A cause for concern: Male couples' sexual agreements and their use of substances with sex

Abstract

Substance use is strongly associated with HIV risk among gay men. Many gay couples establish sexual agreements. However, little is known about gay couples’ use of substances with sex, and whether substance use is associated with couples’ agreements. The present study assessed whether gay couples’ use of substances with sex was associated with their establishment of, type of, and adherence to, a sexual agreement. Dyadic data from 275 HIV-negative US gay couples were collected online in a nation-wide, cross-sectional study, and analyzed at the couple-level. Findings revealed that couples with an established agreement, and a recently broken agreement, were more likely to have used amyl nitrates and marijuana with sex within their relationship. This same trend was also noted, but for alcohol use with sex outside of couples’ relationships. Further research is urgently needed to examine the fluidity of HIV-negative gay male couples’ sexual agreements and substance use with sex.

INTRODUCTION

Compared to heterosexually identified men, gay men and other men who have sex with men (MSM) are disproportionately affected by HIV and account for nearly two-thirds of HIV cases among men in the U.S. [1]. Recent studies also indicate that between one-third and two-thirds of MSM acquire HIV while in a same-sex relationship (e.g., gay male couples) [2, 3]. Given these estimates, a growing body of HIV prevention research has emerged to assess how characteristics of gay male couples’ relationships, including their sexual agreements, affect their risk for acquiring HIV and other sexually transmitted infections (STIs). A sexual agreement is an explicit understanding between two partners about which sexual and other behaviors are permitted to occur within, and if relevant, outside of their relationship (i.e., with causal partners) [4, 5].

A sexual agreement can be classified into one of two broad categories: an “open agreement” that permits certain sexual behaviors to occur outside of the primary relationship and a “closed agreement” that does not permit any sexual behaviors to occur outside of the primary relationship. One specific type of a sexual agreement is called “negotiated safety”, which allows HIV-negative seroconcordant gay male couples to practice UAI within their relationship as long as both partner’s serostatus remains HIV negative and if applicable, both men use condoms for anal sex with secondary partners [6, 7]. One recent study by Jin et al. found that men with seroconcordant HIV-negative partners were not at increased risk for HIV when they practiced negotiated safety and reported no UAI with casual MSM partners [8].

Among gay male couples in the US, sexual agreements appear to be a common phenomenon with prevalence rates from studies with convenience samples ranging from 48% to over 90% [4, 5, 9–21]. Prior studies have documented: the reasons why gay male couples' establish a sexual agreement (e.g., minimize HIV/STI risk, wanting monogamy/exclusivity) [5, 9, 11]; the reasons why one or both partners of the couple had broken their sexual agreement (e.g., feeling sexually unsatisfied) [5, 9, 13]; whether certain characteristics (e.g., trust, commitment) of the relationship are associated with their establishment and/or adherence to the agreement [5, 10]; the types of agreements couples form [4, 5, 9, 16, 17, 19]; and the behaviors they agree to engage in per their agreement (e.g., unprotected anal intercourse [UAI]) [5]. However, little is known on whether male couples’ use of substances with sex is associated with their establishment of, type of, and adherence to, a sexual agreement.

Prior studies have found that gay men who use illegal substances (e.g., methamphetamine, ecstacy) and controlled substances (e.g., alcohol) are at increased risk for acquiring HIV. Specifically, gay men who use substances are more likely to engage in UAI with other MSM [22–30], and gay men who engage in UAI may also be more likely to use substances with sex [28, 29, 31]. Thus, the interaction of UAI and use of substances with sex may increase gay men’s risk and their sexual partner’s risk for acquiring and/or transmitting HIV and other STIs [22, 23, 28, 29, 31–34]. Research has also documented and described the relationship between substance use and sex as intertwined among gay men. Specifically, many of these men now consider some substances as “sex drugs” because they help prolong and/or enhance their sexual experience(s) [35]. Given the strong documented link between gay men's use of substances with sex (e.g., UAI) and their risk for HIV, and the premise of a sexual agreement within male couples’ relationships, research that assesses male couples' use of substances with sex and their formation of, type of, and adherence to, a sexual agreement warrants attention to study for HIV prevention.

