Abstract
Objectives. We surveyed men who have sex with men (MSM) to determine whether sexual risk behaviors, recent drug use, and other psychosocial problems differed between men who engaged in one-on-one and group sexual encounters.
Methods. We conducted an Internet-based cross-sectional survey of 7158 MSM aged 18 years or older in the United States recruited from a gay-oriented sexual networking Web site in 2008. Among MSM who engaged in group sexual encounters, we compared their past-60-day sexual behaviors in one-on-one encounters and group sexual encounters. We also compared risk profiles and syndemic production between men who did and did not participate in group sex.
Results. Men reporting a group-sex encounter had significantly higher polydrug use and sexual risk than did the men not reporting group sex in the past 60 days. The odds of engaging in group sex with 4 or more sexual partners significantly increased with the number of psychosocial problems, supporting evidence of syndemic production.
Conclusions. We identified a particularly high-risk subgroup in the MSM population with considerable psychosocial problems that may be reached online. Research is needed on how to engage these high-risk men in combination prevention interventions.
Men who have sex with men (MSM) continue to be disproportionately affected by HIV and are more than 40 times more likely to be HIV-infected than other men.1,2 This disparity in HIV disease burden can be largely attributed to the high per-act and per-partner HIV transmission probability in receptive anal intercourse, coupled with the lack of awareness of one’s HIV serostatus.3,4 Recent attention in the literature has been given to group-sex environments that facilitate concurrent sexual partnerships, drug use, and lack of serostatus disclosure among MSM, thus representing a challenge to HIV prevention.5–10 Beyond the traditional bathhouse, group sex (i.e., sexual intercourse with 2 or more partners at the same time) is being increasingly reported as occurring in private locations and planned online, thus eluding public health involvement (e.g., HIV testing, sexually transmitted infection [STI] screening, condom distribution).5,6
Group sex among MSM is not a new phenomenon; however, the increasing availability of technology (e.g., advertisements on Web sites and smartphone apps) is likely responsible for creating easier access to group-sex events and like-minded people. This, in turn, may be increasing the potential for HIV transmission in private settings.11 Among the recent studies that have assessed characteristics of MSM who engage in group sex,6,7,9–15 little research has examined psychosocial problems experienced by these men,6 as well as specific rates of overall and polydrug use. The limited extant research, however, suggests that they are more likely to report higher rates of psychosocial problems (e.g., depression and drug abuse6,7), lack of HIV disclosure,14 lower likelihood of HIV testing,6,7,16 and sexual risk (i.e., condomless anal sex [CAS]) than MSM not reporting group sex.9 When co-occurring, these psychosocial problems suggest the presence of intertwining epidemics (i.e., syndemics),17–19 which have not been examined within the context of group sex. When syndemic conditions overlap they can have additive effects in which rises in 1 syndemic condition are hypothesized to be associated with rises in other syndemic conditions.
The theory of syndemic production asserts that intertwining epidemics that exist among MSM are largely socially produced, developmental in nature, and associated with early adolescent male socialization among MSM, in addition to the added stressors associated with migration to urban areas with large gay populations.20 In this study, we defined syndemic production as intersecting psychosocial conditions (i.e., polydrug use, early onset of alcohol use, depression, and incarceration history) that exacerbate one another to produce an overall health effect more negative than any individual condition. Men who have sex with men who engage in group sex have received recent attention in the literature, with researchers calling for more attention to syndemics within this context6,7,21 and for additional research with larger samples of MSM who report sex party attendance to test additional hypotheses concerning constellations of risk behaviors among this subpopulation of men.7
A limitation of these group-sex studies is that they have examined the overall level of sexual risk of MSM who have and have not engaged in group sex, rather than examining what specific risk behaviors men engage in within the group-sex encounter. Although such studies suggest that men who engage in group sex also engage in more sexual risk, they do not address syndemic conditions among group-sex participants that contribute to this risk. Furthermore, past research has not assessed differences in sexual risk across types of sexual encounters, such as one-on-one encounters, threesomes, and sexual activity with 4 or more partners at the same time.6,7,10,12 Therefore, to determine whether risk behaviors differ by encounter type among MSM who engaged in group sex, we compared their past-60-day sexual behaviors in one-on-one encounters and group-sex encounters. We also compared risk profiles and syndemic production between men who did and did not have group sex. We hypothesized that MSM who had more psychosocial health problems (i.e., syndemics) were more likely to engage in group sex.
METHODS
We recruited participants online between April and June 2008. A gay-oriented US sexual networking Web site sent e-mails to all of its US members (n = 609 960). All e-mail recipients were considered potentially eligible (i.e., US male residents, aged 18 years and older) for study inclusion.22 Details of recruitment have been described in detail elsewhere.23 Those who clicked on the recruitment banner were routed to a consent form on a secure study Web site. The online survey took 10 to 15 minutes to complete and assessed demographic characteristics, substance use, sexual behaviors, and HIV and STI testing. No incentives were offered to study participants. A waiver of documentation of written consent was obtained, given the Internet-based research approach.
