This article was published
in the September 1998 issue of the Journal of Acquired Immune
Deficiency Syndrome and Human Retroviruses, 19:61-66. Manuscript received June 20, 1997; accepted March 26,
Determinants of Sexual Risk-Taking Among Young HIV-Negative
Gay and Bisexual Men
Steffanie A. Strathdeea,b, Robert S. Hogga,b,
Stephen L. Martindalea, Peter GA Cornelissea,
Kevin JP Craiba, Julio SG Montanera,c,d,
Michael V. O'Shaughnessya,c,e, and Martin T. Schechtera,b,c
a British Columbia
Centre for Excellence in HIV/AIDS, St. Paul's Hospital;
b Department of Health Care and Epidemiology, University
of British Columbia;
c St. Paul's Hospital;
d Department of Medicine, University of British Columbia;
e Department of Pathology, University of British Columbia,
Vancouver, British Columbia, Canada
from a cohort of young HIV-negative gay and bisexual men were
analyzed to identify determinants of sexual risk-taking at baseline.
Gay/bisexual men aged 18-30 completed a self-administered questionnaire
including demographics, depression, social support, substance
use, and consensual vs. non-consensual sex. Risk takers were
defined as those who had unprotected anal sex with casual male
sex partner(s) in the previous year; non-risk-takers were defined
as those who reported consistently using condoms during anal
sex with all male partners in the previous year. Logistic regression
was used to identify independent predictors of sexual risk-taking.
Of 439 men studied, risk-takers had less education, a
higher depression score, less social support, and were more likely
to report non-consensual sex and recreational drug use relative
to non-risk-takers. Independent predictors of sexual risk-taking
were low education, nitrite use, low social support (adjusted
odds ratio [AOR] = 1.65, 95% CI: 1.04 - 2.59), and non-consensual
sex experienced as a youth or adult (AOR=1.85, 95% CI: 1.15 -
2.96). Young gay/bisexual men reporting non-consensual sex, low
social support or nitrite use were significantly more likely
to have recently had unprotected anal sex with casual partners.
HIV prevention programs aimed at young gay/bisexual men should
include sexual abuse counselling and foster community norms supporting
safer sex practices.
Key Words: HIV
- Risk behaviors - Gay men - Social support - Sexual abuse.
Concern is growing about HIV incidence
rates among young homosexual men.1,2
Reports of a declining trend in AIDS incidence
among homosexual men in the United States since the epidemic began
do not apply to younger birth cohorts and do not reflect HIV incidence
at present.2 Studies
indicate that between 25% and 50% of gay men between the ages
of 18 and 30 have engaged in unprotected anal sex within the previous
often without knowledge of their partner's serostatus.9,10 This suggests
that despite a decade of HIV/AIDS prevention efforts, young gay
men continue to place themselves in situations where they are
at high risk of infection.
Studies have suggested that gay men engaging
in unprotected anal sex tend to be younger11-13 and are more likely to report recreational drug
use, often in conjunction with sex6,9,12-15 Inconsistent findings have been reported with
respect to the role of alcohol as a predisposing factor.3,14-18
Some research has shown that psychological factors, such as depression3,15,19 and low social support11,20,21
predispose to sexual risk-taking among gay men. However, only
a few of these findings have been confirmed among young gay/bisexual
men.3,15 The latter observation is important in that
reasons for sexual risk-taking appear to differ for older versus
younger gay men.4
Social determinants are particularly
important because they may represent avenues for prevention which
are amenable to change. We hypothesised that young gay/bisexual
men reporting more social problems, such as unstable housing,
depression, less social support, or a history of sexual abuse
may be less able to negotiate safer sex practices, thereby increasing
their vulnerability to HIV and other sexually transmitted diseases.
We aimed to determine whether these factors were independent predictors
of high risk sexual behaviour in a cohort of young gay/bisexual
men from Vancouver at baseline.
