Perceived Challenges and Rewards of Forming a Sexual Agreement among HIV-Negative Male Couples

Abstract

Sexual agreements, explicit mutual understandings made between two partners about which sexual and related behaviors they agree to engage in within and/or outside of their relationship, are common among male couples. However, little is known about the perceived rewards and challenges partnered men face in the process of forming a sexual agreement. Such knowledge may be useful for development of future HIV preventive and sexual health programs that encourage male couples to establish a sexual agreement in their relationship. By using qualitative dyadic data from a sample of 29 self-reported concordant HIV-negative male couples who had a sexual agreement, the present qualitative study sought to: assess partnered men’s perceived rewards and challenges of forming a sexual agreement in their relationship; and examine whether both men in the couple concurred about their perceived rewards and challenges of forming a sexual agreement. Themes for perceived rewards were: 1) being honest, 2) improving communication, 3) increasing understanding about expectations and permitted behaviors, 4) enhancing intimacy and relational bond, and 5) building trust. Themes for perceived challenges were: 1) stigma about having an open agreement; 2) awkwardness about the topic and talking about it; 3) jealousy; 4) no perceived challenges. Few couples had both partners concur about their perceived rewards or challenges toward establishing a sexual agreement. The variety of perceived rewards and challenges highlight the need for tailoring given that a variety of factors may influence partnered men’s establishment of a sexual agreement in their relationship.

INTRODUCTION

A sexual agreement is an explicit mutual understanding made between two male partners about which sexual and relational behaviors they agree to engage in within and/or outside of their relationship (Hoff & Beougher, 2010). The prevalence of sexual agreements within male couples’ relationships appears common (e.g., 50% – 90%) yet is dependent on whether data was collected from both men of the couple (i.e., dyadic data) (Crawford, Rodden, Kippax, & Van de Ven, 2001; Gass, Hoff, Stephenson, & Sullivan, 2012; Hoff & Beougher, 2010; Hoff, Beougher, Chakravarty, Darbes, & Neilands, 2010; Kippax et al., 1997; Mitchell, 2014; Mitchell, Harvey, Champeau, Moskowitz, & Seal, 2012; Prestage et al., 2008). For example, in a study with 361 male couples (n=722 men) that collected dyadic data, 506 (70%) partnered men self-reported they had a sexual agreement with their main partner; however, at the couple-level, only 414 (57%) of these men who represented 207 couples had concurred about having a sexual agreement in their relationship (Mitchell, 2014). The types of sexual agreements that male couples form and the behaviors they allow to occur per their agreement vary. For instance, some couples form a ‘closed agreement,’ in which partners agree to only have sex with each other (e.g., condomless anal sex) whereas other couples form an ‘open agreement,’ in which partners may engage in sex within and outside of their relationship, with or without specific guidelines (e.g., is condomless anal sex with casual MSM partners permitted?) (Hoff et al., 2010; Gass et al., 2012; Hosking, 2013; Mitchell, 2014; Parsons, Starks, DuBois, Grov, & Golub, 2013; Prestage et al., 2008).

The reasons why male couples establish a sexual agreement in their relationship have also been documented (Gass et al., 2012; Hoff et al., 2010; LaSala, 2004; Mitchell, 2014). Among a large sample of gay male couples (N=566) residing in the San Francisco Bay area, Hoff and colleagues (2010) reported the reasons why men formed an agreement with their relationship partner. They noted that building trust and honesty were the top two endorsed reasons by the men, irrespective of their relationship HIV status and agreement type (Hoff et al., 2010). In a large Internet-based sample of gay male couples (N=361) in the US, minimizing risk for HIV and other sexually transmitted infections (STIs) and wanting monogamy or sexual exclusivity were the top two primary reasons reported by partnered men for why they wanted to establish a sexual agreement with their relationship partner (Mitchell, 2014).

