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. Author manuscript; available in PMC: 2015 Feb 25.
Published in final edited form as: Int J Sex Health. 2013 Jul 25;26(1):13–24. doi: 10.1080/19317611.2013.823900

The relationship between use of sexually explicit media and sexual risk behavior in men who have sex with men: exploring the mediating effects of sexual self-esteem and condom use self-efficacy

Bente Træen 1, Gert Martin Hald 2, Syed W Noor 3, Alex Iantaffi 4, Jeremy Grey 3, B R Simon Rosser 3
PMCID: PMC4041739  NIHMSID: NIHMS577954  PMID: 24904709

Abstract

This study tests the following three hypotheses: 1) there is a direct association between consumption of sexually explicit media (SEM) depicting non-condom use and STI-related sexual risk behavior among men who have sex with men (MSM), 2) The association between SEM consumption and STI-related sexual risk behavior is mediated by men’s sexual self-esteem, and 3) the relationship between SEM consumption and sexual risk behavior is mediated by condom use self-efficacy. A cross-sectional, Internet-based survey on exposure to SEM and sexual behavior of 1,391 MSM in the USA was conducted in 2011. The results confirmed hypothesis 1 and 3 while hypothesis 2 was rejected. Accordingly, a significant association between the use of SEM picturing condom use and STI related sexual risk behavior among MSM was found. Likewise, we found that the association between the use of SEM and sexual risk behavior was mediated by condom use self-efficacy in an indirect path. However, SEM did not influence sexual risk behavior via sexual self-esteem. To promote STI prevention, the actors in SEM may be used as role models in managing condom use in sexual contexts.

Keywords: SEM, pornography, MSM, sexual risk behavior, condom self-efficacy, sexual self-esteem

Introduction

A clear priority for U.S. health authorities is to prevent the spread of HIV and other sexually transmitted infections (STIs) both in general and in high risk populations (House, 2010). Men who have sex with men (MSM), a concept which covers men with and without gay or sexual minority identity, are a heterogeneous group and several studies including MSM indicate that sexual risk behavior is more characteristic of some MSM individuals than others (Berg, 2008). Identifying risk factors which may increase the likelihood of engaging in STI-related sexual risk behaviors holds the potential to advance the future design of successful sexual health campaigns and interventions, the promotion of STI prevention education, and the assessment by health providers of patients’ risks of contracting STIs (Hald, Smolenski, & Rosser, 2013). One potential risk factor that remains underexplored among MSM is the consumption of sexually explicit media (SEM) (Hald et al., 2013; Rosser, Smolenski, Erickson, Iantaffi, et al., 2013; Stein, Silvera, Hagerty, & Marmor, 2012; Træen & Daneback, 2012). By consumption, we here refer to the frequency, duration, and content of the SEM use. Studies using heterosexual samples and a variety of designs, including longitudinal studies, have consistently shown that SEM consumption may increase the risk of STI-related sexual behaviors (Bleakley et al., 2011; Braun-Courville & Rojas, 2009; Brown & L’Engle; 2009; Carroll, Padilla-Walker, Nelson, Olson, et al., 2008; Gwinn, Lambert, Fincham, & Maner, 2013; Haavio-Mannila & Kontula, 2003; Hald, Kryper, Adams, & de Wit, 2013; Janghorbani & Lam, 2003; Lambert, Negash, Stillman, Olmstead, & Fincham, in press; Lewin, 2000; Morgan, 2011; Peter & Valkenburg, 2011; Sinkovic Stulhofer, & Bozic, 2012; Stuhlhofer, Busko, & Landripet, 2010; Svedin, Åkerman, & Priebe, 2011; Træen, Nilsen, & Stigum, 2006; Wingood, DiClemente, Harrington, Davies, et al., 2001; Wright, 2012). However, the relatively few studies available involving MSM and exploring associations between SEM and STI-related sexual risk behavior remain equivocal. Stein et al. (2012), using a large sample of American MSM and a cross-sectional design, found that participants with higher levels of SEM viewing of unprotected receptive and insertive anal intercourse had significantly elevated odds ratios for engaging in such STI related risk behaviors in real life. Further, viewing SEM depicting unprotected anal intercourse and engaging in unprotected anal intercourse were correlated. In contrast, Rosser et al. (2013), using a large sample of MSM in the USA and a cross-sectional design, found that SEM consumption was significantly associated with an increased interest in having protected anal intercourse but was not significantly associated with an interest in unprotected anal intercourse. Critically, whereas studies on SEM and STI-related sexual risk behavior using heterosexual samples have started to explore potential mediators of such relationships (Gwinn, et al., 2013; Hald, Malamuth, & Lange, in press; Lambert, et al., in press), to the best of our knowledge, this has not yet been done using samples of MSM. Consequently, we were interested in studying potentially mediating mechanisms of the relationship between SEM consumption and STI-related sexual risk behavior. The first potential mediator to be examined is condom use self-efficacy. Bandura’s (1977) construct of self-efficacy has often been studied in relation to sexual risk behavior. To exercise control in a sexual context, a perception of efficacy is required (Bandura, 1995). Perceived self-efficacy may be defined as “beliefs in one’s capabilities to organize and execute the courses of action required to produce given levels of attainments” (Bandura, 1998; p. 2). In the past decades, perceived self-efficacy has been shown to predict intention to use condoms (Jemmott & Jemmott, 1992; Joffe & Radius, 1993; Kvalem & Træen, 2000) and actual use of condoms in heterosexuals (Brafford & Beck, 1991; Bryan, Aiken, & West, 1997; Kasen, Vaughan, & Walter, 1992; Wulfert & Wan, 1993) and MSM (Franssens, Hospers, & Kok, 2009; Kasprzyk, Montaño, & Fishbein, 1998). These studies show that the probability of using condoms increases with increased previous experience of condom use and perception of oneself as a competent condom user. SEM depicting condom use when men have sex with men may guide the viewer in “how to do it”. Even so, one might question to which extent what is seen in SEM is reflected in real life behavior, as barebacking with partners of uncertain or serodiscordant HIV status remains a problem among MSM (Berg, 2008).