The present study aims to help fill this gap in knowledge by using dyadic data collected from a nation-wide, online convenience sample of 275 HIV-negative seroconcordant gay male couples. Specifically, we sought to assess whether gay male couples use of substances with sex is associated with their establishment of, type of, and adherence to, a sexual agreement. These associations were further examined by the type of substance that couples reported using with sex within and/or outside of their relationship. To achieve this aim, we conducted comparative statistics and employed logistic regression models at the couple-level. Research that examines these associations may provide important information toward development of novel prevention interventions for substance-using gay male couples [36].

METHODS

Recruitment, Eligibility and Procedure

The methods for this study have previously been described and reported in detail [5, 37–41]. Recruitment was conducted through Facebook banner advertising during a ten-week period in 2011. Banner advertisements were displayed to home pages of Facebook users whose profile demographics matched our study eligibility criteria: male living in the US, at least 18 years old, “interested in men,” and having a relationship status of “in a relationship, married, or engaged.” All Facebook users whose profiles met our eligibility criteria had an equal chance of being shown one of the three banner advertisements. The advertisements briefly described the study and included a picture of a male couple. A total of 7,994 Facebook users clicked on at least one of the advertisements and were then directed to the study webpage. Among those who visited our study webpage, 4,056 (51%) potential participants answered our eligibility questions; 722 MSM (18%), representing both men of 361 male couples, qualified, enrolled, and completed the survey, and are included in this study.

The study webpage described the purpose of the study, what a participant could expect if he participated, and asked eligibility questions. Interested and eligible participants were also informed that they would be asked to invite their primary, male relationship partner to participate in the study, as well as to have to complete the survey independently and separately from their partner. Both men in the couple had to meet the following eligibility criteria to participate: be 18 years of age or older; live in the US; be in a sexual relationship with another male for a minimum of three months; and, have had oral and/or anal sex with this partner within the previous three months. Eligible participants were directed to an electronic consent form to provide consent before taking the 30–40 minute confidential survey.

We embedded a partner referral system in our survey. Specifically, participants were required to input their own and their primary male partner’s email address. The participant’s primary male partner then received an email inviting him to participate in the study. Email addresses were also used for incentive purposes and for linking the survey responses between the two men within each couple. Every fifth couple (i.e., 5^th, 10^th, etc.) that completed the survey received two modest incentives via email (e.g., one e-gift card worth 20USD per partner). The Medical College of Wisconsin Institutional Review Board approved the study protocol.

Online survey

The online survey service provider Survey Gizmo hosted our study webpage, electronic consent form, and confidential, online survey through the use of a secure access portal (i.e., https://). Only the primary investigator of the study and managers at Survey Gizmo had access to the study survey and data. Other than email addresses, no personal identifying information was collected, including computer Internet Protocol addresses. Email addresses were deleted after data collection and verification of the couples’ relationships.

Measures

A variety of measures were used to assess male couples’ sociodemographic and relationship characteristics, sexual behaviors, HIV status, use of substances with sex (e.g., illegal drugs and alcohol), and sexual agreements. Relationship characteristics assessed included relationship duration and cohabitation duration.

For sexual agreements, participants were asked whether they had established a sexual agreement (yes or no) with their main partner, the type of agreement, and whether they and/or their main partner had recently broken their sexual agreement (yes or no) within the 3 months prior to assessment. For type of sexual agreement, participants could select one of three options, “We only have sex with each other and no one else”, "We have sex with each other, and are allowed to have sex with others under certain guidelines/rules”, or “We have sex with each other, and are allowed to have sex with others without any guidelines/rules”. The latter two options were collapsed into one category, called open sexual agreement, due to small sample size (e.g., only one couple reported “…without any guidelines/rules”).

Participants were also asked if they used any substances before and/or while having sex during the three months prior to assessment by partner type (e.g., main vs. casual). Specifically, participants were asked, “Thinking back to the past three months, please select which drugs and how often you used those drugs before having sex and/or while you're having sex with your partner?” Choosing from of the following categories, "Never used this drug", "Less than half of the time", "About half of the time", "More than half of the time", participants were asked to report which of the ten substances they had used before and/or while having sex during the three months prior to assessment with their main partner: alcohol (slightly buzzed), alcohol (drunk), cocaine, crystal methamphetamine, ecstasy, GHB, ketamine, marijuana, amyl nitrates (i.e., poppers), and Viagra or similar (e.g., erectile dysfunction medications (EDM)). To assess the use of substances before and/or while having sex that occurred outside of the relationship, a very similar measure to the one described above was used for participants who reported having had sex during the three months prior to assessment with a casual MSM partner.