While these studies highlight a few characteristics about male couples’ sexual agreements, further research examining couples’ perceived challenges and rewards associated with establishing a sexual agreement in their relationship is warranted for five important reasons. First, between one- and two-thirds of gay and other men who have sex with men (MSM) in the U.S. acquire HIV from their primary relationship partners (i.e., male couples) (Goodreau et al., 2012; Sullivan, Salazar, Buchbinder, & Sanchez, 2009). Second, sexual agreements have direct implications for HIV prevention because couples decide which sexual and related behaviors to engage in within their relationship (i.e., between the two relationship partners) and if applicable, with any casual sex partners outside of their relationship. Further, couples could also integrate testing for HIV and other sexually transmitted infections (STIs), pre-exposure prophylaxis (PrEP) (Grant et al., 2010), and/or nonoccupational post-exposure prophylaxis (nPEP) (CDC, 2015a) within their sexual agreements. Third, while sexual agreements appear to be common, not all male couples form an agreement as indicated by either one or both partners reporting that they did not establish one in their relationship (Hoff et al., 2009; Mitchell, Harvey, Champeau, Moskowitz, & Seal, 2012; Mitchell, 2014). Lastly, establishment of a sexual agreement is associated with male couples having greater levels of relationship satisfaction, relationship commitment, constructive communication, and trust (Darbes, Chakravarty, Neilands, Beougher, & Hoff, 2014; Hoff et al., 2010; Mitchell, Harvey, Champeau, Moskowitz, & Seal, 2012; Mitchell, Harvey, Champeau, & Seal, 2012). Male couples who establish, and are invested in, their sexual agreements are also less likely to engage in condomless anal sex outside of their relationship, which may help reduce their risk for acquiring HIV and other STIs (Darbes et al., 2014; Mitchell, Champeau, & Harvey, 2013; Mitchell & Petroll, 2013). Thereby, sexual agreements may provide an ideal platform to not only help male couples enhance dynamics within their relationship (e.g., trust, intimacy, communication), but to also assist them with navigating and reducing their risk for HIV and other STIs.

Interdependence theory posits that behaviors within couples’ relationships are independent because each partner has a certain amount of control and influence on the outcome in the behavioral interaction they have together (Kelley & Thibaut, 1978). This outcome is dependent upon each partner’s option, value, and assessment of the particular behavior and whether that behavior is important to their relationship. With respect to establishment of a sexual agreement, each partner’s perceived challenges and rewards of forming a sexual agreement will depend on their value and whether forming a sexual agreement in their relationship is important to them. As such, research which investigates partnered men’s perceived challenges and rewards of establishing a sexual agreement is needed to determine how best to encourage male couples without a sexual agreement to form one tailored to their own needs as well as the needs of their relationship. This dyadic perspective is necessary to consider for health promotion (e.g., formation of sexual agreements) and development of future HIV prevention programs for male couples.

To help address this gap in knowledge, the present qualitative study sought to: 1) assess partnered men’s perceived challenges and rewards of forming a sexual agreement in their relationship; and 2) examine whether both men of the male couple concurred about their perceived rewards and challenges of forming a sexual agreement. Qualitative dyadic data from 29 concordant HIV-negative male couples with an established sexual agreement that resided in either the Atlanta, GA or Detroit, MI metro areas were used to accomplish these aims.

METHOD

Recruitment and Eligibility

The University of Michigan and Emory University Institutional Review Boards approved all procedures for this study. Data for this study are drawn from interviews conducted in 2014 with 29 HIV-negative male couples from Atlanta and Detroit. Participants were recruited via the distribution of flyers at local gay-identified events and venues, ads on email listservs, and business card distribution through places that provide services and/or activities to gay men and other MSM, including local AIDS service organizations (ASOs) and community-based organizations (CBOs), bars, and coffee shops in Detroit and Atlanta metro areas. Placement of ads on Facebook were also used to target Facebook members whose profile webpage lists that they are male, 18 years of age or older, living in either of these metro areas, interested in men, and in a relationship (gender of relationship partner was clarified during the screening process). Active recruitment strategies were also used and included workers at ASOs and CBOs referring their MSM clients to our study. Interested men either clicked on the Facebook ad or called the number listed on the recruitment materials to learn more about the study before being screened confidentially online. Eligible men (aged >18, resident in Atlanta or Detroit, self-reported as being HIV-negative; had been practicing condomless anal sex in their relationship for > 6 months; have reported no recent history (< 1 year) of intimate partner violence or coercion; have formed and had a sexual agreement in their relationship for at least 6 months; had always adhered to their sexual agreement were then directed to an electronic version of the informed consent document. Once consented, participants were prompted to electronically input their first name, phone number, and email address along with their partner’s first name, email address and/or phone number so that their partner could be screened for eligibility and provided consent to participate. Both members of the male couple had to meet all inclusion criteria to enroll in the study.

