Abstract
This study collected cross-sectional data from 307 young Chinese men who have sex with men (MSM) to explore the characteristics of sexual communications, including target of communication (stable partners, casual partners), topics of communication (condom use, HIV/ STDs prevention, and sexual history), and the associations between sexual communication characteristics and condom use. A variety of measures were employed to assess respondents’ condom use with different sexual partners over different recall periods. Chi-square tests were employed to examine the relationships between sexual communication characteristics and condom use. This study found that sexual communications with regular partners about topics such as condom use, HIV/STDs prevention, and current and past sexual relationship were associated with condom use with regular partners. Respondents who had sexual communications with both regular and casual partners were more likely to use condoms with their regular partners. The findings in the current study provided empirical evidence for the importance of frequent sexual communication between Chinese MSM and their sex partners.
Keywords: HIV, Sexual Communication, Condom Use, MSM, China
Men who have sex with men (MSM) is the most-at-risk group experiencing an increasing HIV epidemic in China. As of 2009, 14.7% of the estimated 740,000 HIV-infected individuals were infected through homosexual transmission. Among the estimated 48,000 new HIV cases in 2009, 32.5% were contributed by homosexual transmission (UNAIDS, 2010). Notable increases in HIV infections among MSM were also found in different regions (Feng et al., 2009).
Preventing the spread of HIV among MSM is becoming very crucial because MSM play a significant bridging role in transmitting HIV/STDS to the general population through heterosexual activities (Wang, 2007). In addition, Chinese MSM generally have more sexual risk behaviors than other at-risk groups, including having multiple sexual partners and engaging in unprotected sex at disturbingly high rates (Guo et al., 2009).
Developing interventions to increase condom use among Chinese MSM should therefore be a top priority. Researchers have long agreed that interventions focusing on multiple determinants of condom use are the most successful in changing behaviors (Fisher & Fisher, 2000). Therefore, a better understanding of the factors that influence Chinese MSM’s decision to use or not to use condoms is very crucial to developing effective sexual risk reduction programs. One such factor is the sexual communication between MSM and their sexual partners on sex-related issues.
In the context of HIV prevention among MSM, research suggested an association between improved sexual communication with partners and reduced unprotected sexual practices, or between the absence of sexual communication and unprotected sex (Elwood, Greene, & Carter, 2003; Semple, Patterson, & Grant, 2000). However, the relationship between sexual communication and condom use among Chinese MSM has seldom been documented. The purpose of the current study was therefore twofold: (1) identify the sexual communication patterns in terms of target of communication and the topics of communication, (2) determine the relationship between sexual communication and condom use among a sample of Chinese MSM. We posit that those who reported more sexual communication on condom use, HIV/STDs preventions and sexual history with sexual partners would be more likely to practice safer sex.
METHODS
Participants
A cross-sectional paper-pencil survey was conducted among migrant MSM in Beijing who were 18–29 years of age and did not have permanent residency registration in Beijing. Participants were recruited through peer outreach, snowballing, the Internet outreach, and venue-based outreach (Guo et al., 2011). Participants were ensured of confidentiality of their participation, and provided written consent before participation. A total of 311 (98%) MSM agreed to participate. Four respondents with substantial missing data were excluded, which resulted in a final sample of 307 participants.
Survey Procedure
The questionnaire was self-administered. The participants completed their surveys privately in local CDC or a community medical center in Beijing. The trained interviewers were graduate students and faculty members in psychology at a local university and health workers from a local CDC. The participants received a small monetary incentive (equivalent to US$2) for their participation and reimbursement for their transportation expenses (up to US$5) upon the completion of the survey.
Measures
Consistent Condom Use
Respondents were asked if they used condoms with their regular and casual partners during oral or anal sex in their lifetime (from 1=never to 5=always) and the last three sexual episodes (from 1=0 time to 4=all 3 times). A composite score of consistent condom use was created by counting who responded “often” or “always” or “all 3 times” to these questions.
