A Study in Sexual Health Applying the Principles of Community-Based Participatory Research

Abstract

The principles of community-based participatory research were applied to an exploratory sexual health study that examined “cruising for sex” among men on a college campus. In the context of a study seeking a broad interpretation of the health implications of cruising, and when faced with methodological challenges, the researchers found these principles to provide invaluable guidance. A review of the research process is offered and the manner in which the principles of community-based participatory research were operationalized for this study is described.

INTRODUCTION

To effectively study sexual health requires that researchers attend to the social and cultural fabric of a community being studied and to understand the extent to which that fabric influences sexual behaviors of, and ultimately the health status of, the community’s members. However, situating studies within the context of a community’s social and cultural intricacies can be challenging. It necessitates that researchers acknowledge the diverse range of sexual norms, values, and behaviors of particular communities and commit to exploring, discussing, and debating topics related to the manner in which individuals and groups construct their sexual lives. The research process is further facilitated if researchers have informed insights and frameworks that help to structure the study and its research questions, the methods used to conduct the study, and the manner in which findings are disseminated to the field and digested by community members themselves.

For over a decade, sexual health researchers and practitioners dedicated to improving the sexual health of gay, bisexual, and other men who have sex with men have focused their work largely on the need to reduce the incidence of Human Immunodeficiency Virus (HIV) infection. Given the magnitude of the epidemic, and the extent to which it has challenged social structures and public health systems, a concentration on understanding its behavioral, social, and cultural correlates has been essential. One outcome of the intense focus on HIV by medical, behavioral, and social scientists is that much of the contemporary sexual health knowledge related to these men has been constructed in the context of this particular disease. This has resulted in a body of literature about these communities that is very problem-oriented; it is characterized largely by studies that have examined the correlates of behaviors and societal factors associated with the potential for HIV transmission to occur. It could also be argued that this knowledge base, although highly problem-focused, is perhaps now more informed than ever before. This particular pandemic has created a need for researchers to not only explore the wide range of sexual attitudes and behaviors that occur within these communities, but also to interact directly with community members and practitioners to design and conduct research.

Through engaging community members in the research process, sexual health researchers may realize the limitations of a problem-focused research agenda, even within the context of disease-focused research. Such interactions make obvious the need for research to not only have scientific merit, but also for it to be useful to sexual health practitioners in the community, more consistent with the lived sexual experiences of participants under study, and ultimately, more acceptable to the community members themselves. To meet these requirements, research must maintain a focus on the most apparent and urgent health issues, such as HIV, but do so in a manner that situates these health issues within a broader sexual health context. During a presentation at the Kinsey Institute for Research on Sex, Gender, and Reproduction at Indiana University, Di Mauro (1996) made a call for this type of research when she said

Efforts to enact a more positive research agenda would significantly help to promote a much-needed view of sexuality not as a source of problems and risks but as a domain of well-being and human potential. (p. 4)

Although researchers may endorse such a call for more holistic sexual health research, they may be faced with the need to use innovative research methods and approaches in order to overcome complexities associated with designing and conducting studies consistent with such an approach. Particularly, if researchers simultaneously try to apply a more holistic sexual health framework and continue efforts to engage community members, they may find the need for research frameworks that support their ability to do so.

In a recent study conducted on the phenomenon of men seeking male sexual partners in public places on college campuses (called “cruising”) and its sexual health implications (Reece&Dodge, in press), we found it necessary to frame the study within a more holistic and positive sexual health framework. We also found it necessary to develop and conduct the study, and disseminate its findings, by using participatory research methods that supported this approach to sexual health.

This paper will describe the participatory approach and methods that were used for this study on campus cruising. We are confident that this approach, and the manner in which we operationalized its tenets to inform the research methods, supported our ability to gain a better understanding of cruising and its health implications. By sharing an approach that has rarely been discussed in the sexual health literature, our aim is to provide sexual health researchers with an understanding, and examples, of a participatory research framework. This framework is supportive of a movement toward more positive and holistic sexual health research, as it requires the use of an informed and ecological interpretation of health issues facing communities. It also provides philosophies that help to overcome some of the methodological challenges of such work and offers valuable insights concerning the way that such research is disseminated throughout the field and digested by members of the communities under study.

We will provide an overview of campus cruising and the reasons that this phenomenon necessitated a participatory research approach. In addition, we will offer a description of the participatory framework used to conduct the study and the manner in which this framework was operationalized. Some of the limitations of a participatory approach to sexual health research will also be discussed.

THE CAMPUS CRUISING STUDY AND THE NEED FOR A PARTICIPATORY RESEARCH APPROACH

Campus Cruising

Cruising can be described as a ritualistic pattern of behaviors associated with seeking, and interacting sexually with, other individuals. Typically, these sexual interactions occur with those who were previously unknown to one another and most often in spaces that are legally defined as public (Reece & Dodge, in press). The college campus offers multiple public and semipublic spaces in which men are able to cruise and engage in sexual activities with one another. Popular locations include campus restrooms, campus athletic facilities, libraries, computing centers, student unions, vacant campus buildings and classrooms, and stairwells (Hoover, 2003; Reece & Dodge, in press).

