Abstract
The ongoing HIV epidemic among men who have sex with men (MSM) in New York City and the increased use of Internet sexual social networking websites by MSM fosters a need to understand the characteristics and sex-related behaviors of this group. The authors conducted an online survey of 195 MSM who use sexual social networking websites in New York City. Demographic characteristics, sexual sensation seeking, and HIV optimism–skepticism were compared among participants reporting sex with and without condom use (safe sex and high-risk sex, respectively) with partners met online. There was no difference in income, education, race, or employment status between the groups. The groups differed significantly in age, sexual sensation seeking, and HIV optimism–skepticism. In a multivariate logistic regression both HIV optimism–skepticism (p < .05) and sexual sensation seeking (p < .05) were significant predictors of high-risk sexual behavior (pseudo-R2 = .24). This information should be considered when developing interventions for this group. For example, to reach those with high sexual sensation seeking, public health professionals should design sex-positive prevention messages for online distribution that highlight safer sex without condemning risky sexual practices.
New York City remains the epicenter of the HIV/AIDS epidemic in the United States. More than 100,000 New Yorkers are living with HIV, and thousands more do not know they are infected. New York City has the highest AIDS case numbers in the country, with more AIDS cases than Los Angeles, San Francisco, Miami, and Washington D.C. combined. HIV is the third leading cause of death for those aged less than 65 in New York City, and each year more than 1,000 people in New York City first find out they are HIV infected after the disease has already progressed to full-blown AIDS. Approximately 1 in 70 New Yorkers is infected with HIV, but the proportion of people in different groups who are infected varies widely: 1 in 40 Black men, 1 in 25 men living in Manhattan, 1 in 12 Black men aged 40 to 49 years, 1 in 10 men who have sex with men, 1 in 8 injection drug users, 1 in 5 Black men aged 40 to 49 in Manhattan, and 1 in 4 men who have sex with men in the Chelsea neighborhood (New York City Department of Health and Mental Hygiene, 2007).
Men who have sex with men (MSM) continue to account for more than half of newly diagnosed HIV infections in the United States well into the third decade of the epidemic (Centers for Disease Control and Prevention, 2005). Specifically, according to preliminary epidemiological data from the New York City Department of Health and Mental Hygiene (2007), HIV infection is on the rise among young men who have sex with men in New York City. The agency reports that new HIV diagnoses among MSM aged less than 30 increased by 33% in 6 years, from 374 in 2001 to nearly 500 in 2006. New diagnoses have doubled among MSM ages 13 to 19, while declining by 22% among older MSM. The age-group less than 30 now accounts for 44% of all new diagnoses among MSM in New York City, up from 31% in 2001. Men of color (Black and Hispanic) continue to bear a disproportionate share of New York City’s HIV burden. Among all MSM, Black men received twice as many HIV diagnoses as White men in 2006 (232 vs. 101), and Hispanic men received 55% more than White men (157 vs. 101). The disparity is even more striking among adolescents; more than 90% of the MSM aged less than 20 diagnosed with HIV in 2006 were Black or Hispanic (81 out of 87).
Every borough except Staten Island has seen HIV increases among MSM aged less than 30 since 2001. In 2006, 20% of MSM diagnosed with HIV received a concurrent diagnosis of AIDS (285 men), meaning that they had missed opportunities for care to stay healthy and may have unknowingly spread HIV to others (New York City Department of Health and Mental Hygiene, 2007).
Although still a relatively new venue, the Internet has assumed a role similar to the more traditional “gay bar,” providing a popular way for men who have sex with men to communicate with and to meet sexual partners. Nicknames such as “technological tearoom” (Tikkanen & Ross, 2003) and “erotic oasis” (Ross, Tikkanen, & Mansson, 2000) have been used to describe the Internet as a tool for online and offline sexual behavior. For some men, the Internet may serve as a more accessible or interim point of socialization in terms of their sexuality, desires, and behaviors. Unlike traditional face-to-face settings, the Internet offers a varied array of chat rooms, bulletin boards, websites, and other settings—each carrying its own set of social norms among very specific groups and cultures. Brown, Maycock, and Burns (2005) note that online communities provide opportunities for encouraging safe sex in this difficult to reach group.
