The Social/Sexual Environment of Gay Men Residing in a Rural Frontier State: Implications for the Development of HIV Prevention Programs

Abstract

Context

The incidence and prevalence of HIV/AIDS is increasing among rural men who have sex with men (MSM). Yet little is known about the social/sexual environment of rural frontier areas.

Purpose

The purpose of this study was to assess the social/sexual environment of gay men living in rural areas and how this environment contributes to the development of HIV/AIDS prevention programs.

Methods

A qualitative study was conducted in Wyoming. In-depth guided interviews were conducted with 39 self-identified gay men. Data were analyzed for emergent themes using constant comparative analysis.

Findings

Four broadly related themes emerged. Participants perceive that they live in a hostile social environment in which the potential for becoming a target of violence is present. In order to cope with this social reality, men adopt strategies to assimilate into the predominant heterosexual culture and to look for sex partners. These, in turn, are related to their attitudes about HIV/AIDS and prevention activities. Notably, the Internet was discussed by participants as a means for men to connect to a larger gay society and look for sex partners and as a potential venue to HIV/AIDS prevention programs.

Conclusions

Data provided a number of implications for developing HIV/AIDS prevention programs targeting rural MSM. Especially apparent was the need for programs to be mindful of the desire to keep one's sexual preferences shielded from public knowledge and the effect this may have on recruiting rural MSM to participate in prevention activities. The Internet, because men can access it privately, might provide a venue for prevention projects.

HIV / AIDS continues to be a pressing public health problem in the United States.¹ Although the majority of persons who are infected with HIV or who have been diagnosed with AIDS reside in urban centers, the prevalence of AIDS in rural areas is increasing at 3 or more times rates in urban centers.^2-6 While the epidemic may be shifting to rural areas, little is known about who is HIV positive or who might be at risk of infection in rural areas. A notable study by Lansky et al⁷ surveyed HIV-positive persons living in small cities or in rural areas in 4 southern states. They found that the majority was male, African American, and infected through sexual contact. A quarter of the sample had been infected in a rural area, almost half through male-to-male sex. These data suggest that rural gay men, even if they never visit an urban AIDS epicenter, are at risk for HIV infection. While this study is an important contribution to delineating persons with HIV in rural areas, demographic patterns evident among HIV-positive southerners may not be indicative of patterns in other regions of the United States.

The number of epidemiological studies of HIV / AIDS in rural areas may be small, but there is a substantial literature on the social/sexual environment of gay men in rural areas.^8-12 A study by Preston et al¹³ found that antigay violence is an ever-present threat, such that openly gay rural men risk being targets for ridicule and physical assault. Rural men feel subjected to rigid and morally traditional standards of sexuality leading to secretive lives and feelings of isolation and loneliness. Approaches for meeting sexual partners are limited or restricted to informal friendship networks. Understanding the everyday social/sexual environment of rural gay men is important, as it provides some guidance for developing appropriate HIV prevention programs targeting rural men who have sex with men (MSM).

Research on HIV / AIDS prevention services for rural areas strongly suggests that programs need to take the social/sexual environments of rural gay men's lives into account.^13,14 Recruiting and training peer educators to deliver prevention messages or building and strengthening social networks to support reducing risky behaviors may be viable approaches. These types of prevention strategies, however, are often dependent on the identification of public venues in which MSM congregate or identifiable networks of MSM. Little is known about the venues, virtual or real, in which rural MSM congregate to socialize. In many rural areas, these venues might be truly hidden or might not exist at all. Furthermore, little is known about the social and sexual networks of rural MSM or how easily such networks might be identified, especially in areas that are not near urban areas.

The purpose of this study was to examine the HIV-relevant social/sexual environment of gay men in a rural frontier state and to use the results to inform the development of contextually appropriate HIV / AIDS prevention programs. Toward this end, a qualitative study with 39 self-identified gay men was conducted in Wyoming.

Methods

University committees for the protection of human subjects reviewed and approved study procedures. The project coinvestigator and 2 trained staff conducted in-depth interviews with 39 self-identified gay men residing in Wyoming between January 2001 and January 2002. Prior to an interview, the investigator explained the purpose of the study and the interview process, including audiotaping. Participants were told that if they chose to be a part of the study, they would not be required to answer questions they perceived as uncomfortable or threatening. Written informed consent was obtained, and participants were given a copy of the consent form. Interviews were conducted in a private setting of the participant's choice. The investigators were gay men who resided in the local community or who had spent substantial parts of their lives living in rural areas.