Procedure

At the appointment, each partner was provided a copy of the consent document. Partners of each couple were interviewed simultaneously yet apart from one another (by different interviewers). Semi-structured individual-level interviews were used to record partnered men’s understandings about the history and aspects of their sexual agreement. All interviews were digitally recorded, transcribed verbatim, checked for accuracy, and de-identified.

Sexual Agreement Measures

A semi-structured interview guide was used for the interviews, which included questions about couples’ sexual agreements and associated experiences. Development of the interview guide was informed by findings from our prior studies conducted about male couples’ sexual agreements (blinded). Specifically, in the individual interview, men were asked, “How, if at all, was this experience [forming an agreement] challenging for you? How, if at all, was it rewarding?”

Analytic Plan

Thematic analysis (Braun & Clarke, 2006) was then employed to identify patterns (themes) of participants’ perceived rewards and challenges of forming a sexual agreement with their partner, and whether both partners of the couple concurred about their perceptions. Using a step-by-step iterative process (Frost, McClelland, Clark, & Boylan, 2014), each of the three research team members read the transcripts, took notes, and identified any overarching themes. Then each member reread and coded the transcripts for these themes. During meetings, the research team compared and discussed their coding for these themes and made adjustments as needed before creating the codebook. The codebook provided a description of the themes for coding along with their corresponding definitions. Each team member then used the codebook to code the transcripts once again. This process was applied for all transcripts and each team member reviewed one another’s coding of the transcripts to ensure consistency was achieved for the themes identified.

RESULTS

Twenty-nine self-reported HIV-negative male couples participated: Fifteen from the Detroit metro area and fourteen from the Atlanta metro area. Fifteen couples had an open sexual agreement and 14 male couples had a closed agreement. Participants’ mean age was 33 years (range: 19–65). Most partnered men self-identified as Non-Hispanic (n=56, 97%) and/or white (n=50, 86%) yet at the couple-level, 28% of couples were of mixed race (N=8).

Partnered Men’s Perceived Challenges of Forming a Sexual Agreement

As shown in Table 1, four themes were identified about partnered men’s perceived challenges of forming a sexual agreement with their partner: 1) awkwardness about the topic and talking about it; 2) jealousy; 3) stigma about having an open agreement; and 4) no perceived challenges.

Table 1.

Themes of partnered men’s perceived challenges and rewards of forming a sexual agreement in their relationship, by agreement type

Perceived challenges, n=52	Formed a closed sexual agreement	Formed an open sexual agreement
	n = 25	n = 27
	Awkwardness of topic and talking about it	4	2
Jealousy	3	8
Stigma about open	4	5
relationships/agreements
Not challenging	14	12
Perceived rewards, n=50	n = 25	n = 25
Being honest	3	4
Improving communication	4	4
Increasing understanding	6	4
Enhancing intimacy / relational bond	6	9
Building trust	6	4

Note. Partnered men who were not represented in the table either reported other reasons that were quite different from the themes identified from the sample, or were not asked about their perceived challenges and/or rewards in forming a sexual agreement with their partner.

Awkwardness about the topic and talking about it

Six partnered men (10%) expressed that a challenge for them was bringing up the topic of sexual agreements and talking about it with their relationship partner. Of these six men, two formed an open sexual agreement and four of the men formed a closed agreement with their main partner. Some shared that their insecurity or not knowing how their partner would respond made initiating the conversation difficult, as noted by this representative participant:

The challenge comes with not knowing how the other person will respond… So the challenge was really all the what-ifs, you know. What if he’s not going to agree to that, what if they say they agree but they don’t follow it. Those kind of things. (closed agreement)

Another participant similarly shared:

I would say it was a little bit harder to bring up the topic because I really liked him and I had the insecurity, like okay, I didn’t want to push or push too hard and be like, ‘Okay how do I be cool and casual about this and let him know that this is what I really want.’ (closed agreement)

However, a few of the partnered men indicated that being transparent with their partner helped them overcome the awkwardness of the topic. For instance, one participant revealed, “You know, I want to say there is a tinge of awkwardness to it… I’m not gonna lie. But… both of us just had to be pretty transparent” (open agreement).

