Intentional Condomless Anal Intercourse Among Latino MSM Who Meet Sexual Partners on the Internet

Abstract

Data on intentional condomless anal intercourse in risky contexts, also known as “barebacking,” among ethnic minority MSM, whose rates of HIV infection continue to rise, is extremely limited. In this study, thirty-one Latino MSM who seek barebacking partners via the Internet underwent in-depth interviews about bareback sex and its association to pleasure, substance use, HIV concerns, and cultural identity. Participants reported engaging in bareback sex due to the physical and emotional pleasure they experience. They expressed concern about HIV infection and took steps to reduce risk of infection. While a majority of participants reported using alcohol or drugs in the context of bareback sex, substance use did not appear to propel the behavior. Crystal methamphetamine use, prevalent only among our HIV-positive participants, was related to very high HIV-risk behavior. In this sample, culture did not seem to play a large role in barebacking.

INTRODUCTION

In recent years, the academic literature on men who have sex with men (MSM) has started to focus on the intentional practice of condomless intercourse, often referred to as “bareback sex.” While it is generally agreed that the core definition of bareback sex or barebacking is “condomless anal intercourse,” variations have added intention, HIV-risk, and type of partner to the definition (Carballo-Diéguez, et al. 2007; Carballo-Dieguez & Bauermeister, 2004; Halkitis, Wilton, & Galatowitsch, 2005; Mansergh, et al., 2002; Suarez & Miller, 2001; Wolitski, 2006). However, no consensus has been reached on differentiating condomless anal sex from “barebacking,” limiting comparisons across studies (Huebner, Proescholdbell, & Nemeroff, 2006).

Within this constraint, studies have associated barebacking to a dislike of condoms and a desire for greater physical pleasure and emotional closeness (Halkitis, Parsons, & Wilton, 2003; Mansergh, et al., 2002), AIDS fatigue and decreased concerns about HIV infection (Wolitski, 2005; Wolitski & Branson, 2002), and drug use, especially “club drugs” such as ecstasy, GHB, and methamphetamines (Halkitis, Parsons, & Stirrat, 2001; Purcell, Moss, Remien, Woods, & Parsons, 2005; Wilton, 2005). The Internet has also contributed to the emergence of barebacking by facilitating contact between men into barebacking (Carballo-Diéguez, et al., 2006; Davis, Hart, Bolding, Sherr, & Elford, 2006; Halkitis, Parsons, & Wilton, 2003; Wolitski, 2005).

To date, though, much of the literature on barebacking has focused on HIV positive, white, gay identified men, with less attention to barebacking among MSM of color whose rates of HIV infection continue to rise (Wolitski, 2005). Data on barebacking among minority MSM has been mostly limited to using ethnic identity to group participants and compare them on different variables. For example, ethnic minority MSM have been found to be less familiar with the term “bareback” than white men (Carballo-Diéguez, et al. 2007; Halkitis, et al., 2005; Mansergh, et al., 2002), but no significant differences have been found between ethnic groups in terms of barebacking behavior (Mansergh, et al., 2002). However, most studies have been quantitative surveys which have not explored the ethno-cultural context of bareback sex.

Prior studies (Diaz, 1998; Diaz & Ayala, 1999, Warren, et al, 2007) have demonstrated the importance of culture in understanding risk behavior among Latino MSM. In a recent exploratory study of ethnic minority MSM and barebacking, Wilton, Halkitis, English, & Roberson, (2005) suggest that “bareback sex holds differential cultural and phenomenological meanings for Black and Latino men” (p. 67) and that that compared to African American men and men of other ethnicities (White, mixed race, Asian-Pacific Islander and any other race/ethnicity), “Latino men of unknown HIV status perceived the most benefits from barebacking” (p.68). The authors suggest that this might be related to the “machismo discourse” that Diaz (1998) proposes, linking masculinity to risk behavior, but they do not elaborate on these conclusions or explain how culture may influence barebacking for Latino MSM. Furthermore, the level of acculturation of the Latino participants is not specified, making it difficult to speculate on their connectedness to traditional cultural values. And lastly, this investigation, extrapolated from a study on club drug use, is also limited by the requirements of drug use as criteria for inclusion into the study.