Measures
Three survey sections assessed past-60-day sexual risk behaviors that took place within (1) one-on-one encounters, (2) encounters with 2 or 3 partners, or (3) encounters with 4 or more partners. All participants were asked to report up to 3 one-on-one encounters that occurred in the past 60 days. Depending on the number and type of past-60-day sexual partners that were reported, a participant could answer all 3 sections. For example, only men who reported 2 or more anal sexual partners in the past 60 days were asked whether they had multiple-partner encounters during that time period. We defined main partner as a boyfriend, life partner, spouse, or significant other. We defined city size of residence by population size (i.e., ≤ 49 999, 50 000–249 999, 250 000–1 million, > 1 million).
We defined anal sex as insertive or receptive anal intercourse with a male partner. We defined CAS as any insertive or receptive anal sex without a condom by either the participant or his partner. We constructed serodiscordant CAS from a set of variables including the participants’ self-reported HIV status, whether they had anal sex without a condom, whether they knew the HIV status of their partners, and whether they had insertive or receptive anal sex or both. Men who reported a past-60-day STI diagnosis selected from a list the STIs with which they had been diagnosed: chancroid, chlamydia, gonorrhea, genital herpes, human papillomavirus (genital anal warts), lymphogranuloma venereum, nongonococcal urethritis, syphilis, and hepatitis A, B, and C.
Psychosocial problems comprised 4 domains: (1) past-60-day polydrug use, defined as use of 3 or more recreational drugs (e.g., marijuana; cocaine smoked, snorted, or injected; crystal methamphetamine smoked, snorted, or injected; heroin smoked, snorted, or injected; γ hydroxybutyrate [GHB]; ketamine; ecstasy; nitrite inhalants [poppers]; downers; and erectile dysfunction medications); (2) current depression symptoms, assessed with the 2-item Patient Health Questionnaire Depression Scale, with scores greater than 3 indicating a positive screen24,25; (3) as arrest history among MSM has been addressed in the syndemics literature,26 we assessed incarceration history with: “Have you ever spent at least 1 night in jail or prison?”; and (4) on the basis of longitudinal research indicating that age 14 years or younger is a vulnerable period for initiation of drinking and is associated with lifetime alcohol dependence, we dichotomized age at onset of alcohol consumption as 14 years or younger versus 15 years or older.27 We dichotomized all psychosocial problems to create a count score of the number of problems experienced for the purpose of examining syndemic production.
Statistical Analysis
We performed data analyses with SPSS version 20 (IBM, Somers, NY). We used χ2 and logistic regression analyses to assess group differences. Men with encounters with 4 or more partners differed significantly in their risk profile from men with encounters with 2 or 3 partners and we analyzed them separately. We included bivariate associations significant at a P level of less than .05 in multivariate and multinomial logistic regression models.
We used Stall et al.’s analytic framework18 to test for the presence of syndemic production. We calculated count scores based on the number of psychosocial problems reported, yielding scores ranging from 0 to 3 or more. We then compared the 3 groups on the number of psychosocial problems and additive effects. For post hoc analyses, we used partial χ2 and logistic regression to show comparisons across the 3 groups on various characteristics.
RESULTS
A total of 23 213 (3.8%) men clicked on the study recruitment e-mail hyperlink that took them to the study landing page. Of those, 9539 (41%) broke off from the landing page immediately and 13 674 (59%) consented to participate in the survey. Among men who consented, 12 109 (88%) completed most of the online survey. The participation rate (i.e., number of respondents providing usable data divided by the number of initial personal invitations requesting participation)22 was 1.9%. A detailed description of the overall sample and exclusions are described elsewhere.23,28 Briefly, we excluded 231 ineligible individuals (i.e., non–male-identified, resided outside the United States) and 311 duplicate cases. Men who dropped out of the survey and were missing data on key outcomes (n = 3114) were slightly younger (median age 38 vs 39 years; P < .001) and had significantly more lifetime male anal sexual partners (≥101 partners: 37% vs 26%; P < .001) compared with men who did not drop out. We omitted men not currently sexually active (n = 1116) or who were missing data on sexual partners (n = 179), resulting in an analytic sample of 7158.
We categorized men reporting past-60-day sexual behaviors into 3 groups based on the type of sexual encounter: one-on-one encounters only, encounters with 2 or 3 partners, and encounters with 4 or more partners. In Table 1, the median age was 39 years (range 18–81 years) and most men were White. Men resided in each US state. More than half had at least a college degree and resided in urban areas. Most men self-identified as homosexual (85%); 16% self-reported as HIV-positive; 15% self-reported having a past-60-day STI diagnosis; and 27% reported more than 100 lifetime male anal sexual partners. Regarding psychosocial problems, 25% reported past-60-day polydrug use, 16% reported current depressive symptoms, 17% had ever been incarcerated, and 25% had their first drink at 14 years or younger.