In the HIV era, MSM are encouraged to use condoms for protection, that is, to act rationally (Davis, 2002). However, rational behavior is always related to context and the perception of reality (Træen & Hovland, 1998; Træen & Gravningen, 2011). In some sexual contexts, other factors may take priority. For example, sexual self-esteem may influence MSM’s behavior. Sexual self-esteem is here defined as positive regard for and confidence in the capacity to experience one's sexuality in a satisfying and enjoyable way (Snell, Fisher, & Walters, 1993). Most parents do not show their children how to have sex, let alone gay sex; accordingly, sexual conduct is not learned by direct observation. According to Bandura’s social cognitive theory, sex and sexual self-esteem is learned and internalized in cultural and group-specific socialization processes between the individual and his environment. For example, people may adopt elements from pornography in their own sex-life (Löfgren-Mårtenson & Månsson, 2009; Schick, Rima, & Calabrese, 2011). Additionally, pornography depicting homosexual activity may be an important source of learning for youth and MSM just coming out (Kubicek, Beyer, Weiss, Iverson, et al., 2010; Kubicek, Carpineto, McDavitt, Weiss, et al., 2011; Mustanski, Lyons, & Garcia, 2011). SEM offers insight into the most private arena for a sub group of the population surrounded by prejudices and secrecy, and by teaching them the skills and rules needed to be perceived as sexually competent individuals, it may also contribute young MSM’s sexual self-esteem.

High sexual self-esteem is closely related to the individual’s ability to appreciate himself (Lyttkens, 1989). The ability to appreciate oneself can partly be regarded as the product of the positive self-attitudes the individual learns and internalizes from others starting in early childhood. In a society characterized by negative attitudes towards homosexuality, a child will most likely not learn and internalize positive attitudes towards homosexuality (Gonsiorek, 1988; Meyer, 1995). Overcoming such attitudes may be critical for the homosexual child’s general self-esteem and, later, for his or her sexual self-esteem.

Different aspects of emotional control, acceptance of one’s own sexuality, and sexual self-esteem are important predictors of condom use self-efficacy (Baele, Dusseldorp & Maes, 2001; Bryan, Aiken & West, 2004; Salazar, DiClemente, Wingood, Crosby et al., 2004). The mechanism underlying the relationship may be that a positive and confident sexual self-esteem is connected to lower need for social approval (Leary, Tchividjian, & Kraxberger, 1999). This notion is supported by findings of a relationship between negative self-conscious emotions (e.g. shame and guilt) and low self-esteem (Adler, 1984; Yelsma, Brown, & Elison, 2002). For MSM, high sexual self-esteem is likely to be associated with less negative emotions and greater condom use self-efficacy, which may make it easier for the man to communicate with his partner about use of condoms and refuse unprotected sex.

Purpose

This study aims to explore the association between the use of SEM and sexual risk behavior in a cross-sectional sample of MSM. Although causality cannot be assumed in such a sample and design, three specific hypotheses are tested in the paper:

Hypothesis 1:

a. We hypothesize that there is a direct association between consumption of SEM depicting non-condom use and STI-related sexual risk behavior among MSM.

Hypothesis 2:

We hypothesize that the association between SEM consumption depicting non-condom use and STI-related sexual risk behavior is mediated by men’s sexual self-esteem.

Hypothesis 3:

We hypothesize that the relationship between SEM consumption depicting non-condom use and sexual risk behavior is mediated by condom use self-efficacy.

Methods

Study design

The SEM study was a large, cross-sectional, Internet-based survey of MSM conducted between May and August, 2011. The survey was designed to collect data on exposure to SEM, sexual behavior, and psychosocial factors associated with HIV transmission risk behavior. Participants were recruited through banner advertisements placed on 148 gay-oriented websites through the Gay Ad Network. A total of 7,939,758 impressions were displayed during this period; banners yielded a click-through-rate of 0.16%. An eligibility screener restricted participation to those identifying themselves as male, at least 18 years of age, who reported at least one male sexual partner in the last five years, and who were living in the US or one of its territories. Participants were quota-sampled by race/ethnicity to increase diversity in the sample. A total of 5,201 MSM met the eligibility criteria (excluding racial caps). By design, to ensure a racially/ethnically diverse sample, 3,338 MSM were excluded because that racial/ethnic category had filled, leaving a total of 1,863 MSM who met all eligibility criteria. Of these, 1,479 (79.4%) consented to participate in the study and provided information on exposure to pornography. After excluding 88 participants for impossible or nonsensical data patterns on sexual behavior data, the final sample size for this study was 1,391. The average completion time for the survey was 42 minutes, and participants were compensated $25. All study protocols and consent procedures were approved by the Institutional Review Board at the investigators’ home institution.

The questionnaire contained questions about socio-demographic, questions about HIV status, being in a long-term relationship, number of partners, drug use, SEM consumption and preferences in SEM, sexual behavior, and use of condoms. As a large study, multiple papers report key findings from various parts of the study (BLINDED).

