Sex Parties among Young Gay, Bisexual, and Other Men Who Have Sex with Men in New York City: Attendance and Behavior

Abstract

Very little information exists with regard to sex party behaviors in young men who have sex with men (YMSM), often defined as men ranging in age from 13 to 29 years. The current analysis examines sex party attendance and behavior in a sample of 540 emergent adult gay, bisexual, and other YMSM in New York City, ages 18–29 years. Findings indicate that 8.7% (n = 47) of the sample had attended a sex party 3 months prior to assessment. Sex party attendees reported that parties included both HIV-positive and HIV-negative men; attendees also reported unprotected sex and limited access to condoms and lubricant. As compared with those who did not attend sex parties, those who did indicated significantly more lifetime and recent (last 3 months) casual sex partners, drug use (both number of different drugs used and total lifetime use), psychosocial burden (history of partner violence and number of arrests), and total syndemic burden (a composite of unprotected anal sex, drug use and psychosocial burden). These results indicate that while only a small percentage of the overall sample attended sex parties, the intersection of both individual risk factors coupled with risk factors engendered within the sex party environment itself has the potential to be a catalyst in the proliferation of the HIV/AIDS epidemic in urban settings. Lastly, given that sex parties are different than other sex environments, commercial and public, with regard to how they are accessed, public health strategies may need to become more tailored in order to reach this potentially highly risky group.

Introduction

Three decades since the emergence of HIV/AIDS in the USA,¹ the epidemic continues to affect over 1.2 million Americans.² This is particularly true for men who have sex with men (MSM) who, despite being only 4% of the population, account for 53% of all new HIV infections every year and 48% of all persons living with HIV.² In particular, HIV infections appear to be increasing among young men who have sex with men (YMSM). In urban centers like New York City (NYC), new HIV diagnoses in YMSM rose 33% between 2001 and 2006, with most infections noted in racial and ethnic minority men.³ In this time frame, new HIV infections increased 126% in Black YMSM and 81% in Latino YMSM. Additionally, Black and Latino youth accounted for roughly 90% of all new infections in men under 20.³ Studies from other metropolitan areas have paralleled these findings.^4,5

Specific environmental settings in which YMSM meet their sexual partners have been implicated in sexual risk taking and the potential transmission of HIV.^6–15 For example, studies of MSM in commercial sex environments (CSEs; e.g., bathhouses and sex clubs) have reported high levels of sexual risk.^16,17 Studies of MSM in public sex environments (PSEs; e.g., rest stops and cruising parks) also indicate elevated levels of unprotected sexual acts.^18–20 One recent study of 398 MSM by Xia et al.²¹ found differences in risk patterns between men who attended CSEs and those who did not. Specifically, men who visited CSEs reported higher frequencies of male sexual partners and unprotected anal intercourse with casual partners compared with men who did not attend CSEs. Another study by Halkitis, Moeller, and Pollock²² indicated that HIV-positive men tended to frequent CSEs in order to meet casual sex partners more often than HIV-negative men did.

Private sex parties, which are neither CSEs nor PSEs, present a unique challenge for HIV prevention efforts. These sex parties are often organized in private spaces (e.g., hotel rooms or rented spaces), inaccessible by the general public.⁹ Further, sex parties are often themed²³ (e.g., sadomasochism, urophilia, barebacking, or POZ only), and researchers have suggested that traditional outreach strategies may not be as effective in such venues. A 2007 study by Grov et al.⁸ suggests that MSM who met partners at private sex parties were at greater risk for unprotected anal sex relative to MSM who met partners at CSEs, PSEs, or the gym after controlling for a number of variables including HIV status and level of self-reported temptation for unprotected sex. Further, Pollock and Halkitis⁶ found that MSM who attended sex parties indicated a greater number of overall casual sex partners of both HIV-positive and HIV-negative status. The authors also reported that those participants who used CSEs to meet casual sex partners were also significantly more likely to use sex parties to meet casual sex partners.