TABLE 1—
Demographic Characteristics Among Men Who Have Sex With Men Reporting Sexual Encounters in the Past 60 Days: United States, 2008
| Characteristic | Total Sample,a (n = 7158), No. (%) | Group x: One-on-Oneb Sex (n = 5038), No. (%) | Group y: 2–3 Partners per Encounterc (n = 1320), No. (%) | Group z: ≥ 4 Partners per Encounterd (n = 800), No. (%) | P | Post Hoc Group Comparisonse |
| Demographics | ||||||
| Age, y | ||||||
| 18–29 (Ref) | 1970 (27) | 1468 (29) | 337 (26) | 165 (21) | ||
| 30–39 | 1699 (24) | 1170 (23) | 319 (24) | 210 (26) | x < y < z | |
| 40–49 | 2208 (31) | 1494 (30) | 424 (32) | 290 (36) | x < y < z | |
| ≥ 50 | 1281 (18) | 906 (18) | 240 (18) | 135 (17) | <.001 | z > x |
| Race/ethnicity | ||||||
| White (Ref) | 5858 (82) | 4138 (83) | 1054 (80) | 666 (84) | ||
| Black | 281 (4) | 203 (4) | 55 (4) | 23 (3) | – | |
| Hispanic | 607 (9) | 407 (8) | 129 (10) | 71 (9) | x < y | |
| Other race | 382 (5) | 270 (5) | 76 (6) | 36 (4) | .19 | – |
| Education | ||||||
| College degree or more | 3943 (55) | 2732 (54) | 770 (58) | 441 (55) | x < y | |
| No college degree | 3193 (45) | 2287 (46) | 549 (42) | 357 (45) | <.05 | |
| HIV status | ||||||
| HIV-negative (Ref) | 5403 (76) | 3937 (78) | 977 (74) | 489 (61) | ||
| HIV-positive | 1154 (16) | 598 (12) | 279 (21) | 277 (35) | x < y < z | |
| Untested | 584 (8) | 490 (10) | 62 (5) | 32 (4) | <.001 | x > y, z |
| Any STI (past 60 d)f | ||||||
| Yes | 1040 (15) | 641 (13) | 214 (16) | 185 (23) | x < y < z | |
| No | 6102 (85) | 4391 (87) | 1100 (84) | 611 (77) | <.001 | |
| Sexual orientation | ||||||
| Heterosexual (Ref) | 55 (1) | 37 (1) | 13 (1) | 5 (1) | ||
| Bisexual | 989 (14) | 700 (14) | 191 (15) | 98 (12) | – | |
| Homosexual | 6084 (85) | 4278 (84) | 1109 (84) | 697 (87) | .48 | – |
| Lifetime male anal sex partners | ||||||
| ≥ 101 | 1912 (27) | 833 (17) | 519 (41) | 560 (72) | x < y < z | |
| ≤ 100 | 5059 (73) | 4086 (83) | 756 (59) | 217 (28) | <.001 | |
| City size of residence | ||||||
| ≤ 49 999 | 1664 (25) | 1244 (27) | 267 (22) | 153 (20) | x > y, z | |
| 50 000–249 999 | 1365 (21) | 988 (22) | 232 (19) | 135 (18) | x > y, z | |
| 250 000–1 million | 1619 (24) | 1135 (24) | 317 (26) | 167 (22) | x, y > z | |
| > 1 million (Ref) | 1973 (30) | 1271 (27) | 406 (33) | 296 (40) | <.001 | |
| Psychosocial problems | ||||||
| Polydrug use (past 60 d)g | ||||||
| Yes | 1812 (25) | 1106 (22) | 382 (29) | 324 (41) | x < y < z | |
| No | 5343 (75) | 3932 (78) | 937 (71) | 474 (59) | <.001 | |
| PHQ-2 (past 14 d) | ||||||
| Yes | 1100 (16) | 778 (16) | 193 (15) | 129 (16) | – | |
| No | 5973 (84) | 4199 (84) | 1111 (85) | 663 (84) | .63 | |
| Ever incarceratedh | ||||||
| Yes | 1216 (17) | 808 (16) | 216 (17) | 192 (24) | x, y < z | |
| No | 5836 (83) | 4154 (84) | 1081 (83) | 601 (76) | <.001 | |
| First drink, age ≤ 14 yi | ||||||
| Yes | 1723 (25) | 1153 (24) | 331 (26) | 239 (31) | x, y < z | |
| No | 5244 (75) | 3749 (76) | 953 (74) | 542 (69) | <.001 | |
| No. of psychosocial problems | ||||||
| 0 (Ref) | 3218 (45) | 2394 (48) | 562 (43) | 262 (33) | ||
| 1 | 2485 (35) | 1719 (34) | 482 (37) | 284 (36) | x < y, z | |
| 2 | 1037 (14) | 671 (13) | 194 (15) | 172 (21) | x < y < z | |
| ≥ 3 | 415 (6) | 251 (5) | 82 (5) | 82 (10) | <.001 | x, y < z |
Note. PHQ-2 = Patient Health Questionnaire, 2 item screener for depressive symptoms in the past 14 days; STI = sexually transmitted infection.
Totals may differ because of missing cases.
Up to 3 one-on-one encounters with sexual partners, past 60 days.
Sex with 2–3 sexual partners in an encounter, past 60 days.
Sex with 4 or more sexual partners in an encounter, past 60 days.
