in terms of (a) the emphasis on physically proximate partners that decreases barriers to in-person meeting12; (b) the real-time nature of partner choosing that facilitates rapid meeting11; and (c) the widespread default profile photos, which may simplify partner selection.2,13 These differences may accelerate sex seeking and promote condomless sex.7

Along with the rapid proliferation of social media, using multiple types of platforms for social networking is generally on the rise, from 42% of Internet users in 2014 to 52% in 2015.14 Evidence from online and offline research indicates that diversifying platforms to meet sex partners may increase the possibilities of causal sexual encounters and spread infections among MSM.15,16 There is uncertainty about whether adopting multiple dating tools, for example, using both websites and apps together, facilitates riskier sexual behaviors when compared with only using 1 platform.10,17

In China, gay dating websites have been emerging since the late 1990s16 and nearly half of Chinese MSM have used websites for sex seeking.18 Gay apps have rapidly expanded in China during recent years.5,6 As of 2015, 27 million MSM have used Blued,19 the world's largest sex-seeking gay app. Despite the similar purpose of both platforms, their features vary, which likely attract different groups of MSM. Identifying the characteristics of MSM groups based on sex seeking platforms could help tailor interventions. Studies on comparison of website users, app users, and men who use both platforms are limited, especially in middle-income countries.2,17 The purpose of this study was to identify and compare sociodemographics and sexual risk behaviors between Chinese MSM in the following subgroups: website-only users, gay app-only users, and men who use both platforms.

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METHODS

Setting

In China, approximately 7.7% of MSM have human immunodeficiency virus (HIV) infection. The proportion of new HIV cases attributable to MSM behaviors has increased from 2.5% in 2006 to 25.8% in 2014.20

The data for this study were collected through a cross-sectional online survey from September through October 2014. Advertisements for study participation were put on 3 large gay Web portals that reach a large number of MSM in China. Banner links were presented on each Web portal homepage, and the announcement was sent out to registered users. The survey was developed based on interviews with MSM and then reviewed by many local stakeholders (local MSM, community-based organization workers, social media experts, physicians, and public health experts).6

To be eligible for the survey, participants must have stated that they were born biologically male, were older than 16, and engaged in anal or oral sex with a man in the previous year. Participants signed a consent form before filling in the survey, and eligible participants received a small (US $10) phone card reimbursement upon completion. Overall, a total of 1424 eligible MSM finished the online survey. Among them, we excluded those who did not have sex in the last 6 months (n = 174) and those who only used offline means for finding sex partners (n = 49).

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Measures

The survey measured sociodemographic information, sexual orientation, and online sex seeking behaviors. Based on survey responses, MSM were divided into 3 subgroups: website-only users, gay app-only users, and men who used both platforms for online sex seeking in the past 6 months. Each subgroup was further questioned about behaviors with sex partners they met in the past 6 months, including number of partners, condom use, time from initial conversation to in-person meeting, negotiation of condom use before meeting, HIV and STI testing, and exposure to STD-related messages. Sexual behaviors, including group sex, commercial sex, and sex when using drugs, were also assessed.

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RESULTS

Of the 1201 individuals who were engaged in online sex seeking, 377 (31.4%) men were website-only users, 487 (40.5%) were app-only users, and 337 (28.0%) were men who used both platforms.

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Sample Sociodemographics

Overall, the average age of men was 25.6 years old (±6.8), with the majority between 20 and 29 years old (n = 814, 67.8%). One quarter (25.6%) had attended high school at most, and 10.7% were married. In addition, 89.8% of men lived in urban areas and 81.9% had an annual income less than US $9600. In total, 64.4% of men (n = 773) reported sexual orientation disclosure to anyone other than their partners. Nearly half (51.6%) of the participants had a main male sexual partner (Table 1).

TABLE 1

TABLE 1

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Sociodemographic Characteristics of 3 MSM Subgroups

Sociodemographic characteristics were significantly different between the 3 groups of men (Table 2). First, there was significant difference in age (χ2 = 36.29, P < 0.001). Younger men (20–29 years of age) constituted 72.3% of gay app-only users and 70% of men who used both platforms, as compared with 59.9% of website-only users. Education level was also different between the 3 groups (χ2 = 18.52, P = 0.001). For instance, 32.4% of website-only users, 24.4% of gay app-only users, and 19.9% of men who used both platforms received no more than a high school education. Furthermore, the 3 groups were different in marital status (χ2 = 45.36, P < 0.001). The percentages of those who had ever married were 26.0%, 9.4%, and 13.6% for website-only users, gay app-only users, and men who used both platforms, respectively. Lastly, the 3 groups were different in disclosure of sexual orientation (χ2 = 14.98, P < 0.001). Among men who used both platforms, 70.6% had disclosed their sexuality or sexual history to someone, as compared with 57.0% of website-only users and 65.7% of gay app-only users.