Sexual Communication
Respondents were asked whether they communicated with their regular and casual partners about topics such as condom use, HIV prevention, STDs prevention, sexual history, and each other’s other sexual partners (yes/no). Two dichotomous composite scores were created for the target of communication (i.e., regular/casual partners) and three composite scores for the topics of communication (condom use, HIV/STD prevention, and sexual history).
Data Analysis
Descriptive statistics were reported to describe demographic characteristics, the rate of consistent condom use, and sexual communication targets and topics among the study sample. Chi-square tests were employed to examine the relationships between sexual communication variables and various consistent condom use measures.
Results
The respondents had a mean age of 23.73 years (SD=2.86). About 59.9% reported that they were homosexual, 30.9% bisexual, 1.3% heterosexual, and 24 (7.8%) were uncertain about their sexual orientation. Table 1 presents the summary statistics of the demographic variables, and Table 2 presents summary statistics of consistent condom use, and sexual communication patterns for the full sample and for the subgroups categorized by respondents’ sexual orientation.
Table 1.
Sample Demographic Characteristics by Sexual Orientation
| Total | Homosexual | Bisexual | Other | |
|---|---|---|---|---|
| N(%) | 307(100%) | 184(59.9%) | 95(30.9%) | 28(9.1%) |
| Age | 23.73(2.86) | 24.04(2.80) | 23.03(2.81) | 24.11(3.13) |
| Length of migration (month) | 49.27(30.98) | 49.95(29.91) | 48.52(32.12) | 47.36(34.84) |
| # of cities stayed | 2.71(2.95) | 2.41(2.00) | 3.23(4.27) | 2.89(2.46) |
| Time in Beijing | 39.50(30.56) | 37.45(26.29) | 32.73(27.38) | 39.32(31.94) |
| # of workplaces last yr | 1.92(2.54) | 1.62(1.35) | 2.39(3.84) | 2.32(2.72) |
| Monthly Income (100yuan) | 22.08(16.80) | 22.09(18.75) | 22.32(14.56) | 21.25(87.92) |
| Han Ethnicity | 282(92%) | 172(93.5%) | 87(91.6%) | 23(82.1%) |
| Never Married | 287(94%) | 172(93.5%) | 81(85.3%) | 26(92.9%) |
| Hometown Type | ||||
| City | 102(33%) | 66(35.9%) | 29(30.5%) | 7(25%) |
| County seat | 63(21%) | 38(20.7%) | 19(20%) | 6(21.4%) |
| Township | 44(14%) | 26(14.1%) | 17(17.9%) | 1(3.6%) |
| Rural | 98(32%) | 54(29.3%) | 30(31.6%) | 14(50%) |
| Education | ||||
| ≤ Middle School | 51 (17%) | 28(15.2%) | 16(16.8%) | 7(25%) |
| High School | 121(39%) | 67(38.4%) | 43(45.3%) | 11(39.3%) |
| ≥ 3yr college | 135(44%) | 89(48.4%) | 30(31.6%) | 10(35.7%) |
| Employment | ||||
| Company | 97(32%) | 57(31%) | 29(30.5%) | 7(25%) |
| Entertainment | 99(32%) | 59(32.1%) | 28(29.5%) | 12(42.9%) |
| Freelance | 68(22%) | 37(20.1%) | 24(25.3%) | 7(25%) |
| Other | 43(14%) | 31(16.8%) | 14(14.7%) | 2(7.1%) |
| Frequency of Visiting Home | ||||
| Never | 23(8%) | 16(8.7%) | 6(6.3%) | 1(3.6%) |
| Once/2–3 yrs | 40(13%) | 25(13.6%) | 11(11.6%) | 4(14.3%) |
| Once/year | 148(48%) | 88(47.8%) | 43(45.3%) | 17(60.7%) |
| 2–3 times/year | 95(31%) | 55(29.9%) | 34(35.8%) | 6(21.4%) |
Table 2.