Interviews took about 2.5 hours and were semistructured. Investigators followed a guide but were given the discretion to make in-depth inquiries into topics that emerged during an interview. Each interview covered sexual history, social and sexual relationships, socializing, looking for sex partners, sexual behaviors, perceptions of HIV / AIDS, the impact of HIV / AIDS on sexual activities, and accessing gay-oriented media, including the Internet. The interview concluded by reviewing topics with participants and asking if they wished to clarify or expand on anything discussed during the interview.

Interviews were audiotaped and transcribed verbatim, and transcripts were compared to the original audiotape. Discrepancies between the recorded interview and the transcript were corrected.

Analysis

Data were analyzed using a constant comparative method consistent with the principles of grounded theory.^15-17 The search for emergent themes commenced with data collection. After each interview, the investigator recorded his impressions and noted themes that emerged. He then met with another of the investigators for debriefing, where emergent themes were assessed and areas for further investigation were developed. The 3 interviewers met monthly to discuss themes using notes, debriefing sessions, and coded transcripts.

Data were coded by one of the coinvestigators using printed copies of the transcripts. Codes were recorded in the margins. Codes were compiled and organized by theme.¹⁸ Themes were generated until no new themes emerged. The reliability of emergent themes was determined by agreement among all investigators. During latter interviews, themes were presented to participants as a further reliability check.

Sample

Men were eligible to be interviewed if they were 18 years or older and self-identified as gay or bisexual or had had sex with another man in the past year. Residency anywhere in Wyoming was acceptable. There are 23 counties in Wyoming, 18 of which are defined as frontier and 3 as rural. The remaining 2 are defined as urban, although no city in the state has more than 60,000 residents.^19,20

Men were recruited using snowball sampling.²¹ To assist in recruiting men of color, the single organization in the state providing HIV / AIDS-related services to people of color was asked to provide information about the study and contact information to any client who might be interested. Although eligibility criteria were more inclusive, no self-identified bisexual or heterosexual men were interviewed. (In presentation of the data, participants will be referred to as gay men.) The number of participants was sufficient to reach saturation in the data.

The sample consisted of 39 self-identified gay men residing in Wyoming. Eleven of the 39 participants (28%) were known to at least 1 of the interviewers. Five participants (13%) referred 1 friend, and the remainder did not know one another. Eighteen men (46%) resided in 1 of the 3 cities (Laramie, population approximately 27,000; Casper, 50,000; and Cheyenne, 53,000) with the highest HIV seroprevalence in the state.²² The remainder of the sample lived in rural or frontier counties. Participants' ages ranged from 20 to 65, averaging 35.9 years (SD = 11.2, median = 35). Thirty-two participants were white (82%), 4 Hispanic (10%), 1 Native American (3%), and 2 of mixed race/ethnicity (8%). The sample is consistent with the racial/ethnic characteristics of HIV-infected people in the state.²² The majority of participants, 36 (92%), were single. Two (5%) had been married to women and were divorced. Three (8%) said that they were partnered with other men.

Most participants, 27 (69%), had some college or were college graduates. Twenty-six men (67%) had full-time jobs and 3 (8%) regular part-time jobs. Four (10%) were students. The remainder (15%) were not working or were retired. Four participants (10%) told us that they were HIV positive. Two said that they became positive while residing outside the state and 2 while they were living in Wyoming.

Results

Four broadly related themes about the social/sexual environment of MSM residing in frontier/rural areas emerged from the data: social hostility, violence, assimilation, and social/sexual isolation. These were related to 2 additional themes: looking for sex partners and attitudes toward HIV prevention.

Social Hostility

Participants were very aware of an overtly hostile environment for gay men in Wyoming. By hostility, participants meant not only social disapproval of homosexuality as such but also the imposition of a rigid standard of social interaction that was strictly heterosexual. The most often mentioned form of social hostility was an enforced silence surrounding the issue of homosexuality. Participants said they were aware of the heterosexually dominated social standards and avoided behaviors and topics of conversation that could be construed as being gay. Participants believed that communicating anything positive about gay men or questioning negative communications about gay men was perceived by others as an admission of homosexuality. One study participant told us, “So much was the attitude that, well, if you're talking about it [being gay], you must be gay, too.”