Data analysis

Though dyadic data from 361 male couples (722 individuals) were collected in the original study, we restricted our sample to only include 275 HIV-negative concordant couples. We excluded HIV-discordant and HIV-positive concordant couples because we were most interested in examining how the use of substances were associated with aspects of couples’ sexual agreements with respect to HIV risk and prevention. Dyadic data from the 275 male couples were analyzed using Stata Version 12 (StataCorp, College Station, TX). Descriptive statistics including means, standard deviations, rates, and percentages were calculated, as appropriate, for the measures. With the exception of describing certain characteristics of the sample (e.g., age, relationship duration), all analyses of the dyadic data were employed at the couple-level. Generalized logistic regression models were then constructed to assess whether: 1) couples’ use of substances with sex within their relationship was associated with their establishment of, type of, and recent adherence to, a sexual agreement by type of substance; and 2) couples’ use of substances with sex outside of their relationship was associated with their establishment of, type of, and recent adherence to, a sexual agreement by type of substance. Logistic regression models for within the relationship controlled for engagement of UAI with the main partner; logistic regression models for outside the relationship controlled for UAI with a casual MSM partner. All logistic regression models included a clustered sandwich estimator to account for the non-independence of the nested data (e.g., dyadic data) to produce robust standard errors and odds ratios with corresponding confidence intervals. Further, logistic regression models that assessed couples’ use of a substance with sex outside of the relationship were adjusted by restricting the sample to only include those who had reported having had sex with a casual MSM partner within the three months prior to assessment; thus, adjusted odds ratios with corresponding confidence intervals were reported to reflect this adjustment.

For analytic purposes, some categorical items were transformed into binary variables. For example, few men reported using substances with sex for either partner type. As such, categories other than “never used this drug” were collapsed into one category to create a dichotomous measure for both partner types, which represented men who used substance (type) with sex in the three months prior to assessment with their main partner (1) versus men who never used that substance with sex with their main partner (0), and men who used substance (type) with sex in the three months prior to assessment with a casual MSM partner (1) versus men who never used that substance (type) with sex with a casual MSM partner (0). In addition, three other variables were created for purposes of this study. “Party drugs” represent the use of any of the following substances with sex: ecstacy, ketamine, GHB, cocaine, and/or methamphetamine. Couples’ aspects of their sexual agreements (e.g., establishment, type, and adherence) were also transformed into dummy binary variables to represent whether both men of the couple had established a sexual agreement (versus not); concurred about the type of agreement (versus not); had recently adhered to the agreement (versus not). Other details about this sample’s sexual agreements (e.g., allowed behaviors), prior HIV and STI testing rates and patterns, attitudes toward use of couples-based HIV testing, and use of risk-reduction strategies have been reported in detail elsewhere [5, 37–41].

RESULTS

Sample Characteristics

Most of the 275 HIV-negative seroconcordant male couples self-identified as gay (96%), had one or both partners who had at least a Bachelor’s degree (64%), and/or had one or both partners who were employed (95%). The mean age for the individual was 31.4 years (SD = 10.0) whereas the average duration of the couples’ relationships was 4.7 years (SD = 5.2). Seventy-five percent of the couples also lived together.

The majority of couples practiced UAI within their relationship (87%). About a third of the sample had sex outside of their relationship (N = 83, 30%), and of these 83 couples, 61% had one or both partners who had had UAI with a casual MSM within the three months prior to assessment. Regarding sexual agreements, 59% of couples (N= 162) concurred about having a sexual agreement; of these 162 couples, 81% of couples had kept their sexual agreement within the previous three months. Among the couples who concurred about establishing a sexual agreement, 46% reported having a closed agreement, 38% had an open agreement, and 15% had disagreed about their agreement type. Both partners of the couples also reported the type of substances they used with sex within and outside of their relationships, which are detailed in Table 1.