Consistent condom use and sexual communication patterns among MSM in China
| Sexual orientation | |||||
|---|---|---|---|---|---|
| # of Valid response |
Overall Sample |
Homosexual | Bisexual | Other | |
| N(%) | 307 | 184(59.9%) | 95(30.9%) | 28(9.1%) | |
| Consistent Condom Use (CCU) | |||||
| Lifetime CCU | |||||
| Regular male partners | 182 | 110 (60.4%) | 75(40.8%) | 30(31.6%) | 5(17.9%) |
| Casual partners | 304 | 235(77.3%) | 143(77.7%) | 70(73.7%) | 22(78.6%) |
| Oral sex | 239 | 72(30.1%) | 43(23.4%) | 20(21.1%) | 9(32%) |
| Anal sex | 306 | 227(74.2%) | 134(72.8%) | 70(73.7%) | 23(82%) |
| CCU in recent 3 episodes | |||||
| Regular partner | 200 | 158(79%) | 96(52.2%) | 56(58.9%) | 6(21.4%) |
| Casual partner | 304 | 261(85.9%) | 156(84.8%) | 83(87.4%) | 22(78.6%) |
| Anal sex | 306 | 268(87.6%) | 160(87%) | 85(89.5%) | 23(82%) |
| Target of Communication | |||||
| Only regular partners | 307 | 43(14%) | 23(12.5%) | 17(17.9%) | 3(10.7%) |
| Only casual partners | 307 | 77(25.1%) | 46(25%) | 20(21.1%) | 11(39.3%) |
| Both regular and casual partners | 307 | 180(58.6%) | 111(60.3%) | 55(57.9%) | 14(50%) |
| Topics of communication | |||||
| Condom use | 307 | 154(50.2%) | 98(53.3%) | 46(48.4%) | 10(35.7%) |
| HIV/STI | 307 | 252(82.1%) | 151(82.1%) | 75(78.9%) | 26(92.9%) |
| Sexual history | 307 | 190(61.9%) | 116(63%) | 58(61.1%) | 16(57%) |
Among the 307 respondents, 182 reported having regular male partners and 60.4% (n=110) of them consistently used condoms with their regular male partners. Among the respondents who reported having casual partners, 77.3% (n=235) consistently used condoms with their casual partners. In addition, 223 (72.6%) reported that they had communications with their regular sexual partners about sex-related topics, and 257 (83.7%) had such communications with casual partners.
Topics of Communication and Consistent Condom Use
In both lifetime and recent three episodes, respondents who communicated about condom use, HIV/STDS, each other’s sexual history and sex partners with their regular partners were more likely to use condoms frequently than those who did not have such communications with their regular partners. Table 3 presents the association between consistent condom use and various topics of communication with their regular partners.
Table 3.
Consistent condom use (CCU) by topic of communication with regular partners
| Topics of the communication with regular partners | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| Condom use | HIV/STD | Sexual History | |||||||
| Yes | No | Chi- Square |
Yes | No | Chi- Square |
Yes | No | Chi- Square |
|
| Life time CCU | |||||||||
| Regular male partners | 97(47.5%) | 12(12%) | 36.87*** | 97(48%) | 13(12.4%) | 38.17*** | 91(48.9%) | 19(15.7%) | 35.19*** |
| Casual partners | 162(79.4%) | 70(70%) | 3.29 | 154(76.2%) | 81(77.1%) | .032 | 147(79%) | 88(72.7%) | 1.62 |
| Oral sex | 51(25%) | 21(21%) | .59 | 49(24.3%) | 23(21.9%) | .21 | 48(25.8%) | 24(19.8%) | 1.46 |
| Anal sex | 151(74%) | 73(73%) | .04 | 146(72.3%) | 81(77.1%) | .85 | 137(73.7%) | 90(74.4%) | .02 |
| CCU in recent 3 episodes | |||||||||
| Regular partner | 138(67.6%) | 19(19%) | 63.59*** | 138(68.3%) | 20(19%) | 67.14*** | 132(71%) | 26(21.5%) | 71.86*** |
| Casual partner | 177(86.8%) | 81(81%) | 1.74 | 171(84.7%) | 90(85.7%) | .06 | 162(87.1%) | 99(81.8%) | 1.60 |
| Anal sex | 183(89.7%) | 82(82%) | 3.56 | 178(88.1%) | 90(85.7%) | .36 | 168(90.3%) | 100(82.6%) | 3.90* |
p<.05,
P<.01,
p<.001
However, as shown in Table 4, no significant differences were found in condom use of lifetime and recent three episodes measures between those who had sexual communication with casual partners and those who did not have such communications.