Our study seeks to further the current understanding of Latino MSM who engage in intentional condomless sex in risky circumstances, which we will refer to as bareback sex. We present findings from a descriptive qualitative study of MSM who use the Internet to seek partners for condomless sex, and aim to provide a description of the phenomenon of barebacking from the viewpoint of the participants (Giorgi, 1992; Sandelowski, 2000). Based on the previous research findings on barebacking among MSM, this paper explores how the desire for intimacy and closeness, dislike of condoms, substance use, and decreased concerns about HIV/AIDS affect decisions to bareback in Latino MSM. Then, we proceed to explore the role of culture in barebacking among Latino MSM.

METHODS

PARTICIPANTS

Participants were recruited from April 2005 to March 2006 exclusively through websites previously identified as sites where one could find men “into barebacking” (Carballo-Diéguez, et al., 2006). Men were informed of the study via emails, instant messages (IMs), or an online profile directing them to the study website and, if interested in participating, were asked to call for an eligibility screening. Of the 5,165 IMs sent, 54% were acknowledged and, of those men, 9% were screened, while of the 2,467 emails sent, 4% were acknowledged and, of these men, 70% were screened. A total of 538 Website users contacted us via our profile, of which 17% were screened (Ventuneac, et al., in preparation).

Recruitment targeted four ethnic groups (European-American, Latino, African-American, and Asian/Pacific Islander). Furthermore, recruitment was divided into higher-risk (HIV-negative men who engage in receptive anal intercourse) versus lower-risk participants (HIV-positive participants or HIV-negative participants who only engage in insertive anal intercourse), with an oversampling of higher risk participants. This resulted in eight recruitment cells based on different combinations of race/ethnicity and level of risk. Men who self-identified as a “barebacker” or “into barebacking” were invited to participate, with no definition of the terms provided by the screener. Other inclusion criteria included being at least 18 years of age, residing in the New York City metropolitan area, using the Internet to meet men at least twice per month, having had intentional condomless anal intercourse with a man met over the Internet, and using one of the six Internet sites identified in the first phase of the study as most popular for meeting men into barebacking. Participants also had to meet the race/ethnicity and level of HIV risk requirements for cells in which recruitment was still occurring.

Of the 394 men who were screened for the study, 190 (48%) qualified, of whom 125 (65%) completed a face-to-face interview. Of the 394 men who were screened, 111 (28%) were Latino. Of these, 57 (51%) didn’t qualify, 23 (21%) qualified but did not complete an interview, and 31 (28%) completed an interview. For information on the entire study sample, please see Carballo-Dieguez, et al. (2008) and Wilson, et al. (2008).

INTERVIEW

After signing informed consent, participants underwent an in-depth interview with one of three doctoral-level clinical psychologists. The interview inquired about participants’ definition of bareback sex, feelings toward and experiences of barebacking, concerns about HIV infection, substance use, and ethnic and racial identity. Following the interview, participants completed a structured, quantitative assessment using Computer Assisted Self-Interview (CASI) whose results are not presented in this paper. Participation in the study lasted approximately two hours and participants received $50 in cash as an incentive. Recruitment was conducted on English language websites and interviews were conducted in English. However, to accommodate one participant, one interview was conducted in Spanish. The study was approved by the Institutional Review Board of the New York State Psychiatric Institute.

DATA ANALYSIS

Indepth interviews were audiotaped, transcribed by a transcription service, and verified for accuracy. A preliminary codebook, constructed from the structure of the interview guide, was developed by a six-person team of researchers involved with the study. The codebook specified the first level code headings, which were based on the different sections of the interviews (i.e. Feelings about Bareback Sex, Condom Use, Substance Use), the definition of the code, and inclusion and exclusion criteria for using each code. Four transcripts were coded independently to assess concurrence in coding using these first level codes. Subsequently, the codebook was further specified and a team of four coders who reached at least 80% intercoder convergence (Hruschka, et. Al., 2004; Marques & McCall, 2005; Morse, et al., 2003; Thompson, et al., 2004) using NVivo qualitative analysis software proceeded to code all the transcripts. Once the initial coding reports for the content areas to be explored in this paper were generated, thematic analysis was used to identify issues that emerged during the interviews.