Little scientific literature has addressed cruising that occurs in campus-specific spaces. The exploration of cruising, as it occurs in other venues, has existed on the fringe of sex research for several decades, beginning with the landmark study by Humphreys (1970), the first scientific investigation of cruising for sex among men. Since that time, it has received a fair amount of attention in both the scientific and nonscientific (e.g., erotic) literatures (Desroches, 1990; Tewksbury, 1995, 1996, 2002; Weinberg & Williams, 1975).

In public health research, cruising has primarily been studied for its potential to challenge the physical health of its participants. Like much of the other sexual health research over the past decade, this work has been highly problem-focused and concentrated on factors associated with the transmission of HIV and other diseases. Findings from these studies often have suggested that the phenomenon, and the venues in which it occurs, place men at increased risk for HIV infection (French, Power, & Mitchell, 2000; Harding, Dockrell, Dockrell, & Corrigan, 2001; Somlai, Kalichman, & Bagnall, 2001). As a result, much of the literature about cruising would characterize it only as negatively contributing to sexual health.

Little is actually known about the role that cruising plays in the lives of men who participate in it and whether cruising has any health protective characteristics. Further, in the context of campus cruising and among a generation of men who have been regularly exposed to warnings about HIV risk, virtually nothing is known about the reasons that men choose to cruise, how they make decisions about sexual behaviors in the cruising venue, and the components of cruising that are positively reinforcing.

The Need for a Participatory Approach

Moving away from the problem-focused nature of this research by exploring the health implications of cruising using a more holistic and comprehensive sexual health framework was a primary goal of the campus cruising study. To do so required research methods that facilitated our ability to understand cruising from the perspective of those who cruise. This was necessary for two reasons, one methodological and the other philosophical.

Cruising on college campuses is a phenomenon that, by definition, requires that its participants are able to retain their anonymity and that its venues, at least the extent to which they are socially constructed as sexual spaces, are not openly acknowledged among the general campus community. As a result, we perceived there to be significant methodological challenges associated with conducting this study, particularly in terms of activities such as participant recruitment. Addressing such challenges required an innovative methodological approach.

Given the limited literature in this area, we were faced with developing the framework for the study and the research questions without the benefit of a solid knowledge base on the topic. Particularly given our desire to move away from the manner in which cruising has typically been studied, we found it necessary to draw directly upon the lived experience of cruising participants as we developed a more holistic framework for the study.

To accomplish this, we operationalized and applied a set of guiding principles that have been developed by public health researchers. These are known as the “principles of community-based participatory research” (Israel, Schulz, Parker, & Becker, 1998). These principles provided guidance helpful to designing and conducting the study and disseminating its findings. To better articulate the manner in which the principles were operationalized for our exploration of campus cruising study, a brief overview of the study and its findings will be presented. More detailed information about the study is available elsewhere (see Reece & Dodge, in press).

The Campus Cruising Study

Three primary sexual health questions were considered in the campus cruising study. These included

1. Are the characteristics of campus cruising venues, and the nature of sexual behaviors that occur in these venues, likely to facilitate increased or decreased risk for health issues like sexually transmitted diseases and HIV infection?

2. To what extent do cruising behaviors contribute, both positively and negatively, to the mental health of cruising participants?

3. Does cruising make contributions, both negative and positive, to the social well-being of its participants?

Preliminary insights gained from the cruisers who partnered with us in this study, as will be explained later, led us to believe that the actual risk for HIV transmission risk specific to campus cruising was quite low. From a social justice perspective, this study was relevant given that public health issues, such as HIV, tend to influence legal policies and other social standards. It was, and continues to be, our view that policies based on science that is limited in its understanding of behaviors and their consequences are inappropriate and we felt it necessary to further develop the understanding of this phenomenon.

Another goal of the study was to gain insights that would be beneficial to campus-based health care providers, student service professionals, and other campus officials working to improve the quality of life for gay, bisexual, and other men questioning and exploring their sexual orientation while in college. Many college campuses possess a multitude of such resources, and with cruising appearing to be quite frequent on many campuses (Hoover, 2003), the ability to use the study findings to educate these individuals about cruising was of interest. Lastly, if study findings had indicated that campus cruising did, in fact, place men at high risk for HIV or other infections, or that cruising was associated with psychological or social distress, the study would provide data that could be used to develop health-promoting interventions.

Thirty adult men who self-identified as current or past campus cruisers participated in the study. The mixed methods design included collecting data using both individual in-depth interviews and a paper–pencil sexual behavior inventory. Findings suggested that there were both positive and negative implications for the physical health of the cruisers. For example, sexual activities described by participants were low in their risk for HIV infection as men mostly reported mutual masturbation in these venues; however, men did describe behaviors that placed them at risk for other sexually transmissible infections.