Attending sex venues such as sex parties, CSEs, or PSEs has also been shown to correlate with other individual life burdens including current and lifetime use of illicit drugs and history of victimization.^9,24,25 Thus, given that the context in which MSM meet sex partners may influence sexual behaviors and their frequencies,⁶ a more thorough understanding of such environments and contexts may facilitate the identification and provision of effective health education and prevention for MSM at greatest risk for HIV transmission. Research has suggested that providing prevention services within these spaces is one potential method for effectively reaching populations at risk.^{10,19,26–31}

The majority of the data collected on sex parties in prior studies has focused on non-MSM, MSM 30 to 50 years in age, or HIV-positive MSM.^9,10 In a recent study, Friedman et al.⁷ captured data on 465 individuals aged 18–30 years, the majority of whom identified as Latino (70%) or Black (20%). Fifty-six percent of their sample was between the ages of 18 and 30 years and 15% identified as MSM. Their findings suggest that sex parties are of particular epidemiological significance, especially among YMSM. Of the participants who were identified as having participated in a sex party, 13% reported having unsafe sex. Further, unsafe sex was reported at greater rates among MSM and drug users. Further, 61% of attendees tested positive for at least one of three types of infections: HIV, Herpes Simplex Virus-2, or Chlamydia.

The current behavioral research examining the role and influences of sex parties particularly among YMSM is limited, leaving a significant gap in our understanding of sex party attendance and the risks undertaken therein. Moreover, there is a new generation of YMSM emerging into adulthood who remain at a significant risk for HIV infection and onward transmission. Thus, interventions must specifically address the contexts and environments in which these risks may occur.

Our study begins to address this dearth in the published literature by delineating patterns of sex party attendance and behavior in a racially and ethnically diverse sample of 18–29 year-old YMSM in NYC. In our analysis, we (1) describe rates of participation in sex parties and note the specific characteristics of those who attend, (2) differentiate patterns of drug use and sexual risk between those who attend sex parties vs. those who did not engage in such venues, and (3) consider differences in total psychosocial burden between these two groups.

Methods

Project Desire was a cross-sectional survey of 540 emergent adult gay, bisexual, and other MSM in NYC, ages 18–29 years. Recruitment for the survey occurred during the summer of 2008, through a total of 75 hours of recruitment. The research staff employed a nonprobability sampling procedure of various venues throughout the five boroughs (Manhattan, Brooklyn, Bronx, Queens, Staten Island) of NYC, including several large community events, social venues, bars, dance clubs, and public spaces (e.g., parks, street corners, etc.). The sampling frame was stratified by race and age. Specifically, we stratified for race so that Black and Latino men accounted for at least 67% of the sample. For age, we stratified so that one third of the sample accounted for each of the age groups: 18–20, 21–25, and 26–29.

Research staff approached all men in these venues, regardless of perceived age or sexual orientation, to engage potential participants in a conversation about participating in the survey. Staff provided their New York University affiliation, information about the study, and incentivized participants with $10 for completing the survey. Interested participants were verbally screened for eligibility, which included being biologically male and between the ages of 18 and 29 years. Those who were not eligible were provided information about community services in NYC. Data collection spanned a period of 90 days in summer 2008.

Surveys were conducted on touch screen personal digital assistant (PDA) devices, using ForAllSurveys® survey software. Participants were given the PDA and allowed to fill out the survey autonomously in private. We sought to replicate an audio-computer-assisted self-interview (ACASI) as closely as possible in the field and the PDAs allowed us to conduct computer-assisted self-interviews. Studies have shown that ACASI increases the proportion of individuals reporting sexual behaviors and illicit drug use.^32,33 Des Jarlais et al.³⁴ found that drug users were more likely to report injection risk behaviors, as well as more same-sex sexual activity, through an ACASI assessment, compared with a face-to-face interview. This system, which we have used extensively, allows greater respondent privacy and removes barriers to honest responding, such as embarrassment, feedback from facial expressions of the interviewer, and other social influences.³⁵ This approach is also helpful when gathering retrospective data as we do in this investigation. Four PDAs were employed to collect the data. The protocol was approved by the IRBs of New York University and the NYC Department of Health and Mental Hygiene (NYCDOHMH).

Measures

Project Desire included measures of sociodemographics, substance use, episodic sexual behaviors, drug use, HIV testing experiences, and HIV prevention attitudes. Measures included for the ensuing analyses are as follows:

Sociodemographics

Participants were asked to self-report age, race/ethnicity, sexual orientation, perceived family SES, and self-reported HIV status.