Post hoc comparisons were made by using partial χ2 and logistic regression. Significant comparisons are shown with a “<” symbol. If differences were not significant, a comma was used. Dashes indicate no significant differences.
Any STIs diagnosed by a nurse or physician in the past 60 days, including chancroid, chlamydia, gonorrhea, herpes, human papillomavirus, lymphogranuloma venereum, nongonococcal urethritis, syphilis, and hepatitis A, B, or C.
Three or more recreational drugs.
Response to the question, “Have you ever spent at least 1 night in jail or prison?”
Comparison group is those aged 15 years or older.
Men with encounters with 4 or more partners had a distinct demographic and behavioral risk profile compared with men in the other groups (Table 1). They were significantly older, more likely to live in a big city, had a higher HIV prevalence, and were more likely to have a past-60-day STI diagnosis. Men with encounters with 4 or more partners reported a greater prevalence and number of psychosocial problems than men in the other groups. Men with encounters with 4 or more partners had significantly higher use of individual and multiple drugs in the past 60 days than did other men (Table 2). They were also significantly more likely than were men with only one-on-one encounters to ever have been in drug treatment.
TABLE 2—
Drug Use Behaviors Reported in the Past 60 Days in a Sample of Men Who Have Sex With Men: United States, 2008
| Variable | Total Samplea (n = 7158), No. (%) | Group x: One-on-Oneb Sex (n = 5038), No. (%) | Group y: 2–3 Partners per Encounterc (n = 1320), No. (%) | Group z: ≥ 4 Partners per Encounterd (n = 800), No. (%) | P | Post Hoc Group Comparisonse |
| No. of drugs used (past 60 d) | ||||||
| 0 (Ref) | 2566 (36) | 2036 (41) | 354 (27) | 176 (22) | ||
| 1 | 1753 (25) | 1227 (24) | 358 (27) | 168 (21) | x < y, z | |
| 2 | 1024 (14) | 669 (13) | 225 (17) | 130 (16) | x < y, z | |
| ≥ 3 | 1812 (25) | 1106 (22) | 382 (29) | 324 (41) | <.001 | x < y < z |
| Individual drugs used (past 60 d), n = 4545f | ||||||
| Cocaine injected | 78 (2) | 34 (1) | 15 (2) | 29 (5) | <.001 | x, y < z |
| Cocaine smoked or snorted | 1432 (32) | 960 (32) | 260 (27) | 212 (35) | <.01 | y < x, z |
| Crack | 204 (5) | 120 (4) | 37 (4) | 47 (8) | <.001 | x, y < z |
| Crystal methamphetamine injected | 199 (4) | 68 (2) | 47 (5) | 84 (14) | <.001 | x < y < z |
| Crystal methamphetamine smoked or snorted | 875 (19) | 462 (16) | 206 (22) | 207 (34) | <.001 | x < y < z |
| Downers | 414 (9) | 274 (9) | 77 (8) | 63 (10) | .33 | – |
| Ecstasy | 975 (22) | 625 (21) | 167 (18) | 183 (30) | <.001 | y < x < z |
| γ hydroxybutyrate | 515 (11) | 249 (8) | 113 (12) | 153 (25) | <.001 | x < y < z |
| Heroin injected | 23 (1) | 10 (0.3) | 4 (0.4) | 9 (1.5) | <.01 | x, y < z |
| Heroin smoked or snorted | 73 (2) | 49 (2) | 10 (1) | 14 (2) | .16 | – |
| Ketamine | 360 (8) | 211 (7) | 67 (7) | 82 (13) | <.001 | x, y < z |
| Marijuana | 2926 (64) | 2021 (68) | 547 (57) | 358 (58) | <.001 | x, y > z |
| PDE-5 inhibitor | 1989 (44) | 1181 (40) | 461 (48) | 347 (56) | <.001 | x < y < z |
| Poppers | 2602 (57) | 1550 (52) | 614 (64) | 438 (71) | <.001 | x < y < z |
| Drug or alcohol treatment program | ||||||
| Yes, past 60 d | 200 (3) | 133 (3) | 40 (3) | 27 (3) | – | |
| Yes, > 60 d ago | 658 (9) | 430 (9) | 135 (10) | 93 (12) | z > x | |
| No (Ref) | 6195 (88) | 4401 (88) | 1122 (87) | 672 (85) | <.05 |
Note. PDE-5 inhibitor = phosphodiesterase type 5 inhibitor (i.e., Viagra, Levitra, Cialis); poppers = nitrite inhalants.
Totals may differ because of missing cases.
Up to 3 one-on-one encounters with sexual partners, past 60 days.
Sex with 2–3 sexual partners in an encounter, past 60 days.
Sex with 4 or more sexual partners in an encounter, past 60 days.
Post hoc comparisons were made by using partial χ2 and logistic regression. Significant comparisons are shown with a “<” symbol. If differences were not significant, a comma was used. Dashes indicate no significant differences.
Participants who responded “yes” to drug use in the past 60 days saw a list of recreational drugs from which to choose.