Also identified were both positive and negative implications for the mental health of cruisers. For many participants, cruising had helped them become more comfortable with their sexual orientation. For others, there appeared to be clear associations between cruising and negative impacts on psychological well-being. For example, several participants described cruising-related behaviors associated with negative, and somewhat intense, perceptions of their bodies. There were also both positive and negative impacts on the social well-being of cruisers. Men reported both positive social outcomes, such as making friends in the cruising environment over time, and negative social impacts, such as having lost other friends once they had discovered the participant’s cruising behaviors.

Collectively, the findings of the study supported the study goals and provided rich answers to the research questions. In addition, through dissemination activities, these findings have been shared with the individuals originally identified as potentially benefiting from more information about cruising, such as campus health and social service professionals (Reece & Dodge, 2002a, 2002b, in press).

We suggest that using the principles of community-based participatory research facilitated our ability to not only design and conduct the study, but also supported more informed analyses of the data and more appropriate decisions about the dissemination of findings. Following is a description of the manner in which these principles were operationalized and examples of how their use benefited, and in some instances challenged, the campus cruising study.

THE PRINCIPLES OF COMMUNITY-BASED PARTICIPATORY RESEARCH

Community-based participatory research (CBPR) is an approach to research that “equitably involves, for example, community members, organizational representatives, and researchers in all aspects of the research process” (Israel et al., 1998). In a community-based participatory research study, partners collaborate to gain enhanced understanding of a given phenomenon and, in response, act to improve the health and well-being of the community members (Hatch, Moss, Saran, Presley-Cantrell, & Mallory, 1993; Israel et al., 1998, 2003; Allen, & Guzman, 2002).

The notion of participatory research frameworks is not new. Lewin’s (1946) early work on action research in the 1940s was followed by an onslaught of participatory approaches in the fields of anthropology, humanistic psychology, and sociology and, over the last 60 years, researchers have continued to move in directions that directly immerse them into communities under study. As a result, there are similar principles, guidelines, and recommendations for conducting community-based participatory research that exist in, and guide the work of, multiple academic disciplines. However, the principles applied to this study emerged from, and are specific to, the field of public health.

Over the past decade, the field of public health has increasingly endorsed more community-based and participatory approaches. This has largely occurred as researchers in public health have responded to increasing calls by community members for more collaborative research and also in response to the increased availability of funding for such initiatives (Minkler&Wallerstein, 2003). According to Minkler and Wallerstein, this has resulted in alternative research approaches that stress community partnership and action for social change and reductions in health disparities as essential components of the research process.

Israel et al. (1998) have articulated nine principles that collectively represent the current state of theory with regard to community-based participatory research (CBPR) in the field of public health. These are

1. CBPR recognizes community as a unit of identity.

2. CBPR builds on strengths and resources within the community.

3. CBPR facilitates collaborative, equitable partnerships in all phases of the research.

4. CBPR promotes co-learning and capacity building among all partners.

5. CBPR integrates and achieves a balance between research and action for the mutual benefit of all partners.

6. CBPR emphasizes local relevance of public health problems and ecological perspectives that recognize and attend to the multiple determinants of health and disease.

7. CBPR involves systems development through a cyclical and iterative process.

8. CBPR disseminates findings and knowledge gained to all partners and involves all partners in the dissemination process.

9. CBPR involves a long-term process and commitment.

We suggest that these principles offer a valuable philosophical framework within which sexual health researchers are more likely to capture a lived experience expression of the sexual behaviors and values of individuals and communities under study. This may offer researchers with a diversity of insightful views as to the social and cultural relevance of behaviors and values that is different from the insights to be gained by our existing knowledge base. Such insights may be particularly beneficial during the process of developing research questions and ensuring that the purpose of the study is consistent with the needs, concerns, and desires of those in the community of interest.

These principles may be of significant benefit when overcoming or avoiding methodological challenges in sexual health research. For example, community members, as active research partners, can provide guidance on issues related to participant recruitment, question development, and data collection strategies. Given their familiarity with the social and cultural norms of the community under study, such guidance can help researchers to avoid protocols and tools that are insensitive, inappropriate, or otherwise ineffective.

The principles of CBPR are fairly ambiguous in nature in that they are highly philosophical and do not provide researchers with specific information as to how they should be applied in an actual study. This ambiguity is advantageous on some level as it allows for the principles to be interpreted and used differently by researchers across a range of health topics and communities; however, to use the principles requires that they be operationalized. In our cruising study, the principles of CBPR were operationalized in the context of, and in order to increase their utility for, a study on sexual health.

PRINCIPLES OF CBPR AND THE CAMPUS CRUISING STUDY

As Israel et al. (2003) have maintained, the nine principles of CBPR are applicable in many research situations, yet it is not always the case that each principle will be applied in a single study and some or all may not be applicable in certain settings or in some cultures or communities. In this study, we applied eight of the nine principles at particular points in the research process.