RESULTS

CHARACTERISTICS OF STUDY SAMPLE

Thirty-one self-identified Latino men participated in the study, of which 22 were HIV-negative and 9 were HIV-positive. As Table 1 shows, most participants were gay-identified, were 30 years of age, on average, and had a high school education. Approximately half were employed full-time. Almost one-fourth of the participants were born outside the U.S., including in Puerto Rico (4), Colombia (2), Nicaragua (1), Peru (1), and Brazil (1).

Table 1.

Demographic characteristics and sexual behavior of the Latino sample by HIV status

	HIV- (n = 22)	HIV+ (n = 9)	Total (n = 31)
	M (SD)	M (SD)	M (SD)	t/χ2
Sociodemographic Characteristics
Age	28.50 (8.16)	34.33 (4.98)	30.19 (7.77)	2.43*
Education	13.59 (3.31)	13.56 (1.59)	13.58 (2.88)	0.03
Income, in thousands (Mdn)	24.50	10.00	23.00	1.16a
Born outside of the US (%)	18.2	55.6	29.0	4.33*
Age when moved to the US	15.25 (11.98)	18.20 (4.44)	16.89 (8.13)	0.47*
Sexual self-identification (%)				2.44
Gay/Homosexual	77.3	100	83.9
Bisexual	18.2	0	12.9
Gay and Bisexual	4.5	0	3.2
# of times tested for HIV (Mdn)	5.00	2.00	4.00	2.56a**

^*p≤05;

^**p≤.01.

^aMann-Whitney test

Among the HIV-negative participants, over 80% reported getting an HIV test at least yearly. One participant had never been tested for HIV and another had not been tested for the past eight years. Testing behavior for two participants was unclear.

DEFINITION OF “BAREBACK SEX”

When asked to offer a “dictionary definition” of the term “bareback sex,” most participants said “anal sex without a condom,” “sex without protection,” or “fucking without a condom.” Two participants spontaneously addressed the issue of HIV-risk in their definition, stating:

Condom-less, unprotected sex, with the knowledge that you could be having sex with men who have sexually transmitted diseases, or who do not know their HIV status, or who are HIV positive. That’s important to lump into the definition, because that’s what it really all boils down to. [010, 25 y.o., HIV-]

Just have unprotected sex. I mean… it’s completely you give it just to luck, because when I practice bareback, I don’t even look [to see] if the guy looks clean… it’s just like going blind…jumping a hill, you know? [144, 45 y.o., HIV-]

The great majority of men considered that if a condom broke during intercourse and the participants continued having sex, it “turns into bareback,” although when presented with this scenario, some participants clarified that intention not to use condoms should be a part of the definition of barebacking. Similarly, when asked whether an HIV negative couple who is monogamous and decides not to use condoms is considered barebacking, the great majority considered it so. Only five participants, all HIV-negative considered this not to be barebacking, due to decreased risk, greater intimacy, and it being “the norm” and “what straight people do.”

FACTORS ASSOCIATED WITH BAREBACKING

Feelings About Bareback Sex

Both HIV positive and negative men spoke of bareback sex as more intimate and emotionally satisfying than sex with condoms. One stated that bareback sex allows for an “entire connection with the person you are with, feeling every part of them, without interruption,” [#097, 25 y.o., HIV-] and another said that “the exchange of fluids…the feeling of when somebody comes inside… it’s more personal, the beauty of it, the beauty of sex.” [#065, 41 y.o., HIV+]. Many reported deriving greater pleasure from condomless sex due to increased physical sensation. For some, condoms made receptive anal sex more painful due to drying out.

Nine HIV negative participants reported barebacking “in the heat of the moment” or when they were very turned on sexually, with a few reporting that their attraction to their sexual partner determined whether or not they used condoms. However, many appeared to approach a sexual event consciously preferring not to use condoms and using them only if concerns arose due to the person’s lack of hygiene, appearance of being ill, or if their sexual interest in the person diminished upon meeting them in person.

Most of the HIV-positive participants reported rarely, if ever, using condoms, but doing so at the request of their partner. Two of these men spoke of primarily using them to protect others, one stating that he felt uncomfortable not using condoms with younger men. About half could not imagine situations in which they would insist on condoms being used for sex, with one participant stating that “those that I would insist on using a condom, I wouldn’t have sex with.” [#040, 37 y.o., HIV+] This was usually due to their hooking up only with other men with whom they felt comfortable having bareback sex, whether due to appearance or serostatus.