Table 4.
Consistent condom use (CCU) by topics of the communication with casual partners
| Topics of the communication with casual partners | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| Condom use | HIV/STD | Sexual History | |||||||
| Yes | No | Chi- square |
Yes | No | Chi- Square |
Yes | No | Chi- square |
|
| Life time CCU | |||||||||
| Regular partners | 81(34.8%) | 28(38.9%) | .41 | 73(33.5%) | 37(41.6%) | 1.80 | 61(31.6%) | 49(43%) | 4.03 |
| Casual partners | 182(78.1%) | 51(70.8%) | 1.62 | 166(76.1%) | 69(77.5%) | .07 | 145(75.1%) | 90(78.9%) | .58 |
| Oral sex | 59(25.3%) | 13(18.1%) | 1.61 | 56(25.7%) | 16(18%) | 2.09 | 47(24.4%) | 25(21.9%) | .23 |
| Anal sex | 176(75.5%) | 49(68.1%) | 1.59 | 163(74.8%) | 64(71.9%) | .27 | 141(73.1%) | 86(75.4%) | .21 |
| CCU in recent 3 episodes | |||||||||
| Regular partner | 114(48.9%) | 43(59.7%) | 2.57 | 106(48.6%) | 52(58.4%) | 2.43 | 94(48.7%) | 64(56.1%) | 1.59 |
| Casual partner | 200(85.8%) | 59(81.9%) | .65 | 184(84.4%) | 77(86.5%) | .22 | 161(83.4%) | 100(87.7%) | 1.04 |
| Anal sex | 205(88%) | 61(84.7%) | .52 | 189(86.7%) | 79(88.8%) | .24 | 169(87.6%) | 99(86.8%) | .03 |
Targets of Communications and Consistent Condom Use
The differences in lifetime condom use among the groups who communicated about sex-related topics with either type of partners, with only one type of partners (either regular or casual partners), and with both regular and casual partners are significant (χ2 = 18.04, p<.001, see Table 5). Also, the differences in condom use in the last three sexual encounters among these groups are significant (χ2 = 37.38, p<.001, see Table 5).
Table 5.
Consistent condom use (CCU) by target of communication
| Targets of sexual Communication | Chi-square | |||
|---|---|---|---|---|
| None | One | Both | ||
| N(%) | 7(2.3%) | 120(39.1%) | 180(58.6%) | |
| Lifetime CCU | ||||
| Regular male partners | 2(28.6%) | 26(21.7%) | 82(45.6%) | 18.04*** |
| Casual partners | 6(85.7%) | 91(75.8%) | 138(76.7%) | .36 |
| Oral sex | 0(0%) | 28(23.3%) | 44(24.4%) | 2.24 |
| Anal sex | 5(71.4%) | 95(79.2%) | 127(70.6%) | 2.79 |
| CCU in recent 3 episodes | ||||
| Regular partner | 2(28.6%) | 37(30.8%) | 119(66.1%) | 37.38*** |
| Casual partner | 7(100%) | 100(83.3%) | 154(85.6%) | 1.54 |
| Anal sex | 7(100%) | 102(85%) | 159(88.3%) | 1.76 |
p<.05,
p<.01,
p<.001
Discussion
The data in the current study provide additional empirical evidence for the body of relevant literature that Chinese MSM had engaged in unprotected sex with both regular and casual partners. However, the current study revealed that condom use with their partners was discussed less than other sexual issues such as HIV/STDs prevention and sexual history among MSM and their partners. Theses findings underscore the importance to study the sex communication and its association with condom use among Chinese MSM.
