Sexually transmitted diseases (STDs) are a significant public health concern in the United States. While estimates of the incidence and prevalence of STDs in the United States vary according to method of data collection and source of the data, the latest estimates of STD incidence indicate that there are 18.9 million new cases each year.1
- U.N. Moves To Eliminate Disclosure Laws For HIV Infected People Having Sex ~ Obama Rescinds $6.6 Billion Funding For AIDS Prevention.
There are more than 25 diseases that are transmitted through sexual activity, the most common of which are human immunodeficiency virus (HIV) infection/Acquired Immunodeficiency Syndrome (AIDS), chlamydia, gonorrhea, syphilis, genital herpes, human papillomavirus (HPV), hepatitis B, trichomoniasis, and bacterial vaginosis. Each disease affects different audience segments and requires different communication approaches to prevent and control the disease.
Men who have sex with men (MSM) are at increased risk for multiple sexually transmitted diseases including HIV/AIDS, syphilis, gonorrhea, chlamydia, hepatitis B and hepatitis A. It has been stated that high rates of STDs among MSM appear to be associated with the return of unsafe sexual practices such as unprotected sex.2 Non-gay identified men who have sex with men (NGI MSM) are men who engage in sexual activity with other men and with women, but who do not self-identify as gay or bisexual and who cannot easily be reached through the social or community support systems associated with the gay/bisexual community.3
Given the dearth of information available about NGI MSM, their knowledge of STDs, and their communication preferences, resources for this study were dedicated to address these particular gaps in health communication literature. Specifically, the intent was to collect data regarding the behaviors, attitudes, and community/culture of African-American and Hispanic/Latino NGI MSM aged 20 – 45 relevant to STDs and their ideas for increasing knowledge of how to prevent these diseases.
Due to the lack of health communication information available regarding African- American and Hispanic/Latino NGI MSM men between the ages of 20 – 45, CDC indicated that these populations were the central focus of the study.
In-depth interviews were conducted to address the following five research questions about African-American and Hispanic/Latino NGI MSM aged 20 – 45:
1. Are there identifiable sexual behaviors of NGI MSM that are important to consider when developing STD prevention messages?
2. Are there identifiable attitudes of NGI MSM regarding STDs and sexual behavior that are important to consider when developing STD prevention messages?
- 1 Weinstock, H., Berman, S., Cates, W. 2004. Sexually Transmitted Diseases Among American Youth: Incidence and Prevalence Estimates, 2000. Perspectives on Sexual and Reproductive Health, v36 (1).
- 2 US Department of Health and Human Services, Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, National Center for Infectious Diseases. 2004. Dear Colleague Letter. Retrieved August 11, 2004 from NCID Website: http://www.cdc.gov/ncidod/diseases/hepatitis/msm/dear_colleague.htm.
- 3 Vermont HIV Prevention Community Planning Group, Comprehensive HIV Plan for Vermont. 2001. Section 3C Meeting The HIV Prevention Needs Of Men Who Have Sex With Men (MSM): Notes on Terminology. Retrieved August 24, 2004 from http://www.nvtredcross.org/cpg/ Section%203C_Pt2_MSMTerms.htm.
STD Communications Database Interviews with NGI MSM Executive Summary – 1
- To what extent do NGI MSM believe that same-sex relationships are supported by institutions and organizations in their communities?
- Do NGI MSM believe they can turn to organizations and institutions in their communities for information and services regarding STDs?
- What are the most effective channels/sources of information to reach NGI MSM with STD prevention messages?
Forty-nine men were interviewed from March – June 2004. Each interview consisted of open- ended questions and lasted approximately one hour. The men were interviewed in four geographically dispersed U.S. sites, selected through an analysis of high male-to-female ratio of syphilis cases (proxy for male-to-male transmission) as well as available census data including a high percentage of the population identifying as African-American and/or Hispanic/Latino. Interviews were conducted in Atlanta, Georgia; Washington, D.C.; Houston, Texas; and San Diego, California.
Emerging research literature identified the Internet as a popular way for NGI MSM to meet other NGI MSM or gay men as sex partners.4,5,6 To take advantage of this, the primary strategy for recruitment of the African-American and Hispanic/Latino NGI MSM population for this study was to use free Internet posting sites. Information describing the study and eligibility criteria was provided with a toll free number for potential interviewees to call if interested.
