“What does it matter?” Young sexual minority men discuss their conversations with sexual partners about HPV vaccination

Abstract

Objective:

Human papillomavirus (HPV) vaccination coverage is suboptimal, especially among males. Social networks influence young adults’ health behaviors and could be leveraged to promote vaccination. We sought to describe how young sexual minority men communicate about HPV vaccination with their sexual partners.

Participants:

National (U.S.) sample of sexual minority men ages 18–26 (n=42) from January 2019.

Methods:

We conducted four online focus groups and identified salient themes using inductive content analysis.

Results:

Across groups, participants described that HPV vaccination is not a focus of their conversations with sexual partners. Key themes related to HPV vaccine communication included: relationship type; safe sex; knowledge and awareness; and feelings of discomfort.

Conclusions:

Findings provide novel insight into how young sexual minority men communicate with their sexual partners about HPV vaccination and identify potential areas for interventions to promote communication. Future research is needed to investigate associations between partner communication and HPV vaccine uptake.

Introduction

Human papillomavirus (HPV) infection and associated cancers are a serious public health concern in the United States. HPV is the most common sexually transmitted infection (STI) in the U.S.; nearly all sexually active people will be infected with at least one type of HPV at some point in their lives.¹ HPV accounts for nearly 50% of all STIs in adolescent and young adult males aged 15 to 28.^1–2 Some types of HPV infections (such as types 6 and 11) can cause genital warts and other types of HPV infections (such as types 16 and 18) can lead to cancer, such as penile, oropharyngeal and anal cancers.³

HPV vaccination is approved by the U.S. Food and Drug Administration to help prevent certain types of HPV-associated cancers and genital warts.⁵ HPV vaccination is recommended for all adolescents aged 11–12, ideally before sexual activity generally begins, though it can be given as early as age 9.⁷ The Advisory Committee on Immunization Practices (ACIP) also recommends catch-up vaccination for older adolescents and young adults through age 26 if the series was not received at the recommended ages.⁸ If initiated before age 15, HPV vaccine is administered as a series of two doses; and if initiated after age 15, three doses are required.⁵

Despite these national recommendations, HPV vaccine uptake is suboptimal, especially among males and young adults. Only about 50% of age-eligible male adolescents in the U.S. have received any doses of the vaccine.^9–11 Vaccination estimates among young adults suggest lower coverage. For example, one study found that only one out of six young adults ages 18–26 had completed the vaccine series, with males being less likely than females to complete the series.¹² With this in mind, it is important to target college-aged males in order to increase HPV vaccine coverage. For this reason, HPV vaccination is listed as one of the Healthy Campus 2020 objectives by the American College Health Association.¹³

Among college-aged males, young sexual minority men (YSMM; i.e., men who have sex with men or identify as gay, bisexual, or queer, or report attraction to men) are an important group to receive HPV vaccine as they have disproportionally high rates of HPV infection and HPV-related disease. For example, incidence rates for anal cancer are higher among sexual minority men (60 cases per 100,000 population) than for heterosexual men (2 .cases per 100,000 population).^14–16 Moreover, fewer than half of sexual minority men have received any doses of HPV vaccine, and fewer than 20% have completed the series.^17–21

Given the many transitions that often come with emerging adulthood¹ (i.e., starting college, engaging in sexual relationships), the influences on vaccination decisions during this time may differ from those during adolescence. Although parents are the key decision-makers for routine HPV vaccination in adolescence,²² older adolescents and young adults (i.e., college students) are increasingly involved in making decisions regarding their own health care.²³ Thus, it is important to identify factors that influence vaccination decisions in young adults to increase vaccine coverage.

Older adolescents and young adults are influenced by their social networks.²⁴ As youth age and gain independence from parents or caregivers, they may begin to be more influenced by, and rely more heavily on, sexual partners for support than their parents and friends.²⁵ Further, interactions between young adults and their partners are distinct from those with their parents or friends.²⁶ While both friends and parents may provide social support, the intimate nature of the relationship between sexual partners that provides key emotional support may have a different influence on certain behaviors.²⁷ For example, communication with sexual partners has been found to increase sexual protective behaviors, including contraceptive use.^28–31 Similarly, it is possible that communication with sexual partners could encourage HPV vaccination. However, little is known about whether young adults, including sexual minority individuals, talk with their sexual partners about HPV vaccination, and whether such communication influences vaccination decisions. In this qualitative study, we sought to describe how YSMM communicate about HPV vaccination with their sexual partners.