Although many MSM continue to meet one another in traditional settings such as bars, clubs, cultural events, and through friends, Benotsch, Kalichman, and Cage (2002) argue that the Internet provides a new venue, especially for MSM, for sex-seeking behaviors that did not exist in the past. The Internet provides a vast array of outlets for sex-seeking behavior among MSM. These include a range of “gay”-related websites providing sexual social networking and other computer-mediated real-time and responsive interaction. Sexual social networking websites like these are often geographically specific and designed to facilitate specific types of relationships (i.e., friendship, sex seeking; Benotsch et al., 2002). The role the Internet plays in the relationships between individual risk behavior factors and online sex seeking is of particular interest, especially considering many unanswered questions remain about whether the Internet facilitates high-risk sexual behavior among MSM.
Few studies have recruited MSM directly from the Internet to examine sex-seeking behavior on the Internet and subsequent high-risk sexual behavior. The majority of these studies found associations between having met sex partners online and rates of high-risk sexual behavior (Bolding, Davis, Hart, Sherr, & Elford, 2005; Hirshfield, Remien, Humberstone, Walavalkar, & Chiasson, 2004; Hospers, Harterink, Van Den Hoek, & Veenstra, 2002). Additional studies have shown that men who use the Internet to meet male sex partners may also engage in more high-risk behaviors than those who do not (Benotsch et al., 2002; Kim, Kent, McFarland, & Klausner, 2001; Liau, Millet, & Marks, 2006; Whittier, Seeley, & St. Lawrence, 2004). This study was designed to investigate these online sex-seeking behaviors of MSM in New York City and assess their attitudes toward HIV risk. Specifically, the three research questions guiding the study were the following:
Research Question 1: What are the characteristics of MSM who use the Internet in seeking sex partners?
Research Question 2: What are the attitudes and beliefs regarding the risk of HIV infection of men who use the Internet in seeking sex partners?
Research Question 3: How are sexual sensation seeking, Internet-initiated sexual behavior, and attitudes and beliefs toward HIV risk and the Internet related?
Method
Participants and Procedures
Men who have sex with men who lived in New York City (defined by NYC zip code) and were aged 18 years and older were recruited on social networking websites that target gay men and MSM during January to February 2008. New York City community-based organizations (CBOs), which provide HIV prevention services to MSM and have Internet outreach and/or education components, were consulted in the choice of sexual social networking websites to use in recruitment. Approval was received from three of the recommended sites, and the survey was advertised on these sites. Institutional review board approval was obtained for the protection of human subjects through the Office of Sponsored Programs at Teachers College, Columbia University.
The link to the online survey was posted in a health educator profile or section on the approved social networking sites. Data were collected and stored securely in an online server. Participants who accepted the consent form online were assigned an arbitrary, computer-generated numeric code and could proceed to take the survey confidentially. The consent form was linked to the participant survey through the assigned code. Participants were assured that their responses remained confidential and were not linked to any identifying information. To participate in the study, potential respondents had to be at least 18 years of age, reside in a New York City zip code, identify as male, and report having sex with men or primarily men in the last year. Men not meeting these criteria were excluded from completing the survey.
Measures
Several instruments were used to assess sexual behavior, Internet sex seeking, attitudes and beliefs toward HIV and HIV prevention, and sexual sensation seeking. These include the Sexual Sensation Seeking Scale (Kalichman et al., 1994), the HIV Optimism–Skepticism Scale (Van de Ven, Kippax, Knowx, Prestage, & Crawford, 1999), an Internet Usage Questionnaire (Elford, Bolding, Davis, Sherr, & Hart, 2004), and a demographic questionnaire based on the New York City Department of Health and Mental Hygiene’s Community Health Survey (2006).