Sex Party Behavior

Participants were asked whether they had been to a sex party in the last 3 months and what type of sex party it was (i.e., whether or not they paid to enter, the HIV status of party participants, what prevention materials were available at the party, the manner in which the party was publicized, and the location of the party).

Sexual Behavior

Participants were asked with how many male partners they had engaged in sexual activity within their lifetime and in the 3 months prior to assessment, as well as their number of casual sex partners in the past 3 months. For those who had engaged in sex with a casual partner, we gathered episodic level data for the last sexual episode. In this episode, participants were asked to indicate if they had engaged in unprotected anal receptive intercourse (URAI), or unprotected anal insertive intercourse (UIAI). We then created a third variable to indicate any unprotected anal intercourse regardless of position (UA). Those participants who indicated no casual partners were coded as “0” on these behaviors. In addition, we asked participants to indicate the age at which they first engaged in oral, anal receptive, and anal insertive sex with another man.

Drug Use

Using a checklist, participants were asked if they had used any of the following drugs in the 3 months prior to assessment: alcohol to intoxication, crack cocaine, Ecstasy, GHB, hallucinogens, heroin, ketamine, marijuana, methamphetamine, poppers, powdered cocaine, nonprescribed phosphodiesterase type 5 (PDE-5) inhibitors (Viagra, Cialis, or Levitra), nonprescribed steroids, nonprescribed benzodiazepines (Xanax, Valium, or other relaxants), and HIV antiviral medications without a prescription.

Arrest History

Participants were asked to indicate if they ever had been arrested.

Intimate Partner Violence

Participants were asked if they had ever been physically harmed by a boyfriend or partner.

Total Burden

A composite score was created to represent total burden, which consisted of the following dichotomous variables: (1) any unprotected anal intercourse with a casual partner in the 3 months prior to assessment, (2) any drug use or use of alcohol to intoxication in the 3 months prior to assessment, (3) ever being arrested, and (4) having ever been physically harmed by a boyfriend (participants who had indicated never having a boyfriend were not included in the analysis). For each of these variables, participants were given a score of 1 if the burden was present; thus scores could range from 0 to 4.

Results

The sample consisted of 540 gay, bisexual, and other MSM, ranging in age from 18 to 29 years old. The mean age of participants was 22.79 (SD = 3.42; median = 22). In terms of groups, 66% of the sample were ages 18–24 years, and 34% were ages 25–29 years.

Sex Party Attendance

Of the 540 men who took part in the survey, 490 YMSM (90.7%) indicated that they had not attended a sex party in the 3 months prior, 47 (8.7%) had attended, and three (<1%) did not provide this data. The characteristics of men who attended sex parties as compared with men who did not are shown in Table 1. No significant relations emerge between sex party attendance and any of the examined demographic variables.

Table 1.

Sample demographics of sex party nonattendee vs. attendees

	Did not attend sex party (n = 490)		Attended a sex party (n = 47)
	%	n	%	n
Race/ethnicity
Black	26.3	128	34.0	16
Latino	30.6	149	29.8	14
White	20.7	101	14.9	7
API	11.9	58	17.0	8
Mixed/other	10.5	51	4.3	2
Sexual orientation
Gay	75.5	370	80.9	38
Bisexual	19.8	97	17.0	8
Straight	2.7	13	2.1	1
Unsure/don’t know	2.0	10	0	0
Self-reported HIV status
HIV positive	7.1	35	12.8	6
HIV negative	75.3	369	66.0	31
HIV unknown/never tested	17.6	86	21.3	10
Perceived family SES
Lower	8.4	41	8.5	4
Lower middle	16.1	79	17.0	8
Middle	47.3	232	29.8	14
Upper middle	22.9	112	31.9	15
Upper	5.3	26	12.8	6

Sex Party Characteristics

Among those who had attended a sex party, 63.3% (n = 31) indicated that the party was the “safe sex only” type (i.e., condom use was required) while 32.7% (n = 16) indicated a “mixed” party type (i.e., with both protected and unprotected sex). Only 4.1% (n = 2) of the men surveyed indicated attending a “bareback”-type party (i.e., where condoms were not used). With regard to the specific HIV serostatus of men at the sex parties, 60.4% (n = 29) of the men who indicated attending sex parties reported that those parties were for HIV-negative men only while only 6.2% (n = 3) reported attending parties for HIV-positive men only. Thirty-three percent of men (n = 16) indicated attending a party that was open to both HIV-positive and HIV-negative men. Slightly more than half of the participants who had attended sex parties, 60.4% (n = 29), indicated that they had paid to attend, with 39.6% (n = 19) indicating that attendance was free.