While there was a clear preference for bareback sex, some of the men were conflicted about barebacking. Ten of the HIV-negative men acknowledged the risk involved, stating “It’s risque, like I told you, I’m playing Russian roulette” [#057, 39 y.o., HIV-] with a few of them expressing regrets afterwards, such as “I just don’t think it’s a good idea,” [#090, 24 y.o., HIV-] and “it happens more than I should let it happen…. and it’s nothing that I’m proud of” [#092, 25 y.o., HIV-] Two HIV-positive participants related barebacking to social responsibility, stating “it’s socially irresponsible, you could promote a whole host of other health risks” [#045, 35 y.o., HIV+] and “irresponsible. Lack of responsibility about myself,” [#065, 41 y.o., HIV+], who adds that when he has sex with condoms it is “without feeling guilty about it… but I know the real sense, that lack of responsibility is like driving drunk or not complying with society’s rules, when you cross the light when you’re not supposed to, it’s like risky.”

Concerns About HIV Infection

Only three HIV-negative participants expressed little concern about HIV infection, with two of them attributing this to the treatments available and decreased fear of dying of AIDS. The remainder expressed significant concern about HIV infection and recognized that barebacking increases their risk of contracting HIV or other sexually transmitted infections. Participants struggled to make sense of the contradiction between their concerns and their risk behavior. They reported that often, when barebacking, they did not think about HIV, and that it was afterwards that concerns about their behavior emerged.

They [HIV and other STIs] are a huge concern. That’s funny because there are so many diseases out there. But I always think of like AIDS and HIV as like one of the biggest. I mean, I’ve always thought that diseases like cancer and, arthritis or Alzheimer, you can’t prevent those. Those just happen. But something like AIDS or HIV, you could prevent. So, to me, that’s very scary. And, you know, if I get a disease I can’t do anything about, that’s fine, but the idea of having HIV or AIDS, something that I could have prevented, you know, that scares me. [#102, 25 y.o., HIV-]

[HIV is a] huge concern… but not that big, obviously, because I still have bareback sex. I guess I just try to push it out of my mind while I’m having sex. Also figure I’m only here for so long, why not enjoy myself? But then I also think about lying in the hospital for the last two years of my life. So it’s hard to balance it. When I’m thinking about the HIV, I try to forget about the barebacking. When I’m doing the barebacking, I try to forget about the HIV. [#097, 25 y.o., HIV-]

Almost all participants, whether HIV-positive or negative reported taking steps to reduce the risk of HIV infection. These included serosorting (i.e. choosing partners of reportedly same serostatus), using condoms for sex with partners assumed (or known to be) serodiscordant, limiting the partners with whom they have bareback sex, and not barebacking in what they perceived to be high-risk settings such as bathhouses.

Substance Use

Seven participants (6 HIV-negative, 1 HIV-positive) reported no current alcohol or drug use, while eleven (7 HIV-negative and 4 HIV-positive) reported alcohol use with sex. These men all described alcohol as increasing sexual desire and decreasing inhibitions.

It [sex] is more interesting, more passionate, I would say. It tends to last longer, yeah, really good. Water sports and fisting I would have to be drunk, can’t do it without it. Um, I don’t know, I’m like more amped up when I am drinking than when I am sober so I am willing to do a lot more. [#060, 20 y.o., HIV-]

There were a couple of incidents where the guy knew he was positive, and I was just drunk, and I was aware, but it was like, I didn’t care… and I said ‘OK, why the hell not?’ [#090, 24 y.o., HIV-]

It doesn’t necessarily mean that if I drink I will not use condoms. It’s easier, you’re less inhibited when you are drunk. That’s what they call ‘liquid courage.’ [#108, 28 y.o., HIV-]

Seventeen men (11 HIV-negative and 6 HIV-positive) reported currently using drugs, mostly in conjunction with sex. Drugs currently being used by participants included marijuana, poppers, cocaine, Ecstasy, and methamphetamines. Marijuana was the drug used most often by the participants and a few reported using it unrelated to sex–for two participants, it interfered with sex. Only six men (all but one HIV-positive) reported current use of methamphetamines. For all methamphetamine users, the drug was associated with extremely high risk behavior, for all but one participant involving voracious sexual appetite and multiple sex partners.