Sexual Sensation Seeking Scale
The Sexual Sensation Seeking Scale is a nine-item scale based on the most widely used measure of sensation seeking. Sensation seeking, the propensity to prefer exciting, optimal, and novel stimulation or arousal, is a potential mediating factor in sexual risk for HIV infection (Kalichman et al., 1994). Items on the scale are measured on a 4-point scale, from 1 (Not at all like me) to 4 (Very much like me). Higher scores indicate greater levels of sexual sensation seeking. The nine items on the scale are added together to make one composite score for sexual adventurism. These scale scores were used in analysis. As a point of reference, the following ranges are often used in studies of sexual sensation seeking: 11-19 = low sexual sensation seeking, 20-27 = moderate sexual sensation seeking, 28-38 = high sexual sensation seeking. An original Cronbach’s alpha level of.75 was reported for this scale (Kalichman et al., 1994).
HIV Optimism–Skepticism Scale
The HIV Optimism–Skepticism Scale is used to measure associations among knowledge, perceptions, and attitudes toward new HIV treatments and sexual behavior of MSM (Van de Ven et al., 1999). This 12-item instrument is organized using a 5-point Likert-type scale, ranging from Strongly Disagree to Strongly Agree. Composite scores range from 2 to 25, with higher scores indicating greater optimism (e.g., perceived decrease in the threat of HIV and the increased belief in the effectiveness of new treatments). The scale score was used in analyses. Scores on this scale are typically categorized as follows: 2-9 = HIV skepticism, 10-16 = neutral HIV optimism–skepticism, 17-25 = HIV optimism. The original instrument was shown to be reliable (α = .83).
Internet Usage Questionnaire
To assess frequency counts of self-reported Internet usage and reasons for Internet use, we used the Internet Use section of the Internet and HIV Study Questionnaire (Elford, Bolding, Davis, Sherr, & Hart, 2004). The instrument comprises 24 questions, consisting of items ranging from questions on access to the Internet, access to and frequency of visits to MSM sexual social networking websites, sex seeking on the Internet, and sexual behavior (both protected and unprotected anal intercourse) resulting from initial contact using the Internet. Questions regarding sexual behavior with a partner met on the Internet during the past 3 months were asked initially, and if no partner had been met during that time, respondents were asked about sexual behavior during the past 12 months.
Demographic questionnaire
A four-item demographic questionnaire assessing employment status, education level, self-identified ethnicity, and annual household income was used. The instrument is an abbreviated version of the demographic questionnaire used in the New York City Department of Health and Mental Hygiene’s Community Health Survey (2006).
Analyses
We used descriptive statistics to examine the demographic and behavioral characteristics of our sample and bivariate inferential statistics (chi-square and t test) to determine which of the demographic and behavioral variables were significantly associated with high-risk sexual behavior. The results of the bivariate analyses were then used to develop a logistic regression model predicting the likelihood of high-risk sex behavior. Model fit for the final logistic model was examined using the Nagelkerke pseudo-R2 statistic and the Hosmer and Lemeshow test. Pseudo-R2 values are analogous to the R2 in linear regression and range from 0 to 1, with 1 indicating a model that fits the data perfectly. Hosmer and Lemeshow tests the null hypothesis that there is no difference between the observed and predicted values of the dependent variable. As such, a nonsignificant Hosmer and Lemeshow χ2 (failure to reject the null) indicates a model that fits the data.