Jealousy

Jealousy was a perceived challenge for 11 of the participants (19%); eight of these partnered men formed an open sexual agreement, and three of the partnered men formed a closed sexual agreement with their main partner. Some men felt jealous whereas others perceived their partner to be jealous, therefore making it difficult to initiate the conversation to form a sexual agreement in their relationship. One participant shared his experience about jealousy and getting past it:

Uhm… it was challenging for me, especially in the beginning, because I do kinda have some jealousy issues uh –but when I realized that it wasn’t about me, it was about us, it became a lot easier to –to kinda wrap my head around. (open agreement)

Conversely, another shared his challenges with his partner’s jealousy:

I probably pushed the boundaries for our relationship further than uh… at times he was ready for… So I think jealousies can come up. I think they come up a little bit more for him than they come up for me. Uhm… and I think that insecurity’s probably been the biggest struggle with it, and me pushing the boundaries. (open agreement)

Stigma about having an open agreement

Nine partnered men (16%) shared that a challenge in initially forming a sexual agreement with their partner was overcoming the potential stigma about having an open relationship. Due to this stigma, these men appeared to have an internal conflict between re-specifying their desires to form an open agreement and breaking past the social norms of monogamy.

What makes you feel guilty when you’re with someone? Even though everything you did is okay, why does it make you feel guilt? So I think as we say, like, being human with each other, there’s a lot of humanness that comes up… But I think it’s – uh… it’s almost like we’re kinda, like, getting closer to an alligator pit or, like something in order to experience and train ourselves, and, like, you know, we’re kind of giving ourself more experience and more stuff to work with, I think, than a traditionally closed relationship. (open agreement)

Interestingly, this participant’s partner expressed his challenge in a different view that stemmed from how others’ may perceive him and their relationship:

Uhm… [the stigma]’s the first thing that my friends think is, ‘Oh, he’s–he’s open that means he’s like sleeping around with other people.’ And that could be the case for open relationships, but it’s not for ours. (open agreement)

Of the nine participants who were included in this theme, five formed an open sexual agreement while four formed a closed agreement with their main partner.

No perceived challenges

A little less than half of the participants (n=26, 45%) perceived forming a sexual agreement with their main partner to not be a challenge. Twelve of these partnered men formed an open sexual agreement with their main partner while the remaining 14 formed a closed sexual agreement. Most of these men expressed that the experience was a part of the evolution of their relationship yet shared they knew what they wanted from the beginning.

I didn’t sense it being difficult to have an agreement or keep the agreement. I think we’re both pretty much on the same page about what we expected. I knew going into it [relationship] in June when we decided to become exclusive that that was part of the territory. (closed agreement)

Partnered Men’s Perceived Rewards of Forming a Sexual Agreement

In addition to the perceived challenges that participants shared about forming a sexual agreement, many also shared how they perceived forming a sexual agreement with their partners to be rewarding (Table 1). Several themes pertaining to this rewarding aspect were identified, including: 1) being honest, 2) improving communication, 3) increasing understanding about expectations and permitted behaviors, 4) enhancing intimacy and relational bond, and 5) building trust.

Being honest

Seven partnered men (12%) shared that being honest and open with their partner was a rewarding aspect of forming a sexual agreement. For these men, being honest helped to relieve some of the stress related to developing the relationship they wanted to be in:

It [agreement] was something that we were both thinking about for a while and it was just like a weight off of our shoulders, we’re finally honest. We weren’t playing into what we [thought] that our relationship would be. We really started to forge something that we know is going to work for us… The reward was getting it out there. (open agreement)

Four of the men who perceived being honest as a reward to forming a sexual agreement established an open sexual agreement while the other three formed a closed sexual agreement with their partner.