Most participants could recall hearing hostile comments made by others about gay men, and could talk about such instances at length, as the following quote illustrates:

I didn't know what gay was until I grew up and went to college my freshman year. I did not know what it meant. I knew it was a bad thing growing up. It was a bad thing to be gay. It wasn't discussed in my house. My parents weren't anti-gay by any means, but, it just wasn't discussed. In school it was bad. But, I didn't have any idea what a gay lifestyle meant, not a clue.

An awareness of social hostility toward homosexuality influenced how participants interpreted their environment and the intentions of others toward them. Discussions of homosexuality by the heterosexual community or by the local media were viewed with suspicion and sometimes alarm. One participant illustrated this by referring to a newspaper article reporting the 2000 Wyoming census, which included the number of same-sex couples in a rural county. Although the article may have been value neutral, this man strongly suspected that some would use the information as a reason for hostile behavior:

The headline in their paper was, “Seven same sex couples in ______ County.” And, you didn't have to read between the lines too damn much to realize that the gist of the article was that they wanted to know who those 14 people were, or 7 households. They wanted to know who so they could run them out of town on a rail.

Violence

Men in the study were generally concerned about violence directed at them because they were gay. The most consistently mentioned behavior that men believed would attract violence was “acting gay.” Participants said that they believed that heterosexual men were most likely to become violent if their sensibilities about maleness were offended. To avoid becoming targets of violence, participants said that they closely monitored the gender appropriateness of their appearance and behavior. Even younger gay men living in a college town, where definitions of appropriate male behavior were believed to be less rigid, were conscientious about how they acted and appeared to others. As one of the more extreme examples mentioned illustrates, the assault experienced by the man in this interview was, in the opinion of those whom he told about it, the fault of the respondent because he was “acting gay”:

[M]y boyfriend and I were dancing in ______ in a Holiday Inn and we were beat up out in the parking lot. That's probably the worst that ever happened to me as far as being gay. … People were like, “Well, what do you think you were doing, dancing together at a Holiday Inn in _____.” Well, there you go.

The reactions of this man's friends are as telling as the violence itself. The friends clearly expected that he should have known better than to have pushed the boundaries of acceptable “male” behavior.

Participants also said that they believed violence against gay men was socially tolerated and on occasion officially sanctioned. In the following quote, the participant felt that the police officers justified their unwillingness to investigate an assault because the officers believed that being assaulted was part of the gay experience:

I had been beaten up in my home. But, the police department didn't want anything to do with it. So, they told me to deal with it. I had reported [it] and they didn't want anything to do with it. They told me it's a gay thing. So, it's normal [to be beaten up].

Assimilation

To cope with a hostile and sometimes violent environment, participants told us that they attempt to assimilate into the predominant heterosexual culture. Assimilation occurred across a number of social activities but almost always involved an avoidance of information about the self being communicated to others. Work was a common arena of assimilation. Participants told us that their conversations at work were almost always general and infrequently centered on the self. While participants' coworkers perceived them as sympathetic listeners, listening instead of talking was a means of directing a conversation away from the self. Participants particularly directed conversations away from their sex lives or avoided their sexuality as a topic altogether. One man told us, “I don't go around telling people I'm gay. And, since I don't have anybody in my life right now, it's not something that comes up at work.”

Assimilating not only consisted of self-regulating verbal communication but also encompassed monitoring and self-regulating nonverbal communication. Participants were aware of what they were communicating by their appearance and body language. Men adopted what they perceived to be masculine mannerisms and dress. While none of the participants said that they attempted to appear hypermasculine, thought and effort were taken to appear “normal.” Most importantly from the participants' point of view, they were extremely aware of their body language around men they did not know. “Like, if I saw a guy I thought was cute, I probably won't make eye contact or anything like that. I would probably keep to myself. I would be very conscientious, especially around other men, [to] keep my distance.”