I think drugs and the Internet are so accessible, and that’s the problem. Sex and drugs are just, there are so many people, the minute I get online, I can have drugs and sex in my apartment. Then, I have to decide whether I want just a sex orgy or I want a sex and drug orgy, or if I just want a drug orgy. [#040, 37 y.o., HIV+]

So at first, without doing the drugs, I would have intercourse with people, but I would be like, you know ‘Just don’t come inside me.’ When I did crystal, then all of a sudden, that idea seemed enticing, to just let someone do that. […] The porn nowadays is so explicit, especially the barebacking porn. And this is what they were doing in the porn. There was one guy that took I don’t know how many loads inside him. And then, all of a sudden, that idea seemed enticing. So what happened was… anybody who was pig-oriented raised my interest, which is something that I wasn’t into before. The idea of, of watching porn and watching the guy coming inside another guy that whole theme seemed more enticing only when I did crystal. It didn’t seem as enticing when I didn’t. So that’s something that the drug did, that I didn’t do, that I, that I don’t think I would have even thought of thinking that far, if I was sober. So I know that’s one of the things that the drug does to you. It loosens you of your---inhibitions. [#067, 39 y.o., HIV+]

Culture

When asked about their ethnic identification, 26 participants identified as some variation of Latino, whether it was Latino, Hispanic, or their national origin (i.e. Puerto Rican), with one participant identifying as a White Latino. Five identified as Mixed or Other, usually due to a combination of races/ethnicities, such as Hispanic and African-American, Black and Colombian, or Cuban-Lebanese. Almost all participants reported including their ethnicity in their online profiles or when communicating with others online, although one of the men who self-identified as Latino in person identified as White online, and another identified as White Latino online.

The majority of the men considered that being Latino was viewed as desirable by others online. Participants attributed their online desirability to being perceived as “hot in bed” or “passionate,” being “well-endowed,” and being uncircumcised. However, some participants disliked the stereotypes, whether positive or negative. A few spoke of feeling objectified by the stereotypes, which one participant considered a “fetish.” Two felt stigmatized by the stereotype Latinos as dark-skinned, inner-city thugs, which they did not feel accurately represented them.

When asked about higher rates of HIV among MSM of color, some participants attributed this to cultural issues such as homophobia, machismo, and denial of homosexuality, whereas economic difficulties were seen as contributing to people not caring about the risk of HIV infection. However, only two participants, the oldest in the sample, spontaneously linked their culture to sexuality, one to his sexual behavior in general, and the other to having bareback sex.

Back home, like, when you get raised in South America, if you’re the bottom, you’re really gay, if you’re top, you’re really a horny guy, you know? So with all this macho mentality, it took years to break that pattern. Years. [#144, 45 y.o., HIV-] Well, to tell you the truth, I like barebacking. I mean, you know, I’m Latin -- and I like it… I was born with it. And since I tried it for the first time, which was many years ago, yes! And to use a condom, for me, is like, oh, no! Because you don’t feel nothing, not the whole thing about fucking. (laughs) It’s true! [#145, 46 y.o., HIV-]

Overall, most of the participants attributed bareback sex to factors that cut across ethnic groups, rather than attributing it specifically to Latin culture or their specific ethnicity.

DISCUSSION

Study participants overwhelmingly reported engaging in barebacking due to the physical pleasure and emotional closeness they experience with their sexual partners, as has been reported elsewhere (Halkitis, Parsons, & Wilton, 2003; Mansergh, et al., 2002). Although AIDS fatigue and decreased concern about HIV infection have been previously associated to barebacking (Wolitski, 2005; Wolitski & Branson, 2002), nearly all participants in this study expressed concern about HIV infection and transmission and were not actively seeking to become infected or infect others, employing a variety of approaches to reduce risk of HIV transmission. Nonetheless, this concern may be lessened from the fear of infection that was more common in pre-HAART years. For most, the decision to engage in bareback sex did not appear related to impaired mental state, substance use, or fatalism about HIV infection. While often associated to barebacking, substance abuse did not seem to propel the behavior in our sample. Crystal methamphetamine, which has often been linked to barebacking, was used by only one-fifth of the sample, all but one of which were HIV positive. However, the use of crystal methamphetamine was associated with very high risk behavior with multiple partners.