Improving communication

Eight participants (14%) reported that one reward of forming a sexual agreement with their partner was improving the communication in their relationship. For example, one participant expressed:

I think it is rewarding that you can have a conversation that for some might be really difficult, uh… but have it so easily and not really have it cause any strife … sometimes you take things for granted but if I–if I hafta be have thankful for something its- it’s that we can talk about uhm… certain subjects and, you know, not have it be–not have it turn into an argument. (open agreement)

Others shared that forming a sexual agreement helped to facilitate their conversations to be more constructive with their partners, whereas in the past, those same types of conversations would have led to them having arguments [before the agreement was formed].

It was the first time I think that I was able to have a conversation where we were open and just talked. No anger, no nothing getting thrown or anything crazy like that, no yelling, no screaming, nothing. It was just flat out conversation, which I appreciated. (closed agreement)

Half of these eight men formed an open sexual agreement with their partner while the other half had formed a closed agreement.

Increasing understanding about expectations and permitted behaviors

Another rewarding aspect of forming a sexual agreement noted by 10 participants (17%) was their increased understanding about expectations and permitted behaviors within and/or outside of the relationship. Of these 10 participants, six formed a closed agreement with their partner while the other four formed an open agreement. Many reported feeling rewarded because they and their partner cleared uncertainties and boundaries, and thus felt ‘on the same page’. For instance:

It was nice that he was so open to this conversation, and that we have like, a clear understanding of what we want and how a relationship looks to us and how we want it to look to other people, so I think it was really rewarding to not have a grey area when it comes to uh, the two of us. (closed agreement)

Some found that increasing understanding about expectations and behaviors strengthened their ways of resolving other issues that arose in the relationship. For example, one participant shared, “I think so. I mean, like I said, I think it really strengthened us in regards to understanding, being able to deal with everything else when you’ve dealt with that one glaring issue” (open agreement).

Enhancing intimacy and relational bond

Several partnered men (n = 15, 26%) reported that forming a sexual agreement was rewarding because it enhanced the intimacy and relational bonds within their relationship (i.e., with their main partner). Some participants felt that forming a sexual agreement alleviated sexual tension or frustration within the relationship, and thus enhanced the intimacy with their partner. For example, one participant answered that forming an agreement was rewarding sexually, and added, “I’d just say it’s a way for us to be able to–to enjoy being together… no tension there between us” (open agreement). Others felt that forming a sexual agreement allowed them to explore sexually outside the relationship, and thus enhanced intimacy and other dynamics within the relationship. For example, a participant expressed his feeling of being sexually liberated:

Oh sure, yes, because I think we’ve found ways of being intimate that we haven’t found uhm… just individually… I didn’t have to feel guilty about finding someone else, having sex and then coming home and being this sort of psychological wreck that I had been in other relationships. So it’s been rewarding in that– in that way too. I–I think it’s for my mental health it’s been a lot better. (open agreement)

Further, some men shared that while intimacy was enhanced, relational bonds were enhanced as well. They felt a stronger connection with their partners and felt that each of them could grow together in their relationship:

I think the rewards have been watching each other grow, watching myself grow, having someone there–someone there with me to help me through that process, sometimes to kick me in the ass to get me in that process in a good way… it makes our relationship stronger, because we have had to negotiate a lot. We’ve had to face ourselves with someone else there seeing us… you know, and he has helped me face [my insecurities at moments in my relationship] and also uhm… you know helped me get through those things, and so–and I’ve done the same in reverse for him, I believe. (open agreement)

Of the 15 participants, nine men had formed an open agreement, and the remaining six had formed a closed agreement with their partner.

Building trust

Lastly, about a fifth of the participants (n = 10, 17%) shared that forming a sexual agreement was rewarding because it helped build trust in their relationship. They felt sexually secure knowing that their partner was trustworthy, as expressed by this one participant, “I feel comfortable with him. I feel like… like we don’t use condoms when… um we have intercourse but I feel completely comfortable and safe knowing that he’s not the guy that’s gonna go ahead behind my back” (closed agreement). Others expressed that building trust helped to maintain security and stability in their relationship. For example, “I know that he’s always gonna come home to me and he knows I’m always gonna come home to him” (open agreement). Six of these 10 men who perceived building trust as a reward to forming a sexual agreement established an closed sexual agreement while the other four formed an open sexual agreement with their partner.