Measures

Sexual risk behavior

Participants were asked to report the number of casual unprotected anal intercourse male partners (UAIMP) in the last 90 days. We asked participants to provide this count separately for partners with whom they engaged in insertive (UAIMP-I) and receptive (UAIMP-R) anal intercourse. In addition, participants reported the number of UAIMP that were HIV-negative, HIV-positive, or unknown. Using each participant’s self-reported HIV-status, we developed a binary indicator of whether or not the participant had engaged in serodiscordant or potentially serodiscordant unprotected anal intercourse. HIV-negative participants who reported any HIV-positive or unknown UAIMP, and HIV-positive participants who reported any HIV-negative or unknown UAIMP were classified as engaging in serodiscordant or potentially serodiscordant unprotected anal intercourse (SDUAI).

SEM Consumption

Exposure to SEM was measured in terms of content preference for protected and unprotected anal intercourse, the frequency of exposure to protected and unprotected anal intercourse, and the typical frequency and duration of exposure to SEM of any kind. The preference for viewing condom use during anal intercourse in SEM was measured by a single item, “In general, do you prefer to watch actors perform anal sex with condoms or without?” with three nominal response options: (1) without condoms, (2) with condoms, and (3) I do not care either way. Participants also responded to two 5-point, Likert-type items on the frequency of viewing protected and unprotected anal intercourse when they watched SEM during the past 3 months. The response range was from 1 = “rarely or never” to 5 = “always or almost always”. We created an index by subtracting the frequency of viewing protected anal intercourse from the frequency of viewing unprotected anal intercourse to provide an ordinal measure of the tendency to view unprotected anal intercourse versus protected anal intercourse. This index ranged from −4 to 4, with −4 indicating exclusive viewing of protected anal intercourse and 4 indicating exclusive viewing of unprotected anal intercourse. A score of zero indicated equivalent exposure to both forms of anal intercourse. Then, frequency and duration measures of SEM consumption of any kind in the last 3 months were combined to create an index of the hours per week dedicated to SEM consumption.

In addition, four items were used to assess the frequency of accessing SEM through the following four sources: (1) magazines, (2) video/DVD, (3) Internet on a computer, and (4) Internet through a phone or mobile device. Response options to each of these items ranged from 1 = not at all to 6 = more than once a day. One item asked participants to report the typical duration of use of SEM when it was used in the last 90 days, with response categories including: (1) 1–15 min, (2) 16–30 min, (3) 30–45 min, (4) 46–60 min, (5) between 1 and 1½ h, (6) between 1½ and 2½ h, and (7) >2 h. Finally, we multiplied exclusive viewing of protected anal intercourse and exclusive viewing of unprotected anal intercourse by hours of SEM consumption by week to create a composite measure of SEM consumption. We treated this index as ordinal and calculated the regression estimates (β) to assess the effects of one unit dispersion from the absolute condom watching towards the absolute no-condom watching on the outcome variable.

Condom use self-efficacy

(Marin, Gomez, Tschann, & Gregorich, 1997). This was measured by thirteen items listed under the heading “Please read the following statements and indicate whether or not you would be able to use condoms in the following situations. Can you …. ”. The items were: “Use a condom regularly even if a partner might think less of you?”, “Use a condom regularly when the time to have sex is limited?”, “Insist on condom use when the person you are with appears clean?”, “Use a condom even if you are with a person you're in love with?”, “Start to use a condom with a long-term partner?”, “Use a condom regularly when your partner is under the influence of alcohol or drugs?”, “Stop and look for condoms when you are sexually aroused?”, “Put a condom on yourself whenever you have sex?”, “Use a condom regularly even when you're under the influence of alcohol or drugs?”, “Put a condom on yourself without spoiling the mood?”, ”Continue to insist on using a condom with a person who gets angry when you suggest it?”, “Use a condom if a partner do not want to use one?”, and “Continue to insist on using a condom with a person who threatens to leave if you use it?”. Each item was rated from 1 = definitely no, 2 = probably not, 3 = unsure, 4 = probably yes, 5 = definitely yes. The scale was created by calculating the arithmetic mean of the thirteen items and higher score indicating better condom use self-efficacy (Cronbach’s alpha =0.96).

Sexual self-esteem

The scale, developed by Snell, Fisher, & Walters (1993), was measured by ten different items listed under the heading “Please indicate how much the following items describe how you have felt about yourself in the three last months”. The items were: “I am better at sex than most other people”, “I am a pretty good sexual partner”, “I would rate myself pretty favorably as a sexual partner”, “I would be very confident in a sexual encounter”, “My sexual relationship(s) is very good compared to most”, “I am confident about myself as a sexual partner”, “I am very satisfied with my sexual relationship(s)”, “I am very satisfied with the way my sexual needs are currently being met”, “My sexual relationship(s) meets my original expectations”, and “I am very satisfied with the sexual aspects of my life”. Each item was rated from 1 = not at all like me, 2 = only a little like me, 3 = somewhat like me, 4 = a lot like me, and 5 = exactly like me. We used arithmetic mean of the ten items to create a composite measure of sexual self-esteem. Higher scores on the composite measure indicate greater sexual self-esteem and Cronbach’s alpha of this measure in the sample was 0.93.

Statistical analysis

The goal of this analysis was to estimate the direct association of SEM consumption (SEM) on sexual risk behavior (SUDAI) and the indirect associations of SEM consumption on SUDAI that are mediated by condom use self-efficacy (CONDOM_SE) and sexual self-esteem (SEXUAL_SE). We conducted this analysis in two steps.

In step one, we used summary statistics to describe the study sample. We also calculated the prevalence of serodiscordant unprotected anal intercourse among the participants, and means and standard deviations of the other variables. Using simple logistic regression, we estimated the direct association (path c in Figure 1) of SEM on SDUAI.

Figure 1.

Figure 1

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The hypothesized relationship between use of sexually explicit media and sexual risk behavior, and indirect effects of sexual self-esteem and condom use self-efficacy as mediators.