Table 1.

Characteristics of 275 HIV-negative seroconcordantgay male couples

Couple-level characteristic	N	%
Sexual orientation
Both men in couple identified as gay	265	96
One or both partners in couple identified as bisexual	10	4
Race
Mixed	83	30
White	192	70
Education: Had a Bachelor’s degree or higher
Both partners	98	36
Only one partner	78	28
Neither partner	99	36
Employment status
Both partners employed	185	67
Only one partner employed	77	28
Neither partner employed	13	5
Practiced unprotected anal intercourse (UAI) within relationship	238	87
One or both partners in couple had sex outside the relationship	83	30
One or both partners had UAI outside the relationship	51	19
Establishment of a sexual agreement
Couple concurred about having an agreement	162	59
Couple disagreed or did not have an agreement	113	41
Current type of sexual agreementa
Closed agreement	75	46
Open agreement	62	38
Couple did not concur about agreement type	25	15
Recent adherence to the sexual agreement (i.e., within past three months)
Both partners in couple kept agreement	132	81
One or both partners in couple had broken the agreement	30	19
Substance use with sex within relationship onlyb
Party drugsc	15	5
Marijuana	58	21
Alcohol	177	64
Erectile dysfunction medication	22	8
Amyl nitrates	16	6
Substance use with sex outside relationship onlyb
Party drugsc	0	0
Marijuana	0	0
Alcohol	0	0
Erectile dysfunction medication	0	0
Amyl nitrates	7	3
Substance use with sex both within and outside relationshipb
Party drugsc	9	3
Marijuana	25	9
Alcohol	49	18
Erectile dysfunction medication	22	8
Amyl nitrates	20	7
	Mean	SD
Individual age [range: 18 – 67 years]	31.4	10.0
Relationship duration in years [range: 0.25 – 35 years]	4.7	5.2
Cohabitation duration in years [range: 0 – 31.2years]	3.6	5.1

Notes.

^aRepresents couples with both partners who concurred about having a sexual agreement (N = 162 dyads).

^bData represent couples with one or both partners who reported using substances with sex during the three months prior to assessment.

^cParty drugs include ecstasy, ketamine, GHB, cocaine, and methamphetamine.

Couples' Establishment of a Sexual Agreement and Substance Use with Sex

With the exception of alcohol, a higher proportion of HIV-negative gay male couples with an established sexual agreement had one or both partners who reported using substances with sex within their relationship than those who did not have an established agreement. The odds of couples having an established sexual agreement were positively associated with one or both partners using party drugs (OR = 2.93 [CI 1.06, 8.07], p < .05), marijuana (OR = 1.88 [CI 1.08, 3.27], p < .05), EDMs (OR = 2.09 [CI 1.02, 4.30], p < .05) and/or amyl nitrates (OR = 2.80 [CI 1.23, 6.39], p < .05) with sex within their relationship.

In general, a higher proportion of gay male couples with an established sexual agreement had one or both partners who reported using substances with sex outside of their relationship than those who did not have an established agreement. The odds of having an established sexual agreement were positively associated with one or both partners using alcohol (OR = 6.09 [CI 1.81, 20.52], p < .01) with sex outside of the relationship. Table 2 provides additional information about these results.

Table 2.

Comparison and odds of establishment of a sexual agreement based on HIV-negative gay male couples’ use of substances with sex

	Establishment of a sexual agreement
	Couple concurred yes		Couple disagreed or concurred no (ref)
Sample size: 361 dyads	N = 162 dyads		N = 113 dyads
Substance use with sex	One or both partners used		One or both partners used
Within relationship	N	%	N	%	AOR	CI
Party drugsa	19	12	5	4	2.93*	1.06 – 8.07
Marijuana	57	35	26	23	1.88*	1.08 – 3.27
Alcohol	138	85	98	87	0.89	0.44 – 1.80
EDMb	32	20	12	11	2.09*	1.02 – 4.30
Amyl nitrates	28	17	8	7	2.80*	1.23 – 6.39
Sample size: 83 dyads, 132 gay men	N = 112 gay men		N = 20 gay men
Outside of relationshipc	N	%	N	%	AOR	CI
Party drugsa	14	13	2	10	1.32	0.15 – 11.52
Marijuana	36	32	3	15	2.86	0.66 – 12.38
Alcohol	75	67	5	25	6.09**	1.81 – 20.52
EDMb	34	30	2	10	4.08	0.78 – 21.47
Amyl nitrates	39	35	4	20	2.43	0.59 – 10.06

Notes.