In Table 3, we assessed past-60-day risk behaviors in one-on-one sexual encounters across the 3 groups. Men with encounters with 4 or more partners were most likely to report multiple one-on-one encounters (88%), followed by men in encounters with 2 or 3 partners (82%) and men with only one-on-one encounters (55%). Men in both group-sex groups were significantly more likely to have met their one-on-one sexual partners online than men with only one-on-one encounters. Men with only one-on-one encounters were significantly more likely than those in the group-sex groups to have had a main partner involved in their one-on-one encounter. Whereas 68% of men with only one-on-one encounters reported anal intercourse, 96% of men in both group-sex groups reported anal intercourse in their one-on-one encounters; men with encounters with 4 or more partners were significantly more likely than men in the other groups to report CAS (83%) and CAS with serodiscordant or unknown-status partners (41%). Drug use before sexual activity was significantly more prevalent among men with encounters with 4 or more partners than other men, though no differences were found for alcohol use.
TABLE 3—
Sexual Risk Behaviors Reported in the Past 60 Days in a Sample of Men Who Have Sex With Men: United States, 2008
| Variable | Total Samplea (n = 7158), No. (%) | Group x: One-on-Oneb Sex (n = 5038), No. (%) | Group y: 2–3 Partners per Encounterc (n = 1320), No. (%) | Group z: ≥ 4 Partners per Encounterd (n = 800), No. (%) | P | Post hoc Group Comparisonse |
| One-on-one sexual encounter data (past 60 d)f | ||||||
| Met partner(s) online | ||||||
| Yes | 5775 (81) | 3991 (79) | 1113 (85) | 671 (85) | <.001 | x < y, z |
| No | 1353 (19) | 1047 (21) | 191 (15) | 115 (15) | ||
| Sexual partner included main partner | ||||||
| Yes | 2955 (41) | 2218 (44) | 481 (36) | 256 (32) | <.001 | x > y > z |
| No | 4203 (59) | 2820 (56) | 839 (64) | 544 (68) | ||
| No. of one-on-one encounters | ||||||
| 1 (Ref) | 1088 (15) | 963 (19) | 90 (7) | 35 (4) | ||
| 2 | 1530 (21) | 1327 (26) | 141 (11) | 62 (8) | x > y, z | |
| 3 | 4510 (63) | 2748 (55) | 1073 (82) | 689 (88) | <.001 | x < y < z |
| Any anal sex | ||||||
| Yes | 5472 (76) | 3439 (68) | 1268 (96) | 765 (96) | <.001 | x < y, z |
| x < y, z No | 1686 (24) | 1599 (32) | 52 (4) | 35 (4) | ||
| Any CAS | ||||||
| Yes | 3975 (73) | 2396 (70) | 942 (74) | 637 (83) | <.001 | x < y < z |
| No | 1497 (27) | 1043 (30) | 326 (26) | 128 (17) | ||
| Any serodiscordant CAS | ||||||
| Yes | 1527 (28) | 852 (25) | 363 (29) | 312 (41) | <.001 | x < y < z |
| No | 3908 (72) | 2568 (75) | 895 (71) | 445 (59) | ||
| Alcohol before sex | ||||||
| Yes | 2701 (38) | 1898 (38) | 511 (39) | 292 (37) | .51 | – |
| No | 4423 (62) | 3139 (62) | 790 (61) | 494 (63) | ||
| Drugs before sex | ||||||
| Yes | 1255 (18) | 694 (14) | 296 (23) | 265 (34) | <.001 | x < y < z |
| No | 5867 (82) | 4342 (86) | 1005 (77) | 520 (66) | ||
| Group-sex encounter data (past 60 d)g | ||||||
| Organized online | ||||||
| Yes | 890 (42) | – | 466 (35) | 424 (53) | <.001 | |
| No | 1230 (58) | – | 854 (65) | 376 (47) | ||
| Sexual partner(s) included main partner | ||||||
| Yes | 357 (17) | – | 241 (18) | 116 (15) | <.05 | |
| No | 1763 (83) | – | 1079 (82) | 684 (85) | ||
| Any anal sex | ||||||
| Yes | 2059 (99) | – | 1291 (99) | 768 (99) | .07 | |
| No | 11 (1) | – | 4 (1) | 7 (1) | ||
| Any CAS | ||||||
| Yes | 1159 (56) | – | 651 (50) | 508 (65) | <.001 | |
| No | 925 (44) | – | 653 (50) | 272 (35) | ||
| Any serodiscordant CAS | ||||||
| Yes | 821 (40) | – | 387 (30) | 434 (56) | <.001 | |
| No | 1251 (60) | – | 911 (70) | 340 (44) | ||
| Alcohol before sex | ||||||
| Yes | 296 (14) | – | 161 (12) | 135 (17) | <.001 | |
| No | 1787 (86) | – | 1142 (88) | 645 (83) | ||
| Drugs before sex | ||||||
| Yes | 256 (12) | – | 111 (9) | 145 (19) | <.001 | |
| No | 1825 (88) | – | 1192 (91) | 633 (81) | ||
Note. CAS = condomless anal sex, which was defined as “any” insertive or receptive anal sex without a condom; serodiscordant CAS = CAS with serodiscordant or unknown-HIV-status partners.