TABLE 2

TABLE 2

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Sexual Behaviors Between 3 MSM Subgroups

Gay app-only users (69.0%) were more likely to have multiple sex partners than website-only users (52.8%) (χ2 = 204.81, P < 0.001). However, there was no significant difference in condomless anal sex behaviors between the 3 subgroups. In total, 57.6% of men reported that they had engaged in condomless anal sex with their last male partner in the past 6 months. The percentages were 55.7%, 59.5%, and 57.0% for website-only users, gay app-only users, and men who used both platforms, respectively. Also, exposure to STD-related messages was different between men using different platforms (χ2 = 23.58, P < 0.001); 58.1% of website-only users, 63.2% of gay app-only users, and 75.1% of men who used both platforms attained STD-related messages (Table 3).

TABLE 3

TABLE 3

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Factors Associated With Choices of Sex-Seeking Platforms

Table 4 shows the association between online sex seeking platforms and men's sexual behaviors after adjusting for potential confounders, including age, education, income, marital status, residency, sexual orientation, sexual orientation disclosure, and currently had a main partner. Compared with website-only users, gay app-only users have multiple sex partners (adjusted odds ratio [aOR], 2.15; 95% confidence interval [CI], 1.60–2.88). There was also an association between sex-partner seeking platforms and the time duration between initial conversation and in-person meeting. Compared with website-only users, gay app-only users were more likely to meet sex partners within a day (aOR, 2.24; 95% CI, 1.57–3.19) or within 2 to 7 days (aOR, 1.88; 95% CI, 1.34–2.64). Men who used both platforms were more likely to meet in person within 1 day or 2 to 7 days in comparison with website-only users (aOR, 3.71; 95% CI, 2.50–5.51) and gay app users (aOR, 2.32; 95% CI, 1.56–3.43). Using different online platforms to seek sex partners was also significantly associated with condom use negotiation. MSM who used both platforms were less likely to negotiate for condom use compared with website-only users (aOR, 0.52; 95% CI, 0.39–0.71). Finally, the results showed that men who used both platforms were exposed to more STD-related information than website-only users (aOR, 2.19; 95% CI, 1.57–3.05).

TABLE 4

TABLE 4

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DISCUSSION

Multiple online platforms are now available for MSM to meet sex partners around the world, creating barriers and opportunities for HIV prevention.21 The online environment creates a new local context that may influence sexual risk taking.6,7 This study extends the literature on online sex seeking2,17 by differentiating website and gay app channels, examining men who used both types of platforms as a separate group, and focusing on a middle-income country. Our data may help inform the development of tailored online interventions.

Our data suggest that these 3 MSM subgroups have distinct sociodemographic characteristics. Men who only used websites were more likely to be older, received less education, and married compared with men who only used gay apps. Men who used both platforms were similar to men who were gay app-only users, except that men who used both platforms were more likely to have ever disclosed their sexual orientation to others. This observation is consistent with other literature showing that online sex seeking preferences are related to sexual orientation disclosure.22 Openness of sexual identity is likely to be associated with active engagement in community and sexual networks because such men may feel safer and more comfortable to get involved.

Young men are more likely to use either gay apps exclusively or both platforms. This trend may be because young men generally adopt new technologies faster and are more interested in getting involved in multiple platforms.11 This trend suggests targeting interventions for older MSM through websites and for younger MSM through both websites and gay apps. Although dating websites are decreasing in frequency as compared with gay apps, this study reemphasizes the importance of performing promotional interventions on websites. A subgroup of MSM remains active on websites because they have become used to websites or they have privacy concerns regarding the geo-locating features of gay apps.13,16

We found similar rates of condomless sex among different MSM subgroups. Our study showed that 57.6% of men had condomless sex in the past 6 months, which is consistent with earlier literature.2,18,23 This high prevalence of unsafe sex behaviors underlines the importance for HIV prevention intervention to reach men on both websites and gay apps. Prior studies reported inconsistent findings on whether sex seeking platforms influence risky sexual behaviors. Some studies indicated gay app users were riskier compared with non–app users,7,24 some studies suggested gay app users were less risky,11 and other studies found no difference between these 2 groups.17,21,25 Our study also found no difference and is consistent with findings from Hong Kong21 and the United States.25 More importantly, it is consistent with the only identifiable empirical study in China that gay app users were associated with higher rates of multiple sex partners but not associated with higher rates of condomless anal sex behaviors.5 Despite similar condomless behaviors, gay app users had greater numbers of sex partners compared with website users. Our findings indicate that sex seeking platforms may be facilitators for meeting sex partners, but they are not necessarily related to risky sexual behaviors.