Findings in this table were produced from couple-level analyses. Logistic regression models for within the relationship controlled for engagement of unprotected anal intercourse with the main partner whereas the logistic regression models for outside the relationship controlled for unprotected anal intercourse with a casual MSM partner.

AOR adjusted odds ratio, CI confidence interval

^*p<.05,

^**p<.01

^aParty drugs include ecstasy, ketamine, GHB, cocaine, and methamphetamine.

^bEDM denotes Erectile Dysfunction Medication.

^cRates, percentages and adjusted odds ratios only included those who reported they had sex with a casual MSM partner within the prior three months to assessment.

Couples’ Type of Sexual Agreement and Substance Use with Sex

Tables 3 and 4 provide data about HIV-negative gay male couples’ use of substances with sex with respect to whether couples concurred about their type of sexual agreement (versus not), and their sexual agreement type (open vs. closed). With the exception of EDMs, a higher proportion of gay male couples that concurred about their agreement type had one or both partners who reported using party drugs, marijuana, and alcohol with sex within their relationship than those who did not concur about their agreement type. The odds of concurring about the type of sexual agreement were positively associated with one or both partners using marijuana (OR = 3.21 [CI 1.04, 9.89], p < .05) with sex within their relationship.

Table 3.

Comparison and odds of concordance about type of sexual agreement based on HIV-negative gay male couples’ use of substances with sex

	Concurred about type of sexual agreement
Sample size: 162 dyads	Couple reported yes N = 137 dyads		Couple did not concur (ref) N = 25 dyads
Substance use with sex	One or both partners used		One or both partners used
Within relationship	N	%	N	%	AOR	CI
Party drugsa	17	12	2	8	1.59	0.34 – 7.47
Marijuana	53	39	4	16	3.21*	1.04 – 9.89
Alcohol	118	86	20	80	1.54	0.52 – 4.54
EDMb	25	18	7	28	0.55	0.21 – 1.47
Amyl nitrates	25	18	3	12	1.60	0.44 – 5.82
Sample size: 67 dyads, 112 gay men	N = 95 gay men		N = 17 gay men
Outside of relationshipc	N	%	N	%	AOR	CI
Party drugsa	13	14	1	6	2.51	0.27 – 23.52
Marijuana	33	35	3	18	2.52	0.45 – 14.21
Alcohol	68	72	7	41	3.59	0.90 – 14.39
EDMb	29	31	5	29	1.03	0.23 – 4.60
Amyl nitrates	39	41	3	18	3.24	0.58 – 17.97

Notes.

Findings in this table were produced from couple-level analyses. Logistic regression models for within the relationship controlled for engagement of unprotected anal intercourse with the main partner whereas the logistic regression models for outside the relationship controlled for unprotected anal intercourse with a casual MSM partner.

AOR adjusted odds ratio, CI confidence interval

^*p<.05

^aParty drugs include ecstasy, ketamine, GHB, cocaine, and methamphetamine.

^bEDM denotes Erectile Dysfunction Medication.

^cRates, percentages and adjusted odds ratios only included those who reported they had sex with a casual MSM partner within the prior three months to assessment.

Table 4.

Comparison and odds of having an open sexual agreement based on HIV-negative gay male couples’ use of substances with sex

	Type of sexual agreement
	Open agreement		Closed agreement(ref)
Sample size: 137 dyads	N = 62 dyads		N = 75 dyads
Substance use with sex	One or both partners used		One or both partners used
Within relationship	N	%	N	%	AOR	CI
Party drugsa	10	16	7	9	1.85	0.64 – 5.35
Marijuana	28	45	25	33	1.52	0.74 – 3.14
Alcohol	52	84	56	75	0.73	0.27 – 1.98
EDMb	19	31	6	8	5.19**	1.86 – 14.47
Amyl nitrates	18	29	7	9	4.03**	1.51 – 10.78
Sample size:56 dyads, 95 gay men	N = 84 gay men		N = 11 gay men
Outside of relationshipc	N	%	N	%	AOR	CI
Party drugsa	12	14	1	9	1.41	0.14 – 13.72
Marijuana	31	37	2	18	1.92	0.31 – 11.84
Alcohol	65	77	3	27	9.64**	1.80 – 51.57
EDMb	27	32	2	18	1.80	0.30 – 10.70
Amyl nitrates	34	40	5	45	0.82	0.17 – 3.95

Notes.