Note:

Sexual self-esteem: lowest value = less positive → highest value = very positive; Use of sexually explicit media: lowest value = less use → highest value = highest use; Condom use self-efficacy: lowest value = less SE → highest value = highest SE; Sexual risk behavior: 0=No; 1= Yes.

In step two we conducted the mediation analysis. The multiple mediator model is presented in Figure 1. As seen in the Figure, the model specified direct associations from SEM to the mediating variables: SEXUAL_SE (a1) and CONDOM_SE (a2). The model also specified effects of mediating variables on SDUAI (b1 and b2). Each of these direct associations was estimated along with two mediated associations (a1b1 and a2b2). In Figure 1, the path c‘ represents the association of SEM on SDUAI after controlling for the mediated effects of the mediators. The difference between estimates for path c and path c` indicates the strength of the mediation. Full mediation is evident when c becomes zero after the inclusion of the mediators. We tested a multiple mediator model following the approach proposed by Precher and Hayes (2004; 2008). This approach is preferred for addressing the low power issue associated with Sobel test (MacKinnon, Lockwood, Hoffman, West, et al., 2002; Precher & Hayes, 2004). We used weighted least squares means and variance adjusted (WLSMV) estimation to estimate the model. To test the significance of the mediated efforts, we calculated confidence intervals of the estimates using bias corrected (BC) bootstrapping. Five thousand bootstrap draws with DELTA parameterization were used (Muthén & Muthén, 1998–2010). An indirect effect is considered to be statistically non-significant if the associated bias corrected 95% confidence interval contains the zero value. Furthermore, we conducted a contrast test comparing the two indirect effects (path a1b1-path a2b2) using BC bootstrapping (Cheung, 2009). All statistical tests were two-tailed, data management and simple logistic regression models were conducted in Stata 11 software (StataCorp., 2010), and mediation analyses were conducted using Mplus 6.01 (Muthén & Muthén, 1998–2010).

Results

Table 1 shows the socio-demographic characteristics of the sample participants. Similar to previous work with Internet-based samples of MSM, participants were younger, well-educated, gay-identified, and mostly HIV-negative (Rosser, Oakes, Horvath, Konstan, et al., 2009). Unlike other studies, only a minority of participants were non-Hispanic White. That most participants (58.6%) were in other racial/ethnic designations is greater than what is usually observed in Internet-based convenience samples (Rosser, Wilkerson, Smolenski, Oakes, et al., 2011), and reflects the quota-sampling on race/ethnicity to over-recruit men of color into the study.

Table 1.

Socio-demographic characteristics of the sample (N = 1,391 Internet-using MSM)

n %
Age
18–24 521 37.5
25–34 440 31.6
35–44 203 14.6
≥45 227 16.3
Race/ethnicity
White1 576 41.4
Black1 161 11.6
Latino 421 30.3
Asian/Pacific Islander1 104 7.5
Native American1 24 1.7
Other1/Multi racial 105 7.6
Education
Up to high school 157 11.3
Some college 561 40.3
College graduate 397 28.5
Postgraduate 275 19.8
Missing 1 0.1
HIV status†
Positive 121 8.7
Negative 1,269 91.2
Missing 1 0.1
Sexual Identity
Gay 971 82.5
Bisexual 138 11.7
Straight 7 0.6
Same-gender loving 14 1.2
Queer 25 2.1
Other 22 1.9
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Note:

1

Non-Hispanic;

†

For this analysis, HIV status was collapsed to compare those who have tested HIV positive by self-report with all others, including HIV negative and unsure.

The means, standard deviations, and percentage of the variables of interest are shown in Table 2. Most participants reported viewing between 1.2 and 6.8 hours of SEM per week in last 90 days. In terms of content viewed, the typical respondent reported equivalent amounts of protected and bareback SEM consumption, although the small negative value of the mean suggest that more participants reported consumption of protected anal intercourse SEM over bareback SEM. Of the participants, 11.2% reported SDUAI in the last ninety days. Though a majority of the participants reported high scores on both the scales, condom use self-efficacy scores were higher than sexual self-esteem scores.

Table 2.

Use of sexually explicit media, condom use self-efficacy, sexual self-esteem, and sexual risk behaviour in a web sample of U.S. MSM

Variable n % Mean ± Std Deviation Median (IQR) Range α
Dose of SEM hours/week 1379 6.07 ± 9.16 2.87 (1.2, 6.8)1 0.3, 84.4
SEM content: absolute protected to absolute unprotected anal intercourse 1349 −0.36 ± 1.641 0 (−2, 0) −4, +4
SEM Consumption 1347 −0.36 ± 18.17 0 (−2.6, 0)1 −108.5, 238.5
Condom use self-efficacy 1175 3.99 ± 1.01 4.23 (3.4, 4.8)1 1, 5 0.96
Sexual self-esteem 1181 3.15 ± 0.981 3.10 (2.4, 3.9) 1, 5 0.93
Sero-discordant unprotected anal intercourse in last 90 days (Yes) 134/1192 11.2 0, 1
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1

Indicate more appropriate measure of central tendency

Note: IQR: Inter-quartile range, α: internal-consistency reliability

The estimates of associations of SEM consumption on sexual risk behaviors and the results of mediation analysis are reported in Table 3. The association (path c) of SEM consumption on sexual risk behavior was statistically significant (β = 0.02; 95% CI: 0.01,0.03; p < 0.001) without any mediators in the model. Condom use self-efficacy was statistically significant with SEM consumption (β = −0.01; 95% CI: −0.02, −0.01; p < 0.001), indicating that with one unit increase in SEM consumption, condom self-efficacy was reduced by 0.01. Condom use self-efficacy was also statistically significantly associated with sexual risk behavior (β = −0.62; 95% CI: −0.78, −0.45; p < 0.001). However, sexual self-esteem was not statistically significant (β = 0.05; 95% CI: −0.13, 0.24; p = 0.57) with sexual risk behavior.