Lastly, this study showed that men who used both platforms received more STD-related messages. This finding suggests that social media interventions may benefit from using multiple platforms. It aligns with prior studies that using a combination of active (eg, instant messaging, mobile apps) and passive (Web banners) channels can reach a larger population for sexual health promotion.26 This study also echoes reports that consider online dating and sex seeking channels as important sources for health information and support.17 Social and sexual networks may provide more opportunities to conduct innovative interventions for HIV prevention.27

This study examines men's online sex seeking and risky sexual behaviors in the context of China. Due to the highly stigmatized environment in China, MSM often use fast, convenient online channels for sex seeking.15 In addition, advanced development of mobile internet allows individuals to be connected at all times in any place. The accessibility and affordability of mobile internet in China facilitate men to adopt mobile apps as social networking channels.28 With more platforms available, men's likelihood of finding a sex partner increases. However, we found no correlation between condomless sex and platforms used. Furthermore, men are likely to transfer from old platforms (eg, websites) to new platforms (eg, gay apps).29 It is important for this study to note that, although an increasing number of men are adopting gay apps in China, some men prefer to remain on websites for sex seeking. This suggests that interventions should consider using both old and new platforms.

This study has limitations. First, we only examined men who had sought sex online in the past 6 months. Although this may overestimate sexual behaviors among the general MSM population, it would not influence the validity of comparing men's online sex seeking platforms. Second, men self-reported their behaviors and this may lead to social desirability bias. Nevertheless, participants' personal information was not collected except for their cell phone numbers for compensation. Third, this study used a cross-sectional survey and, thus, could not claim causal relationship between men's online sex seeking behavior and their risky sexual behavior.

This study has policy and research implications. First, MSM social media interventions may opt to use multiple platforms in order to better reach MSM. Future studies can look more closely into men who use multiple platforms.2,17 Moreover, as online sex seeking platforms proliferate alongside an expanding HIV epidemic among MSM,20 how these online behaviors relate to disease transmission requires research. Additionally, men acknowledged receiving health messages when seeking sexual partners online. This finding is of great importance for men who are not motivated to actively search for health information. Further investigation can be done on the behavioral differences associated with actively seeking versus passively receiving sexual health information on safe sex behaviors and disease control.

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CONCLUSIONS

The persistent increase in newly diagnosed HIV infections among gay men in China calls for intensifying interventions in key areas and target groups.20 Given that gay dating websites and apps are both risk environments where low prevalence of consistent condom use are identified, focusing HIV prevention interventions in these online platforms may be useful.27 Different sociodemographic features between MSM subgroups suggest tailoring interventions on different platforms for different generations. Meanwhile, government and health agencies have collaborated with gay dating apps to fight the spread of HIV.30 Because MSM who used both platforms reported receiving more online health messages than single platform users, more such cooperation with both gay websites and apps should be encouraged.

