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. Author manuscript; available in PMC: 2015 Mar 1.
Published in final edited form as: Sex Res Social Policy. 2014 Jan 24;11(1):11–19. doi: 10.1007/s13178-014-0145-x

Men who have sex with men’s attitudes toward using color-coded wristbands to facilitate sexual communication at sex parties

Christian Grov 2,3,1, Jackeline Cruz 4, Jeffrey T Parsons 2,5
PMCID: PMC3959108  NIHMSID: NIHMS559586  PMID: 24659929

Abstract

Sex parties are environments where men who have sex with men (MSM) have the opportunity to have sex with multiple partners over a brief period of time. Dim lighting and non-verbal communication are characteristics of sex parties that make sexual communication more challenging. We report on qualitative data from 47 MSM who attended sex parties in New York City. Participants responded to distinct hypothetical scenarios involving the use of color-coded wristbands to communicate (1) condom use preferences, (2) sexual position (e.g., top, bottom) and (3) HIV status at sex parties. The majority had positive-to-neutral attitudes toward color-coded wristbands to indicate (1) condom use preference and (2) sexual position (70.8%, 75.0% HIV-positive; 63.6%, 81.8%, HIV-negative respectively). These men cited that wristbands would facilitate the process of pursuing partners with similar interests while also avoiding the discomforts of verbal communication. In contrast, 41.7% of HIV-positive and 50.0% of HIV-negative men expressed unfavorable attitudes to using wristbands to communicate HIV status. These men cited the potential for HIV-status discrimination as well as suspicions around dishonest disclosure. Although participants were receptive to utilizing color-coded wristbands at sex parties to convey certain information, it may be unfeasible to use wristbands to communicate HIV status.

Keywords: Gay and bisexual men, sex parties, sexual communication, HIV status disclosure

INTRODUCTION

Gay, bisexual, and other men who have sex with men (MSM) are one of the only populations for whom HIV prevention efforts have been unable to reverse the growing trends in national HIV incidence over the past decade (CDC, 2012b; Higa et al., 2013; Prejean et al., 2011). They accounted for 79% of all new HIV diagnoses among men 2011 (CDC, 2013) and are one of the only groups to see increased infections in recent years (CDC, 2012b). One study found that the mean incidence rate of HIV among MSM in the U.S. is 2.39% per year, which, if sustained in a cohort of young MSM, will result in 40% of them being HIV-positive by age 40 (Stall et al., 2009). Taken together, these rates suggest that there remains an urgent need to create innovative, evidence-based, and tailored approaches to HIV prevention amongst this highly vulnerable group.

Studies have noted that the venues where MSM meet their sex partners may have an influence on whether they engage in unprotected anal intercourse (UAI) (Grov, Hirshfield, Remien, Humberstone, & Chiasson, 2013b; Grov, Parsons, & Bimbi, 2007; Mimiaga et al., 2011; Pollock & Halkitis, 2009; Prestage et al., 2009). Early in the HIV epidemic, a lot of this work focused on bathhouses (Shilts, 1987); however, much of this focus has shifted to the Internet (Chiasson et al., 2006), particularly because of the high frequency with which MSM meet partners online (Grov et al., 2013b; Liau, Millett, & Marks, 2006). Yet, urban centers, including New York City (NYC), have seen growth in private sex parties, and these environments potentiate HIV transmission risks (Clatts, Goldsamt, & Yi, 2005; Grov, Golub, & Parsons, 2010; Grov, Rendina, Ventuneac, & Parsons, 2013c; Mimiaga et al., 2010; Mimiaga et al., 2011; Solomon et al., 2011).

A community-based study of MSM in NYC and Los Angeles reported that 24.9% (of n = 886) had met partners at sex parties in the last 90 days (Grov et al., 2007). The study compared MSM who met partners at private sex parties with those who met partners at bathhouses and public sex environments, and found that men who attended private sex parties had higher rates of UAI. In a second study with sexually active MSM in NYC, Grov et al., (2010) noted that HIV-positive men (58%) were more likely to have attended sex parties than HIV-negative men (26%). In a cross-sectional survey of gym-attending MSM in NYC, Pollock and Halkitis (2009) reported that 23% had been to a sex party in the previous 6 months, and 8% had been to a sex party themed around barebacking. A 2011 study of 540 NYC MSM aged 18–29 noted 8.7% had been to a sex party in the last 3 months and these men reported significantly more sex partners (lifetime and recent) and were more likely to report drug use compared to others (Solomon et al., 2011). And a 2012 US national online survey of 2,063 MSM from a sexual networking website found 45.2% of men had been to a sex party in the last year and an additional 23.3% had been to one more than 12 months ago (Grov et al., in press). Collectively, these findings indicate that sex party attendance is not uncommon and that men who attend sex parties might be appropriate candidates for targeted HIV prevention.