Following is a description of how these eight principles were operationalized and applied to the campus cruising study. Table I provides a summary of the principles and the phases of the study for which we found them most helpful. Table II provides specific examples of the manner in which certain principles were operationalized during particular phases of the study.

Table I.

Application of CBPR Principles by Phase of Research

	Application of principles by research process
Principles of community-based participatory research	Research question development	Study design	Participant recruitment	Data collection	Data analysis	Dissemination
CBPR facilitates collaborative, equitable partnerships in all phases of the research	•	•	•		•	•
CBPR integrates and achieves a balance between research and action for the mutual benefit of allpartners	•					•
CBPR recognizes community as a unit of identity		•	•			•
CBPR builds on strengths and resources within the community		•	•	•		•
CBPR promotes co-learning and capacity building among all partners					•	•
CBPR involves a long-term process and commitment	•	•				•
CBPR emphasizes local relevance of public health problems and ecological perspectives that recognize and attend to the multiple determinants of health and disease	•	•			•	•
CBPR disseminates findings and knowledge gained to all partners and involves all partners in the dissemination process						•
CBPR involves systems development through a cyclical and iterative process (not operationalized in this study)

Table II.

Selected CBPR Principles Used in Cruising Study and Examples of Their Application

Research phase	CBPR principle	Application of principles
Research question development	CBPR facilitates collaborative, equitable partnerships in all phases of the research	Involving community members in synthesis of literature Collaboratively developing research questions
	CBPR integrates and achieves a balance between research and action for the mutual benefit of all partners	Planning for the collection of data to be used for potential health interventions Developing questions that support mutual goals of researchers and community members
Study design	CBPR recognizes community as a unit of identity	Identifying socially constructed symbols, values, and characteristics of cruising community Selecting methods appropriate with community’s characteristics
	CBPR builds on strengths and resources within the community	Conceptualizing potential study barriers as strengths to facilitate research
Participant recruitment and data collection	CBPR facilitates collaborative, equitable partnerships in all phases of the research	Involving community members as research assistants for participant recruitment
	CBPR builds on strengths and resources within the community	Using ecological approaches to ensure responsiveness to community member perspectives Developing and using data collection protocols that were sensitive to community strengths related to a need for secrecy Open discussions with community members and debriefing with study participants about ecological goals of study
Data analysis	CBPR promotes co-learning and capacity building among all partners	Involving study participants and community members in data analysis activities
	CBPR emphasizes local relevance of public health problems and ecological perspectives that recognize and attend to the multiple determinants of health and disease	Open discussions with participants about their perceived benefits of study participation and involvement in analysis Using ecological sexual health framework as lens for qualitative data analysis
Dissemination	CBPR integrates and achieves a balance between research and action for the mutual benefit of all partners	Selecting dissemination venues that have potential to facilitate action Maintaining emphasis on social justice in dissemination products
	CBPR disseminates findings and knowledge gained to all partners and involves all partners in the dissemination process	Engaging community members in discussions about appropriate venues for dissemination Involving community members in manuscript development and manuscript reviews

CBPR Recognizes Community as a Unit of Identity

This particular principle was central to our ability to conceptualize and conduct this study; however, it presented challenges given the need to consider the notion of “community” in the context of campus cruising. Israel et al. (1998) have suggested that community, as an aspect of collective and individual identity, is central to CBPR. Community has been characterized by the existence of common symbol systems, shared norms, and common interests (Israel et al., 2002; Israel, Checkoway, Schulz, & Zimmerman, 1994; Klein, 1968; Sarason, 1984; Steuart, 1993).

In health-related research, the “community” is often conceptualized according to its geographic boundaries or other distinguishing characteristics of its members, such as ethnicity, race, sexual orientation, or age. The notion of community can also be applied to groups whose members share a common behavioral characteristic, as was the case with this study.

We applied this principle by conceptualizing men who cruise on college campuses as a community. We also strived, through partnering with its members, to identify the shared activities, symbols, norms, and interests that collectively shaped this community’s identity. We learned that cruisers acknowledged their identity with this community and that they actually drew upon its symbols and norms to recognize one another. Cruising, and its dependence upon its participants to remain somewhat anonymous, may seem inconsistent with this notion. However, men who partnered with us to conduct this study described unique elements of cruising that simultaneously enabled an individual to be both anonymous and recognizable as a member of the cruising community.

CBPR Facilitates Collaborative, Equitable Partnerships in All Phases of the Research

Once the community of interest has been defined, the principles of CBPR hold that researchers actively take steps to conduct the study in a collaborative and equitable manner with members of that community. This principle was operationalized in almost each phase of the study by engaging men who cruised as active participants in the research process.

