Using a Syndemics Theory Approach to Study HIV Risk Taking in a Population of Men Who Use the Internet to Find Partners for Unprotected Sex

Abstract

This study examines the value of using syndemics theory as a model for understanding HIV risk taking in a population of men who are at great risk for acquiring and/or transmitting HIV. The principal aim is to provide an empirical test of the applicability of the theory to sexual risk behaviors in this particular research population. The study was based on a national random sample of 332 men who have sex with men, or MSM, who use the Internet to seek men with whom they can engage in unprotected sex. Data collection was conducted via telephone interviews between January 2008 and May 2009. As hypothesized in the syndemics theory model, attitudes toward condom use were central to understanding men’s involvement in risky sex. As hypothesized, these attitudes depended on various demographic, psychological/psychosocial functioning, and sex-related preference measures. Also as hypothesized, psychological and psychosocial functioning were found to be very important to the overall model, and as expected, these factors were shaped greatly by factors such as demographic characteristics and childhood maltreatment experiences. The structural equation assessing the fit of the overall model indicated solid support for the syndemics theory approach. Overall, syndemics theory seems to apply fairly well to understanding the complexity of the factors that underlie men’s risk-taking practices. The complicated interplay among factors such as attitudes toward condom use, childhood maltreatment experiences, psychological and psychosocial functioning, and substance use and abuse—all of which are central to a syndemics theory approach to studying risk—was demonstrated.

Keywords

syndemics theory HIV risk men who have sex with men (MSM)Internet unprotected sex

During the mid-1990s, Merrill Singer (1994) coined the term syndemic. This term refers to the tendency for multiple epidemics to co-occur and, in the process of affecting some of the same people, for the various maladies to interact with one another, with each one worsening the effects of the others (Singer, 2009; Singer et al., 2006). The adoption of the concept of syndemics represents a recognition of the fact that many diseases and social problems do not exist in isolation from one another and the fact that many diseases and social problems worsen the effects of others already being experienced by their host. Singer et al. (2006) stated,

Beyond disease clustering and interaction, the term syndemic also points to the importance of social conditions in disease concentrations, interactions and consequences. In syndemics, the interaction of diseases or other health problems . . . commonly arises because of adverse social conditions . . . that put socially devalued groups at heightened risk. (p. 2011)

Walkup et al. (2008) noted that health problems may be construed as syndemic when two or more conditions/afflictions are linked in such a manner that they interact synergistically, with each contributing to an excess burden of disease in a particular population. It is noteworthy that their work addresses the syndemic of HIV, substance abuse, and mental illness. A good example of how conditions may become syndemic is offered by Romero-Daza, Weeks, and Singer (2003) in their study of street prostitution. The authors wrote,

Streetwalkers’ continuous exposure to violence, both as victims and as witnesses, often leaves them suffering from major emotional trauma. In the absence of adequate support services, women who have been victimized may turn to drug use in an attempt to deal with the harsh realities of their daily lives. In turn, the need for drugs, coupled with a lack of educational and employment opportunities, may lead women into prostitution. Life on the street increases women’s risk for physical, emotional, and sexual abuse as well as their risk for HIV/AIDS. Exposure to traumatic experiences deepens the dependence on drugs, completing a vicious cycle of violence, substance abuse, and AIDS risk. (pp. 233-234)

In recent years, the term syndemic has been expanded to constitute syndemics theory, which is the overarching conceptualization that diseases and social conditions not only co-occur but also interact with one another such that the sum of the effects of experiencing each of the co-occurring conditions is greater than merely experiencing its constituent maladies alone would be. A number of authors, particularly during the past few years, have written about syndemics and syndemics theory as they apply to the HIV epidemic (Gielen et al., 2007; Mustanski, Garofalo, Herrick, & Donenberg, 2007; Romero-Daza et al., 2003; Singer et al., 2006), including specific mention of the applicability of the concept and theory to men who have sex with men (MSM; Mustanski et al., 2007; Stall et al., 2003; Stall, Friedman, & Catania, 2008). It is noteworthy that syndemics theory may be applied to understanding not only the factors underlying or leading to medical diseases but also social maladies or sociobehavioral outcomes, such as HIV risk taking.