Interestingly, although available research suggests men who attend sex parties are at greater risk for UAI, there has been little work to investigate men’s actual behavior at sex parties. Yet, sex parties can occur around themes—including barebacking and “anything goes,” see www.cumunion.com-suggesting these might be appropriate environments to not only reach a vulnerable population, but also intervene such to avoid HIV and STI transmission (Clatts et al., 2005; Grov et al., in press). Likewise, there is little data on the availability of condoms at sex parties. One study noted that having condoms available at a sex party was associated with decreased odds of serodiscordant UAI at the event (Mimiaga et al., 2011); however, it would be necessary to know what other strategies could be used to further enhance condom use.

To our knowledge, there are no published studies reporting on the number of sex parties that occur in NYC. In reviewing online listings on sexual networking websites (e.g., craigslist, adam4adam, barebackrt), sex blogs (e.g., adventuresingroupsex), as well as event spaces that regularly house sex parties, it appears that between 25 to 35 parties occur each week in NYC. In our conversations with event promoters to conduct the present study, we have learned that these events can attract anywhere from 20 to 120 MSM. Events take place at licensed commercial sex clubs as well as private residences and hotel rooms (Clatts et al., 2005; Mimiaga et al., 2010; Mimiaga et al., 2011; Solomon et al., 2011). In order to facilitate a sexually charged environment and to encourage rapid and frequent partnering, sex parties are often characterized by low lighting, non-verbal communication, and sometimes loud music (Mimiaga et al., 2010). Group sex, anonymous sex, and frequent partnering in the course of the event increase the risk of HIV and STI transmission (Clatts et al., 2005; Gwadz et al., 2006). Although some researchers have turned their focus to sex parties (Mimiaga et al., 2010; Mimiaga et al., 2011; Mullens, Staunton, Debattista, Hamernik, & Gill, 2009; Pollock & Halkitis, 2009; Reisner et al., 2009; Solomon et al., 2011; Wilson, Cook, McGaskey, Rowe, & Dennis, 2008), there are currently no evidence-based interventions developed for these venues despite the potential for substantial HIV/STI transmission.

Similar to bathhouses, the low lighting and non-verbal communication that are inherent characteristics of sex parties may impede sexual communication and the ability of event promoters to monitor condom use (Elwood, Green, & Carter, 2003; Richters, 2007). Thus, it is necessary to offer a novel way of improving condom use or other harm reduction strategies within the confines of these physical and social environments (Cohen & Scribner, 2000; Ko et al., 2009; Parker, Easton, & Klein, 2000; Wohlfeiler, 2000). These may include communication around condom use, HIV status disclosure, and sexual positioning (e.g., top, bottom, versatile, oral-sex-only). Intervening on environmental factors (e.g., adding lighting) or social norms regarding audible communication (e.g., encouraging men to speak) are considered counterintuitive to nature of a sex party (i.e., will “ruin the mood”) (Mimiaga et al., 2010). Thus, alternate means to achieve that communication are warranted.

Historically, some MSM have taken to using the “hanky code,” whereby a handkerchief is worn in the rear pocket of a man’s pants with the color and location (right pocket or left) indicating something about his sexual interests; however, this has often been relegated to men into leather, sadism and masochism, or other kinky behaviors (Kulick, 2000; Patton, 2002; Perkins & Skipper Jr, 1981). Yet, perhaps there is something to be gleaned from the hanky code for implementation at sex parties? To the extent that verbal communication may be difficult in sex parties, use of similar non-verbal codes could facilitate finding a partner with congruent interests. At a sex party, this could include color-coded wristbands. However, before the efficacy of such an intervention can be tested, it is necessary to determine its feasibility and acceptability among the target population.