Two men with a history of engaging in cruising activities approached the authors after they had participated in a previous study we conducted and wanted to discuss a series of questions on the study instrument that were related to public sex (Dodge, Reece, Cole, & Sandfort, in press). The ensuing discussions between these men and the researchers led to the decision to conduct this study. Being approached by these men was a critical event in the research process. Prior to this, we had briefly discussed the notion of conducting a study on campus cruising and had discussed utilizing the principles of CBPR to do so. It was our belief that a CBPR approach would be highly relevant to a study on cruising given previous experiences with using a CBPR approach in other work (Reece, 2003; Reece& Plate, 2002). In fact, we felt that a CBPR approach would perhaps be the only way to accomplish such a study given that it would help us to develop more informed research questions and also could help overcome methodological challenges.

The participatory nature of the principles was actually the component that initially challenged us as we considered using this approach. We could not conceptualize a way to effectively engage cruisers into the developmental stages of the study given the secrecy that surrounded cruising and our hesitancy, as instructors at a university, to approach a suspected cruiser and talk to him about partnering with us in research. Through the cruisers’ initiative to make this contact, we had an immediate connection to individuals who self-identified as cruising and who approached us to talk about cruising in the context of research. Once we realized the potential for engaging with the cruisers throughout the remainder of the study, it became apparent that a CBPR approach could be implemented and steps were taken to operationalize the principles of CBPR throughout the other phases of the study.

To operationalize this principle during the phase of research question development, the researchers and the cruisers collaborated during a series of meetings to conduct a review of the cruising literature. As a result of these activities, and in-depth discussions with the cruisers about the role that cruising played in their lives, we developed a broad list of research questions that both partners (the researchers and the cruisers) believed were appropriate, important, and that, if answered, would ultimately be supportive of the sexual health needs of men who cruise.

In addition to the original cruisers that helped design the study, two other men became involved with the study as research assistants and helped to facilitate participant recruitment. Their contributions were beyond those typical of participants involved in a snowball recruitment approach. Given their familiarity with the cruising venues and the norms of interaction within those venues, these men were able to recruit not only those individuals with whom they were personally acquainted, but also men that they did not know but that they were able to recognize as cruisers on the basis of their behaviors in the cruising venues.

We also worked collaboratively with cruisers during data analysis, in planning for dissemination, and in the actual development of manuscripts and presentations. In summary, this principle was operationalized by actively involving cruisers in the majority of the phases of the study. Additionally, we strived to make the involvement of the cruisers as equitable as possible through the manner in which we interacted with them, sought their feedback, and showed our appreciation for their efforts.

CBPR Builds on Strengths and Resources Within the Community

Given the cruising community’s dependence upon privacy, secrecy, and anonymity, we had to recognize that the study design had to be such that these were not violated. Prior to operationalizing this principle, we had viewed these characteristics as barriers to designing a study on campus cruising; however, in our earliest discussions with the cruisers, it appeared that cruisers were generally reliant upon unspoken commitments not to violate each other’s need for, and dependence on, secrecy. We were able to reconceptualize this dependence upon privacy, secrecy, and anonymity as characteristics of the community that were actually strengths and, as a result, characteristics that helped to facilitate the study.

This principle was applied to the process of participant recruitment by collaboratively working with the cruisers to develop recruitment tools (i.e., flyers and Internet messages) that used wording and symbols likely to be recognized by potential participants. Additionally, the initial cruisers suggested that the recruitment tools had to be fairly transparent, i.e., they had to be simultaneously recognizable to the cruising community yet insignificant to the general campus community. Recruitment tools could have easily violated the cruising community’s norms of secrecy and anonymity if they made it apparent to non-cruisers that sexual behaviors were occurring in a particular venue. This would have been both inconsistent with many of the principles and may have also resulted in a rejection of the study by the cruising community.

The application of this principle helped to build a sense of trust between the researchers and participants, which was helpful in the data collection process. In almost every instance of discussing an individual’s potential participation in the study, and during the actual interviews themselves, questions arose as to whether one’s participation in the study would make others aware that they were cruisers or support eventual harm to cruisers by exposing their community. By using recruitment materials that were jointly designed with the cruisers, using collaboratively designed scripts at the beginning of data collection and having pre-prepared, and collaboratively developed answers to questions that were likely to arise during the initial contact with a potential participant, we were able to demonstrate that we held a commitment to not violating their trust.

CBPR Integrates and Achieves a Balance Between Research and Action for the Mutual Benefit of all Partners

Although our study did not include a predetermined action component, it was important that the study’s purpose and goals moved the study in a direction such that its findings could be used for subsequent action and that we conceptualized plans for how this could occur so that all partners would benefit (Green et al., 1995; Israel et al., 2003; Petras & Porpora, 1993).

Although some of the more tangible outcomes for the researchers at the beginning phases of this study were clear, such as scientific presentations and publications, the beneficial outcomes for the cruisers were initially less concrete. The cruisers did express interest in a study that would ultimately make contributions to efforts toward social justice for men who have sex with men and we were in agreement. They were clear that, particularly in the gay community, common stereotypes of cruisers would typically characterize them as sexually compulsive, socially inept, and highly promiscuous. For the cruisers, a study that would seek to negate these stereotypes was highly desirable.