As a supplemental recruitment strategy for slow recruitment sites, ads were placed in free weekly newspapers. Field interviewers also distributed and posted flyers in bookstores, grocery stores, coffee shops, and university areas in Atlanta, Washington D.C., and San Diego. As a strategy to increase participation of Hispanic/Latino men, Spanish language flyers were also provided to field interviewers for posting in heavily populated Hispanic/Latino areas.
There were two levels of screening to ensure participants met the study qualifications. The initial telephone screener was based on the study criteria and included questions determining the sex, age, race, location, and self-identification as an NGI MSM of the individual calling. The screener also assessed the caller’s ability to speak and understand English to ensure accurate communication between interviewer and participant.
In addition to the initial telephone screener, a second, in-person screener was administered by the interviewer at the time of the interview to ensure inclusion criteria were met. This in-person screener also captured additional information on participants’ Internet use, whether they accessed health information on the Internet, and which health Websites they visited.
- 4 Mettey, A., Crosby, R., DiClemente, R.J, and Holtgrave, D.R. 2003. Associations between Internet sex seeking and STI associated risk behaviours among men who have sex with men. Sexually Transmitted Infections. 79(6):466-468.
- 5 Halikitis, P.N., Parson, J.T. 2003. Intentional unsafe sex among HIV-positive gay men who seek sexual partners on the Internet. AIDS Care. 15(3):367-378.
- 6 Koblin, B. A., Chesney, M.A., Husnik, M. J., Bozeman, S., Celum, C. L., Buchbinder, S., Mayer, K., McKirnan, D., Judson, F. N., Huang, Y., Coates, T.J., the EXPLORE Study Team. 2003. High-Risk Behaviors Among Men Who Have Sex With Men in 6 US Cities: Baseline Data From the EXPLORE Study. American Journal of Public Health. HIV RETURNS. 93(6):926-932.
STD Communications Database Interviews with NGI MSM Executive Summary – 2
Four field interviewers, one in each site, conducted the interviews. The interviews in three of the four sites were conducted in private study rooms of public or university libraries. The interviews in the remaining site were conducted in a conference room of a local health research company.
A skilled interviewer who had received specific training in interviewing sensitive populations conducted the interviews. The role of the interviewer was to ask the questions on the interview guide, guide the discussion, take detailed notes, and ask probing questions about salient, related topics that arose during the interview. Once the questions from the guide had been covered, participants were thanked for their participation; offered CDC fact sheets with information concerning STDs and local resources for finding out more information, and asked to spread the word concerning the study to people they knew who fit the study criteria. They were also provided with their incentive payment.
The analysis strategy for the project was considered and outlined when the study design was developed, taking into account the available resources and the anticipated quantity of data that would be generated from such a large number of interviews. Using a grounded theory approach, the data was analyzed for themes, patterns, and interrelationships relevant to an understanding of the behavior, attitudes, community/culture and communication preferences of NGI MSM.
As such, a note-based analysis was used for this project. Note-based analysis relies primarily on field notes, debriefing sessions, and summary comments made at the conclusion of each interview. The interview is taped, but the tape is used primarily to verify specific quotes. The primary analysis documents are the detailed field notes.
Data collected from each participant were thoroughly read and notes taken across interviews. A rigorous, systematic process was implemented to ensure reliability and consistency among the researchers in how data were being summarized, and to ensure neutrality in the reporting and interpretation. The researchers met on a regular basis to discuss and come to agreement on categorizing responses. Particular attention was given to capturing the frequency of topics and the level of detail and explanation of the responses across participants. Based on these discussions and preliminary conversations with the field interviewers, themes across the interviews were identified.
Highlights of Results
Key findings are presented by research question below.
Research Question 1: Identifiable Sexual Behaviors of NGI MSM
• Participants were asked for their thoughts, words, feelings, or concerns in response to a man’s choice of sexual partners as a way to learn of their basic perceptions of sexual behavior. When asked about a man having sex with a woman, participants stated that this was common, normal behavior.