Results
Research Question 1
The participants (n = 195) ranged from 18 to 66 years of age (M = 29.34; SD = 7.02). Men self-identified as White (n = 100, 64.1%), Black (n = 28, 17.9%), Native Hawaiian or other Pacific Islander (n = 5, 3.2%), Asian (n = 8, 5.1%), American Indian/Alaskan Native (n = 1, 0.6%), Latin/Hispanic (n = 21, 13.5%), and other (n = 6, 3.8%). The majority (n = 103, 66.9%) reported being employed for wages/salary during the past 3 months, and more than half (n = 123, 79.9%) reported completing a bachelor’s degree or more. The most commonly reported annual household income from all sources was >$75,000 (n = 52, 34.2%). These data are consistent with other studies (Chiasson et al., 2007). In comparing demographic characteristics between men who have sought sex partners online in the past year and men who have not, the only statistically significant difference we found was in mean age (t = −2.49; p < .05). Although significant, there was not a large difference in age, with men who had looked for sex partners online being 27.6 years old on average (SD = 4.1) whereas those who had not looked for sex partners online were 30.1 years old (SD = 7.3; see Table 1).
Demographics and Attitudes of Men Who (A) Used the Internet to Seek Sex Partners in the Past Year and (B) Used Condoms With Men They Met on the Internet for Anal Sex in the Past Year
Among MSM who specifically reported having used the Internet to seek sexual partners (n = 143), the most commonly reported reason for accessing the sexual social networking websites was “It’s entertaining/exciting when I’m bored” (n = 41, 28.7%) followed by “To find sexual partners” (n = 38, 26.6%). Sixteen participants (11.2%) reported using the sexual social networking websites “To find a boyfriend,” whereas 11 men (7.7%) reported using them “To make new friends” and “To meet people like myself.”
Of the 143 (83.1%) who reported looking online for sex partners in the past year, more than one third (n = 50, 35.0%) of the participants reported meeting their past five sex partners online. During the past 3 months, the majority of these men reported meeting someone from online face to face (n = 121, 84.6%). Most of the 143 men (n = 105; 73.4%) reported having oral sex with a man met on the Internet, 71 (49.7%) reported having anal sex with a man met online in the past 3 months, and 26 (18.2%) reported having anal sex without a condom in the past 3 months with a man met online.
When asked about the past year, nearly all the 143 men reported having met someone face to face after first having met them online (n = 140, 97.9%). A large majority reported oral sex with a man met online (n = 130, 90.9%), 92 men (64.3%) reported anal sex with a man met on the Internet during the past 12 months, and 42 (29.4%) reported anal sex without a condom with a man met on the Internet in the past year (Table 2).
Attitudes and Behaviors of Men Seeking Sex Partners Online in the Past Year (n = 143)
Reasons why the 42 MSM choose to engage in anal sex without a condom during the past year and when they chose to engage in the behavior were assessed by analyzing the frequencies of several individual items on the Internet Usage Questionnaire (Elford et al., 2004). The majority of respondents who reported anal sex without a condom during the past year reported that the point at which the decision was made to have anal sex without a condom was as follows: “It was spontaneous/it just happened” (n = 26, 61.9%). This was followed by “After we had sex a few times” (n = 6, 14.3%). When asked why they chose to have sex without a condom, 26 men (61.9%) reported “For pleasure,” 21 men (50.0%) reported “I got carried away,” and 18 men (42.9%) reported “He had the same HIV status as me,” whereas only 2 men (4.8%) reported “I didn’t have a condom.”
The average level of sexual sensation seeking was moderate (M = 24.62; SD = 5.19; range = 11-36), and internal consistency was shown to be sufficient with the sample (α = .77). There was no significant difference in average sexual sensation seeking score between men who reported seeking sex partners online and those who did not (t = −0.88; p = .38; see Table 1).
Research Question 2
The 12-item HIV Optimism–Skepticism Scale instrument was used to make one composite score. On average, participants showed HIV skepticism (M = 7.84; SD = 4.86). The instrument was show to be reliable with a Cronbach’s α of .77. There was no significant difference between mean HIV optimism–skepticism scores for men seeking sex partners online compared with those who did not seek partners online (t = −1.78; p = .08; see Table 1). There was a weak, positive, statistically significant correlation (r = .16; p < .05) between HIV optimism–skepticism score and the sexual sensation seeking score. That is, as participants showed more optimism toward HIV treatments, their sexual sensation seeking also increased.