Totals may differ because of missing cases.
Up to 3 one-on-one encounters with sexual partners, past 60 days.
Sex with 2–3 sexual partners in an encounter, past 60 days.
Sex with 4 or more sexual partners in an encounter, past 60 days.
Post hoc comparisons were made by using partial χ2 and logistic regression. Significant comparisons are shown with a “<” symbol. If differences were not significant, a comma was used. Dashes indicate no significant differences.
All respondents were asked about one-on-one sexual encounters in the past 60 days.
Men who reported 2 or more sexual partners in the past 60 days were asked about group-sex encounters.
We also assessed a past-60-day group sex among men with encounters with 2 or 3 partners and encounters with 4 or more partners (Table 3). The 2 most common locations for group sex were private residences (94%) and private parties (61%); other less common locations included public places (31%), bars or clubs (28%), and bath houses (9%). In Table 3, men with encounters with 4 or more partners were significantly more likely than men with encounters with 2 or 3 partners to organize their group encounter online in advance, and they were significantly less likely to have had a main partner involved in the group-sex encounter. Almost all men in both group-sex groups (99%) reported anal intercourse during their group-sex encounter; however, men with encounters with 4 or more partners were significantly more likely than were men with encounters with 2 or 3 partners to report CAS with serodiscordant or unknown-status partners and to use alcohol or drugs before the group encounter.
In multinomial logistic regression (Table 4), compared with men reporting only one-on-one encounters, men reporting an encounter with 2 or 3 partners in the past 60 days were significantly more likely to report being HIV-positive (adjusted odds ratio [AOR] = 2.92; 95% confidence interval [CI] = 2.04, 4.19) and were significantly more likely to have had multiple one-on-one encounters (AOR = 2.53; 95% CI = 2.12, 3.01) but were significantly less likely to have had a main partner in these encounters (AOR = 0.69; 95% CI =0.59, 0.79). Compared with men with only one-on-one encounters, men with an encounter with 4 or more partners had an even greater likelihood of reporting an HIV-positive serostatus (AOR = 5.60; 95% CI = 3.51, 8.95) and were significantly more likely to report a past-60-day STI diagnosis (AOR = 1.45; 95% CI = 1.16, 1.80). Men with an encounter with 4 or more partners were also significantly more likely than men with only one-on-one encounters to report CAS with serodiscordant or unknown-status partners in their one-on-one encounters (AOR = 1.54; 95% CI = 1.27, 1.87). In addition, men with an encounter with 4 or more partners were significantly more likely to have multiple one-on-one encounters (AOR = 3.80; 95% CI = 2.96, 4.89) and significantly less likely to have a main partner in these encounters (AOR = 0.63; 95% CI = 0.52, 0.76) compared with men with only one-on-one encounters.
TABLE 4—
Multinomial and Multivariate Logistic Regression, Comparing Characteristics Associated With Type of Sexual Risk Among Men Who Have Sex With Men: United States, 2008
| Characteristic | 2–3 Partners per Encounter,a AOR (95% CI) | ≥ 4 Partners per Encounter,b AOR (95% CI) | ≥ 4 Partners per Encounter,c AOR (95% CI) |
| Age ≥ 50 y | 0.93 (0.78, 1.12) | 0.78 (0.62, 0.99) | 0.85 (0.65, 1.09) |
| College degree or more | 1.15 (0.99, 1.33) | 1.11 (0.93, 1.33) | 0.98 (0.79, 1.19) |
| HIV status | |||
| HIV-negative | 1.80 (1.29, 2.52) | 2.17 (1.38, 3.41) | 1.27 (0.75, 2.16) |
| HIV-positive | 2.92 (2.04, 4.19) | 5.60 (3.51, 8.95) | 2.09 (1.22, 3.59) |
| Untested (Ref) | 1.00 | 1.00 | 1.00 |
| Any STI (past 60 d)d | 1.13 (0.93, 1.37) | 1.45 (1.16, 1.80) | 1.28 (1.00, 1.63) |
| City size of residencee | |||
| Rural | 0.91 (0.75, 1.11) | 0.82 (0.64, 1.04) | 0.93 (0.71, 1.22) |
| Suburban | 0.87 (0.71, 1.07) | 0.76 (0.59, 0.98) | 0.90 (0.68, 1.19) |
| Urban | 0.95 (0.79, 1.15) | 0.74 (0.59, 0.93) | 0.79 (0.61, 1.02) |
| Big city (Ref) | 1.00 | 1.00 | 1.00 |
| Psychosocial problems,f No. | |||
| 0 (Ref) | 1.00 | 1.00 | 1.00 |
| 1 | 1.12 (0.96, 1.31) | 1.38 (1.12, 1.69) | 1.26 (1.01, 1.58) |
| 2 | 1.08 (0.88, 1.34) | 1.99 (1.56, 2.55) | 1.89 (1.43, 2.49) |
| 3 | 1.30 (0.96, 1.78) | 2.42 (1.73, 3.38) | 1.84 (1.27, 2.67) |
| One-on-one sexual encounters (past 60 d) | |||
| Met partner(s) online | 0.97 (0.79, 1.18) | 0.85 (0.67, 1.09) | 0.85 (0.64, 1.13) |
| Main sexual partner involved | 0.69 (0.59, 0.79) | 0.63 (0.52, 0.76) | 0.93 (0.76, 1.14) |
| 3 one-on-one encounters | 2.53 (2.12, 3.01) | 3.80 (2.96, 4.89) | 1.49 (1.11, 1.99) |
| Any serodiscordant CAS | 1.05 (0.89, 1.24) | 1.54 (1.27, 1.87) | 1.49 (1.21, 1.85) |
Note. AOR = adjusted odds ratio; CAS = condomless anal sex; CI = confidence interval; STI = sexually transmitted infection.