When asked about a man having sex with a man, participants stated that this behavior was often regarded as out of the norm, abnormal, not right, or “weird.” When asked what words, thoughts, or feelings come to mind when thinking about a man having sex with both a man and a woman, participants described this behavior as secret, sneaky, deceitful, and dangerous. However, they also believed that the behavior is exciting, adventurous, and boundary-less.
STD Communications Database Interviews with NGI MSM Executive Summary – 3
- Participants were asked about the types of places they had heard about where a man might go to find a male sexual partner. Men responded that they had heard of the Internet (especially chat rooms and gay Websites), public parks, public restrooms, bars, bathhouses, and adult bookstores as places where a man might find a male sexual partner. Respondents also mentioned a number of other venues that they had heard of for this purpose including beaches, bus stations, and concerts.
- Participants spoke about several factors in determining the choice of venue when attempting to find a male sexual partner. The availability of privacy or seclusion was noted as an important consideration in deciding where to go to meet a sex partner. Venues that are discreet and allow for an inconspicuous meeting were identified as preferred sites for meeting partners. Most respondents stated that the Internet is a common meeting place because it is both private and discreet and allows the partners to then plan where they will meet in person.
- Participants noted that venues that facilitate an individual’s anonymity are also preferred meeting sites. Public parks, restrooms, and bathhouses were cited as specific meeting places that foster anonymity. Respondents also stated that venues in which alcohol or drug use is common are preferred meeting places. Bars or clubs where drinking and the use of drugs can influence behavior or impair judgment were identified as particular locations where it is easy to meet a sex partner.
- When asked about the types of places they have heard of where male-to-male sexual encounters take place, participants agreed that common venues include public parks, public restrooms, bars, bathhouses, and adult bookstores. Participants went further to mention other venues where male-to-male sexual encounters take place including movie theaters, sex clubs, and truck stops. They noted that these venues must be convenient to allow for quick interaction such as in public parks, restrooms, or bathhouses. Participants also believed that these venues must promote privacy such as in a private home or car, but also ensure anonymity such as in public parks, bars, or bathhouses. Furthermore, access to alcohol and drugs in a venue was noted as an important factor influencing whether or not a sex encounter will take place in that venue.
- When asked how being diagnosed with an STD might influence a man’s sexual behavior, participants believed that, for some men, the diagnosis would change their behavior, while for other men, it would not change anything at all. Respondents stated that once the STD is diagnosed, some men would stop having sex and stay away from sexual partners while they are treating the STD. In contrast, respondents stated that it is also common for some men not to change their behavior in any way after being diagnosed with an STD. They noted that these men believed that compared with HIV, an STD is not as serious since it is curable.
- Respondents were asked about specific places where they would go if they had a concern about an STD. When probed, participants agreed that they would turn to the Internet, the hospital emergency room, a public health facility, their private doctor, or an STD clinic or other organization such as Planned Parenthood. Respondents said they would choose a resource based on whether or not their privacy and confidentiality would be maintained. Hours of operation and location of the health care provider or facility were cited as important factors.
STD Communications Database Interviews with NGI MSM Executive Summary – 4
• Participants were asked when a discussion about the STD or HIV status of a same-sex partner usually occurs. Respondents noted a difference in when this discussion should occur and when it actually does occur. Participants stated that the conversation with a same-sex partner about STD/HIV status should take place before any sexual activity with the partner begins. However, these men were quick to admit that the reality is that this discussion usually happens after the partners have already had sex or does not happen at all.
Research Question 2: Identifiable Attitudes of NGI MSM
- In response to the question asking participants if they thought males were at equal risk for contracting an STD with a male partner as they were with a female partner, most of the respondents answered that men were at equal risk with both partners. Many of the participants thought this was the case because if protection is not used, regardless of the type of sex partner, there is a risk for STDs.
- Respondents who did not think the risk of acquiring an STD was equal for both male and female partners thought so for a number of reasons. A few participants mentioned the increased number of possible physical interactions with women (anal, oral, and vaginal) as opposed to men (anal and oral) as additional means of contracting an STD; thus having sex with only women would increase the risk of acquiring an STD. Other participants believed women were more promiscuous than men so they would be more likely to pass on an STD.
- All of the participants believed in the importance of using condoms with male partners when having anal and oral sex. The respondents listed the fear of contracting an STD as the primary reason to use condoms. Some participants thought it was only necessary to use condoms during anal sex and not during oral sex. A few reasons participants stated for not using a condom during oral sex included less risk involved in oral sex (anal sex being a more dangerous act), being able to feel during oral sex, and being “in the moment.”
