Group Sex in Gay Men: Its Meaning and HIV Prevention Implications.

HIV/AIDS continues to pose a serious health hazard for gay men. Large numbers of men continue to become HIV infected each year, despite access to knowledge concerning how HIV is transmitted. Although gay men changed their sexual practices early in the epidemic, there is growing concern that there is a resurgence of risky sexual activities occurring in this group. Of particular concern is the resurgence of group sex activities. The purpose of this study was to explore the experiences of group sex in gay men to gain insight into the meaning of group sex to these men, the context in which it occurs, and men's views of how group sexual encounters relate to HIV transmission. The study used a qualitative approach to data collection. Ten self-identified gay men who reported engaging in group sex activities were interviewed concerning their experiences. Men reported that the most likely place for them to engage in group sex activities was in sex clubs, and a majority of their discussions centered on these clubs. Study data were analyzed using content analysis. Two overall categories of responses emerged from men's descriptions of their group sex experience: sexual desire and HIV/STD risk behaviors. Four themes--access to sex, sexual excitement or stimulation, sexual options, and control and sexual freedom--comprised the category of Sexual Desire. The themes identified within the category of HIV/STD risk behaviors included reframing risk, rejection of safer sex, and alcohol and drug use. The findings of the study suggest that sex in group settings such as sex clubs is a reality that must be addressed by HIV prevention efforts. Additionally, results indicate that current HIV prevention messages are being rejected by many gay men and need to be reevaluated for relevance two decades into the HIV/AIDS epidemic.

The number of individuals newly infected with HIV continues to rise, and the prevalence of HIV/AIDS remains higher among men who have sex with men than any other group (Centers for Disease Control and Prevention [CDC], 1996). With prevention being the most effective weapon against HIV, the continued high rates of infection among gay men mandate a reexamination of risk behaviors in this population and the assumptions underlying HIV/AIDS prevention programs targeting these men.

Although there is evidence that many gay men changed their sexual behaviors early in the HIV/AIDS epidemic to avoid infection (Becker & Joseph, 1988; McKusick, Coates, Morin, Pollack, & Hoff, 1990; Stall, Coates, & Hoff, 1988), anecdotal reports suggest that gay men's sexual behaviors may be returning to preepidemic norms (Shilts, 1988). A review of selected newspapers and other print media marketed to men within urban gay communities reveals an increasing incidence of men's clubs (sex clubs) being advertised (Damron Road Atlas, 1997; Etcetera Magazine, 1997; The Washington Blade', 1996). Additionally, an exploration of gay-related "chat rooms" on the Internet reveals discussion and solicitation of unprotected anal intercourse (i.e., barebacking). If such advertisements and discussions on the Internet represent a renewed interest in "casual" sex among gay men, this situation has profound implications for HIV/AIDS prevention efforts. Therefore, the purpose of this study was to explore the experiences of group sex in gay men to gain insight into the meaning of group sex to these men, the context in which it occurs, and men's views of how group sexual encounters relate to HIV transmission.

Background

In spite of the large amount of information concerning the modes of transmission for HIV, the rate of HIV infection continues to spiral upward. In 1996, men identifying sex with men as their only risk made up approximately 39% (n = 27,270) of all newly diagnosed cases of AIDS and 50% of new cases of AIDS in men. If men who reported both engaging in sex with men and injecting drugs are added to the above figures, men who report sex with men as a potential HIV transmission mode accounted for approximately 44% of all new AIDS cases (CDC, 1996). Additionally, many men being diagnosed with AIDS were most likely infected with HIV as adolescents or young adults. Of new AIDS cases reported in 1996, 75 adolescent males (13 to 19 years-old) and 797 young adult males (20 to 24 years-old) identified sex with men as their only risk factor for HIV infection. Of all men having been diagnosed with AIDS since the beginning of the epidemic, 42% have been younger than 35 years of age (CDC, 1996).