Findings in this table were produced from couple-level analyses. Logistic regression models for within the relationship controlled for engagement of unprotected anal intercourse with the main partner whereas the logistic regression models for outside the relationship controlled for unprotected anal intercourse with a casual MSM partner.

AOR adjusted odds ratio, CI confidence interval

^**p<.01

^aParty drugs include ecstasy, ketamine, GHB, cocaine, and methamphetamine.

^bEDM denotes Erectile Dysfunction Medication.

^cRates, percentages and adjusted odds ratios only included those who reported they had sex with a casual MSM partner within the prior three months to assessment.

Overall, a higher proportion of couples that concurred about their type of agreement had one or both partners who reported using substances with sex outside of their relationship than those who did not concur about their type of sexual agreement. However, substance use with sex outside of the relationship was not significantly associated with couples who concurred about their type of sexual agreement.

With respect to couples’ type of sexual agreement, a higher proportion of those with an open sexual agreement had one or both partners who reported using party drugs, marijuana, alcohol, and EDMs with sex within and/or outside of the relationship compared to couples with a closed agreement. The odds of having an open agreement were positively associated with one or both partners using EDMs (OR = 5.19 [CI 1.86, 14.47], p < .01) and/or amyl nitrates (OR = 4.03 [CI 1.51, 10.78], p < .01) with sex within their relationship. In addition, the odds of having an open sexual agreement were positively associated with one or both partners using alcohol (OR = 9.64 [CI 1.80, 51.57], p < .01) with sex outside of the relationship. No other significant differences about couples’ use of substances with sex, by substance type, were noted for within and/or outside of couples’ relationships and their type of sexual agreement.

Couples’ Adherence to a Sexual Agreement and Substance with Sex

As presented in Table 5, a higher proportion of couples with a recent broken agreement had one or both partners who reported using party drugs, marijuana, alcohol, EDMs, and amyl nitrates with sex within and/or outside of the relationship compared to couples that had recently kept their agreement. The odds of having a recent broken agreement were positively associated with one or both partners using marijuana (OR = 2.28 [CI 1.01, 5.10], p < .05) and/or amyl nitrates (OR = 3.84 [CI 1.55, 9.55], p < .01) with sex within their relationship. No other significant differences about couples’ use of substances with sex, by substance type, were noted for within and/or outside of couples’ relationships and their recent broken sexual agreement.

Table 5.

Comparison and odds of having a recently broken sexual agreement according to HIV-negative gay male couples’ use of substances with sex

	Recent adherence to sexual agreement
	One or both partners had broken their agreement		Both partners in couple kept their agreement(ref)
Sample size: 162 dyads	N = 30 dyads		N =132 dyads
Substance use with sex	One or both partners used		One or both partners used
Within relationship	N	%	N	%	AOR	CI
Party drugsa	5	17	14	11	1.61	0.53 – 4.93
Marijuana	16	53	41	31	2.28*	1.01 – 5.10
Alcohol	28	93	110	83	2.79	0.61 – 12.68
EDMb	9	30	23	17	1.91	0.77 – 4.74
Amyl nitrates	11	37	17	13	3.84**	1.55 – 9.55
Sample size: 67 dyads, 112 gay men	N = 42 gay men		N = 70gay men
Outside of relationshipc	N	%	N	%	AOR	CI
Party drugsa	7	17	7	10	1.56	0.34 – 7.16
Marijuana	20	48	16	23	2.42	0.78 – 7.51
Alcohol	30	71	45	64	1.29	0.41 – 4.11
EDMb	13	31	21	30	0.80	0.25 – 2.62
Amyl nitrates	19	45	23	33	1.70	0.57 – 5.02

Notes.