Sex with 2–3 sexual partners in an encounter, past 60 days; reference group is up to 3 one-on-one encounters with sexual partners, past 60 days.
Sex with 4 or more sexual partners in an encounter, past 60 days; reference group is up to 3 one-on-one encounters with sexual partners, past 60 days.
Sex with 4 or more sexual partners in an encounter, past 60 days; reference group is sex with 2–3 sexual partners in an encounter, past 60 days.
Any STIs diagnosed by a nurse or physician in the past 60 days, including chancroid, chlamydia, gonorrhea, herpes, human papillomavirus, lymphogranuloma venereum, nongonococcal urethritis, syphilis, and hepatitis A, B, or C.
Rural = up to 49 999; suburban = 50 000–249 999; urban = 250 000–1 million; big city = more than 1 million residents.
Includes 2-item screener for depressive symptoms in the past 14 days; affirmative answer to the question “Have you ever spent at least 1 night in jail or prison?”; use of 3 or more recreational drugs, past 60 days; and first drink, aged 14 years or younger compared with those aged 15 years or older.
Compared with men reporting an encounter with 2 or 3 partners, men with an encounter with 4 or more partners were significantly more likely to report being HIV-positive (AOR = 2.09; 95% CI = 1.22, 3.59), have a past-60-day STI diagnosis (AOR = 1.28; 95% CI = 1.00, 1.63), report multiple one-on-one encounters (AOR = 1.49; 95% CI = 1.11, 1.99), and report CAS with serodiscordant or unknown-status partners in their one-on-one encounters (AOR = 1.49; 95% CI = 1.21, 1.85).
We assessed syndemic production in the multinomial and multivariate logistic regressions. We found no evidence of syndemic production between men with an encounter with 2 or 3 partners and men with only one-on-one encounters, though men with an encounter with 4 or more partners demonstrated syndemic production, compared with men with only one-on-one encounters. Specifically, the odds of having a recent encounter with 4 or more partners (vs one-on-one encounter) significantly increased with the number of psychosocial problems (1 problem: AOR = 1.38; 95% CI = 1.12, 1.69; 2 problems: AOR = 1.99; 95% CI = 1.56, 2.55; 3 or more problems: AOR = 2.42; 95% CI = 1.73, 3.38). Finally, men with an encounter with 4 or more partners had significantly greater psychosocial problems than men with an encounter with 2 or 3 partners, but syndemic production was partially supported (1 problem: AOR = 1.26; 95% CI = 1.01, 1.58; 2 problems: AOR = 1.89; 95% CI = 1.43, 2.49; 3 or more problems: AOR = 1.84; 95% CI = 1.27, 2.67), as the odds of having a recent encounter with 4 or more partners significantly increased with 1 or 2 psychosocial problems but not 3 or more.
DISCUSSION
This online study of MSM in the United States provides important information on sexual risk, drug use, and syndemic production associated with men who engage in group sex. Regarding sexual risk, men with encounters with 2 or 3 partners and men with encounters with 4 or more partners in the past 60 days reported significantly more anal sexual partners and risk behavior (across all of their encounter types) compared with men reporting only one-on-one encounters. This study is also the first to compare past-60-day sexual behaviors in one-on-one encounters and group-sex encounters among MSM who engaged in group sex. In one-on-one encounter data, men with encounters with 4 or more partners were significantly more likely than men with encounters with 2 or 3 partners and men with only one-on-one encounters to report CAS (83% vs 74% vs 70%) and CAS with serodiscordant or unknown-status partners (41% vs 29% vs 25%). In group-encounter data, virtually all men reported anal sex; however, men with encounters with 4 or more partners were significantly more likely than men with encounters with 2 or 3 partners to report CAS (65% vs 50%) and CAS with serodiscordant or unknown-status partners (56% vs 30%). These findings are consistent with the current literature in that MSM who engage in group sex are more likely than MSM who do not to report CAS with partners whose HIV status is serodiscordant or unknown.10,29
As online studies of MSM tend to report more drug use than offline studies,23,30–32 it is not surprising that past-60-day drug use was widely prevalent in the overall sample, with 64% reporting any drug use and 25% reporting polydrug use. Men with encounters with 4 or more partners were significantly more likely to report individual drug (78%) and polydrug use (41%) than men in the other groups. These rates are higher than those previously reported.11,12,14 Despite the high substance use profiles found among this sample, only a small proportion of these men reported current or lifetime drug treatment.