Roughly 58% (n = 28) of participants reported that condoms and lubricant were made available to them at the parties that they had attended. Other participants reported attending parties where only condoms were available (14.6%, n = 7) or only lubricant was available (16.7%, n = 8). Only 10.4% (n = 5) indicated attending a sex party where neither condoms nor lubricant were available.

The greatest proportion of participants who had attended a sex party had either heard about it from a friend (38.3%, n = 18) or via the Internet (31.9%, n = 15). Other participants indicated finding out about sex parties at clubs/bars (17%, n = 8) and magazines (12.8%, n = 6). Participants indicated that they had attended sex parties in homes (54.2%, n = 26), hotels (22.9%, n = 11), or an industrial or commercial space (22.9%, n = 11).

Attendance at Sex Parties in Relation to Indices of Risk

Sex Behavior We examined differences between those who reported attending a sex party and those who did not in terms of lifetime and recent sexual behaviors as well as recent drug use. First, we considered the age at which men first engaged in oral sex, receptive anal intercourse, and insertive anal intercourse with another man. With regard to these sexual behaviors, no differences in age were discerned between men who did not attend sex parties and those who did: (oral sex, 16.04 vs. 15.67 years old; 226 receptive anal, 17.51 vs. 17.05 years old; anal insertive, 18.24 vs. 17.22 years old).We then examined differences with regard to number of male lifetime sexual partners and recent sexual partners (in the last 3 months). Those who attended sex parties indicated more lifetime male sexual partners (median = 18) as compared with nonattendees (median = 11; Kruskal–Wallis χ² (1) = 5.69; p = .02). This pattern also holds when we examine recent casual sex partners, with median = 5 for attendees and median = 1 for nonattendees (Kruskal–Wallis χ² (1) = 18.00; pG.01). Differences were also noted in the number of recent male sex partners (Kruskal–Wallis χ² (1) = 21.79; p < .01), and those who reported attending a sex party also indicated a greater number of total sex partners in the 3 months prior to assessment (median = 8) than those who had not attended such a party (median = 2). See Table 2. We also examined the relations between attendance of sex parties and probability of engaging in unprotected anal intercourse (both insertive and receptive) with casual partners in the 3 months prior to assessment. No significant differences were found between those participants who attended sex parties and those who did not attend sex parties with regard to the likelihood of unprotected anal intercourse with casual partners for any of the following acts: UIAI (12.8% vs. 7.8%), URAI (12.8% vs. 11.9%), and any UA (23.4% vs. 15.4%).

Table 2.

Lifetime and recent (past 3 months) sexual partners of sex party nonattendees vs. attendees

	Did not attend a sex party (n = 490)	Attended a sex party (n = 47)
	median	median
Lifetime sexual partners*	11	18
Recent casual sex partners** (3 months prior)	1	5
Total sex partners** (3 months prior)	2	8

*P ≤ .05; **P ≤ .01

Drug Use We considered use of illicit substances and pharmaceuticals without a prescription in relation to sex party attendance. These data are shown in Table 3. Significant differences between men who indicated attending sex parties and those who did not were found for use of powder cocaine (χ² (1) = 7.73; p < .01), crack cocaine (χ² (1) = 16.65; p < .01), inhalant nitrates (χ² (1) = 36.84; p < .01), GHB (χ² (1) = 12.45; p < .01), methamphetamine (χ² (1) = 7.07; p < .05), PDE-5 inhibitors without a prescription (χ² (1) = 14.56; p < .01), benzodiazepines without a prescription (χ² (1) = 15.32; p < .01), and HIV medications without a prescription (χ² (1) = 5.50; p < .05), with sex party attendees indicating higher probabilities of use. We also analyzed the total number of different drugs used in relation to sex party attendance. For the entire sample, the number of drugs used ranged from 0 to 12 different drugs (mean = 1.38; SD = 1.81; median = 1.0). Differences were noted in terms of total drugs used, with those who attended sex parties using, on average, significantly more total drugs (Kruskal–Wallis χ² (1) = 15.36; p < .01; median = 2 vs. = 1).

Table 3.