Methods

Participants

During January 2019, we conducted four focus groups (eight to ten participants in each focus group) with sexual minority young adult men as part of the development of an online intervention to increase HPV vaccination.¹⁶ The broader goal of the focus groups was to solicit men’s experiences with HPV vaccination and their input on intervention content and recruitment strategies. We recruited participants through itracks,³² a qualitative research company that maintains a multimillion-member panel and provides a platform for focus groups to have real-time conversations in an online environment. The research company invited potentially eligible panel members to participate via an email, which contained information about the study including days and times of focus group sessions. Interested individuals then confirmed their eligibility status. Panel members were eligible if they (a) were cisgender male; (b) were 18–26 years old; (c) reported ever having oral or anal sex with a male, being sexually attracted to males, and/or identified as gay, bisexual or queer; and (d) lived in the U.S. We capped eligibility at age 26 to align with recommendations for HPV vaccination at the time of the study.⁸ Panel members confirmed eligible provided informed consent and completed a brief questionnaire about additional demographic and health characteristics prior to the start of their focus group.

Data Collection

A moderator from the research team used a semi-structured guide to conduct focus groups, which maintained a standard structure and question sequence while also allowing participants to introduce new ideas. Focus group questions for the present analysis are shown in Figure 1.

Figure 1.

Semi-structured focus group questions

Focus groups were real-time, text-only discussions conducted through the research company’s web-based platform, so neither the moderator nor the participants could see or hear one another. Participants created screen names/pseudonyms for use during the online focus group to maintain anonymity. Focus group sessions lasted roughly one hour, and participants were compensated with an incentive of $100. Focus group transcripts were stored in a secure database that could only be accessed by members of the research team. The Ohio State University Institutional Review Board approved study protocols.

Data Analysis

We first described the sample using participant responses to a demographic questionnaire, calculating means and standard deviations (for continuous variables) and percentages (for categorical variables). We then conducted a thematic content analysis³³ of focus group data to better understand how YSMM communicate with their sexual partners about HPV vaccination. Two members of our research team (MM and AG) served as analysts first independently reviewed data and developed initial inductive codes. The analysts met to develop a codebook to apply across all four transcripts. For the purpose of this analysis, the coding scheme was only applied to questions which focused on communication with sexual partners. The analysts compared codes applied to each transcript to increase intercoder reliability.³⁴ The whole research team met to resolve any discrepancies and discussed findings from the content analysis to identify overarching themes.

Results

Sample Description

As shown in Table 1, about half of participants (52%) identified as non-Hispanic white. The majority (73%) reported having at least some technical, college, or graduate level education. About two-thirds of participants (64%) of identified as gay, bisexual or other sexual orientation, 83% reported ever having had sex with a male, and 79% reported attraction to men. Fewer than half of participants reported that they had talked with a sexual partner about HPV vaccine (41%).

Table 1.

Sample characteristics (n=42)

	n	(%)
Age, in Years
18–21	11	(26.2)
22–24	14	(33.3)
25–26	17	(40.5)
Race/Ethnicity
Non-Hispanic White	22	(52.4)
Non-Hispanic Black	6	(14.3)
Non-Hispanic Other	5	(11.9)
Hispanic	9	(21.4)
Highest Level of Education
High school graduate	11	(26.2)
Some college or technical school	13	(30.9)
College graduate or higher	18	(42.9)
Relationship Status
Single	33	(78.6)
In a relationship	9	(21.4)
Sexual Identity
Straight	15	(35.7)
Gay	12	(28.6)
Bisexual	14	(33.3)
Not Sure	1	(2.4)
Ever Had Sex with a Man
Yes	35	(83.3)
No	7	(16.7)
Attracted to other men
Yes	33	(78.6)
No	9	(21.4)
Ever Infected with HPV
Yes	6	(14.3)
No	36	(85.7)
Received at least one dose of HPV Vaccinea
Yes	19	(55.8)
No	15	(35.7)
Talked to Sexual Partner about HPV Vaccineb
Yes	17	(41.5)
No	24	(58.5)

^an=34

^bn=41.

Themes

We identified three overarching themes regarding communication with sexual partners about HPV vaccine. The themes include (1) HPV vaccine is not a focus in conversations; (2) Relationship type matters; and, (3) Practicing safe sex is discussed. Table 2 displays each theme along with illustrative quotes.

Table 2.

Overarching themes

Theme	Illustrative Quotes
Theme 1: HPV vaccine is not a focus in conversations	“[HPV vaccination] might come up more readily in a monogamous relationship, but in either case, I feel like it’d be more important to disclose if you had an STD than having the vaccine.”
	“I don’t think people have to tell their sexual partners if they have gotten the HPV vaccine. Doesn’t really matter.”
	“I always tell my partners I got tested for [STI].”
Theme 2: Relationship type matters	“I don’t think the type of relationship should matter. I think everyone should be honest about their vaccine history.”
	“Casual conversation [about HPV vaccine] doesn’t necessarily happen during casual sex. I would say it’s more talked about in a relationship.”
	“It should be [discussed in] any [relationship], but people might not be ready to talk about STD’s in a casual hook up.”
Theme 3: Practicing safe sex is discussed	“I agree to telling your sexual partner because he should be the person you trust with about anything if you truly care about them.”
	“I think it’s important to share [vaccine history] information because you wouldn’t want to endanger your partner.”
	“If it’s a hook-up, [whether you talk about HPV vaccination] doesn’t really matter if you use protection.”