Couples’ Concurrence on Perceived Challenges and Rewards about Forming a Sexual Agreement

Tables 2 and 3 illustrate perceived challenges and rewards of forming a sexual agreement at the couple-level by examining differences and similarities between the two partners of the male couple. Ten of the 29 male couples concurred about their perceived challenges in forming a sexual agreement (Table 2). Seven of the 10 male couples who concurred about their perceived challenges indicated the process was not challenging, while two couples had both partners agree that stigma regarding having an open relationship was challenging, and the remaining one couple had both partners agree that jealousy was challenging. Seven of the 29 male couples concurred about their perceived rewards in forming a sexual agreement (Table 3). Four couples concurred that enhancing intimacy and relational bond was rewarding, two couples concurred about building trust, and the remaining couple concurred about improving communication in their relationship was rewarding. All other male couples had partners who differed on their perceptions about what was challenging and/or rewarding in forming a sexual agreement in their relationship.

Table 2.

Perceived challenges of forming a sexual agreement at the couple-level: Differences and similarities between the two relationship partners

	Partner 2’s perceived challenges
Partner 1’s perceived challenges	Awkwardness of topic and talking about it	Jealousy	Stigma about open relationships / agreements	Not challenging
Awkwardness of topic and talking about it		1
Jealousy	2	1	2
Stigma about open relationships/agreements	1		2
Not challenging	2	3	2	7

Note. Of the 23 couples represented, ten male couples had partners who concurred about their perceived challenges of forming a sexual agreement; the remaining 13 couples had partners who each reported different challenges. The six male couples who were not represented in the table either had one or both partners reporting other reasons that differed from the rest of the sample (e.g., transportation issues) or were not asked about their perceived challenges of forming a sexual agreement.

Table 3.

Perceived rewards of forming a sexual agreement at the couple-level: Differences and similarities between the two relationship partners

	Partner 2’s perceived rewards
Partner 1’s perceived rewards	Being honest	Improving communication	Increasing understanding	Enhancing intimacy / relational bond	Building trust
Being honest		1	1
Improving communication		1	3	1
Increasing understanding	2			2
Enhancing intimacy / relational bond		1	1	4
Building trust			1	1	2

Note. Of the 21 male couples represented, seven male couples had partners who concurred about their perceived rewards of forming a sexual agreement in their relationship; the remaining 14 couples had partners who each reported different perceived rewards from one another. The eight male couples that were not represented in the table either had one or both partners reporting other reasons that differed from the rest of the sample (e.g., having more fun at bars) or were not asked about their perceived rewards of forming a sexual agreement.

DISCUSSION

The present study extends our understanding about male couples’ sexual agreements by examining partnered men’s perceived challenges and rewards of forming a sexual agreement in their relationship. Understanding both partnered men’s and collectively, male couples’ experiences in forming a sexual agreement is important to investigate as this information can be used to encourage male couples who do not have a sexual agreement to form one tailored to their own individual needs as well as their needs within the relationship. Emphasizing the perceived rewards partnered men have identified and attempting to minimize potential challenges may help to achieve this goal as formation of a sexual agreement has been associated with greater levels of relationship dynamics (e.g., better communication and trust) and lower sexual risk for acquisition of HIV among male couples (Darbes et al., 2014; Mitchell et al., 2013).