Social and Sexual Isolation

A hostile social environment that has the potential for turning violent is related to feelings of isolation. Men expressed this feeling as being a social outsider. Being “the outsider” was not restricted to heterosexual society but extended to feelings of isolation from other gay men or gay society. When asked about the gay community where they lived, participants expressed a limited sense of shared identity or common experiences with other gay men in the state. As one man told us, “There's no gay community here. There's not an open gay community here that everybody knows about.”

Participants told us that gay men met and were connected with other gay men in Wyoming through personal networks. However, they also told us that personal networks were small and usually not connected one to another. Friendships among gay men were the exception, not the rule. When participants spoke about meeting gay men in the state, they said they were introduced by other gay men or by female friends.

Not only was it difficult to meet other gay men, meeting potential sex partners, as the following quote illustrates, was viewed as a rare event, especially in the more rural areas: “I met that one gay man, and that's the only guy that I met for like a year, you know what I mean? So, I was like, there aren't any gay people in this town. … They're all locked up somewhere.”

The Internet has become a virtual setting for socializing with other gay men in the state and from other areas. Every participant reported having had accessed gay sites on the Internet, including chat lines. For some participants, the Internet was a way into a larger gay society that could not be experienced in reality. The man quoted below had a virtual gay life that was far more complex and connected to a gay community than his real life:

I know [gay] people from the Internet that I chat with from Laramie or from Cheyenne or from other parts of Wyoming. But, people I have a conversation with [face to face], probably only one really, and that's not like he and I are going out really. I don't call him up. I don't even know his phone number.

Looking for Sex Partners

A sense of social hostility, potential violence, the need to assimilate, and a feeling of social/sexual isolation were related to how men went about looking for sex partners. One commonly mentioned way of looking for sex partners was to travel to urban centers outside the state. Participants told us that traveling to look for sex partners was necessary because there were no venues in Wyoming where men might meet other men. However, men also told us that travel was not without a positive side. Visiting cities provided a sense of anonymity for those who preferred to conceal their sexuality at home. As the following quote illustrates, some men had a different sense of themselves when visiting an urban center outside the state: “So it was kind of, when I was in Wyoming I was a student and, then, on the weekends, [I would] go down to Ft. Collins or Denver and that's where I would explore the gay part of me.”

Participants told us that looking for sex partners in urban areas usually meant visiting gay bars. For those participants who did not prefer bars, bathhouses provided an alternative venue. Time and distance play a role in choosing these venues. Getting to an urban area, except for the occasional vacation, involved traveling for several hours. Time constraints encouraged men to look for gay-identified venues in urban centers where the chances of finding a sex partner were high. While the following quotation presents an extreme example, it emphasizes the effects of isolation on looking for sex partners: “I go to the bath [house] usually once a month, twice a month when I can afford it, down in Denver, and I'll screw everything for 10 to 12 hours.”

In addition to travel, the Internet has become a virtual venue for some men to look for sex partners. There were variations in how participants described using the Internet to look for partners. Some men said they looked for virtual sex partners but never arranged to meet the men they met on the Internet face to face. Others said that they looked for local men with whom they could arrange a real encounter. Some men said they were concerned about the safety of a face-to-face meeting, but others who had met sex partners on-line said it was a relatively secure way to meet sex partners:

I personally have had answered some ads [on the Internet], and have had successful meetings and that, they weren't there to beat me up or kill me. They were there to meet and to see if, you know, there's a potential to date.

Attitudes Toward HIV Prevention

The themes of hostility, violence, assimilation, and isolation were also related to attitudes toward HIV prevention. Participants were generally aware of the risk of HIV infection and could accurately describe modes of transmission. Personal awareness, however, was not the result of exposure to prevention programs. Like homosexuality in general, HIV / AIDS was avoided in conversations and participants could recall few mentions of HIV / AIDS in local media. None of the men could identify an in-state HIV / AIDS prevention program. The only clinics specifically for the purpose of HIV testing that the men could name were in cities outside Wyoming.