Findings from this study support syndemic production among MSM who engaged in group-sex encounters. Specifically, a significantly greater number of psychosocial problems were reported by men with encounters with 4 or more partners compared with men in the other groups. They also reported a significantly higher prevalence of HIV and lifetime male anal sexual partners than other men. These reported risk behaviors have been theorized to serve as mutually reinforcing epidemics, known as syndemics,17–19,33 that can have additive effects resulting in substantially poorer health outcomes. As the number of psychosocial problems increases, so does HIV sexual risk-taking.18,19,34–36 Furthermore, behaviors among MSM who engaged in encounters with 4 or more partners were distinct from men who engaged in encounters with 2 or 3 partners. In addition, men residing in large metropolitan areas were more likely to report group sex than men residing elsewhere. This finding is similar to other reports of urban settings where sex parties appear to be growing in popularity.6,7 Web sites and smartphone apps for meeting sexual partners have become ubiquitous and have likely facilitated the growth of such parties. As a result, there has been increasing attention in the literature to group-sex parties as a source of HIV transmission risk.6,7,21,37
According to the Centers for Disease Control and Prevention, CAS has been increasing among MSM.38 Engaging in CAS within a group-sex setting presents a public health challenge, as these behaviors can increase the probability of HIV transmission by facilitating a greater number of concurrent sexual partners and potentially allowing for interaction among men from previously unconnected sexual networks.9,21 What limited research exists on undiagnosed HIV infection among MSM who engage in group sex suggests that rates may be higher than in other subsets of MSM, as there tends to be a higher HIV prevalence pool among MSM who participate in group sex.6,9 In the current study, the HIV prevalence of men with encounters with 4 or more partners was 35%, compared with men with encounters of 2 or 3 partners (21%) and men not reporting group sex (13%).
Limitations
Our results may not be generalizable to all MSM who access gay-oriented sexual networking Web sites, MSM who were exposed to the study e-mails, or MSM who engage in group sex. The online survey did not cover many areas in need of study to inform effective interventions aimed at this population such as lifetime history of group sex and social norms, whether men engaged in group sex during specific phases in their life (e.g., coming out; between relationships), the group-sex environment itself (e.g., condom availability), sexual partner characteristics, and reasons for drug use before or during group sex.
As this study was conducted in 2008, research is needed on knowledge of and attitudes toward more recent biomedical HIV prevention methods (e.g., preexposure and postexposure prophylaxis), especially now that most MSM can be reached with intervention content on smartphones. We also did not ask about critical childhood antecedents to HIV risk that are necessary to more accurately assess syndemic production, such as history of childhood sexual abuse, victimization, age at onset of sexual debut, or drug use. Although other studies have considered the role of childhood sexual abuse in syndemic production, in the current study we did not inquire about childhood sexual abuse or first sexual encounters. Finally, as this was a cross-sectional study, causal associations among the syndemic conditions and group sex cannot be determined.
Conclusions
Despite these limitations, the high prevalence of HIV, continual increase in new HIV diagnoses, and lack of awareness of partner serostatus calls for novel strategies to identify subgroups of MSM in need of HIV risk-reduction interventions.39 A considerable proportion of MSM who have participated in online research engage in high-risk behaviors and may be particularly in need of HIV prevention.15,30,40 However, individual- and group-level evidence-based interventions may not be a good fit for MSM experiencing syndemic conditions, as evidenced by the fact that many men in this study were using multiple drugs, and yet only a small proportion had ever accessed substance abuse treatment. It is also unlikely that interventions that function to raise awareness of the risks of HIV infection or the risks of drug use, or to raise condom-use skills, would result in lowered HIV-incidence rates in this population because both the direct effects of such interventions and the uptake of these prevention services are likely to be modest.41,42 Furthermore, structural-level interventions at public sex environments that promote condom use may be viewed as stigmatizing for men who wish to engage in CAS at these events.43
Syndemic production in relation to group sex among MSM remains largely unstudied. Our study among men with encounters with 4 or more partners has identified a particularly high-risk subgroup in the MSM population with evidence of syndemic production. Combination HIV-prevention efforts are needed for these high-risk men. For example, one combination approach for HIV-negative MSM who engage in polydrug use and high-risk sexual activity could entail them working with health care providers to use preexposure prophylaxis or postexposure prophylaxis (biomedical), in combination with quarterly HIV testing (biomedical), mental health counseling (psychosocial), and use of a smartphone app that addresses drug and alcohol use (behavioral). Testing the feasibility of preexposure prophylaxis or postexposure prophylaxis uptake and adherence in HIV-negative MSM who experience syndemic conditions and who engage in group sex may be an approach that would yield significant adoption in this population and protect men from HIV infection until such time that they disengage from participation in this high-risk activity.
Acknowledgments
Primary support was provided by the Centers for Disease Control and Prevention, where technical assistance was provided through a federal cooperative agreement in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, and approval of the article.
Note. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Human Participant Protection
The institutional review boards at Public Health Solutions and the Centers for Disease Control and Prevention reviewed and approved all study procedures.
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