Gay men want sexually explicit internet-based health promotion information, US study finds

The largest-ever survey to assess the health promotion information that gay men who use the internet to meet sexual partners in the United States would like to see has found that sexually explicit materials are not only acceptable across a diverse range of demographics but are preferred to non-visual, non-explicit and technical communication when describing HIV risk between men.

The survey, recently published online in the journal, AIDS and Behavior, targeted more than 2,700 users of the US gay social networking site, gay.com, and also found that gay men also wanted information covering much broader topics than HIV prevention, encompassing diverse sexual and mental health concerns.

Even though a significant number of gay men are now using the internet to meet sexual partners, the concept of using internet-based approaches to HIV prevention with gay men is relatively new, and, accordingly there is little evidence-based information on which to base these interventions. (See this news report from the 2006 International AIDS Conference in Toronto for a discussion of the various types of interventions that currently exist).

To rectify this, investigators from Pennsylvania State University and the University of Minnesota conducted an online needs assessment over three months in 2005 to help answer four questions:

• To what degree should internet-based HIV prevention interventions include sexually explicit materials?
• What content areas are of most interest?
• Do different groups of men who use the internet to look for sex with men differ significantly on issues of acceptability of sexual explicitness and content priorities?
• What sources of information are most credible and desired?

A total of 2,716 gay men completed the survey after they had clicked on a banner advert on gay.com. To be eligible, participants agreed that they were male, over 18, resident in the US, and had sex with men. Participants were paid $10 on completion; this rose to $20 in the third month in order to speed recruitment.

The participants were racially and ethnically diverse, with approximately three-quarters identifying as non-white: 25.1% were Latino; 18.9% Asian-American; and 16.4% African-American.

A high proportion (42.7%) were aged 18-24, but older men were also included: 26.7% were aged 30-39, and 11.8% were aged over 40. Almost all had at least a high school education, and 29% were still higher education students.

Of the 2,322 men who answered the question, 20% admitted to more than one act of unprotected anal intercourse (UAI) in the previous six months. However, the vast majority (95.6%) of all of the survey respondents reported being HIV-negative.

Sexually explicit materials

The investigators found that highly sexually explicit language, visuals, depictions and media were very acceptable across all ages and ethnicities. At least 90% agreed (and fewer than 3% disagreed) that sex stories and visual images of men engaged in masturbation, oral and anal sex; pictures of penises, explicit demonstrations, and use of street language (rather than clinical or medical terms) were totally or somewhat acceptable.

The investigators found the least acceptable image was of male–female sex where only 74% reported acceptability, 13% were neutral and 13% considered this kind of image somewhat or totally unacceptable.

Men who had recently engaged in UAI were found to be significantly more likely to report as acceptable images of men engaged in group sex (90% vs. 85%; p < 0.002), but significantly less likely to find acceptable images of male–female sex (68% vs. 74%, p < 0.01).

They identified no consistent differences in finding sexually explicit materials acceptable to men of different ethnicities, although they found that white participants always appeared to be most or least accepting.

Content areas of most/least interest

At least four out of five men in the study expressed an interest in the following topics: how to be a better lover (86%); men’s physical sexual health (86%); aspects of relationships (83– 85%); and understanding their sexual history and its effects (83%).

In contrast, the three topics of interest to the fewest men were: help with coming out (48% interested, 24% neutral, and 28% not interested); evaluating alcohol/drug use (41% interested, 25% neutral, and 33% not interested); and coping with sexual abuse (32% interested, 30% neutral, and 38% not interested).

White men consistently expressed less interest in sexual health topics than men of other ethnicities.

Older men were more interested than younger men in topics addressing aging as a gay man and, surprisingly, correct condom usage (47% of 30–39/40– 49 years olds versus 60% of the 50+ group).

Conversely, younger men were more interested than older men in topics addressing coming out; having anal sex without pain; and alcohol and drug use. Interestingly, another current paper by two of this study’s co-authors, Horvath and Rosser, examining the online and offline risk behaviours of young gay men aged between 18 and 24, found that regardless of where young men met their partners, being drunk and high were significant risks for unprotected anal intercourse.

Men who had recently engaged in UAI were, compared with those who had not, significantly more likely to report interest in the topic of evaluating drug and alcohol use (47% vs. 39%; p < 0.002), but significantly less likely to report interest in the topics of condom demonstrations (43% vs. 54%; p < 0.001), ways to feel better about oneself (71% vs. 77%, p <0.01), and help with coming out (41% vs. 49%; p <0.004).

In addition, the investigators found several statistically significant differences between HIV-positive and –negative men that were larger in magnitude (13–20%) than differences seen for ethnicity, age, or education.

HIV-positive men, compared with HIV-negative men, were significantly less interested in: negotiating safer sex online (53% vs. 66%; p < 0.003); having anal sex without pain (57% vs. 75%; p< 0.001); condom demonstrations (34% vs. 52%; p <0.001); coming out (29% vs. 49%; p < 0.001); and a long-term plan to prevent acquiring/transmitting HIV (56% vs.70%; p < 0.002).

Sources of information

The most common online sources that gay men used for information on safer sex, sexually transmitted infections and other aspects of sexual health were gay websites, like gay.com (67%); and internet health sites, such as WebMD, Yahoo! Health, and the San Francisco Department of Public Health’s 'Ask Dr K' (56%).

Only 30% relied on blogs or online bulletin boards; 29% used US government sites, such as the CDC (which the investigators characterise as “the nation’s leading health site”); 21% used the mainstream media’s websites; 13% used their health insurance website; and 9% emailed their health provider.

Recommendations

The authors conclude by suggesting that, “leading health and media sites conduct studies using members of high-risk populations to assess whether information is accessible, credible, and helpful”.

Since different topics were of interest to men of different ages, ethnicities, UAI risk and HIV status, the investigators suggest that in order “to retain participants, internet-based interventions should be built with sufficient learner navigability to allow topics that disinterest participants to be skipped; alternatively, where the topic is central (e.g., condom use) but interest is low (e.g., in condom demonstrations), new approaches to motivate condom use should be tried.”

In addition, since HIV-positive men and men engaging in UAI “are presumably among persons at high risk of transmitting or contracting HIV, further research is needed to identify if and how prevention efforts can most engage these groups.”

They conclude by recommending that health promotion specialists who plan to create internet-based approaches to HIV prevention should focus on re-engaging HIV-positive men and men who engage in UAI with multiple partners; consider using “highly sexually explicit media”; integrate “HIV prevention content into broader sexual and mental health curricula”; pay “attention to user determined navigability”; and incorporate “features such as communicating with peers, and e-access to experts on sexual behaviour and homosexuality” into their websites.