Although the cruisers were interested in a study that would essentially “prove that they were normal,” the researchers had to be very clear in the discussions with the cruisers that a true scientific understanding of cruising may actually result in the validation of some of the negative stereotypes and that, as a result, some findings may not be supportive of the cruiser’s goals. In-depth discussions between researchers and community members about the potential for such findings are not only an integral step to a participatory process, they are essential for studies that explore sensitive sexual health topics such as those addressed in this study.

During the collaborative process of discussing the potential benefits of this study, we collectively came to the realization that the outcomes for each were mutually beneficial. Although the researchers could articulate the academic benefit of scientific publications about cruising, the cruisers also realized that some of their broad social goals could be realized through activities such as publishing. For example, the cruisers saw the potential for publications to educate individuals who work professionally in campus healthcare or those involved with professional gay and bisexual organizations and who would be likely to read a publication or see a scientific presentation.

Each entity also agreed that the research questions should frame the study in a manner that would allow for an understanding of both the positive and the negative implications of cruising. As discussed previously, cruising and public sexual behaviors have been viewed exclusively from a disease perspective in most health-related literature. Both the researchers and the cruisers were clear that gaining a holistic understanding of cruising, and the potential to use study results for action and mutual benefit, would not be possible if solely viewed within a disease framework.

CBPR Emphasizes a Local Relevance of Public Health Problems and Ecological Perspectives That Recognize and Attend to the Multiple Determinants of Health and Disease

Given its ecological emphasis, this principle was consistent with our desire to study cruising using a more holistic interpretation of sexual health. To that end, this principle was important to the entire research process. It was operationalized by making a commitment to an ecological view of cruising and its health outcomes and by expressing this commitment throughout all phases of the project.

We did not explicitly choose a particular definition of sexual health to guide this study, and, in retrospect, we believe that it may have been helpful to do so. For example, this principle of CBPR is consistent with two particular perspectives on sexual health. The World Health Organization’s (1986) formulation of sexual health includes three fundamental elements: (1) a capacity to enjoy and control sexual and reproductive behavior in accordance with a social and personal ethic; (2) freedom from fear, shame, guilt, false beliefs, and other psychological factors inhibiting sexual response and impairing sexual relationships; and (3) freedom from organic disorders, diseases, and deficiencies that interfere with sexual and reproductive functioning. Additionally, Aggleton and Campbell (2000) offered four principles of sexual health that assert it should be viewed (1) as affirmative; a state of well-being imbued with positive qualities, not merely the absence of those that are undesired; (2) as focusing on more than reproductive health; being concerned with more than the procreative relationships and modes of sexual expression; (3) as an expression of individual and collective needs as well as broader human rights and responsibilities; and (4) as focusing on the attainment and expression of sexual pleasure, not the repression of sexual energies and desires or their denial.

These sexual health frameworks articulate a more ecological understanding of sexual health and, as a result, are highly consistent with this principle of CBPR. The elements of frameworks such as these may provide researchers with a well-established set of criteria that serve as theoretical or issue-specific mechanisms for the operationalization of this principle.

CBPR Promotes Co-Learning and Capacity Building Among all Partners

As data were collected, men consistently expressed an interest in assisting with the study beyond being a participant. One typical strategy that researchers have used to involve participants, particularly in qualitative studies, is asking them to help with validity checks, a process of providing participants with data or with data summaries and asking them to review it for accuracy.

Study participants assisted with validity checks; however, this principle suggests an involvement that exceeds a typical review for validity. Men in this study were involved in reviewing nonidentifying data and our summaries of the data not simply to verify that we had correctly captured their conversations. Men also reviewed these items and engaged in conversations with us about our interpretations of the data and helped us to identify themes that we had not identified in our more independent analyses.

In doing so, men not only contributed to the research process as a partner, they also commented that it was a valuable process for them in terms of their own understanding of their behaviors and, for some, the health implications of those behaviors. This collaborative process facilitated a more comprehensive interpretation of the data, apparent by a range of insights into findings that were not initially identified by the researchers alone. On multiple occasions throughout this process, participants expressed that they also gained additional insight about themselves and the other members of the cruising community. Additionally, cruisers reported that their participation in the study activities served as an important learning experience for them in terms of gaining research experience and that, for at least one, it had motivated him to consider a graduate degree in the behavioral sciences.

CBPR Disseminates Findings and Knowledge Gained to All Partners and Involves All Partners in the Dissemination Process

Our past, current, and future dissemination activities clearly demonstrate the application of this principle. In fact, this component of the research process collectively represents the application of all nine CBPR principles on some level.