Results of the current study suggest that sexual communication with regular partners were associated with respondents’ condom use with regular partners. These findings are consistent with those of a meta-analysis study conducted by Noar, Carlyle and Cole (2006), who found that overall communication about condom use had the strongest relationship with overall condom use (r=.23). Sexual communications with casual partners, however, were not associated with respondents’ condom use. One possible explanation for this insignificant association is that, although the communication topics might be the same, the communication styles that the Chinese MSM employed might be different between casual and regular partners, which affected the condom use behavior. Another potential explanation is that the participants were more aware of the risk of HIV/STDs infections with casual partners so that they tried to use condoms as often as they could with casual partners no matter if they were able to talk about these topics. The third potential explanation is that the condom use with casual partners (including commercial sex partners) was a more complex issue than the one with regular partner and could be affected by other salient factors than the communication. Future research may need to examine factors that may potentially mediate or moderate the effect of sex communication with causal partners (e.g., communication styles) on the condom use.
Data in the current study suggested that those respondents who had sexual communications with both regular and casual partners were more likely to use condoms with their regular partners, compared with those respondents who had no sexual communications at all or had sexual communications with either regular or casual partners. These findings suggest the importance of consistent sexual communications with both types of sexual partners. Intervention programs could aim to increase MSM’s sexual communication with both regular and casual sexual partners.
There are several limitations to this study. First, this study used the dichotomous variables (yes or no) to assess sex-related communication, which did not distinguish those who communicated frequently from those who communicated less frequently, as the frequency might be a critical element of such communication. Second, migrant MSM in Beijing, the cultural and political center of the nation, might become more social and comfortable with their sexual orientation or homosexual behaviors. Therefore, their sexual communication behavior might be different from those of MSM in other areas of China. Third, the current study did not differentiate commercial clients from other casual partners (one-night stands, online partners). The sexual communication behavior might be different between these two types of casual partners.
Despite these limitations, the current study provides empirical evidence for the importance of sexual communication between Chinese MSM and their sex partners. Intervention programs could aim to promote frequent and open sexual communications with sex partners as normative and socially-desired behaviors for Chinese MSM. Programs may promote their motivation and willingness to initiate sexual communications and negotiate condom use with all of their sex partners. Meanwhile, intervention programs should make efforts to build their self-efficacy to talk about and negotiate condom use and other important risk reduction skills. Future study needs to address the effectiveness of the communication and potential barriers (e.g., embarrassment and discomfort) that preclude Chinese MSM from engaging in effective sexual communication. Future research also needs to identify psychosocial correlates of Chinese MSM’s infrequent, relatively hidden and involuntary sexual communication that have not been previously studied in the existing literature.
Acknowledgement
The study described in this report was supported by NIH Research Grant R01NR10498 by the National Institute of Nursing Research and National Institute of Mental Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Nursing Research and National Institute of Mental Health. The authors also want to thank Joanne Zwemer for assistance in preparing the manuscript.
Contributor Information
Zhiwen Xiao, Valenti School of Communication, University of Houston, 101 Communication Bldg, Houston, TX 77204-3002, Tel: 713-743-2243, zxia2@central.uh.edu.
Xiaoming Li, Wayne State University School of Medicine, Detroit, MI.
Yingjie Liu, Chaoyang District Center for Disease Control and Prevention, Beijing, China.
Shulin Jiang, Chaoyang District Center for Disease Control and Prevention, Beijing, China.
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