Drug use of sex party nonattendee vs. attendees

Type of drug	Did not attend a sex party (n = 490)		Attended a sex party (n = 47)
	%	n	%	n
Marijuana	40.7	199	38.3	18
Alcohol to intoxication	38.0	186	48.9	23
Powdered cocaine	12.9	63	27.7	13
Crack cocaine	1.4	7	10.6	5
Poppers	9.8	48	40.4	19
Ecstasy	7.3	36	10.6	5
Ketamine	1.2	6	4.3	2
GHB	1.2	6	8.5	4
Methamphetamine	2.0	10	8.5	4
Heroin	0.4	2	0	0
Hallucinogens	3.1	15	2.1	1
PD5 Inhibitors w/o script	1.6	8	10.6	5
Steroids w/o a script	0.6	3	17.0	2
Benzodiazepines w/o a script	3.9	19	29.6	8
Stimulants w/o a script	4.3	21	6.4	3
HIV medication w/o a script	0.4	2	4.3	2

Arrest History and Intimate Partner Violence We then considered whether factors relating to psychosocial burden differed between sex party attendees and nonattendees. A greater proportion of men who attended a sex party (34%, n = 16) also reported having been arrested, as compared with nonattendees (20%, n = 99) χ² (1) = 4.88; p < .01.). No difference was found between attendees and nonattendees with regard to partner violence.

Total Burden in relation to Sex Party Attendance

Finally, we compared attendees and nonattendees with regard to the total burden score. Significant differences were found with regard to total burden scores for those participants who indicated attending sex parties t(436) = 3.00; p < .01 (mean = 1.7, SD = 1.1; mean = 1.2, SD = 1.0)

Discussion

Findings from the present analysis indicate nearly 10% of YMSM ages 18–29 years in NYC had attended a sex party in the 3 months prior to assessment. Despite this seemingly small percentage of sex party attendance in the overall sample, we believe that the intersection of individual risk factors coupled with the risk factors engendered within the sex party environment has the potential to contribute to the spread of HIV/AIDS in urban settings. In that regard, our findings suggest this intersection of risk profiles may also represent an important venue for public health interventions in sex party environments as a part of comprehensive HIV prevention.^25,36,37 Research has demonstrated that venue-based interventions can serve as viable and effective methods for reaching high-risk populations.^38–40

Our findings indicate that sex party attendees reported higher risk in a number of important individual factors such as sexual risk taking, drug use, intimate partner violence, and arrests, as compared with nonattendees. This combination of risk factors creates an overall profile in sex party attendees that is significantly different from that of their peers. More specifically, sex party attendees reported significantly higher frequencies of sexual risk taking, including more lifetime partners, more recent sex partners, and more recent casual sex partners. Sex party attendees also reported higher levels of substance use, including methamphetamine, powder cocaine, crack cocaine, nonprescribed PDE-5 inhibitors, nonprescribed benzodiazepines and nonprescribed HIV medications, as well as a higher total of unique drugs used in their lifetime. Lastly, sex party attendees indicated a significantly greater amount of psychosocial burden including history of arrest and physical abuse by a boyfriend or partner. While previous studies have paralleled our findings for sexual risk taking,^7–10,41 drug use,^25,42,43 and psychosocial burden^44–46 as separate indices of risk, the present analysis accounts for each risk factor in combination. In doing so, risk factors may be understood as acting in concert, compounding the risk to the individual or even elucidating characteristics of individuals who may be likely to navigate certain types of venues and engender higher levels of sexual risk.

With regard to the sex parties being risky in and of themselves, the sex party environment may be a catalyst for risky behavior which may result in HIV exposure or transmission. For example, a third of respondents indicated that there were both HIV-positive and HIV-negative men present at the parties they attended. In addition to the mixed serostatus of attendees, roughly 37% of respondents indicated they attended a party where unprotected sex had transpired. Further, only about half of the respondents indicated that the party that they had attended provided adequate HIV prevention materials including both lubricant and condoms. Previous literature has documented patterns of serodisconcordant attendance at sex parties^9,47 and high rates of unprotected sex to be commonplace in these group settings.^48,49 Our data also indicated that 65% of party attendees in the study identified as Black or Latino. While this finding may be an artifact of our overall sampling strategy, men of color do shoulder a disproportionate share of new HIV infections,³ and thus sex party attendance may potentially facilitate and perpetuate these disparities.