Gay and bisexual men aged 18 to 30 who
were living in the Greater Vancouver region were recruited through
physician's offices, clinics and outreach for a prospective study
of HIV incidence and risk behaviours beginning in May, 1995. Men
were eligible to participate if they had not previously tested
HIV-seropositive and if they self-identified gay/bisexual or had
sex with other men. Participants complete a confidential self-administered
questionnaire and undergo an HIV test on an annual basis. Specimens
which were HIV reactive upon ELISA were confirmed by Western Blot
at the provincial laboratory of the British Columbia Centre for
Disease Control, British Columbia Ministry of Health.
The baseline questionnaire requested
information on demographics, sexual behaviours with men and women,
and substance use. Questions on sexual activity were prefaced
by a definition of sex as "oral, anal or vaginal intercourse."
Sexual behaviours were classified as either consensual (defined
as "sex you engaged in willingly"), non-consensual ("sex
you were forced or coerced into, including rape, sexual assault
or childhood sexual abuse") or paid sex ("exchange of
sex for money, goods or drugs").
Data were collected on total numbers
of male and female sexual partners in the previous year and lifetime,
the age at which respondents first willingly had sex, and frequencies
of specific consensual sexual practices over the last year (e.g.
insertive vs. receptive anal intercourse, with and without ejaculation).
Sexual behaviours were recorded for regular partners, defined
as men with whom respondents had sex more than once a month on
average, and casual male partners, less than once a month on average.
Respondents were also asked to indicate
the frequency of condom use during these encounters, reasons for
inconsistent condom use, and whether or not they had unprotected
insertive or receptive anal intercourse with a male they knew
at the time was HIV-positive. Respondents were asked whether they
had ever experienced non-consensual sex, as defined above. Those
answering in the affirmative were asked to indicate whether the
experience(s) occurred under age 12, between 12-17 years, or over
age 18, and their relationship to the perpetrator(s).
Respondents indicated their frequency
of use of each of the following substances within the last year:
alcohol, cigarettes, marijuana/hashish, LSD, cocaine and crack,
heroin, speed, amyl/butyl nitrite inhalants, or other drugs. They
were also asked whether they had injected drugs within the last
year or used a needle someone else had already used. Finally,
the questionnaire included the Instrumental-Expressive Social
Support Scale (IES) which asked respondents to indicate the frequency
with which they experienced a list of 26 problems (e.g. "not
having a close companion"),22 and an abbreviated 7-item version of the Center
for Epidemiologic Studies Depression scale (CES-D) which has been
For the purpose of this analysis, we
defined risk-takers as men who reported at least one episode of
unprotected anal sex with casual male partner(s) in the previous
year, or who had unprotected anal sex with someone they knew at
the time was HIV-positive. Non-risk-takers were defined as men
who reported always using condoms during anal sex with all male
sex partners in the previous year, or reported not engaging in
anal sex. To avoid potential misclassification in these extreme
groups, we excluded men who engaged in unprotected anal sex only
with regular partners from the analysis. Similarly, we excluded
ten men who tested HIV-positive at baseline, since subjects who
suspected themselves to be HIV-infected may have altered their
behaviour prior to recruitment into the study.
Unstable housing was defined as living
in a hotel, boarding house, group home or in the street at the
time of enrolment. Frequencies for the IES and CES-D scales were
independently scored (e.g. never=1, always=5) and summed; scores
above the 75th percentile were considered as either a low social
support or high depression score, respectively.
Comparisons between risk-takers and non-risk
takers were carried out with respect to individual social, demographic,
and behavioral variables using Mantel-Haenszel methods. Unadjusted
relative risk estimates were calculated using the sample odds
ratio, and test-based 95 percent confidence intervals were calculated.
Stepwise logistic regression analysis was used to assess the independent
effect of these variables on sexual risk taking. All variables
which were significant at the 5% level in univariate analyses
were considered for inclusion in the final multivariate model.
In addition, all two-factor interactions were assessed for their
effect on the outcome. All reported p-values are two-sided.