Our findings revealed a number of challenges that partnered men faced in the process as well as the rewards that accompanied forming a sexual agreement with their partner. Overall, partnered men had positive views in forming a sexual agreement and shared the many benefits and rewards they felt during this process. Some of the themes that emerged from our interviews align with a number of previous studies’ findings. Hoff and Beougher (2010) detailed male couples’ motivations to maintain their sexual agreement among a sample of HIV-negative male couples, which highlights that the primary motivator was to benefit the relationship (i.e., deepening emotional bond, understanding boundaries). Many of the couples in our sample reported similar experiences as the rewarding aspects of forming a sexual agreement (i.e., enhancing intimacy and relational bond, increasing understanding of boundaries). Similarly, Hoff et al. (2010) described that the primary reasons to form a sexual agreement among a sample of HIV-negative partnered men were honesty, trust, strengthening the relationship, and the ability to be more sexually adventurous, all of which align with our themes about partnered men’s perceived rewards of forming a sexual agreement. Further, LaSala (2004) illustrated reasons partnered men establish monogamy (i.e., “closed agreement”) or sexually nonexclusive agreements (i.e., “open agreement”). In that study, the primary reasons partnered men established monogamy were for exclusivity, avoidance of jealousy, and fear of HIV; primary reasons partnered men established sexually nonexclusive agreements were for personal and sexual freedom and to protect the primary relationship (i.e., clearer rules and boundaries, safer sex) (LaSala, 2004). Our findings about partnered men’s perceived rewards and challenges of establishing a sexual agreement align with the prior work of these studies while taking into account the variety that exist in the nature of sexual agreements (i.e., open vs. closed agreement). Our findings also contribute to existing literature because it presents not only the motivations/reasons/rewards of why partnered men form sexual agreements, but also, simultaneously, the challenges that partnered men have faced in the process of forming a sexual agreement. With respect to the couple’s formation of their sexual agreements, data from these interviews did not capture how much time (e.g., few hours vs. one week) it took couples to form their sexual agreement; other findings from these interviews note how (i.e., what initiated the process) and when couples formed their sexual agreement in the relationship (e.g., at beginning of their relationship) and are discussed elsewhere (blinded ref).

Partnered men also perceived some important challenges while forming a sexual agreement with their main partner. These challenges are noteworthy for promotion of sexual agreements in current and future sexual health and HIV prevention efforts targeting male couples. One perceived challenge identified pertained to some participants feeling awkward and uncomfortable about bringing up the topic of a sexual agreement with their relationship partner. Some felt uneasy initiating the conversation, and others felt insecure about how their main partner would respond. To help minimize this perceived challenge, we recommend future preventive efforts to develop and provide templates (e.g., talking points, sample conversations) for partnered men to use to help initiate the conversation with their relationship partner. For example, through the use of the different templates, partnered men may outline and practice how they would approach the topic through role-playing either by themselves, with a counselor and/or peer before they would initiate the conversation with their relationship partner (Sullivan et al., 2014). Providing these templates combined with the practice of role-playing may help increase men’s comfort level and self-efficacy for talking with their partner about forming a sexual agreement. These types of templates may be developed and disseminated through trained sexual health and prevention counselors (e.g., HIV/STI testing), other healthcare providers, and couples and family therapists. The use of technology-based platforms, such as a smartphone apps and web-based programs, should also be considered for dissemination of communication-focused templates about sexual agreements to help maximize reach and potential by health professionals and male couples alike.

Furthermore, participants also shared that overcoming the stigma they had, or perceived others to have about being in an open relationship (i.e., non-monogamous) was a challenge for them to overcome to form a sexual agreement. These partnered men reported difficulty in adopting the notion that having more than one sex partner is acceptable while being in a romantic relationship with their main partner. One way to help diminish this perceived challenge is to assist partnered men with identifying the reasons why they may have negative attitudes about open relationships, as well as why they may think others may not view open relationships positively. Acknowledgment of this potential stigma toward open sexual agreements could be addressed through a therapeutic component such as couples counseling or more broadly through individual- and couples-based HIV testing and counseling (CDC, 2011; CDC, 2015b; Stephenson et al., 2011; Wagenaar et al., 2012).

In addition to understanding the reasons for their negative attitudes toward open relationships, these men may also benefit by receiving social support about being sex-positive. Sex positivity can be defined as a form of sexual expression aiming to detach any shame or guilt about one’s thoughts and/or desires to engage in sexual behaviors [with others], as well as embracing the full benefits of sex as being healthy (WGAC, 2015). Embracing a more sex-positive attitude may help some partnered men overcome their negative attitudes about open relationships and as such, may help them facilitate their formation of a sexual agreement and support other male couples who do want to form an open sexual agreement.