To that end, we conducted qualitative interviews with 50 MSM who attend sex parties in NYC, querying them with distinct hypothetical scenarios about the use of color-coded wristbands at sex parties to indicate (1) condom use preferences, (2) sexual positioning, or (3) HIV status. Our intent was to determine the acceptability of using color-coded wristbands at sex parties, as well as determine differences based on a person’s HIV status. Since this area of research is relatively new, the questions posed in this study were framed in order to generate hypotheses rather than test a hypothesis. Determining how MSM will respond and accept HIV prevention efforts in sex parties can influence policies regarding the way these efforts are delivered and implemented. As MSM in urban centers across the US continue to attend sex parties, it is important to develop policies regarding acceptable and appropriate methods to improve sexual communication and avert HIV and STI transmission.

METHOD

Participants and Procedures

The data used for this study were taken from Project Score, a study investigating the venues where MSM meet their sex partners. One aim was to interview 50 MSM who were recruited via sex parties. Eligibility criteria included: aged 18 years or older, biologically male, residentially stable, and reported having two or more casual male sex partners in the last 30 days. Eligible men were invited to attend a face-to-face interview at our research office.

The participants for this study were recruited via partnership with sex party promoters. The promoters either used passive recruitment methods—such as leaving informational materials with details about the study at their events (e.g., near the clothing check)—or by circulating study materials electronically via their list serves. Given the pilot nature of this study, there were insufficient resources to conduct active on-site recruitment (i.e., project staff at the event). Those interested in joining the study contacted us and were screened by research staff. Eligible participants were scheduled to complete an assessment (target n = 50). All procedures were approved by the City University of New York Institutional Review Board.

MEASURES

Participants completed an audio-recorded face-to-face semi-structured interview at our research office. These interviews were approximately 45 minutes. Interviews were transcribed verbatim and reviewed for accuracy by research staff. Participants were queried about their attitudes toward three distinct hypothetical scenarios involving the use of color-coded wristbands to facilitate sexual communication at sex parties. This included a scenario in which wristbands would indicate condom use preferences (e.g., one color signified “I always use condoms,” a second signified “ask me” or “let’s discuss,” and a third that signified “I never use condoms”). A second scenario involved the use of color-coded wristbands to indicate sexual positioning (e.g., a color for top, bottom, versatile, or oral-sex-only). A third scenario involved using color-coded wristbands to indicate one’s HIV status. We were unable to utilize three interviews due to interviewer error, thus the final sample size for the current study was 47 qualitative interviews.

Analytic Strategy

Following the guidelines of thematic analysis, the research staff reviewed the transcriptions around narratives describing attitudes toward using color-coded wristbands in various scenarios at sex parties. Studies have shown that thematic analysis is very useful in assessing qualitative data (Miles & Huberman, 1994; Patton, 1990). The research team reviewed responses to the three scenarios and first broadly coded them into three categories, “favor”, “neutral”, and “oppose”. Examples included, “That’s awesome! I think that’s cool” (Favorable), “I don’t think I would have a problem with that” (Neutral), and “Actually, I think it’s a bad idea” (Oppose). Subthemes within codes were then identified. A second member of the team verified all coding and discrepancies (e.g. one reviewer coded as “neutral” and the other coded as “favor”) were discussed and resolved via 100% consensus between the coder(s) and the principal investigator. All the themes shown in the results were commonly expressed by a number of participants. Adjacent to quotes are men’s ages and their self-reported HIV status.

RESULTS

The participants ranged in age from 18–71 years (M = 41.5, SD = 13.8) (see Table 1). Forty-four percent were MSM of color and 51.1% were HIV-positive. One participant did not know his status. The majority (85.1%) identified as gay, six (12.8%) as bisexual, and one (2.1%) who indicated “other.” Participants provided descriptive narratives about sex parties that included details about meeting partners, venue characteristics, and discussing condom use and HIV status with partners. We asked participants to express their attitudes towards using color-coded wristbands to identify their condom use preferences (i.e. always, ask me, never), sexual positioning (i.e. top, bottom, versatile), and HIV status (see Table 2). In analyzing the data, several themes emerged within each wristband scenario. Across all three scenarios, and whether participants thought they were a good idea or not, there was overall agreement that wristbands would be an effective way to circumnavigate norms against audible communication at sex parties.

Table 1.

Sample characteristics

n %
HIV status
 Positive 23 48.9
 Negative 23 48.9
 Unknown 1 2.1
Race or ethnicity
 White 27 57.4
 Black 8 17
 Latino 4 8.5
 Multiracial and “other” 8 17
Education
 High school or less 7 14
 Some college 12 24
 4-year college degree 20 40
 Graduate school 11 22
Sexual identity
 Gay 40 85.1
 Bisexual 6 12.8
 Other 1 2.1
Age (Mean, SD) 41.5 13.8
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Table 2.