Of 473 men who were eligible for
this analysis as of October, 1997, we excluded 34 for whom data
on sexual partnerships or condom use was not provided. The latter
group did not differ from those who were included in terms of
age, ethnicity or other characteristics (p >0.05). Of the 439
men included in the analysis, 177 (40%) were classified as risk-takers
and 262 (60%) as non-risk-takers according to the above criteria.
Four men who reported having unprotected anal sex only in situations
of condom failure were considered non-risk-takers.
A summary of sociodemographic characteristics
is reported in
for risk-takers, non-risk-takers, and overall. Median age was
26 years. The majority of participants were white (71%), had completed
high school (84%), and reported stable housing at baseline (92%).
There were no differences between risk-takers and non-risk-takers
with respect to age, ethnicity, or housing conditions (p >0.05).
However, risk-takers were significantly more likely to have a
lower social support score (p=0.001), a higher depression score
(p=0.04), and were less likely to have completed high school (p=0.03).
Relative to non-risk-takers, men
reporting sexual risk-taking were more likely than to report having
used all of the recreational drugs studied, including nitrite
inhalants and cocaine. Due to the small number reporting crack
use within the last year (5%), these data were collapsed with
cocaine use. Risk-takers were also more likely to report smoking
cigarettes, and having more than 10 alcoholic drinks per week
(i.e. 75th percentile).
One third of respondents reported non-consensual
sex at some point in their lives, an experience which was more
common among risk-takers (39% vs. 30%). In particular, risk-takers
were significantly more likely to report experiencing non-consensual
sex in adolescence (i.e. 12-17 years) or adulthood (i.e. over
18 years). Differences were noted in the nature of the relationship
between the respondent and the perpetrator, depending on the victim's
age. Among men reporting non-consensual sex as a child, 90% identified
the perpetrator as a male relative or family friend. Those who
reported non-consensual sex as a youth most commonly reported
that the perpetrator was a male stranger (30%) or family friend
(19%), and those over the age of 18 at the time most commonly
cited a male date or boyfriend (44%), or a male stranger (34%).
Several factors remained independently
associated with sexual risk-taking in the final multivariate model (Table 2). Respondents
who reported less than a high school education or who used nitrite
inhalants in the previous year were significantly more likely
to be risk-takers. A significant interaction was observed between
education and nitrite use. Among subjects with greater than high
school education, risk takers were significantly more likely to
use nitrites than non-risk-takers, although there was no corresponding
difference among men with less education. Even after controlling
for these factors, however, respondents who had less social support (AOR =1.65, 95% CI: 1.04
- 2.59), or those who experienced
nonconsensual sex as a youth or adult (AOR=1.85, 95% CI: 1.15 - 2.96)
were significantly more likely to report sexual risk-taking. Results
were essentially unchanged after controlling for age, ethnicity,
and involvement in the sex trade.
Given the above findings, we conducted
a sub-analysis to compare behaviours of young gay men who had
ever experienced nonconsensual sex to those who had not. The former
were significantly more likely to report having been paid for
sex in the previous year (p=0.001), and reported first having
consensual sex with men, and doing so on a regular basis, at an
earlier age (p<0.001). These men also had a higher depression
score (p=0.001), lower social support (p=0.001), and were significantly
more likely to report the use of several recreational drugs in
the previous year.
In our study of young HIV-negative gay
and bisexual men, 40% of subjects willingly had unprotected anal
intercourse with a casual male sex partner in the previous year.
This high level of unprotected anal sex is consistent with other
studies,1,4-7 which underscores the need for intensive prevention
programmes targetted towards young gay/bisexual men. The underlying
factors responsible for this high risk sexual behaviour are of
critical importance in order to tailor these programmes more effectively.
In a previous analysis which focused
on older gay men enrolled in the Vancouver Lymphadenopathy-AIDS
lower income and substance use, most notably the use of nitrite
inhalants ("poppers") were significantly associated
with sexual risk-taking. Other studies of older13,14,24
and younger homosexual men6 have
reported a similar relationship between nitrite inhalants and
unprotected anal sex. The present analysis confirms this relationship
for younger gay/bisexual men, which is a concern since poppers
appear to be regaining popularity. It is of particular concern
that we observed nitrite use to be more common among risk-takers
who had higher levels of education. Like others3,17,18 we
failed to find a significant effect associated with alcohol use
after controlling for other factors. However, the present analysis
was limited by the lack of standard scales to measure alcohol
dependency and situational substance abuse.