These findings highlight a “spectrum” of bareback sex, where some of these men (mostly HIV-positive) only have condomless sex, while others are willing to have sex with condoms, and others prefer using condoms under certain circumstances. Nonetheless, these men seemed to approach sexual situations with a willingness or intention to bareback unless the situation triggered concerns for them. This is in contrast to most previous work on condom use among Latino MSM, where men intended to use condoms but occasionally slipped and did not use them (Diaz, Stall, Hoff, Daigle, & Coates, 1996; Diaz, 1998; Diaz & Ayala, 1999).

Our results partially replicate findings exploring why Latino MSM do not use condoms consistently. Our participants viewed condoms as interfering with sexual intimacy, but they were not fatalistic about HIV infection and, except for one participant, did not associate their barebacking to machismo, which has often been implicated in unsafe sex among Latino men (Diaz, 1998; Diaz & Ayala, 1999; Dolezal, et al., 2000). It is interesting to note that while participants strongly identified as Latinos and were able to provide rationales of why men of color might not use condoms, it was only the oldest participants who associated their sexual behavior and barebacking to being Latino. These differences could be due to this sample being much more acculturated than those presented in other work on Latino MSM (Carballo-Dieguez, et al., 2005; Diaz & Ayala, 1999; Diaz, et al., 1996) and less affected by some of the stressors experienced by immigrant men.

These findings highlight a number of important issues that would have to be considered in the development of interventions for this population. First, interventions would need a greater focus on intention and motivation to practice safer sex, which has often been assumed and not been an explicit focus of prior HIV-risk reduction interventions with MSM. Motivational Interviewing (MI) has been suggested as an effective approach with this population (Parsons, 2005). While MI might be helpful to some individuals who bareback, the lack of interest in consistent condom use expressed by participants in this study suggest that other harm reduction approaches, which are not based only on using condoms, need to be pursued. These could focus on improving skills in inquiring about and disclosing serostatus so that assessments of risk are based more on reported status than an assumption of status, which for our sample was usually based on one’s desire to be seroconcordant with the potential sex partner. Other interventions might focus on engaging MSM who bareback to test more regularly for HIV and to increase awareness about the signs, symptoms, and elevated infectiousness present during the acute phase of HIV infection. And finally, interventions aimed at increasing acceptability and use of pharmaceutical approaches to risk reduction such as post-exposure prophylaxis (PEP), and when available, pre-exposure prophylaxis and microbicides, might also be of value to this population (Nodin, et al., 2008). Interventions must also focus on the men’s desire for intimacy, closeness, and pleasure, needs for which many of our participants were willing to risk HIV infection. Although Diaz and Ayala (1999) called for acknowledging and addressing these needs in prevention programs, their call has been unheeded to date.

While this is one of the largest in-depth studies of Latino barebackers conducted to date, our sample is a subset of the Latino men who engage in bareback sex and not representative of all Latino men who bareback. Furthermore, this sample, which required that participants report being “barebackers” or “into barebacking” may not capture the experiences of Latino MSM who engage in intentional condomless anal intercourse, but might not be familiar with or use the term “barebacking.” This sample of Latinos was also highly acculturated and was recruited through English-language websites. Almost all of the participants interacted comfortably in English, which appeared to be the first language for many. As such, their experiences may not reflect that of less acculturated Latinos. As previously mentioned this might be particularly relevant in terms of cultural aspects of condom use experienced by less acculturated Latinos which might not have emerged in this sample.

Nonetheless, the findings provide a richer, more nuanced picture of the experience of barebacking, which has been missing from the predominantly quantitative literature that exists on the topic. While the limited association made by the participants between culture and barebacking was somewhat surprising, it highlights the heterogeneity beneath the umbrella term Latino as well as the importance of viewing research findings through a lens of acculturation. The results also suggest that these acculturated, minority MSM, who are comfortable interacting in English-language websites, might respond to risk-reduction campaigns that are not culturally specific to Latinos, thereby expediting their accessibility to prevention efforts by not having to wait for culturally specific interventions.