Attitudes toward using color-coded wristbands to communicate (1) condom use, (2) sexual position, and (3) HIV status at sex parties

Favorable Neutral Opposed
n % n % n %
(1) Condom use
 HIV-positive 13 54.2 4 16.7 7 29.2
 HIV-negative 12 54.5 2 9.1 8 36.4
 HIV-unknown 1 100.0 0 0.0 0 0.0
(2) Sexual position
 HIV-positive 17 70.8 1 4.2 6 25.0
 HIV-negative* 15 71.4 3 14.3 3 13.6
 HIV-unknown 0 0.0 1 100.0 0 0.0
(3) HIV status disclosure
 HIV-positive 13 54.2 1 4.2 10 41.7
 HIV-negative 9 40.9 2 9.1 11 50.0
 HIV-unknown 0 0.0 1 100.0 0 0.0
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*

One participant’s response could not be coded (i.e., did not respond to the question)

Condom use preferences

With regard to how men felt about using color-coded wristbands to identify condom use preferences, seven participants (14.9%) expressed favorable attitudes mainly indicating that the wristbands would limit or completely eliminate the need to verbally communicate with partners. Five of the participants were HIV-positive and two were HIV-negative. Most of these participants communicated a discomfort that exists in discussing condom use among partners:

“If I saw that [wristbands], I’d agree, because that’s a message that says ‘I’m positive.’ In other words, when I say I don’t want to use a condom, then [I’m saying] ‘I’m positive.’ It’s an elegant way.” (38, HIV-positive).

“That’s a good idea... [because] then you don’t have to ask the person.” (47, HIV-positive).

Both participants agreed that the wristbands would reduce the need for verbal communication between partners; however, the first participant conflated condom use communication with implicit/tacit HIV status disclosure.

Three participants (6.4%) believed that it would save them time in pursuing partners whose preferences complimented their own on condom preference. Of those three participants, one was HIV-negative, one was HIV-positive, and one did not know his status.

“It would save a lot of people time pursuing other people that aren’t into [safe sex].” (30, HIV-negative).

Two HIV-negative participants (4.3%) felt that men could lie about their preferences for reasons not explained. There was one participant who considered the wristband discriminatory towards his own personal condom use preference. However, he admitted to evaluating the risk of engaging in sexual intercourse with sex partners based on their condom use preference:

“I almost [want to] say it would be a little discriminatory because people are [going to] judge you based on, on whether or not you choose to use condoms. I know personally, if I [see] someone with a wristband saying, “I never use condoms,” I probably wouldn’t want to sleep with them, just because I’d be afraid—especially at a sex party—I’d be afraid of what I would be putting myself at risk for.” (32, HIV-negative)

Sexual positioning

With regard to scenarios in which wristbands communicated sexual positioning (e.g., top, bottom, versatile, oral-sex-only), one HIV-positive participant considered the wristband helpful in decreasing the verbal conversation traditionally necessary between partners as it “cuts to the chase”:

“That would be great too, yeah [because] then yeah, that would be, shorten the conversation. You would go to the person, you’ll already know if they’re a top, bottom, that would be great.” (46, HIV-positive)

Three participants described how they did not favor the use of wristbands sexual positioning because they believed in encouraging verbal communication between sex partners. One of the three participants was HIV-positive and two were HIV-negative.

“When you’re with somebody, you just ask them. I mean, you’re at public party with lots of people, you’re not going to do it with everybody there.” (64, HIV-positive)

Fourteen men (29.8%) favored the use of color-coded wristbands to identify sexual positioning, predominantly stating that it would not only make it easier to search for compatible partners, but it would also eliminate the need to guess their partners’ preferred position. Eight of the 14 participants were HIV-negative.

“I love all of that [wristbands], absolutely…everything is up front, there is no guesswork. You don’t end up working on a guy for 20 or 30 minutes and then realize you are both bottoms.” (44, HIV-positive)

The participant’s statement is one that was similar to other participants expressing favorable attitudes. Most felt that the wristbands were a good way to easily indicate their personal likings and also to locate partners that share compatible sexual positioning preferences faster and more efficiently without having to make any inferences.