Of greater interest in this study was
the relationship between social determinants and sexual risk-taking.
Risk-takers were more likely to be depressed, had less social
support, and were more likely to report having experienced non-consensual
sex relative to non-risk-takers. In our multivariate analysis,
young gay/bisexual men who reported experiencing non-consensual
sex as a youth or adult were almost twice as likely to have recently
engaged in unprotected anal sex with a casual male partner. This
association persisted after adjusting for involvement in the sex
trade, substance use and other factors.
A growing body of literature suggests
that past sexual abuse may contribute to increased vulnerability
to HIV and other sexually transmitted diseases.6,25-34
Common long-term sequellae of sexual abuse are depression, sexual
compulsivity, substance abuse and prostitution.26,35
All of these factors can be directly or indirectly linked to the
risk of HIV transmission, and were supported by the results of
our sub-analysis. Studies focusing on gay men have observed that
those who report forced or coerced sex during childhood or adolescence
subsequently report first willingly having sex with men at a younger
are more likely to be paid for sex,25,30
and more frequently report use of recreational drugs.30 In several studies, gay men who reported non-consensual
sex were significantly more likely to report recent unprotected
anal sex with male sexual partners.6,29-32
Some of these studies have also found a significant correlation
between unprotected anal sex and low education29,31
or use of nitrite inhalants,6 after
adjusting for past sexual abuse.
Unlike many studies which primarily focused
on sexual abuse occurring in childhood or adolescence, we also
asked respondents whether or not they had experienced non-consensual
sex in adulthood. Among the men in our study who reported ever
experiencing non-consensual sex, a considerable proportion reported
at least one occurrence over the age of eighteen. The most
common perpetrator in these cases was a male date or boyfriend.
In a study by Hickson,27
25% of 212 gay men who reported having been forced into a sexual
act listed the perpetrator as a casual male partner, or a regular
male partner in an additional 5% of cases. In this study, anal
penetration was significantly more common when prior consent had
been given for some other sexual act.27 Since our data clearly indicate that non-consensual
sex can occur within the context of gay male relationships, as
has been shown for heterosexuals,36 the relationship between sexual victimization
and the ability to negotiate safer sex in subsequent relationships
requires further study.
In addition, the potential for HIV transmission
as a direct consequence of a non-consensual sex act should not
be overlooked. Receptive anal intercourse, which is considered
to pose the greatest risk of HIV transmission, appears to be the
most common mode of sexual assault among males.27,37
Although HIV transmission as a direct consequence of sexual assault
has been rarely reported,38
these situations require appropriate HIV testing, counselling
and support beyond immediate crisis intervention.
Our analysis also found an independent
association between low social support and sexual risk-taking.
Previous studies have reported similar findings among older gay
men.10,20,21 In a prospective study of behaviour change among
gay men, Catania and colleagues21 found that increasing levels of informal support
strongly predicted condom use the following year. More recently,
a controlled study which included both formal and informal supports
in a community-level program aimed at young gay men demonstrated
significant reductions in high risk behaviours.39 These data and our own support the notion that
supportive networks which influence community norms around safer
sex may have a direct impact on future HIV incidence rates among
young gay and bisexual men. An understanding of the mechanisms
by which substance use acts as a barrier to HIV prevention is
needed to promote and sustain salutary behavior change.16,40
Several limitations of our study should
be acknowledged. We may have failed to observe significant associations
between some factors, such as non-white ethnicity, unstable housing
or injection drug use, due to limited statistical power. Since
our study restricts eligibility to a narrow age range (i.e. 18
to 30) and we enrolled smaller numbers of younger men, this may
account for the reason why we did not observe a significant effect
of younger age on the likelihood of risk-taking. Generalizability
of our findings may also be limited. We excluded men who engaged
in unprotected anal sex only with regular partners to reduce the
potential for misclassification, which could have arisen as a
consequence of negotiated safety.41 Another limitation is inconsistency among definitions
of sexual abuse, which has been noted by others.35,42
Previous studies have classified experiences according to the
age difference between the victim and the perpetrator or the degree
of physical force.29-31
we relied on the perception of the respondent to decide whether
or not the experience was coercive or physically forced. This
may have led to some under-reporting and it is possible that the
reporting might be differential between risk-takers and non-risk-takers.