Theme 1: HPV vaccination is not a focus in conversations.

HPV vaccination was not a focus of communication between sexual partners. When asked specifically about HPV vaccination, participants spontaneously brought up STIs, including but not limited to HPV, rather than exclusively discussing HPV vaccination specifically in their responses. Several participants mentioned that it is more important to share if you have an HPV infection or other STI with a sexual partner, rather than whether or not you are vaccinated for HPV.

One participant shared their thoughts on discussing HPV vaccination with a sexual partner: “If you don’t have HPV, it isn’t necessary to mention [vaccination] unless the partner asks.” A handful of participants shared that they did not think they had to mention HPV vaccination status to their sexual partners whatsoever: “What does it matter? You don’t tell your partner when you get vaccinated for measles.” As mentioned above, participants spontaneously brought up other STIs or STI testing even when they were specifically asked about HPV or HPV vaccination. For example, one man said, “When it comes to my partner, [HPV vaccination] came up in a conversation about just getting tested for things.”

Knowledge and awareness also played a role in partner communication around HPV vaccination. A handful of men noted that they had little knowledge about HPV and HPV vaccination or were not aware of the vaccine before having conversations with partners. When asked about conversations around HPV vaccination with others, one man said that he felt “worried, because I didn’t know about [the HPV vaccine] at the time.” Some participants mentioned that discussing HPV vaccination may be informational or educational for their sexual partners who have little knowledge about HPV. Another man said that “not talking [about the HPV vaccine] made me want to educate others about it and make it a conversation.”

For a few participants, feelings of discomfort were a key driver of not discussing HPV vaccine with a sexual partner. One participant stated: “These are awkward, but necessary conversations.” Many participants said that discussing the HPV vaccine and sexual health more broadly makes them feel uncomfortable or judged by others, including, but not limited to, sexual partners.

Theme 2: Relationship type matters.

When participants were asked if they thought that they should tell sexual partners whether or not they received the HPV vaccine, many responded, “yes,” it would be good to discuss in all sexual relationships: “Even if it’s a hookup I would still ask if they got the vaccine, it does not hurt to ask.” This participant made clear that he thought vaccination status is good to bring up to all sexual partners, despite the relationship type, meaning having conversations about HPV vaccination with both casual and serious sexual partners.

Nevertheless, the majority of participants responded that having conversations with sexual partners around HPV vaccination depended on the relationship type (i.e., casual versus serious relationships). One compared and contrasted casual, hook-up relationships to more serious, intimate relationships: “Casual conversation doesn’t necessarily happen during casual sex. I would say it’s more talked about in a relationship.” Many participants agreed that they would be more likely to share whether or not they are vaccinated for HPV with a more serious, long-term partner.

However, several participants shared that they have had experiences where they felt like they should have had more of a discussion around vaccination with their partner than they actually did. For example, one man said: “I would be more likely to tell my serious partner, but it really should be that way in an ideal society, I think. This is a serious issue that all partners should talk about, casual or not.” Participants frequently mentioned this lack of in-depth conversation to be more likely in sexual encounters with casual sexual partners.

Theme 3: Practicing safe sex is discussed.

While the focus of conversations between sexual partners was not on HPV vaccination, the overall goal to maintain open dialogue between sexual partners about sexual health and safer sex was mentioned by almost all men. For example, one participant said, “I think being open about anything to do with sexual health is something to be discussed with a partner.” Many of the men in our sample shared ideas and values that highlight being open and honest with all sexual partners, casual or serious, when it comes to sexual health.

Men also brought up ideas around making sexual experiences safer for both partners, by using protection (e.g., condoms) to do so. One man shared his thoughts on using condoms: “Even in hook ups, I talk with the person about STDs and such before even deciding on doing it. Regardless, I always use condoms.” Participants emphasized that also sharing information about HPV vaccine might increase safety between both partners in addition to usual safer sex practices, like using condoms. When asked if they would share whether or not they have been vaccinated with a sexual partner, one participant responded: “Yes, it makes things safer for both people.”

Discussion

This qualitative study provides novel insight into how YSMM communicate with their sexual partners about HPV vaccination. To our knowledge, it is among the first studies to do so. We found that men in our national sample generally do not discuss HPV vaccination with their sexual partners. However, they did report discussing STIs and condoms, and described circumstances in which conversations about sexual health may happen more readily with a sexual partner. Our findings suggest that many factors may contribute to whether these conversations occur.