In contrast, three participants (6.4%) felt that the implementation of sexual positioning wristbands would eliminate the mystery and spontaneity that comes along with meeting new sexual partners at sex parties. Two of the three participants were HIV-positive and one was HIV-negative:

“It sounds like it would take the fun out of the situation [because] part of the situation is gauging and measuring, seeing where things go and where they don’t go----you know. Yeah, a little bit more spontaneity----is called for.” (48, HIV-positive)

HIV status disclosure

Finally, we report on participants’ attitudes toward using color-coded wristbands to communicate HIV status at sex parties. One HIV-negative participant stated that he does not want to engage in oral sex with anyone who is HIV-positive. Therefore, the use of wristbands to communicate HIV status would help him effectively sort through the crowd to find only HIV-negative partners. Although most participants (n = 26, 55.3%) expressed positive to neutral attitudes towards using the HIV status wristband, the most common themes emerged from the participants who expressed strongly unfavorable attitudes.

For 23.4% of participants (n = 11), dishonesty was a common sentiment for opposition. Seven of the eleven participants were HIV-negative and one did not know his status.

“To me that’s meaningless information because people lie for all different kinds of reasons and if you’re making a decision of your behavior and relaxing your risk tolerance or, you know, doing anything like that based on that information, I think is ultimately destructive.” (45, HIV-positive)

“Guys can say whatever they want to, but unless there’s like a doctor or medical note there along with them, saying that they haven’t had sex in the past six months and ‘here’s my last test’ type of thing… wouldn’t affect me either way. Again, I would still go up and ask them what their status is, just because I don’t trust what a little bracelet says.” (27, HIV-negative)

Both participants responded that they would not put much confidence and trust in the wristbands primarily because people could lie about their HIV status. The second participant, however, suggested that the wristbands would hold greater credibility if the HIV status was confirmed by a doctor via a medical report. Yet, there were participants who deemed the wristbands pointless since they already assume that everyone attending sex parties are HIV-positive:

“I mean, that, in a situation like that it, it would be unnecessary, [because] you just assume that everybody is [HIV-positive], so, why do we need to tell anybody what we are?” (64, HIV-positive)

“I don’t think that would be useful because I always presume somebody either knows that they’re positive or doesn’t know that they’re positive.” (34, HIV-negative)

For these men, HIV status disclosure was considered unnecessary because individuals should practice universal precautions. If a person engages in sex without a condom, it is assumed that individual is HIV-positive or at least comfortable having sex with HIV-positive individuals.

Three men (6.4%) also disagreed with the wristband use, citing that disclosure of this kind of information should remain personal choice, not obligation. Two of these three participants were HIV-negative and one was HIV-positive:

“I think we should be encouraging people to, to be able to talk about [HIV]. I think putting a wristband on, or some demarcation with color or outside kind of marking, doesn’t really allow the person…for you to get to know that person.” (58, HIV-negative)

“People have to make it their own decisions, they do. Everybody makes their own; we’re all adults. We all know what we’re doing. Everybody knows the risks or not, but I don’t think you can brand somebody or tattoo them, which is really what [the wristbands are].” (37, HIV-negative)

The first participant illustrated that HIV status disclosure is something that is best carried out as a conversation, while the second participant saw it as “branding” or “tattooing.” For both these men, their concerns were more out of interest to protect HIV-positive men from experiencing HIV stigma, a sentiment shared by others.

Five participants (10.6%) thought that the color-coded wristbands to specify HIV status would discriminate against men who are HIV-positive. All five men were HIV-negative. Most of these participants stated that it would alienate and also further increase the stigma surrounding HIV-positive people.

“I think if you had wristband [color-coded for HIV status] on, you would get less opportunities to get [oral sex], I feel like, or people would just automatically put that stigma on you.” (33, HIV-negative)

This participant reiterated the sentiment of alienation and stigma that many others also expressed; however, he also mentioned that the wristband would decrease the prospects of engaging in sex simply based on their HIV-positive status.

One participant also added that the wristbands would be detrimental both emotionally and psychologically even though he acknowledged the good intention behind the implementation of the wristbands, which is preventing the transmission of HIV:

“I would not like to be in a [sex party] like that, but it would psychologically make me feel emotionally low in being part of a community that would, you know, make that, even though it’s for the greater benefit of, you know, preventing HIV.” (31, HIV-negative)

Yet when it came to the actual implementation of the wristbands at sex parties, three HIV-positive participants (6.4%) responded that while they tolerated the idea of using the HIV status wristbands, they would either not use them or would not attend sex parties where wristbands are made mandatory.