Table 3.

Direct and indirect (Mediated) effects of sexually explicit media consumption on sero-discordant unprotected anal intercourse

Variable Outcome Step 1 Step 2
β 95% CI β BC 95% CI
Direct Effect
SEM Consumption SDUAI 0.02 0.01, 0.03 0.006 0.000, 0.013
SEM Consumption CONDOM_SE −0.01 −0.02, −0.01 −0.014 −0.018, −0.011
SEM Consumption SEXUAL_SE 0.003 0.001, 0.006 0.003 0.000, 0.006
Condom use self-efficacy SDUAI −0.62 −0.78, −0.45 −0.311 −0.391, −0.228
Sexual self-esteem SDUAI 0.05 −0.13, 0.24 0.013 −0.082, 0.108
Indirect Effect
SEM Consumption-Condom use self-efficacy SDUAI 0.004 0.003, 0.006
SEM Consumption-Sexual self-esteem SDUAI 0.000 0.00, 0.00
Sum of indirect effect SDUAI 0.004 0.003, 0.006
Contrast
Condom use self-efficacy vs. Sexual self-esteem −0.004 −0.006, −0.003
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Note: SE: Standard Error, BC: Bias Corrected, CI: Confidence Interval

SDUAI: sero-discordant unprotected anal intercourse

CONDOM_SE: Condom use self-efficacy

SEXUAL_SE: Sexual self-estee

In the mediated model, the association (path c’) of SEM consumption on sexual risk behavior was smaller and non-significant (β = 0.006; BC 95% CI: 0.00, 0.013; p = 0.11) indicating strong mediation. Condom use self-efficacy was inversely and significantly associated with SEM consumption and with sexual risk behavior. The association of SEM consumption through condom use self-efficacy on sexual risk behavior (path a2b2) was statistically significant (β = 0.004; 95% CI: 0.003, 0.006; p < 0.001) but not through sexual self-esteem (path a1b1). Contrast analysis (path a1b1- path a2b2) indicated the path through condom use self-efficacy was higher and statistically significantly different from the path through sexual self-esteem (β = −0.004; 95% CI: −0.006, −0.003; p < 0.001).

Discussion

In this study, three hypotheses were put to test. The results showed that two were confirmed and one was rejected. First, an association between the use of SEM picturing non-condom use and STI related sexual risk behavior among MSM was hypothesized. This hypothesis was confirmed. The findings from this study support other findings from the same material that have established a relationship between viewing unprotected or protected SEM and engaging sexual risk behaviors in real life (Rosser et al., 2013). The second and third hypotheses were that the association between the use of SEM and sexual risk behavior was mediated by men’s sexual self-esteem and by condom use self-efficacy in two different paths. Sexual self-esteem was statistically significantly and positively associated with SEM consumption depicting non-condom use, but not with sexual risk behavior. While SEM consumption depicting non-condom use may improve sexual self-esteem, it is not associated with sexual risk behavior through sexual self-esteem. The second hypothesis was therefore rejected. An association between SEM consumption and sexual self-esteem is also shown in studies of heterosexuals (Morrison, Bearden, Harriman, Morrison et al., 2004; Watson & Smith, 2012), and this is the first study to confirm it among MSM as well. These findings may be viewed as consistent with theories of vicarious learning. By watching SEM, MSM see scripts for homosexual conduct, preparing them for “in real life” meetings.

We found no support for a relationship between the confidence in oneself as a competent lover (or lack thereof) and sexual risk behavior. Sexual self-esteem and condom use self-efficacy were not significantly associated. Thus, perceiving oneself to be good at sex is not the same as self-perceived ability to use condoms.

Our third hypothesis was confirmed. Condom use self-efficacy was statistically significantly associated with SEM consumption depicting condoms as well as with sexual risk behavior. While the relationship between condom use self-efficacy and condom behavior is well established (Franssens et al., 2009; Kasprzyk et al., 1998), this study showed viewing condom use in SEM may in fact be associated with increased condom use self-efficacy. Alternatively, the association may be explained in other ways e.g. by third factor variable significantly associated with both variables (i.e., spurious effects). Men who consume SEM depicting condom use may learn or gain confidence in skills related to using condoms and negotiating condom use. In our opinion, viewing SEM with condoms may also contribute to a normalization of condom use and, thus, to a change in the perception of the social and sexual reality of MSM. Some limitations of this study should be addressed. First, this is a convenience sample of MSM in the US recruited online. Replication studies are needed to determine the reliability of findings and the generalizability of results. Second, due to cross-sectional nature of the study, causality cannot be assumed. For example, we cannot say whether SEM consumption depicting non-condom use builds sexual self-esteem, sexual self-esteem increases SEM consumption or whether some third variable(s) influence both. Longitudinal and life history studies may be needed to inform temporality.

Implication for STI prevention in MSM

The findings of this study have several implications for the prevention and spread of HIV and other STIs in MSM. The MSM with sexual risk behavior were reporting lower condom use self-efficacy and higher viewing of bareback pornography. Likewise, MSM who viewed SEM with condoms reported higher condom use self-efficacy and less sexual risk behavior. From an HIV/STI prevention perspective, perceived mastery of using condoms – and promoting condom self-efficacy as a skill appears more effective than, say, helping MSM to work on their sexual self-esteem. Future sexual health campaigns and HIV/STI prevention interventions may use the actors in SEM as role models in managing condom use in sexual contexts to the promotion of STI prevention and/or teach STI prevention techniques. This calls for a cooperation between health authorities and the pornography industry.