Findings in this table were produced from couple-level analyses. Logistic regression models for within the relationship controlled for engagement of unprotected anal intercourse with the main partner where as the logistic regression models for outside the relationship controlled for unprotected anal intercourse with a casual MSM partner.

AOR adjusted odds ratio, CI confidence interval

^*p<.05,

^**p<.01

^aParty drugs include ecstasy, ketamine, GHB, cocaine, and methamphetamine.

^bEDM denotes Erectile Dysfunction Medication.

^cRates, percentages and adjusted odds ratios only included those who reported they had sex with a casual MSM partner within the prior three months to assessment.

DISCUSSION

By using dyadic data from a national sample, our study is the first investigation to assess and identify an association between HIV-negative gay male couples’ establishment of, type of, and adherence to, a sexual agreement with their use of substances with sex within and outside of the relationship. The majority of research, including descriptive and intervention development studies, has targeted gay men from an individual perspective about their use of substances with sex [36, 42–47]. Given the current rates that gay men acquire HIV from their main partners [2, 3], the prevalence of sexual agreements among gay male couples [4, 5, 8–21] and the strong association between substance use and engagement of UAI [22–34], our study supports the need for further inquiry about HIV-negative gay male couples’ use of substances with sex within the context of their relationships, sexual agreements, and risk for acquiring HIV and other STIs.

Findings from the present study indicate that HIV-negative gay male couples with an established sexual agreement (i.e., both men concurred about having an agreement) were more likely to use a variety of substances with sex, particularly within their relationship. Couples who had recently broken their agreement were also more likely to use marijuana and/or amyl nitrates with sex within their relationship. However, the use of substances with sex outside of the relationship was not associated with couples who had recently broken their sexual agreement. In general, aspects of couples’ agreements were positively and significantly associated with their use of EDMs, amyl nitrates, and marijuana with sex within their relationship. In contrast, aspects of couples’ agreements were positively and significantly associated with their use of alcohol with sex outside of the relationship. Several possibilities may exist for interpreting this study’s findings. One possibility is that gay male couples who are more inclined to take risks (e.g., use substances with sex) may be more likely to establish a sexual agreement in order to reduce their risk for HIV and/or to be clear about their permitted behaviors and expectations. Another possibility includes gay male couples who established an agreement may feel freer to enact in what they agreed to engage in, including the use of substances with sex. Conversely, gay male couples without an established agreement may have had a heteronormative relationship style and as such, never discussed substance use with sex and/or having sex with outside partners. Additionally, gay male couples’ use of substances with sex and establishing a sexual agreement may be an indication of their preference to practice riskier behaviors in general; this explanation may be possible considering couples who used marijuana and/or amyl nitrates with sex within their relationship were more likely to have had a recently broken sexual agreement.

Despite these associations and possible explanations, we were unable to determine whether gay male couples included substance use with sex as an allowed behavior when they formed their sexual agreements. We are also unable to determine the temporality and related affect with respect to when the partners and couples started to use substances with sex in their life and relationship and the establishment of their agreement. Practitioners who provide services to partnered gay men and gay male couples should assess how dynamics within their relationships, including sexual agreements, and use of substances with sex may impact their risk for acquiring HIV and other STIs. Future research that aims to assess whether gay male couples explicitly include substance use with sex as part of their sexual agreement is warranted and timely.

Prior research has found that relationship characteristics also are associated with aspects of gay male couples’ sexual agreements. For example, Mitchell and colleagues (2012) found that higher levels of relationship satisfaction was positively associated with gay male couples’ establishment of, and adherence to, their sexual agreements, while trust was also found to be positively associated with couples’ adherence to their sexual agreements [16]. Another study noted that partnered gay men who reported having higher levels of commitment, communication, trust, and social support within their primary relationships were less likely to report breaking their sexual agreement with their main partners [10]. In addition to these relationship characteristics, findings from our study also suggest that an association exists between aspects of gay male couples’ sexual agreements and their use of substances with sex. However, our data and study design precludes us from determining whether gay male couples who had recently broken their agreement was solely due to their use of substances with sex. We are also unable to determine whether men’s and couples prior experiences in using substances with sex had influenced their establishment of, type of, and recent adherence to, an agreement, or whether their prior experiences with being in a gay male relationship, including having had a sexual agreement, may have influenced their current use of substances with sex. Thus, additional research is needed to investigate how partners and gay male couples’ history of relationships, sexual agreements, and using substances with sex influences their current relationship characteristics, including sexual agreements and use of substances with sex. Findings from our study and prior studies with gay male couples indicate that relationship characteristics, sexual agreements, and sexual and substance use related-behaviors are important to examine and consider for the development of HIV prevention interventions for gay male couples.