- The majority of the participants thought it important to use condoms with female partners during vaginal, anal, and oral sex. These respondents stated their main reasons to use condoms are for pregnancy and disease prevention.
- Most men referred to the decreased feeling or sensation when using a condom, as the primary reason men do not want to use them. Others also stated the size of condoms is a factor and that they are often too big or too small to fit comfortably and work efficiently. Many men believed not having them available when sex is initiated or the inconvenience of stopping the sexual act to put a condom on is a barrier to some men. Participants also listed the cost, access, and ignorance of some men as barriers to condom use. A few men discussed substance use as another factor in forgetting or not caring about using condoms.
- When participants were asked what they would say to someone who believes that two men having sex with each other are gay and whether or not they agreed with the statement, the majority stated they did not agree and gave a variety of reasons why they felt this way. Many respondents believed the word “gay” represented a lifestyle or identity that was more than the physical act of having sex with another man. Most of the respondents stated men could have sex with other men without being gay.
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STD Communications Database Interviews with NGI MSM Executive Summary – 5
- Many of the respondents who did not agree with the statement that two men who have sex together are gay, believed the word “gay” was a label placed on men who have sex with other men by society and that this label did not apply to them. Some of the men thought that labeling the act as gay brought on feelings of shame or guilt or that it assigned the men to a distinct category they didn’t feel they belonged to. Many of the respondents made a point of saying they do not like labels and preferred not to use them.
- When participants were asked whether having sex with other men would affect the way a man understands and defines himself, the majority of the respondents thought it did affect the way a man thought of himself. Many of the respondents stated the gay stereotype of effeminate men and the ways that they view themselves were not compatible. The respondents said the internal struggle over society’s definition of gay and their own identity caused confusion and uncertainty.Research Question 3: Beliefs of NGI MSM – Support from the Community
- Questions about the meaning of the labels “gay” and “bisexual” provided insight into many of the ways men participating in the study see themselves and how they think community or society views people who are so labeled. A number of participants stated that they do not like to label people and do not identify themselves as “straight,” “gay,” or “bi.” A few said that a label such as gay indicated an overall lifestyle while others suggested that the labels only referred to preferred sex partners.
- Many of the respondents indicated that, for both themselves and society, the term gay suggest that a man is effeminate, weak, and somehow less of a man, and that a gay man is “different” from other men. They suggest that for most people the label also brings up stereotypes of men who dress as women or “queens,” who are passive, or who want to be women. These men discussed stigma and shame associated with the term gay, stating that society judges and rejects men who are perceived as gay for being different, “not a man,” or immoral.
- Participants were asked if the institutions or organizations they belong to discourage or fail to be supportive of same-sex relationships. Fewer than 10 participants describe being lucky enough to have found a church that accepts them and welcomes people as they are. Overwhelmingly, other participants identified the church as an institution that does not support same-sex relationships. Their responses varied in terms of how actively discouraging the church was, with a couple participants describing pastors who go overboard in their message about homosexuality being a sin, and others stating that they know it is frowned on and considered sinful but not talked about openly.
- Participants were asked to talk about what it would be like to be accepted by friends and family as a man who has sex with both men and women. Roughly one-third of the participants responded that they could not even imagine such a scenario, that it would never happen. These men believe they would be rejected and judged if anyone knew they had sex with men and could not see themselves telling those close to them; they could not see themselves taking the risk of losing their family or their friends. A few of the men responded that their families or friends knew about their sexual preferences and accepted them for who they are. These men knew that not everyone has such acceptance and they feel lucky to be in such a situation.
STD Communications Database Interviews with NGI MSM Executive Summary – 6
Research Question 4: Beliefs of NGI MSM – Access to Resources in the Community
- The men participating in this study do not believe they can turn to the organizations and institutions in their communities for information and services regarding STDs. With a few exceptions of participants who have found an organization (clinic, community-based organization, or church) that is open to a gay, lesbian, and bisexual culture and population, the participants talked mostly about fear of rejection and being harshly judged if they were open about their sexual preferences.