Acknowledgments

Understanding Effects of Web-based Media on Virtual Populations was funded by the National Institutes of Mental Health Center for Medical Health Research on AIDS, Grant number 5R01MH087231. All research was carried out with the approval of the University of Minnesota Institutional Review Board, study number 0906S68801.

Footnotes

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References

  1. Adler NE. Contraception and unwanted pregnancy. Behavioral Medicine Update. 1984;5:28–34. doi: 10.1093/abm/5.4.28. [DOI] [PubMed] [Google Scholar]
  2. Baele J, Dusseldorp E, Maes S. Condom use self-efficacy. Effect on intended and actual condom use in adolescents. Journal of Adolescent Health. 2001;28:421–431. doi: 10.1016/s1054-139x(00)00215-9. [DOI] [PubMed] [Google Scholar]
  3. Bandura A. Social learning theory. New Jersey: Englewood Cliffs/Prentice Hall; 1977. [Google Scholar]
  4. Bandura A. Exercise of personal and collective efficacy in changing societies. In: Bandura A, editor. Self-efficacy in changing societies. Cambridge: Cambridge University Press; 1995. pp. 1–45. [Google Scholar]
  5. Bandura A. Health promotion from the perspective of social cognitive theory. Psychology and Health. 1998;13:623–649. [Google Scholar]
  6. Berg RC. Barebacking among MSM Internet users. AIDS and Behavior. 2008;12:822–833. doi: 10.1007/s10461-007-9281-0. [DOI] [PubMed] [Google Scholar]
  7. Bleakley A, Hennessy M, Fishbein M. A model of adolescents seekeing of sexual content in their media choices. Journal of Sex Research. 2011;48:309–315. doi: 10.1080/00224499.2010.497985. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Brafford LJ, Beck KH. Development and validation of a condom selfefficacy scale for college students. Journal of American College Health. 1991;39:219–225. doi: 10.1080/07448481.1991.9936238. [DOI] [PubMed] [Google Scholar]
  9. Braun-Courville DK, Rojas M. Exposure to Sexually Explicit Web Sites and Adolescent Sexual Attitudes and Behaviors. Journal of Adolescent Health. 2009;45:156–162. doi: 10.1016/j.jadohealth.2008.12.004. [DOI] [PubMed] [Google Scholar]
  10. Brown JD, L'Engle KL. X-Rated : Sexual attitudes and behaviors associated with U.S. early adolescents' exposure to sexually explicit media. Communication Research. 2009;36:129–151. [Google Scholar]
  11. Bryan AD, Aiken LS, West SG. Young women’s condom use: The influence of acceptance of sexuality, control over the sexual encounter, and perceived susceptibility to common STD’s. Health Psychology. 1997;16:468–469. doi: 10.1037//0278-6133.16.5.468. [DOI] [PubMed] [Google Scholar]
  12. Bryan AD, Aiken LS, West SG. HIV/STD risk among incarcerated adolescents: Optimism about the future and self-esteem as predictors of condom use self-efficacy. Journal of Applied Social Psychology. 2004;34:912–936. [Google Scholar]
  13. Carroll JS, Padilla-Walker LM, Nelson LJ, Olson CD, Barry CN, Madsen SD. Pornography acceptance and use among emerging adults. Journal of Adolescent Health Research. 2008;23:6–30. [Google Scholar]
  14. Cheung MW. Comparison of methods for constructing confidence intervals of standardized indirect effects. Behavior Research Methods. 2009;41:425–438. doi: 10.3758/BRM.41.2.425. [DOI] [PubMed] [Google Scholar]
  15. Davis M. HIV prevention rationalities and serostatus in the risk narratives of gay men. Sexualities. 2002;5:281–299. [Google Scholar]
  16. Gwinn AM, Lambert NM, Fincham FD, Maner JK. Pornography, Relationship Alternatives, and Intimate Extradyadic Behavior. Social Psychological and Personality Science. 2013;4:1–6. [Google Scholar]
  17. Haavio-Mannila E, Kontula O. Sexual trends in the Baltic sea area. Helsinki: Publication of the Population Research Institute; 2003. [Google Scholar]
  18. Hald GM, Smolenski D, Rosser BRS. Perceived effects of sexual explicit media among men who have sex with men and psychometric properties of the pornography consumption effect scale (PCES) Journal of Sexual Medicine. 2012;10:757–767. doi: 10.1111/j.1743-6109.2012.02988.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Hald GM, Smolenski D, Rosser BRS. Self-perceived effects of pornography consumption. Archives of Sexual Behavior. 2013;37:614–625. doi: 10.1007/s10508-007-9212-1. [DOI] [PubMed] [Google Scholar]
  20. Hald GM, Kuyper L, Adam PCG, De Wit JBF. Does Viewing explain Doing? Assessing the Association between Sexually Explicit Materials Use and Sexual Behaviors in a Large Sample of Dutch Adolescents and Young Adults. Journal of Sexual Medicine. 2013 doi: 10.1111/jsm.12157. (in press) [DOI] [PubMed] [Google Scholar]
  21. Hald GM, Malamuth NM, Lange T. Pornography and sexist attitudes among Heterosexuals. Journal of Communication. (in press) [Google Scholar]
  22. House W. National HIV/AIDS Strategy for the United States. Washington, DC: 2010. [Google Scholar]
  23. Franssens D, Hospers HJ, Kok G. Social-cognitive determinants of condom use in a cohort of young gay and bisexual men. AIDS Care. 2009;21:1471–1479. doi: 10.1080/09540120902883127. [DOI] [PubMed] [Google Scholar]
  24. Gonsiorek JC. Mental health issues of gay and lesbian adolescents. Journal of Adolescent Health Care. 1988;2:114–122. doi: 10.1016/0197-0070(88)90057-5. [DOI] [PubMed] [Google Scholar]