Moreover, the association between couples type of sexual agreement and their use of substances with sex was also described. In general, gay male couples with an open sexual agreement were more likely to have used EDMs and amyl nitrates with sex within their relationship than couples with a closed agreement; the same trend, although unsurprising, was noted for alcohol use with sex outside of the relationship. One possibility to explain these differences is that specific substances (e.g. party drugs, methamphetamine, EDM, etc.) are often associated with increasing the intensity and duration of sexual behaviors (e.g., UAI) and as a result, the rate in which men use these substances with sex would increase [35]. Gay male couples with an open sexual agreement may also have more opportunities to use substances with sex and with a greater number of sexual partners, which could influence the rate in which they use substances with sex both within and outside of their relationships. However, other influencing factors, such as sensation seeking – the tendency to pursue sensory pleasure and excitement [48], may exist to partially explain this finding. For instance, Newcomb et al. (2011) noted how sensation seeking moderates the effects of young MSM’s (YMSM) use of alcohol and drugs prior to sex on their engagement in UAI [49]. In particular, higher levels of sensation seeking were found to significantly increase the positive associations between YMSM’s frequency of UAI and frequency of both alcohol use and drug use with partners [49]. In addition to the aforementioned possibilities, future studies should also ascertain how environmental (e.g., location, circuit party event) and social (e.g., peer and/or sexual networks) factors affect gay male couples’ use of substances with sex, their sexual agreements and other relationship characteristics, and risk for the acquisition of HIV and other STIs. A longitudinal study design paired with a novel dyadic data collection method, which could include daily diaries and/or an ecological momentary assessments, would provide pertinent data to help with the development of prevention interventions. Practitioners and programs that currently provide prevention services to partnered MSM and gay male couples should inquire about their use of substances with sex and how these behaviors relate to their engagement of UAI, overall risk for HIV as well as characteristics of their relationships, including sexual agreements.

The limitations of this study are important to note. The use of a cross-sectional study design with dyadic data from a convenience online sample precludes us from making causal inferences and generalizing our findings to all gay male couples who live in the US, as well as those who do and do not use the Internet and/or Facebook. Our recruitment methods also captured a sample who predominantly and publically self-identified as gay and being interested in “men” as well as in a “relationship”. Although we did not collect identifying information, participation, social desirability, and recall biases may have influenced the men to inaccurately report information about their use of substances with sex and aspects about their sexual agreement. We also did not assess couples’ motivations for using substances with sex, whether both partners within the couple were aware of each other’s use of substances with sex within and/or outside of their relationship, and how other relationship characteristics (e.g., commitment, trust, communication) may affect the association between couples’ use of substances with sex and aspects of their sexual agreements. In addition, participants may have completed the survey with their main partners, despite our request for them to complete it independently and separately, and therefore potentially causing some bias. Our survey also did not assess poly-substance use, nonmedical use of controlled medications such as prescription anti-anxiety, opioid, stimulant, and sleeping medications. Future research that examines gay male couples’ sexual agreements and use of substances with sex should specifically address these limitations. Despite these limitations, our study obtained dyadic data from a large diverse sample of Internet-using HIV-negative gay male couples who reported using substances with sex within and outside of their relationships and aspects about their sexual agreements.

The majority of HIV prevention efforts have targeted gay men at the individual- and/or community-levels [50–52]. Despite the fact that sex requires the participation of at least two individuals, the commonality of sexual agreements among gay male couples, and the frequency that gay men and couples use substances with sex, few CDC-approved HIV prevention interventions have been developed for gay male couples, including those who use substances with sex. To help address this critical public health gap, our findings support the need to conduct additional prevention studies to further examine gay male couples' sexual agreements and their use of substances with sex.