Our data indicates that YMSM who attend sex parties undertake more risk than their nonattending counterparts and supports the ideas put forth in Pollock et al.,⁶ which suggest a significant relation exists between environmental and personal factors. Thus, the risk engendered by this group transpires as a function of both the sex party environment itself, as well as these men’s individual risk profiles outside party attendance (e.g., more casual partners, drug use, and psychosocial burden). It is this combination of risk, both individual and environmental, which has the potential to manifest itself synergistically creating a level of risk greater than then the sum of its parts.

The pattern of multiple risk behaviors noted within this sample is consistent with the theory of syndemics, which posits that illicit drug use interacts synergistically with psychosocial burden and sexual risk taking behavior.^46,50,51 Syndemic theory puts forward that those individuals who experience a greater burden, which can be understood as a set of mutually reinforcing epidemics, also engender more risk, and that this level of risk is greater than the sum of each burden alone.⁵¹ Data indicating a significant relation between composite indices of risk and greater overall risk taking behavior have been corroborated among YMSM.^51,52 The present analysis scaffolds this literature by demonstrating that many of the YMSM attending sex parties may also experience more psychosocial burden—further compounding the number of burdens impacting risk taking, and suggesting again that these risk profiles may drive YMSM to the sex party environment, which in turn facilitates their risk taking behavior. Such an understanding is also supported by the tenents of the cognitive escape model,⁵³ which suggests that environments such as sex parties facilitate disinhibitory behavior leading to high levels of risk.

Limitations

It is important to acknowledge that our data were self-reported from a self-selected cross-sectional sample of NYC-based YMSM. Moreover, data were only captured with regard to sex party attendance in the prior 3 months, thus perhaps underestimating attendance. Further, only a small group of overall respondents indicated sex party attendance. Lastly, while men who attended sex parties had significantly more overall partners, they did not differ significantly with regard to acts of unprotected anal intercourse. With these limitations in mind, it is difficult to generalize our results to all YMSM, nor can we infer specific causal links between sex party attendance and HIV transmission. However, our study is the first to our knowledge to collect data regarding sex party characteristics and attendance in a racially and ethnically diverse sample of YMSM in an urban area.

Conclusions

Our data suggest that YMSM who attend sex parties may have both a propensity for and susceptibility to risk taking behavior and are arguably at a substantially greater risk for exposure to or transmission of HIV and other sexually transmitted infections. Thus, this may represent a key population for HIV prevention efforts. However, in direct opposition to these public health implications, many urban centers with a large MSM population such as San Francisco and NYC^10,31,54 have enforced closure of commercial sex environments (e.g., bathhouses, adult book stores, sex clubs, etc.) rather than using them as focal points for intervention. Further, public health advocates believe this policy only serves to force group sex into private spaces. In an interview for the New York Times, a researcher from the Gay Men’s Health Crisis stated, “If you close down these [public] sex clubs, it just drives this activity underground.”⁵⁵ Results from this analysis corroborate this statement, with 100% of participants surveyed reporting that the sex parties they attended were conducted in private spaces or residences and nearly 70% indicating that information about the party was disseminated via the Internet or through a friend. Such findings are consistent with other recent literature^{9,29,49,56–59} and have served to undermine the ability of public health organizations to provide safer sex materials and educational interventions to sex party attendees. Closure of commercial venues may also impact party organizers’ trust and willingness to collaborate with organizations that provide services like HIV testing and sexual health outreach in the venues. Additionally, recent research has demonstrated the effectiveness of pilot programs that have sought to partner commercial sex environments with groups offering HIV testing and education onsite.^60,61 Results from these studies have shown that interventions have been efficacious in reducing the spread of HIV and other STIs in such environments and these services are currently being replicated.⁶¹

Consequently, only a small percentage of our overall sample indicated sex party attendance and data on specific acts of sexual behavior during sex parties was not collected during this study. Thus, a causal relationship between sex party attendance and the transmission of HIV cannot be determined from the data presented here. However, to dismiss these results would be to overlook a group who may be a potential catalyst in the ongoing HIV/AIDS epidemic in NYC and similar urban areas. Further, while sex parties do share characteristics with both commercial and public sex environments, they are in fact a unique setting that deserves further study and for which effective HIV interventions must be tailored.