- While few participants said they had actually experienced an environment that would encourage them to seek STD information and services, most could articulate the characteristics of such an environment and what it would take for someone like them to feel comfortable going for help. A number of items were identified as important, regardless of the type of setting, including a non-judgmental, supportive, and open environment where confidentiality is maintained.
- The men participating in this study described few ways they dealt with everyday stress. These included general stress reduction techniques of eating healthy, getting enough sleep, and exercising; talking to friends; participating in recreational activities and hobbies. A few of the men mentioned unhealthy techniques to deal with stress such as drinking or using drugs, and a couple of participants talked about withdrawing from others and keeping everything inside. Therapy was mentioned twice, as was talking with someone like you (a stranger).
- Most of the participants thought that support groups for men who have sex with men and women would be a good idea, to encourage men to take better care of their physical and mental health, and to learn to accept themselves. However, many of them also thought that these men would not take part in these types of groups because the stigma is currently too great and the fear of being judged and rejected is too strong. They do believe that community organizations and institutions, such as churches and community-based organizations can do more to encourage these men to protect themselves and their partners by simply acknowledging that this is going on and not being so condemning.Research Question 5: Effective Channels & Sources to Reach NGI MSM
- Participants in this study listen to the radio an average of 15 hours a week, with a range in listening time from 0 to 72 hours a week. Participants most often stated that they listen to rhythm and blues (R & B) radio stations; followed by jazz, talk radio, and gospel stations.
- Participants in this study watch television an average of 28 hours a week, with a range in viewing time from 0 to 100 hours a week. The majority of participants noted that they watch news programs, followed by comedy/situation comedies and sports programs.
- Participants in this study spend an average of ten hours a week reading print media (newspapers, magazines, other publications), with a range in reading time from 0 to 52 hours. The most frequently mentioned print media were local and national newspapers, followed by African-American interest magazines and news magazines. When asked what holds their attention in the publications above, participants most often stated that they read these newspapers and magazines to stay informed of current events locally, nationally, and internationally.
STD Communications Database Interviews with NGI MSM Executive Summary – 7
- The majority of participants in this study (39 out of 49) stated that they use the Internet. For activities other than email, respondents in this study use the Internet an average of 14 hours a week, with a range in use from 15 minutes to 40 hours a week. Types of Websites most commonly visited by participants include entertainment sites followed by news sites, search engines, and adult or pornographic sites.
- Participants were asked if they would first go to radio, television, print media or the Internet if they wanted information on sexually transmitted diseases such as syphilis, gonorrhea or HPV. An overwhelming majority of respondents stated that they would first go to the Internet for this type of information. Participants mentioned a few additional channels they thought might be effective in disseminating STD information, including billboards, healthcare providers and facilities, and public libraries.LimitationsThis study has several limitations:
- First, in-depth interviews rely on convenience samples. As such, the generalizability of these findings is limited.
- Second, all of the participants were willing to participate in an interview. It is not known how, if at all, these participants differ from those who did not participate.
- Third, as a result of participating in a one-hour discussion about this topic, participants are likely very different than those who did not participate. While it is highly unlikely that their attitudes would change as a result of participating, they may have become more open and willing to discuss sex, STDs, and prevention methods.
- Fourth, the findings of this study rely on a small sample size.
- Finally, this study reports the results of aggregated data. As a result, there are cultural and other factors associated with NGI MSM in African-American and Hispanic/Latino communities that cannot be explored.
- Summary The research described in this report was an exploratory look at African-American and Hispanic/Latino non-gay identified men who have sex with men, aged 20 – 45. Based on qualitative, in-depth interviews, a number of important findings emerged regarding the behaviors, attitudes, and community and cultural influences of NGI MSM and how these might affect their preferences for receiving messages for STD prevention.
- The need for a continued focus on reducing high-risk behavior, such as unprotected anal intercourse, regardless of the sex of the partner is emphasized in these findings. This information will be valuable to public health workers at the local and state levels, to community-based organizations, and to national agencies that are committed to preventing and reducing the spread of STDs.
- The results of this study will also be helpful for other researchers interested in NGI MSM, although there are many more questions that can be raised regarding the most effective ways to communicate about STD prevention with this population.
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STD Communications Database Interviews with NGI MSM Executive Summary – 8
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