  25. Janghorbani M, Lam T. The Youth Sexuality Study Task Force. Sexual media use by young adults in Hong Kong: Prevalence and associated factors. Archives of Sexual Behavior. 2003;32:545–553. doi: 10.1023/a:1026089511526. [DOI] [PubMed] [Google Scholar]
  26. Jemmott LS, Jemmott JB., III Increasing condom-use intentions among sexually active black adolescent women. Nursing Research. 1992;41:273–279. [PubMed] [Google Scholar]
  27. Joffe A, Radius SM. Self-efficacy and intent to use condoms among entering college freshmen. Journal of Adolescent Health. 1993;14:262–268. doi: 10.1016/1054-139x(93)90172-l. [DOI] [PubMed] [Google Scholar]
  28. Kasen S, Vaughan RD, Walter HJ. Self-efficacy for AIDS-preventive behaviors among tenth grade students. Health Education Quarterly. 1992;19:187–202. doi: 10.1177/109019819201900204. [DOI] [PubMed] [Google Scholar]
  29. Kazprzyk D, Montaño DE, Fishbein M. Application of an integrated behavioral model to predict conomd use: A prospective study among hiv HIV risk groups. Journal of Applied Social Psychology. 1998;28:1557–1583. [Google Scholar]
  30. Kubicek K, Beyer W, Weiss G, Iverson E, Kipke MD. In the dark: Young men's stories of sexual initation in the absence of relevant sexual health information. Health Education & Behavior. 2010;37:243–263. doi: 10.1177/1090198109339993. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Kubicek K, Carpineto J, McDavitt B, Weiss G, Kipke MD. Use and perceptions of the Internet for sexual information and partners: A study of young men who have sex with men. Archives of Sexual Behavior. 2011;40:803–816. doi: 10.1007/s10508-010-9666-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Kvalem IL, Træen B. Self-efficacy, scripts of love and intention to use condoms among Norwegian adolescents. Journal of Youth & Adolescents. 2000;29:337–353. [Google Scholar]
  33. Lambert NM, Negash S, Stillman TF, Olmstead SB, Fincham FD. A love that doesn’t last: Pornography consumption weakens commitment to a romantic partner. Journal of Social and Clinical Psychology. (in press) [Google Scholar]
  34. Leary M, Tchividjian L, Kraxberger B. Self-presentation can be hazardous to your health: Impression management and health risk. In: Baumeister RF, editor. The self in social psychology. Philadelphia, PA: Psychology Press; 1999. pp. 182–194. [DOI] [PubMed] [Google Scholar]
  35. Lewin B. Part 2: Pornography -- Attitudes and use. In: Lewin B, editor. Sex in Sweden. On the Swedish sexual life. Stockholm: National Institute of Public Health; 2000. pp. 252–263. [Google Scholar]
  36. Lyttkens L. Den disiplinerade människan (The disciplined human being, Swedish text) Stockholm: Almena Förlaget; 1989. [Google Scholar]
  37. Löfgren-Mårtenson L, Månsson S-A. Lust, love, and life: A qualitative study of Swedish adolescents’ perceptions and experiences with pornography. Journal of Sex Research. 2010;47:568–579. doi: 10.1080/00224490903151374. [DOI] [PubMed] [Google Scholar]
  38. MacKinnon DP, Lockwood CM, Hoffman JM, West SG, Sheets V. A comparison of methods to test mediation and other intervening variable effects. Psychological Methods. 2002;7:83–104. doi: 10.1037/1082-989x.7.1.83. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Marin BV, Gomez CA, Tschann JM, Gregorich SE. Condom use in unmarried latino men: a test of cultural constructs. Health Psychology. 1997;16:458–467. doi: 10.1037//0278-6133.16.5.458. [DOI] [PubMed] [Google Scholar]
  40. Meyer IH. Minority stress and mental health in gay men. Journal of Health and Social Behavior. 1995;36:38–56. [PubMed] [Google Scholar]
  41. Meyer IH, Wilson PA. Sampling lesbian, gay, and bisexual populations. Journal of Counseling Psychology. 2009;56:23–31. [Google Scholar]
  42. Morgan EM. Associations between young adults' use of sexually explicit materials and their sexual preferences, behaviors, and satisfaction. Journal of Sex Research. 2011;48:520–30. doi: 10.1080/00224499.2010.543960. [DOI] [PubMed] [Google Scholar]
  43. Morrison TG, Bearden A, Harriman R, Morrison MA, Ellis SR. Correlates of exposure to sexually explicit material among Canadian post-secondary students. The Canadian Journal of Human Sexuality. 2004;13:143–156. [Google Scholar]
  44. Morrison TG, Morrison MA, Bradley BA. Correlates of gay men’s selfreported exposure to pornography. International Journal of Sexual Health. 2007;19:33–43. [Google Scholar]
  45. Mustanski B, Lyons T, Garcia SC. Internet use and sexual health of young men who have sex with men: A mixed-methods study. Archives of Sexual Behavior. 2011;40:289–300. doi: 10.1007/s10508-009-9596-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Muthén LK, Muthén BO. Mplus users's guide. Los Angeles, CA: Muthén & Muthén; 1998–2010. [Google Scholar]
  47. Peter J, Valkenburg PM. The influence of sexually explicit Internet material on sexual risk behavior: A comparison of adolescents and adults. Journal of Health Communication. 2011;16:750–765. doi: 10.1080/10810730.2011.551996. [DOI] [PubMed] [Google Scholar]