Community-based participatory research assumes that there is an equal commitment by the researchers and community members to use the research process as a tool for positive action and ultimately for health improvement within the community. We felt a particularly strong sense of responsibility to ensure that our dissemination products were consistent with the participatory nature of the study. This was driven by our holistic interpretation of sexual health, the unique nature of campus cruising, and the potential for its exposure and discussion to have both positive and negative implications. Further, it was of great importance to us that we did not violate any of the commitments that we had made to participants throughout the study.

We were clear with the original cruisers, and with all subsequent research participants, that we could not simultaneously maintain scientific rigor and avoid the dissemination of some data that would be perceived by cruisers as negative; however, as a result of using a CBPR approach, we had made a commitment to use the study for mutually beneficial outcomes. To do so required us to plan for, and engage in, dissemination activities that were ultimately supportive of our mutual goals. Three specific dissemination activities or decisions made with regard to dissemination are representative of actions consistent with this particular principle.

Participants reviewed manuscripts and provided both editorial and conceptual feedback. We view these activities as an extension of the trusting and collaborative partnership that we sought to establish with the cruising community. For example, we received feedback on our definitions of cruising and the manner in which cruising behaviors were described. Men also helped us develop accurate descriptions of the types of activities that occur (e.g., a detailed description of how mutual masturbation occurs between two stalls). We planned for collaborative writing by researchers and cruisers. There were study participants that held expertise in a particular area related to cruising. For example, one participant with a background in law has agreed to serve as a consultant on a potential manuscript dealing with criminal justice issues.

We have avoided the publication or presentation of data in venues that obviously hold potential for negative consequences to cruisers. In 2002, some data from this study were presented to campus-based health and social service providers as well as other sex researchers during meetings at Indiana University (Reece & Dodge, 2002a) and at an international sex research conference (Reece & Dodge, 2002b). Multiple requests for interviews by news media reporters followed each of the presentations. Although campus-oriented or gay-oriented news articles would have resulted in a widespread dissemination of the study findings, it was our decision that such press could have resulted in negative consequences for cruisers. For example, an article in a university newsletter could have been sensationalistic and could have resulted in more law enforcement of cruising in specific campus locations, regardless of the extent to which the article presented our findings in manner that we would have wanted. This would have violated our mutually agreed upon goals of supporting social justice for this community. As a result, we refused many opportunities to disseminate research findings in the popular press.

Considering the implications of dissemination is incredibly important for sexual health researchers, particularly those who utilize a community-based participatory research approach. Following the end of formal data collection in every interview, we talked with participants about the potential for presentations and publications to expose this phenomenon to individuals who could certainly use the information to support agendas that did not benefit the cruising community. These discussions were highly insightful and influenced our plans for dissemination, particularly with regard to the venues that we have targeted for publications and presentations.

CBPR Involves a Long-Term Process and Commitment

Our dissemination activities, and future research plans, reflect an operationalization of one additional CBPR principle. To collaboratively execute dissemination activities in partnership with the community has required both entities to remain committed over time. It has also required patience among all involved and for all to realize that some of the original goals introduced by one or more partners (e.g., those related to using findings to support social justice) may not be realized for many years, if at all.

Additionally, the exploratory nature of this study resulted in the emergence of many new research questions. As a result, there are expectations among the cruisers that additional studies will be conducted and faculty, other campus professionals, and community members have expressed an interest in collaborating on such work. Such participatory ventures will continue to require a sustained commitment over time and the need for the inclusion of additional partners (such as different cruisers) as we progress.

Related to this, one principle, “CBPR involves systems development through a cyclical and iterative process,” was not explicitly operationalized for this study. It was not an explicit goal of the initial study to facilitate systems development. However, as we move forward with additional research in this area, the development of new partnerships and the potential for targeted health promoting interventions may in fact result in systems development. Should that become a goal, it is certain that steps would be taken to operationalize this principle and use a cyclical and iterative process to support such development.

LIMITATIONS AND CHALLENGES OF A CBPR APPROACH TO SEXUAL HEALTH RESEARCH

Although a CBPR approach was valuable in our study of campus cruising, it is an approach that is not without limitations. Researchers considering a CBPR approach using these principles should consider these limitations carefully and take steps to address them throughout the research process.

Employing a participatory approach will require researchers to maintain a heightened sense of awareness with regard to scientific rigor. Although a goal of participatory approaches to research is to be as inclusive as possible, researchers have to remember that a participatory approach does not decrease the need for, and, in fact, may create the need to be more attentive to, a commitment to scientific rigor.

As with any research study, there is always the potential for random and systematic bias to be introduced by the researchers and the participants. By involving community members throughout the research process, particularly those with little or no formal research training, the potential for the introduction of additional and unanticipated bias was always of concern. Researchers using a participatory approach will find it necessary to have a heightened awareness of the potential for such additional bias and take actions to reduce its influence. For example, when engaging community members in a process such as data analysis, particularly for qualitative data, researchers may want to conduct analysis of data independently from the community members, at least for the initial analyses. After the researchers have completed an initial data summary, involvement from the community members can serve to validate findings or help researchers to understand confusing or complex findings. Although researchers may certainly introduce bias during their independent data analysis activities, this activity might help the partners to better identify the extent to which bias is being introduced by either party at particular points in the process of analysis.