Participants told us that getting an HIV test in Wyoming was not realistically possible. Some said they were aware they could ask their personal physician or a county health department for an HIV test. However, none said they would do so. Requesting an HIV test, even if no reason is given for the request, was perceived by participants to be an admission of homosexuality. Some felt they could trust their personal physician, but they did not believe the physician's staff or anyone who happened to be in the waiting room and knew they had requested an HIV test could be trusted not to speculate about their sexuality. Men said county health departments were no better with regard to confidentiality. Just being seen going into a county public health facility might lead to difficult questions about sexuality, as the following quote illustrates:

I think that they [gay men] are very, very fearful and there is no safe environment. You know they have to go to a public health office … their parents know people at public health. They're afraid to be seen going into the building.

Participants told us that they do not talk with other gay men about HIV / AIDS, nor were they able to discuss it with heterosexual friends. HIV-negative men knew of or had heard about HIV-positive gay men in Wyoming, but the HIV-positive men they personally knew lived in urban areas out of state. The HIV-positive men in the study who had moved back to the state rarely interacted with other gay men and generally kept their HIV status private. The lack of visible HIV-positive men may have led to a false sense of safety among HIV-negative men. One HIV-negative man told us he was not concerned about HIV infection because he lived in Wyoming: “I don't feel there is a great deal of risk here. If I was in New York or Seattle or L.A …”

Men who used the Internet to socialize or to look for sex partners also saw the potential of it as a means to provide HIV / AIDS information. One man told us that because the Internet is easy to access, anonymous, and safe, men in rural areas might use it to access HIV / AIDS information. A number of men suggested how HIV / AIDS prevention messages might be structured. One man explained that prevention messages should be put in the context of learning about sexuality, especially for younger MSM:

With the Internet use I think that, especially in rural Wyoming, rural places, I think that's your option and the reason it's your option is because you can do it comfortably. … [You can] know of a place and be at a place where you can talk to people about being gay and figure out what it's like.

Another, telling us about a similar idea, said that he thought HIV / AIDS prevention messages should be explicitly sexual. One participant suggested that AIDS prevention be placed in the context of educating gay men about intimate sexual relationships. He thought that talking about relationships, especially for younger gay men, might involve learning to overcome difficulties with sexuality and HIV:

I don't know if there is a way to do it on the Internet, but some kind of role playing model where people can learn to say no without saying no to sex. … Younger guys that are new to it or are just becoming sexual, I think, probably have a harder time bringing it up [using a condom] because of a fear that they might be rejected or turned down or something like that. And, I'm sure that some of them intend to be safe, but situations arise.

Discussion

The purpose of this qualitative study was to examine the social/sexual environment of MSM living in frontier rural areas and to identify appropriate topics for HIV / AIDS prevention programs. Four related themes emerged: the perception of social hostility, the potential for violence, the perceived need to assimilate, and feelings of social and sexual isolation. Although each theme has independent components, none is completely unrelated.

Social hostility, potential violence, assimilation, and social and sexual isolation were clearly limiting possibilities for finding sex partners and attitudes toward HIV prevention strategies. None of the men could identify a venue in Wyoming where MSM socialize. Men tended to be circumspect about their sexuality and to travel to urban areas outside the state to look for sex partners. The need to be discrete and the lack of a supportive gay community limited the men's ability to utilize the limited HIV / AIDS prevention services. The perceptions that getting an HIV test might raise questions about one's sexuality and that testing could not be confidential put testing out of bounds for most men.

Participants' use of the Internet had an effect on the social/sexual environment and in some ways ameliorated some of the harsher aspects of the environment. The Internet provided access to sites and chat rooms that were used to create local and long-distance virtual communities. For some, their virtual community was far more extensive than their physical community. Although some men used the Internet to look for men with whom to have sex in person, others maintained exclusively on-line partners. Despite not asking how many on-line men were able to meet off-line for sex, we nevertheless got the sense that those who were interested in looking for local sex partners found a sufficient number on-line to keep returning to the Internet as a venue for meeting local men.

Our findings have implications for developing HIV prevention programs in rural frontier areas. Asking men to participate in HIV prevention programs is for many the same thing as asking them to “out” themselves. Assuring rural MSM that their participation in a program will be confidential and known only to program staff is not sufficient because a program's identity as an HIV prevention program will prove to be a hindrance. Furthermore, anonymity in rural areas and small towns is virtually nonexistent.¹³ Advertising HIV prevention programs in rural areas will be difficult. The lack of a gay community and a gay media means that advertising must be placed in media targeting the dominant, heterosexual population. There is a risk that advertisements will offend the predominant cultural norms and possibly alert those with especially strong negative feelings about homosexuality. This could result in the program or its clients becoming a target of violence. While steps can be taken to maintain secrecy regarding a program's location or activities, methods for screening applicants can be easily circumvented. The potential for violence directed at prevention programs is a concern.