Research Question 3
Using bivariate analyses, we identified demographic and behavioral variables associated with Internet-initiated anal sex acts without a condom in the past 12 months (risky sexual behavior). Although the demographic characteristics of the sample were not significantly associated with the outcome, both sexual sensation seeking and HIV optimism–skepticism were significantly related to risky sexual behavior (p < .05). These two scores were used to develop a logistic regression model predicting the probability of risky sexual behavior. The results indicated that as HIV optimism–skepticism increased (more optimistic) and sexual sensation seeking increased, the probability of engaging in risky sexual behavior also increased (Table 3). Specifically, for every one unit increase in the HIV optimism–skepticism score, the odds of risky sexual behavior increased by 16.7% (odds ratio [OR] = 1.167; 95% confidence interval [CI] = 1.057, 1.289). In addition, for every one unit increase in the sexual sensation seeking score, the odds of risky sexual behavior increased by 11.5% (OR = 1.115; 95% CI = 1.016, 1.223). The model was significantly better than the baseline at predicting risky sexual behavior, χ2(2) = 19.10, p < .001, and fit the data well (Nagelkerke pseudo-R2 = .24; Hosmer and Lemeshow GOF χ2(8) = 9.52; p = .30). The model correctly predicted 69.7% of the observed values. Based on the logistic regression results, Figure 1 shows the increased probability of high-risk sex with higher HIV optimism–skepticism (A) and sexual sensation seeking (B) scores.
Logistic Regression Results Predicting the Probability of High-Risk Anal Sex With a Man Met on the Internet.
Note. OR = odds ratio; CI = confidence interval.
Predicting the likelihood of risky sexual behavior based on sexual sensation seeking and HIV optimism–skepticism: (A) predicting the likelihood of risky sexual behavior based on sexual sensation seeking, holding HIV optimism–skepticism constant at the mean (M = 7.84); (B) predicting the likelihood of risky sexual behavior based on HIV optimism–skepticism, holding sexual sensation seeking constant at the mean (M = 24.62)
Discussion
Through a survey of MSM who use social networking websites that target gay men, we confirmed the results of previous studies with respect to reasons for accessing social networking websites and meeting partners online (Chng & Géliga-Vargas, 2000), sexual sensation seeking, and HIV optimism–skepticism and risky sexual encounters (Elford, Bolding, & Sherr, 2002; Van de Ven, Rawstorne, Nakamura, Crawford, & Kippax, 2002). As one of the first to focus on the online sex-seeking behaviors of MSM in New York City, this study does two things: (a) assists in clarifying the role of the Internet in the New York City HIV crisis and (b) identifies a venue that may be useful in effectively addressing high-risk sexual behavior among MSM.
Most (81%; n = 111) of the men in this sample reported engaging in oral sex, whereas 26% of the men reported having engaged in risky sexual behavior (anal sex without a condom) in the past 3 months with a man met initially online. This indicates that the majority MSM who seek sex partners online could be limiting sex acts to low-risk behaviors such as oral sex or anal sex with a condom to reduce the possibilities of HIV transmission. However, among those participants who reported an increasing number of oral sex acts and anal sex acts over the past 3 months, the number of anal sex acts without a condom during this time frame also increased. That is, men who engage in a greater numbers of oral and anal sex acts also participate in more acts of high-risk sexual behaviors (i.e., anal sex without a condom).