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REFERENCES

1. Liau A, Millett G, Marks G. Meta-analytic examination of online sex-seeking and sexual risk behavior among men who have sex with men. Sex Transm Dis 2006; 33:576–584.
2. Grosskopf NA, LeVasseur MT, Glaser DB. Use of the internet and mobile-based “apps” for sex-seeking among men who have sex with men in New York City. Am J Mens Health 2014; 8:510–520.
3. Grov C, Breslow AS, Newcomb ME, et al. Gay and bisexual men's use of the Internet: Research from the 1990s through 2013. J Sex Res 2014; 51:390–409.
4. Bolding G, Davis M, Hart G, et al. Gay men who look for sex on the Internet: Is there more HIV/STI risk with online partners? AIDS 2005; 19:961–968.
5. Bien CH, Best JM, Muessig KE, et al. Gay apps for seeking sex partners in China: Implications for MSM sexual health. AIDS Behav 2015; 19:941–946.
6. Tang W, Best J, Zhang Y, et al. Gay mobile apps and the evolving virtual risk environment: A cross-sectional online survey among men who have sex with men in China. Sex Transm Infect 2016; doi: 10.1136/sextrans-2015-052469.
7. Zou H, Fan S. Characteristics of men who have sex with men who use smartphone geosocial networking applications and implications for HIV interventions: A systematic review and meta-analysis. Arch Sex Behav 2016; doi: 10.1007/s10508-016-0709-3.
8. Bull SS, McFarlane M, Rietmeijer C. HIV and sexually transmitted infection risk behaviors among men seeking sex with men on-line. Am J Public Health 2001; 91:988–989.
9. Couch D, Liamputtong P. Online dating and mating: The use of the internet to meet sexual partners. Qual Health Res 2008; 18:268–279.
10. Holloway IW, Rice E, Gibbs J, et al. Acceptability of smartphone application-based HIV prevention among young men who have sex with men. AIDS Behav 2014; 18:285–296.
11. Rice E, Holloway I, Winetrobe H, et al. Sex risk among young men who have sex with men who use Grindr, a smartphone geosocial networking application. J AIDS Clin Res 2012;3.
12. Landovitz RJ, Tseng CH, Weissman M, et al. Epidemiology, sexual risk behavior, and HIV prevention practices of men who have sex with men using GRINDR in Los Angeles, California. J Urban Health 2013; 90:729–739.
13. Blackwell C, Birnholtz J, Abbott C. Seeing and being seen: Co-situation and impression formation using Grindr, a location-aware gay dating app. New Media Soc 2014;1–20.
14. Duggan M, Ellison NB, Lampe C, et al. Social Media Update 2014. Pew Research Center, 2015. Available at: http://www.pewinternet.org/2015/01/09/social-media-update-2014/. Accessed August 5, 2016.
15. Wei C, Lim SH, Guadamuz TE, et al. Virtual versus physical spaces: Which facilitates greater HIV risk taking among men who have sex with men in East and South-East Asia? AIDS Behav 2014; 18:1428–1435.
16. Zhang D, Bi P, Lv F, et al. Internet use and risk behaviours: An online survey of visitors to three gay websites in China. Sex Transm Infect 2007; 83:571–576.
17. Ko NY, Tseng PC, Huang YC, et al. Seeking sex partners through the internet and mobile phone applications among men who have sex with men in Taiwan. AIDS Care 2016; 28:927–931.
18. Wu Z, Xu J, Liu E, et al. HIV and syphilis prevalence among men who have sex with men: A cross-sectional survey of 61 cities in China. Clin Infect Dis 2013; 57:298–309.
19. Blued. Blued Official Website. Available at: https://www.blued.com/en/. Accessed August 25, 2016.
20. UNAIDS. 2015 China AIDS Response Progress Report. 2015. Available at: http://www.unaids.org/sites/default/files/country/documents/CHN_narrative_report_2015.pdf. Accessed September 10, 2016.
21. Lee SS, Lam AN, Lee CK, et al. Virtual versus physical channel for sex networking in men having sex with men of sauna customers in the city of Hong Kong. PLoS One 2012; 7:e31072.
22. Duguay S. “He has a way gayer Facebook than I do”: Investigating sexual identity disclosure and context collapse on a social networking site. New Media Soc 2014;1–17.
23. Yeo TE, Ng YL. Sexual risk behaviors among apps-using young men who have sex with men in Hong Kong. AIDS Care 2016; 28:314–318.
24. Beymer MR, Weiss RE, Bolan RK, et al. Sex on demand: Geosocial networking phone apps and risk of sexually transmitted infections among a cross-sectional sample of men who have sex with men in Los Angeles County. Sex Transm Infect 2014; 90:567–572.
25. Lehmiller JJ, Ioerger M. Social networking smartphone applications and sexual health outcomes among men who have sex with men. PLoS One 2014; 9:e86603.
26. Muessig KE, Nekkanti M, Bauermeister J, et al. A systematic review of recent smartphone, internet and Web 2.0 interventions to address the HIV continuum of care. Curr HIV/AIDS Rep 2015;173–90.
27. Tso LS, Tang W, Li H, et al. Social media interventions to prevent HIV: A review of interventions and methodological considerations. Curr Opin Psychol 2016; 9:6–10.
28. Zheng L, Zhang X, Feng Y. The new avenue of online sexual activity in China: The smartphone. Comput Human Behav 2016.
29. Feldmann V. Leveraging Mobile Media: Cross-Media Strategy and Innovation Policy for Mobile Media Communication. Heidelberg: Physica-Verlag, A Springer Company, 2005.
30. Taking Potkin F China's Fight Against AIDS Online. Dipl. 2016. Available at: http://thediplomat.com/2016/01/taking-chinas-fight-against-aids-online/. Accessed August 2, 2016.

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