  48. Preacher KJ, Hayes AF. SPSS and SAS procedures for estimating indirect effects in simple mediation models. Behavior Research Methods, Instruments, & Computers : A Journal of the Psychonomic Society, Inc. 2004;36:717–731. doi: 10.3758/bf03206553. [DOI] [PubMed] [Google Scholar]
  49. Preacher KJ, Hayes AF. Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods. 2008;40:879–891. doi: 10.3758/brm.40.3.879. [DOI] [PubMed] [Google Scholar]
  50. Rosser BRS, Oakes JM, Horvath KJ, Konstan JA, Danilenko GP, Peterson JL. HIV sexual risk behavior by men who use the Internet to seek sex with men: Results of the Men’s INTernet Sex Study-II (MINTS-II) AIDS & Behavior. 2009;13:488–98. doi: 10.1007/s10461-009-9524-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Rosser BRS, Wilkerson JM, Smolenski D, Oakes JM, Konstan J, Horvath KJ, et al. The future of Internet-based HIV prevention: A report on key findings from the Men's INTernet Sex (MINTS-I, II) Studies. AIDS & Behavior. 2011;15:91–100. doi: 10.1007/s10461-011-9910-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
  52. Rosser BRS, Smolenski D, Erickson D, Iantaffi A, Brady SS, Grey JA, Hald GM, Horvath KJ, Kilian G, Træen B, Milkerson JM. The effects of gay sexual explicit media on the HIV risk behavior of men who have sex with men. AIDS and Behavior. 2013 doi: 10.1007/s10461-013-0454-8. (in press) [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Salazar LF, DiClemente RJ, Wingood GM, Crosby RA, Harrington K, Davies S, Hook EW, III, Oh M. Self-concept and adolescents’ refusal of unprotected sex: A test of mediating mechanisms among African American girls. Prevention Science. 2004;5:137–149. doi: 10.1023/b:prev.0000037638.20810.01. [DOI] [PubMed] [Google Scholar]
  54. Schick VR, Rima BN, Calabrese SK. Evulvalution: The portrayal of women’s external genitalia and physique across time and the current Barbie doll ideals. Journal of Sex Research. 2010;48:74–81. doi: 10.1080/00224490903308404. [DOI] [PubMed] [Google Scholar]
  55. Sinkovic M, Stulhofer A, Bozic J. Revisiting the association between pornography use and risky sexual behaviors: The role of early exposure to pornography and sexual sensation seeking. Journal of Sex Research. 2012 doi: 10.1080/00224499.2012.681403. [DOI] [PubMed] [Google Scholar]
  56. Snell WE, Fisher TD, Walters AS. The multidimensional sexuality questionnaire: An objective self-report measure of psychological tendencies associated with human sexuality. Annals of Sex Research. 1993;6:27–55. [Google Scholar]
  57. StataCorp. Stata statistical software: Release 11. College Station, TX: StataCorp LP; 2010. [Google Scholar]
  58. Stein D, Silvera R, Hagerty R, Marmor M. Viewing pornography depicting unprotected anal intercourse: Are there implications for HIV prevention among men who have sex with men. Archives of Sexual Behavior. 2012;41:411–419. doi: 10.1007/s10508-011-9789-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. Stulhofer A, Busko V, Landripet I. Pornography, sexual socialization and satisfaction among young men. Archives of Sexual Behavior. 2010;39:168–78. doi: 10.1007/s10508-008-9387-0. [DOI] [PubMed] [Google Scholar]
  60. Svedin CG, Åkerman I, Priebe G. Frequent users of pornography. A population based epidemiological study of Swedish male adolescents. Journal of Adolscence. 2011;34:779–788. doi: 10.1016/j.adolescence.2010.04.010. [DOI] [PubMed] [Google Scholar]
  61. Træen B, Hovland A. Games people play. Sex, alcohol and condom use among urban Norwegians. Contemporary Drug Problems. 1998 Spring;25:3–48. [Google Scholar]
  62. Træen B, Nilsen TS, Stigum H. Use of SEM in traditional media and on the Internet in Norway. The Journal of Sex Research. 2006;43(3):245–254. doi: 10.1080/00224490609552323. [DOI] [PubMed] [Google Scholar]
  63. Træen B, Gravningen K. The Use of Protection for Sexually Transmitted Infections (STIs) and Unwanted Pregnancy among Norwegian Heterosexual Young Adults 2009. Sexuality & Culture. 2011;15:195–212. [Google Scholar]
  64. Træen B, Daneback K. The use of pornography and sexual behaviour among Norwegian men and women of differing sexual orientation. Sexologies: revue europeenne de sante sexuelle – European Journal of Sexual Health. 2012 [Google Scholar]
  65. Yelsma P, Brown NM, Elison J. Shame-focused coping styles and their associations with self-esteem. Psychological Reports. 2002;90:1179–1189. doi: 10.2466/pr0.2002.90.3c.1179. [DOI] [PubMed] [Google Scholar]
  66. Wingood GM, DiClemente RJ, Harrington K, Davies S, Hook EW, Kim M. Exposure to X-Rated Movies and Adolescents' Sexual and Contraceptive-Related Attitudes and Behaviors. Pediatrics. 2001;107:1116–1119. doi: 10.1542/peds.107.5.1116. [DOI] [PubMed] [Google Scholar]
  67. Wright PJ. A longitudinal analysis of us adults’ pornography exposure: Sexual socialization, selective exposure, and the moderating role of unhappiness. Journal of Media Psychology: Theories, Methods, and Applications. 2012;24:67–76. [Google Scholar]
  68. Wulfert E, Wan CK. Condom use: A self-efficacy model. Health Psychology. 1993;12:346–353. doi: 10.1037//0278-6133.12.5.346. [DOI] [PubMed] [Google Scholar]

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