Recruiting MSM to participate in programs by means other than advertisements in the local media will be time consuming and possibly even frustrating. Strategies developed to recruit active drug users (eg, snowball sampling, peer recruiting) may provide an effective model,^23,24 although they were only moderately successful in this study. Programs using a peer model may also be tried. Programs implemented in some rural areas have been centered on gay-identified venues.¹⁴ However, there are no gay-identified venues, and personal networks are small and disconnected in Wyoming. Peer educators will, at best, have to rely on chain referral through networks. Consequently, a peer educator would need contacts with a number of disparate networks for a program to achieve any type of coverage. Peers would need to be especially conscientious about their appearance and mannerisms. Rural MSM might feel uncomfortable talking with peer recruiters in public if the peers were perceived to look or act “gay.” Even identification with an HIV / AIDS prevention program might be enough to dissuade some men from talking with a peer. For some men, talking to a “gay” peer might be perceived as a public admission of their sexuality.

Technology may provide ways to access rural MSM that avoid many of the problems inherent in person-to-person contacts. Service providers in rural areas have been providing mental health and social support services to HIV-positive persons using teleconferencing technology.^5,25,26 Both telephone technologies and the Internet can be adapted to HIV prevention, and both can be adapted to protect the anonymity of MSM who might be amenable to participating.²⁷ However, the Internet may have advantages over a telephone-based strategy. Rural MSM already access gay-oriented sites on the Internet as a means of socializing with other MSM and as a method for looking for sex partners. Advertisements on gay-oriented sites would allow men to view prevention project advertisements without threatening their anonymity and privacy. Moreover, after seeing an Internet advertisement, interested men could go immediately to a prevention program Web site or could access it at a time and in a place that is convenient for them. Perhaps most importantly, an Internet-based program does not require men to go to a public place or to interact with an individual that could be construed as gay.

Our data also suggested that Internet prevention programs should addresses issues of sexuality and relationships as well as HIV / AIDs. For younger men, issues of sexual identity and sexual exploration might provide a forum for addressing HIV / AIDS prevention. For older men, dating and relationship norms might be an appropriate topic in which prevention messages could be embedded. An intervention format need not be limited to activities for an individual. As our data indicate, socializing with other MSM is one of the reasons that men use the Internet. The desire to be part of a larger gay society could be used as the basis of an intervention. Group activities could be scheduled, and the group could address any issue covered in a face-to-face group meeting, including gay culture issues that might not be related to HIV / AIDS prevention. Peer educators could take part as group leaders, and issues related to the appearance and mannerisms of the peers would not arise.

The study and the conclusions drawn from it are not without limitations. First, the sample was composed of mostly white gay-identified men, which is representative of many rural communities, although not all. Non-gay-identified MSM were not part of the sample, and men of color were undersampled. Therefore, themes that emerged from the data should be generalized cautiously and may not reflect issues important to communities of color. Second, although bias associated with self-reported data cannot be completely eliminated, the consistency of reports across participants supports confidence in their veracity. There was no indication that participants altered their responses in reaction to being interviewed or failed to be fully candid. Third, use of transcript data to identify themes is limited in that the social/sexual environment was not systematically observed by the investigators. However, our confidence in the themes is strong because they were compared to themes recorded in field notes and were presented to later participants for their reactions.

Conclusion

The social/sexual environment of MSM residing in frontier/rural areas presents many challenges for developing HIV / AIDS prevention. Social hostility, fear of violence, “heterosexual assimilation,” and feelings of social and sexual isolation combine to create unique attitudes and behaviors regarding sexuality and HIV / AIDS. The data also suggest that privacy and public exposure are of great concern. Effective HIV prevention programs in rural areas must take these factors as well as a guarantee of anonymity into consideration. The Internet may provide the basis for developing such prevention programs. Research is needed on Internet access and use by MSM in rural areas, as is research on the feasibility of adapting successful prevention programs to an Internet format and their efficacy once on-line.