Despite different definitions, the prevalence of non-consensual
sex among gay men ranges from 27% to 40%, irrespective of age.6,25,27,30,34 Although we observed a stronger relationship
between sexual risk-taking and non-consensual sex for episodes
occurring during adolescence or adulthood, our results should
not be used to trivialize the impact of childhood sexual abuse.
We could not differentiate between situations where persons who
were abused as children were re-victimized as adults, which is
commonly reported.27,35 We therefore cannot rule out the possibility
that a subgroup of individuals who were abused at different points
in their lives by one or more perpetrators were subsequently more
likely to be sexual risk-takers.
The results from the present study suggest
new avenues for identifying and targeting prevention for young
gay and bisexual men who remain at high risk of HIV infection.
Our cross-sectional analysis cannot determine whether or not sexual
abuse is a causal factor or a correlate of sexual risk-taking.
Nevertheless, our results and those of others suggest that young
gay and bisexual men with a history of sexual abuse should be
targeted by HIV prevention programmes. Zierler et al25 have suggested that some safer sex messages
may be inappropriate for persons whose lives have been complicated
by sexual victimization. Young gay /bisexual men with a history
of sexual abuse may be less able to negotiate safer sex or may
be less comfortable with their sexual identity,30 signalling a need for enhanced education and
support. Our results indicate that low social support is also
an independent predictor of sexual risk-taking among young gay/bisexual
men. Such findings may be interpreted as facets of a complex dynamic
which contribute to "HIV vulnerability.42 The situational, social, political and economic
factors which create a climate for such vulnerability pose the
ultimate challenge in HIV prevention.
Table 1: [back to text]
Comparison of young gay/bisexual men categorized as
(n=262) vs. risk-takers (n=177) in Vancouver (a)
age years (IR)
social support score (b)
depression score (b)
| Sexual experience:
| Been paid
for sex (b)
|| 29 (11)
| Nonconsensual sex (d)
|| 78 (30)
| < 12 years
|| 42 (16)
| 12-17 years
|| 24 (9)
| > 18 years
|| 30 (11)
|Recreational drug use
|| 157 (60)
|Used nitrite inhalants
|| 67 (26)
|Alcohol (> or
= 10 drinks/wk)
(a)Based on Chi-square tests.
(b)Based on previous year.
(c)Per 10-year increase.
(d)Categories are not mutually exclusive.
OR, odds ratio; CI, confidence interval.
Table 2: [back to text]
Final multivariate logistic model identifying independent predictors
of sexual risk-taking among 439 young HIV-negative gay/bisexual
men in Vancouver (a)
over age 12 years
|Low social support
|Used nitrite inhalants
nitrite used X education
(a)Based on previous year.
(b)Among subjects with more than high school education, risk-takers
were significantly more likely to use nitrites than non-risk-takers;
no corresponding difference existed among men with less education.
CI, confidence interval.
The authors are indebted to
the participants, physicians, nurses and clinic staff and the
Community Advisory Committee of the Vanguard Project, with particular
thanks to Mary Lou Miller, RN, Arn Schilder, and Fiona Tetlock.
This study is supported by a grant from the National Health Research
and Development Programme (NHRDP), Health Canada. Drs. Strathdee,
Hogg and Montaner are supported by National Health Scholar Awards
granted by the NHRDP, Health Canada; Dr. Schechter is an NHRDP
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Journal of Acquired Immune Deficiency
Syndromes and Human Retrovirology
© 1998 Lippincott Williams & Wilkins, Philadelphia
For more information, contact:
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