“I wouldn’t go if I had to mark, you know? Because uh I’m not into that risk…but there are a lot of people that [are uninformed] about [HIV], for example, all the [HIV-negative people], they [do] not really have inside information because they are not [HIV-positive], so…the [HIV-positive men] for them is a ‘No! Definitely no’ and [sex with an HIV-positive person is] not that dangerous, if you do it with precaution.” (61, HIV-positive)

This participant’s explanation for choosing not to wear a wristband denoting HIV status stems from the belief that most people are not educated about the HIV virus and thus do not fully understand it. As a result, he feels that HIV-negative men would decline engaging in sexual intercourse because they will perceive having sex with an HIV-positive partner as dangerous.

DISCUSSION

Based on the qualitative interviews with a diverse sample of 47 MSM recruited from sex parties in NYC, this study explored the attitudes towards the use of color-coded wristbands at sex parties to facilitate non-verbal sexual communication. Most participants expressed neutral or favorable attitudes toward using the wristbands to indicate interest in condom use and sexual positioning preferences. These men highlighted that the wristbands would allow them to circumnavigate norms against verbal communication at sex parties, thus communicating their own desires/interest, and more effectively identifying partners who have similar interests. The use of color-coded wristbands to communicate sexual positioning may contribute to increased sexual satisfaction and sexual self-efficacy at sex parties. Meanwhile, the use of color-coded wristbands to communicate condom use preferences may help to reduce unwanted UAI. Clearly more work is needed to determine the logistics of feasibly implementing color-coded wristbands to communicate sexual positioning or condom use preferences, as well as their efficacy. Yet, this initial study suggests promise for acceptability.

Interestingly, one participant confounded condom use intentions as tacit disclosure of HIV status (i.e., wearing a wristband to indicate “I never wear condoms,” is indication that one is HIV-positive). More research into this type of attribution would be needed prior to implementing wristbands that indicate condom use preferences. Likewise, it is recognized that the extent to which wristbands for condom use preferences would help men who want to use condoms find partners who also want to use condoms (thus averting unwanted UAI), could facilitate encounters between men who do not want to use condoms (thus facilitating wanted UAI, barebacking). All told, caution is needed if one’s goal is to use color-coded wristbands to avert both unwanted and wanted UAI.

In contrast, fewer participants considered the use of wristbands to communicate HIV status to be acceptable. Common themes around unacceptability included concerns about dishonesty with regard to reported HIV status as well as concerns about further alienating HIV-positive men. Interestingly, all the participants who felt that the wristbands would increase stigma and discrimination of HIV-positive individuals were HIV-negative. Although there were many HIV-positive men who opposed the use of wristbands, none specifically mentioned that they would feel stigmatized or alienated. Instead, HIV-positive men indicated that they would not be bothered by the implementation of the wristband; however, they would personally choose not to wear it and preferred not attending sex parties mandating its use. This finding reflects the belief that status disclosure should not be required and remains both a personal and difficult decision (Golub, Tomassilli, & Parsons, 2009; Grov, Agyemang, Ventuneac, & Breslow, 2013a; Overstreet, Earnshaw, Kalichman, & Quinn, 2012).

A prominent theme among both HIV-positive and HIV-negative participants was the belief that other men would not accurately report their HIV status (as “HIV negative,” when they were actually not). This theme was more common among HIV-negative men than HIV-positive men—presumably an HIV-negative man has more to personally “lose” if his partner is dishonest than does an HIV-positive man (Grov et al., 2013a). Participants cited that motivations for dishonesty could include being unsure of one’s true status (and thus misattributing) and avoiding discrimination and/or rejection from HIV-negative men. It was suggested by several participants that in order for the wristband indicating HIV-status to function more effectively, men should either be tested or bring medical proof of status. Yet, interestingly, none of the participants mentioned the “window period” or acute HIV infection, such that one may test HIV-antibody negative after a recent infection (Pai et al., 2013; Ventuneac et al., 2009). In total, these findings bring to bear the numerous challenges individuals face if attempting to serosort their partners (Golden, Brewer, Kurth, Holmes, & Handsfield, 2004; Golden, Stekler, Hughes, & Wood, 2008), and highlights that perhaps alternate approaches are warranted.