Men in our study described low knowledge and awareness of HPV vaccination for males. Although not explicitly explored during our focus groups, other research suggests that misinformation (e.g., the vaccine is only for females) could contribute to low levels of knowledge about the vaccine.^{18, 35–37} Improving awareness and knowledge about HPV and HPV vaccination amongst YSMM for vaccination behavior ^{18, 35–37} is a critical first step in promoting communication between sexual partners that may guide vaccination decisions.

In contrast to their lack of communication around HPV vaccination, men in our study were in agreement about maintaining open dialogue with sexual partners about sexual health in general. Sexual partner communication has been shown to increase protective behaviors, like condom use.³⁷ For example, adolescents who discuss safer sex have been found to be more likely to use condoms, ^37–38 and HIV prevention interventions that include a safer-sex communication skills training component can increase the frequency of sexual partner communication about safe sex, and increased frequency of condom use.³⁹ Additionally, consistent with other research demonstrating that partner type (e.g., serious vs. casual) factors into discussions about sexual health between partners. YSMM in our study indicated that discussions about HPV vaccine may be more likely to happen between more serious, long-term partners compared to more casual partners.⁴⁰

While little is known about how YSMM discuss HPV vaccination with their partners, other research confirms that men tend to feel uncomfortable disclosing sexual health-related information, like STI status, to their partners.⁴¹ Indeed, participants in our study described the potential discomfort of doing so, consistent with other research.⁴¹ YSMM may experience a range of negative feelings while discussing STI status with a sexual partner, such as feelings of shock or betrayal; disclosure could also lead to physical harm or threats of harm.⁴¹ Feelings of STI-related shame and stigma may prevent young adults from having conversations with their sexual partners and potentially undermine STI testing, treatment, and partner notification programs.^42–43 However, although HPV is sexually transmitted, disclosing an STI to a partner is likely quite different than discussing a routine vaccination to prevent one. To our knowledge, little research has examined young adults’ discussions about similar, preventive health services.

Implications

We undertook this study to explore the potential for promoting HPV vaccination via sexual partner communication. Though our findings are inconclusive in this regard, they nonetheless highlight the need for college-age sexual minority men to receive education about HPV vaccination in order to increase vaccine uptake. With this in mind, college campuses may provide a unique setting to deliver HPV education and increase catch-up vaccination. College students in the U.S. generally have access to college health centers on campus, are required to have health insurance, and make their own healthcare decisions.^44–45 As previously mentioned, HPV vaccination is listed as one of the Healthy Campus 2020 objectives by the American College Health Association,¹³ suggesting that this setting is well-positioned to reach young adults for HPV vaccination. Indeed, several existing interventions have been successful in increasing college students’ acceptability and intention to get vaccinated, but not resulted in increasing actual vaccine uptake among this population.⁴⁴ Interventions that have resulted in vaccine uptake included components that engaged medical professionals and peer educators on college campuses.^{44, 47–48} However, most of these interventions have not been replicated by other institutions and were primarily focused on increasing HPV vaccination among females.⁴⁴

College campuses that implement HPV vaccination education interventions specifically targeting YSMM may consider including approaches from existing effective interventions. For example, a web-based intervention that included targeted information about HPV (e.g., risk of HPV-related disease among gay and bisexual men), HPV vaccine (cost, dosing schedules) and skills for accessing the vaccine (e.g., talking with a healthcare provider) shows promise for increasing uptake among this population.^9,16 Findings from our study suggest that additional components adapted from interventions that aim to enhance safer-sex communication skills for discussing and disclosing sexual health-related information,^39–40 could address YSMM’s needs. However, further research is needed to establish whether or not sexual partner communication is associated with HPV vaccine uptake.

Strengths and Limitations

The present study has notable strengths, including a national sample that was diverse with regards to race/ethnicity and sexual attraction, identity, and behavior; and the use of a convenient, anonymous online platform to conduct focus groups. However, this study also has several limitations. First, we could not go into great depth on all questions about partner communication, as these questions were just one section within a broader focus group guide. Focus groups may be prone to social desirability bias. However, focus groups for the present study were anonymous and conducted online, which may help to mitigate this concern. Additionally, selection bias is also a potential limitation, as men who were already interested in HPV vaccination may have been more likely to participate. Finally, while many participants reported having some college-level education, college students were not specifically recruited for these focus groups, and, as a small qualitative study, findings are likely not representative of the perceptions and experiences of all young sexual minority men on college campuses.

Conclusion

YSMM are an important group to target efforts to increase vaccine uptake. Communication with sexual partners may be a potential avenue to promote vaccination, as well as other behaviors related to sexual health. While many men are not currently discussing vaccination with their partners, many express that they think it could useful and may be amenable to doing so. Further college campuses may be an ideal setting to deliver such interventions among this population. Future research is needed to understand the best way to encourage partner communication and examine its effects on vaccination uptake.