Participants scored moderate to high in sexual sensation seeking, and increased scores in sexual sensation seeking increased the likelihood of engaging in risky sex. In addition, we found sexual sensation seeking increased as optimism toward HIV infection and new HIV treatments increased. Although participants reported a low level of optimism toward HIV infection and new HIV care and treatment options, those with higher HIV optimism–skepticism scores (more optimistic) were more likely to participate in high-risk sex. This suggests that men who feel more confident about recent advances in HIV medications and the availability of emergency treatments like postexposure prophylaxis are more likely to engage in unprotected anal sex with men they meet online.
The primary limitation of the study was the sampling strategy. Information was collected from a self-selected sample of MSM and therefore cannot generalize to all MSM who seek sex with other men in online venues. Another limitation of the study was the initial eligibility criteria. Although MSM from neighboring cities and states may engage in online sex seeking with MSM from New York City, only men reporting a New York City residence (zip code) were included in the study. This may have excluded potentially important data. Moreover, respondents who did not report at least a significant number of male sex partners in the last year were not included in the study, thus perhaps excluding valuable data from men who have engaged in same-sex behavior more frequently in previous years or who may engage in extremely risky same-sex behavior yet have not done so frequently in the past year.
In addition, because respondents completed the survey on the Internet, there was no way for the researchers to control the administration of the survey. Disruptions in the respondent’s environment during completion may have affected his response pattern, which may have included taking breaks to view pornography, chat with other men, or engage in individual or mutual Internet-based masturbation. Engaging in these behaviors while completing the survey may have had an effect on one’s reported sexual sensation seeking scores.
Response bias was also a limitation of the study. The nature of the study involves the disclosure of personal information such as attitudes toward HIV and sexual behavior. Because respondents completed the survey online, by themselves, the data are self-reported and may contain errors in judgment, errors in recollection, or a desire to please the researchers with information about sexuality and health. Likewise, integral and specific data may have been completely omitted or ignored by respondents if they felt the questions were too personal. Some potential respondents may have passed by the survey entirely because of its nature and purpose.
Conclusion and Recommendations
Men are meeting other men online, leading to sex and potentially risky sexual behavior. MSM who use social networking websites that target gay men in New York City have moderate-to-high sexual sensation seeking, increasing the likelihood of risky sex behavior. Furthermore, the HIV optimism–skepticism scores among participants indicate that, although new HIV care and treatment options may offer increased levels of optimism for some, still others continue to believe they are invincible and immune from the disease. Using this information, health educators and practitioners should begin to develop, disseminate, and evaluate tailored safe-sex messages in online venues as one way to combat the devastating impact HIV/AIDS continues to have on New York’s MSM community.
Because the Internet is often regarded as a free-for-all, researchers and practitioners must recognize this risk and approach it seriously and with caution. Prevention messages targeting MSM who are specifically seeking sex online should be developed carefully in light of the characteristics and behaviors of this group. This is not to suggest that public health professionals developing web-based interventions should neglect MSM who are frequenting sex-based websites for other reasons. Nonetheless, researchers and practitioners interested in developing online prevention and education must find new and innovative ways to tailor messages and online education to fit the needs of targeted MSM (e.g., those who engage in high-risk anal sex, those high in sexual sensation seeking, and those high in HIV optimism). For example, to reach those with high sexual sensation seeking, it may be beneficial to design sex-positive prevention messages that highlight and eroticize safer sex without condemning risky sexual practices. For those with higher HIV optimism, health messages should realistically portray the seriousness of HIV even in the era of antiretroviral therapy and postexposure prophylaxis. For men who log on for reasons other than to seek sex, designing holistic health messages emphasizing positive psychological and social well-being might be an alternate approach. Further research is warranted to test the effects of such messages on non-Internet sex-seeking MSM. Researchers and practitioners must also be cognizant that their online prevention and education messages will stand against tough competition (both financially and aesthetically) on social networking websites targeting MSM where advertisements for online pornography, sex toys, and other highly sexualized messages are pervasive.
Footnotes
The author(s) declared no conflicts of interest with respect to the authorship and/or publication of this.
The author(s) received no financial support for the research and/or authorship of this article.