There are important limitations to consider in this study. The sample included MSM who attended sex parties in NYC, thus limiting generalizability. Yet, our sample was similar in age (Clatts et al., 2005; Mimiaga et al., 2010) as well as HIV status distribution (Mimiaga et al., 2010) to other studies of MSM recruited from sex parties. Given the “underground” nature of sex parties, future researchers should carefully consider the best methods for ensuring representativeness. This may include partnering with a diverse array of event promoters, and taking advantage of multiple recruitment approaches such as field recruitment, respondent driven sampling, and electronic media (e.g., list serves).

Additionally, participants were asked to reflect more generally on their thoughts about color-coded wristbands, rather than directly asking whether the participant would use the wristbands themselves. Such an approach allowed us to tap into participants’ thoughts more broadly while perhaps avoiding some social desirability. Yet still, many participants reflected both upon their using wristbands themselves, as well as what they thought about it more generally. In addition, future research should consider determining how wristbands could be used in tandem with men’s current communicative strategies at sex parties.

We posed three scenarios for participants; however, there are other scenarios that could also be considered. For example, the combination of condom use with sex role (e.g., “I use condoms if I bottom, but not if I top”). Taking cues from the historical Hanky Code (Kulick, 2000; Patton, 2002; Perkins & Skipper Jr, 1981), it may be that future researchers should assesses the feasibility and acceptability of using different arms (left vs. right) to indicate sex role (top, bottom, and both arms for versatile), with the color of the wristband specifying condom use preferences. And, although in the minority, some participants indicated that they did not favor wristbands because they believed in encouraging verbal communication between sex partners.

Although this was not the focus of the present study, it would be worth assessing the feasibility and acceptability of other methods to facilitate verbal communication (e.g., encouraging promoters to turn the music down). And, of course, there are many other approaches to improve sexual communication and reduce HIV and STI transmission at sex parties that should be considered, perhaps in tandem with using wristbands. For example, some participants indicated that using wristbands to communicate HIV status would be more useful if men had proof of status. Onsite rapid HIV testing has effectively been used in bathhouses (Daskalakis et al., 2009), an environment that shares some commonalties with sex parties.

Despite these limitations, these results offer insight into potential intervention approaches at sex parties—reaching a population that is at critical risk for HIV and STI transmission (Grov et al., 2007; Pollock & Halkitis, 2009; Solomon et al., 2011). This study found that nearly half of participants expressed unfavorable attitudes toward color-coded wristbands to indicate HIV status and suggests that alternate approaches are warranted. Meanwhile, our findings regarding the acceptability of wristbands to indicate condom use preferences are promising for the development of HIV and STI prevention intervention and policies for sex parties. Proven effective, such an approach may also prove to be a cost effective method for averting HIV and STI transmissions.

MSM who attend sex parties are extremely vulnerable to HIV and STI transmission. This includes with their partners at sex parties, as well as the potential to then inadvertently pass HIV or STIs to partners outside sex parties (i.e., partners who may otherwise be at low risk of infection) (Pollock & Halkitis, 2009). To our knowledge, there are currently no demonstrated effective behavioral interventions (DEBI) that have been developed for sex parties. Yet, the CDC currently supports one (condom distribution) that could be applied in sex parties (CDC, 2012a). This DEBI seeks to improve the availability, accessibility, and acceptability of condom use and has been demonstrated effective in bathhouses (Ko et al., 2009). Implementation of color-coded wristbands to indicate condom use preferences has the potential to enhance condom distribution through providing a means to effectively communicate condom use preferences. Added, this may effectively target other known factors that contribute to condom use such as subjective norms, self-efficacy, and behavioral intentions (Ajzen, 1991).

Acknowledgments

Project Score was funded by the National Institutes of Health (SC2 AI 090923: PI - Christian Grov) and research activities were conducted at the Center for HIV/AIDS Educational Studies and Training (CHEST). Special thanks to the study team: Michael Adams, Linda Agyemang, Bryant Porter, Ruben Jimenez, Aaron S. Breslow, Sarit A. Golub, Sitaji Gurung, Kevin Robin, Amy LeClair, Kristi Gamarel, Chris Hietikko, Anna Johnson, H. Jonathon Rendina, Arjee Restar, Joel Rowe, Inna Saboshchuk, Anthony Surace, Ana Ventuneac, Andrea C. Vial, and the recruitment staff. Finally, a special thanks to Joana Roe at NIAID. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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