Individuals and partners’ jealousy was also identified as a perceived challenge to forming a sexual agreement in couples’ relationships. The approaches previously discussed for helping participants overcome their stigma about open relationships and/or feeling uncomfortable about talking about sexual agreements may also help partnered men feel less jealous. For instance, partnered men may benefit by identifying why they feel jealous and how they can best share these feelings with their relationship partner through the use of templates of conversation starters along with role-playing. Using these tools and skills may help men and their relationship partners develop a plan to alleviate and prevent them from feeling jealous and how best to maintain reassurance with one another. Diminishing jealousy may help male couples more easily form a sexual agreement in their relationship; one prior study has reported that avoiding jealousy was one motivating factor for why some partnered men wanted to establish a sexual agreement with their relationship partner (Mitchell, 2014). Other work has also shown that jealousy also affects partnered men’s satisfaction with their sexual agreements (Hosking, 2014), thereby underscoring the importance for helping couples obtain skills to better understand their jealousy and how best to avoid it from occurring in their relationship.

Further, as evident in our data, not many male couples concurred about their perceived challenges and rewards. This variety suggests the need to be cognizant about the different drivers and experiences that male couples may encounter when forming a sexual agreement in their relationship. As noted in a recent literature review (Mitchell, 2015), different technologies (e.g., eHealth) may be helpful to use to help encourage male couples to establish a sexual agreement; these technologies allow the ability to account and tailor for partnered men’s perceived rewards and challenges as well as the needs of the couples’ relationship. According to Interdependence Theory (Kelley & Thibaut, 1978), when both partners of the couple disagree about what they each perceive to be rewarding and/or challenging toward forming a sexual agreement (i.e., value), this could impact whether they form a sexual agreement (i.e., the option of forming one), the process of forming an agreement (i.e., the experience), as well as when they decide to establishment a sexual agreement in their relationship. It is important to recognize that all male couples in this sample had successfully established a sexual agreement in their relationship, yet how long that process took is worth investigating in future work as well as how best to encourage others who do not have a sexual to form one.

Limitations

This study has limitations. The study sample was a non-generalized, convenience sample of HIV-negative male couples that resided in either the Detroit or Atlanta metro areas, thus these findings may not be representative of all male couples who resided in other regions of the United States. Selection bias is another limitation to consider because the study recruited male couples who had already established a sexual agreement in their relationship and had kept it for at least six months prior to being interviewed. Thus, couples’ experiences in this sample may differ from other couples who formed an agreement but did not adhere to it, as well as couples who do not have an agreement at all. Future work that includes male couples and stratifies the sample based on these key differences would help illuminate and identify which perceived challenges and rewards facilitate or prevent them from establishing a sexual agreement. In addition, the lack of concurrence in couples’ experiences regarding perceived rewards and challenges of forming a sexual agreement might in part be due to the timing of when the agreements were formed in their relationship (i.e., recall bias). Other factors could have also influenced what partnered men perceived as challenges and rewards in forming a sexual agreement, such as power dynamics and intimate partner violence. While our sample size was relatively small, this sample was diverse in terms of age, relationship length, sexual agreement type, and to a lesser extent, by race and ethnicity. Additional research that includes a larger regionally and racial/ethnically diverse sample size and explores how different relationship dynamics may influence couples’ agreement formation is warranted, as well as studies, which include samples of HIV-discordant and concordantly HIV-positive male couples. Future research should also investigate how culture (e.g., Latino) and religion may influence male couples’ perceived rewards and challenges of establishing a sexual agreement in their relationship.

Conclusions

Our findings highlight that a variety of themes were related to male couples’ perceived rewards and challenges of forming a sexual agreement in their relationship. For many of the couples, these perceptions varied between partners within the relationship. Sexual health and HIV prevention programs should emphasize to male couples the potential rewards of forming a sexual agreement in their relationship as well as providing them with tools to help alleviate any potential challenges they may encounter while forming their agreement. Additional research is warranted to better understand the process that male couples undergo when establishing a sexual agreement in their relationship.