By the late 1980s, there was growing evidence that gay men were making behavior changes to reduce their chances of becoming infected with HIV (Becker & Joseph, 1988; Coates et al., 1988; Ekstrand & Coates, 1990; McKusick et al., 1990; McKusker, Stoddard, Zapka, Zorn, & Mayer, 1989; Stall et al., 1988). Specifically, a significant reduction in the frequency of unprotected anal intercourse among gay men living in urban HIV/AIDS epicenters was reported (Ekstrand & Coates, 1990; McKusick et al., 1990). This reduction in unprotected anal intercourse was particularly important because anal intercourse is believed to carry the greatest risk for HIV transmission (Darrow, Jaffe, & Curran, 1983; Detels et al., 1989; Goedert et al., 1984; Goedert et al., 1985; Winkelstein et al., 1987).

Other researchers, however, reported that such changes in high-risk sexual behaviors were not as prevalent in smaller cities and in regions of the United States designated as low HIV/AIDS prevalence areas (St. Lawrence, Hood, Brasfield, & Kelly, 1989). Additionally, over the past several years, there has been growing recognition that gay men continue to engage in high levels of unsafe sexual behaviors (Kelly et al., 1991; Sowell, Seals, & Cooper, 1996; Sowell, Seals, & Phillips, 1996).

Younger gay men have been found to be less likely to reduce risky sexual behavior than older men (Hays, Kegeles, & Coates, 1990; Stall et al., 1988), and a rapid increase in new infections among young gay men has been observed (CDC, 1995; Stall et al., 1988). Many younger men perceive themselves as being invulnerable to HIV infection (Hansen, Hahn, & Wolkenstein, 1990).

Researchers report that gay men who successfully modified risky behaviors earlier in the HIV epidemic (CDC, 1985; Martin, 1987; McKusick et al., 1985; Schechter et al., 1988; Stall, McKusick, Wiley, Coates, & Ostrow, 1986) have now returned to former unsafe behaviors (Ekstrand & Coates, 1990; McKusick et al., 1990). The rates of seropositivity among men ages 26 to 29 living in San Francisco were estimated to be as high in 1994 as they were in 1983. Anecdotal reports suggest that recent advances in HIV treatment using multiple drug therapy may be having an impact on sexual behaviors among gay men. Men who had been extremely ill with HIV/AIDS are, in many cases, experiencing a stabilization of their conditions and improvement in their energy levels. These men are faced with a need to reconstruct their lives including their sexual relationships (Sowell, Phillips, & Grier, in press). Additionally, reports of dramatic improvement in the conditions of persons with HIV/AIDS as a result of new therapies may lead men to the mistaken assumption that the epidemic is approaching an end or that HIV is no longer a life-threatening condition.

Sex clubs in many urban centers are rumored to have reopened or, in some cases, never closed and are attracting a growing number of customers, increasing the potential for casual sex among gay men. Recent articles in the gay media have focused on the resurgence of unprotected sex (especially barebacking) among both HIV-negative and HIV-positive men. These unsafe sexual activities are reported to frequently take place in the sexually charged environments of sex clubs and circuit parties (Gallagher, 1997; Heitz, 1997; Newman, 1998; Peyser, 1997) and include group or multiple partner sex. Furthermore, advances in communication technology provide increased opportunity for men to meet men interested in casual sex and arrange such activities through use of the Internet, cellular phones, and digital pagers (Ofstedahl, 1998). If such sexual behavior among gay men is taking place or increasing in occurrence, there is a need to understand the motivation for such behavior and identify the context in which it occurs. The formulation of effective HIV prevention efforts in the gay community requires insight into the range of sexual behaviors being practiced by gay men. If group sexual experiences are becoming more prevalent, HIV prevention programs must not only acknowledge this fact but work to develop prevention strategies that address sex in group settings.

Methodology

This study used a qualitative research design that explored the experiences of group sex among gay men. Individual face-to-face interviews were conducted with 10 self-identified gay men living in a major metropolitan center in the southeastern United States. Participants in the study represented a nonrandom purposive sample of men who had participated in group sex activities on a number of occasions. The study sought to obtain a description of …