In a participatory approach, it may also be challenging to find a balance between the study interests of researchers and those of community members. A researcher may desire a study that answers questions considered of importance to their respective discipline, whereas community members may view research as primarily a process for resolving immediate and local issues. A strategy for overcoming such a challenge is to commit to an open and honest process. This requires initiating the process with an understanding that although the needs of those in academia are often different from those in the community, they do not have to compete with one another. It is possible to conduct participatory research that simultaneously maintains scientific rigor, is mutually responsive to the goals of the researchers and the community members, and that results in products that are mutually beneficial to both entities.

Although it may be the case with all sexuality and sexual health research, we also suggest that a participatory approach creates a commitment on behalf of the researchers to seriously consider the impact that products such as publications may have on participants. This is certainly not to suggest that research findings with the potential to expose negative or controversial behaviors or attitudes should be suppressed. Rather, it is to suggest that, when working with the community in a participatory manner, the research products are an extension of the participatory process and the involvement of participants and community partners in the dissemination process may prove mutually beneficial.

One of the greatest challenges to participatory research, particularly from the perspective of academic researchers, is that it can be exceedingly time consuming. The process can also be difficult, especially for researchers without training in skills necessary for effectively engaging and working with communities. Given that often researchers and community members may approach a research effort with differing views and agendas, there is always a potential for conflict. We consider ourselves very fortunate because this study was conducted with virtually no conflict between the interests of the researchers and community members. This may have been a result of the unique nature of the topic and all partners’ commitment to a successful study. However, we believe that the commitment to a transparent research process facilitated our ability to work together and avoid conflict.

Additionally, this article reflects our experiences as researchers situated within an academic institution. Had this article been written by the cruisers instead, they may have chosen to focus on different activities or to describe the research process in a way that was more meaningful to community members rather than other academic researchers. Alhough cruisers have reviewed this article and provided feedback, it is important to acknowledge that our academic perspective has driven the manner in which we have presented issues.

It is also important to note that one of us (M.R.) had previously completed a postdoctoral fellowship focused on CBPR methods, which provided our team with leadership in applying these particular principles. For those without such training and with limited community-based experiences, there are multiple resources, mostly contained in the public health field, which can provide researchers with training, mentorship, and access to resources that will facilitate their ability to effectively launch a community-based participatory research project. Table III includes a listing of some well-known CBPR resources from the field of public health.

Table III.

Selected CBPR Resources

CBPR initiatives and organizations	Description	Website
Community-Based Public Health Caucus	Independent community-based public health organization that is affiliated with the American Public Health Association	www.sph.umich.edu/cbph/caucus
Community Health Scholars Program	Post-doctoral training program to provide faculty with training in community-based participatory research	www.sph.umich.edu/chsp
Community-Campus Partnerships for Health	Organization that promotes partnerships between communities and higher education institutions	http://futurehealth.ucsf.edu/ccph.html
Community Research Network of Loka Institute	Community-oriented network of this research and advocacy organization	www.loka.org
W.K. Kellogg Foundation	Major international foundation with a history of supporting community-based initiatives	www.wkkf.org

CONCLUSIONS

Actively involving community members in the majority of the research phases, from the conceptualization of the study to the final version of manuscripts to be submitted for publication, provided us with a wealth of insights that would not have been available from any other source and that we did not develop on our own. Involving these men in the development of research questions helped us to ensure that they were clearly aligned with the study goals and the potential benefits that were important to both partners. Having men participate in the design of the recruitment flyers, recruitment scripts, and interview questions helped to ensure that they were culturally appropriate and that they did not violate the norms and needs of this community.

Additionally, the principles of CBPR were integral to our ability to overcome the methodological challenges that faced us early in the research process. As discussed in this article, one of the initial concerns of this study was that we would never be able to get men to actually participate in such a study; however, we were forced to stop recruitment at the point when our limited funding for further participants was exhausted. To this day, men continue to call our offices to enroll in this study, although all recruitment materials have been out of sight for over 1 year. Additionally, we did not have a single cancellation from a participant who scheduled to be interviewed. Lastly, we believe that using the principles of CBPR also helped us to explore this topic and its sexual health implications in a more holistic manner. The ecological nature of a CBPR approach was particularly helpful to study design, research question development, data analysis and interpretation, and dissemination activities. As a result, the principles served as a valuable mechanism for integrating this holistic philosophy throughout all major phases of the study.

Although we found a CBPR approach incredibly valuable to this study, it is not an appropriate approach for all forms of inquiry and it is not an approach that is likely to be endorsed by all researchers; however, for those desiring to conduct research that strives to support the attainment of goals that are mutually beneficial to both researchers and those in their communities of interest, the principles of CBPR can serve as a strong source of guidance and motivation.