With limited research having been conducted to examine the applicability of syndemics theory to HIV risk taking among MSM, the present study represents an effort to examine this very issue in a sample of men who are at especially great risk for contracting and/or transmitting HIV, namely, men who use the Internet specifically to find other men with whom they can engage in unprotected sex.

The conceptual model used in the present research is presented in Figure 1. As the figure demonstrates, the principal outcome measure is HIV risk taking. Six types of influences are hypothesized to operate syndemically to affect the extent to which men engage in risky behaviors. Three of these factors (demographic characteristics, sex-related preferences, and childhood maltreatment experiences) are construed as being exogenous factors, and three of them (psychological/psychosocial functioning, substance use/abuse, and attitudes toward condom use) are considered to be endogenous factors. The basic notion with respect to the endogenous measures is that they are conceptualized as affecting HIV risk taking while simultaneously affecting one another and being affected by other factors in the model. For example, how men feel about using condoms is hypothesized to have a direct impact on the extent to which they engage in risky sex. At the same time, condom-related attitudes are expected to be shaped by men’s experiences with childhood maltreatment, their overall psychological/psychosocial profiles, their substance use/abuse practices, and so forth.

Figure 1.

Conceptual model

Method

Recruitment and Participation

This article draws from data that were collected between January 2008 and May 2009 for The Bareback Project, a study funded by the National Institute on Drug Abuse. The study sample consisted of men who use the Internet specifically to find other men with whom they can engage in unprotected sex. Some of the 16 websites from which the sample of 332 men was recruited catered exclusively to unprotected sex (e.g., Bareback.com, RawLoads.com). Other websites used did not cater to unprotected sex exclusively but did make it possible for site users to identify which individuals were looking for unprotected sex (e.g., Men4SexNow.com, Squirt.org). Using the 16 websites, a national random sample of men was derived. Random selection was based on a combination of the first letter of the person’s online username, his race/ethnicity (as listed in his profile), and the day of recruitment. Recruitment took place 7 days a week, during all hours of the day and nighttime, variable from week to week throughout the project, to maximize the representativeness of the research sample, in recognition of the fact that different people use the Internet at different times.

Initially, men were approached for participation either via instant message or e-mail (much more commonly via e-mail), depending on the website used. Potential participants were provided with a brief overview of the study and informed consent–related information, and they were given the opportunity to ask questions about the study before deciding whether or not to participate. Potential participants were also provided with a website link to the project’s online home page to offer additional information about the project and to help them feel secure in the legitimacy of the research endeavor. Interested men were scheduled for an interview soon after they expressed an interest in taking part in the study, typically within a few days. To maximize convenience for participants, interviews were conducted during all hours of the day and night, 7 days a week, based on interviewer availability and participants’ preferences. All the study’s interviewers were gay or lesbian to engender credibility with the target population and to enhance participants’ comfort during the interviews. This information was disclosed to study participants only if they inquired about it, either prior to consenting to participate or at some point during their interview.

Participants in the study completed a one-time, confidential telephone interview addressing a wide array of topics. The questionnaire that was used was developed specifically for The Bareback Project. Many parts of the survey instrument were derived from standardized scales previously used and validated by other researchers. The interview covered subjects such as degree of “outness,” perceived discrimination based on sexual orientation, general health practices, HIV testing history and serostatus, sexual practices (protected and unprotected) with partners met online and offline, risk-related preferences, risk-related hypothetical situations, substance use, drug-related problems, Internet usage, psychological and psychosocial functioning, childhood maltreatment experiences, HIV/AIDS knowledge, and some basic demographic information. The interviews lasted an average of 69 minutes (median = 63, SD = 20.1, range = 30-210). Participants who completed the interview were offered $35. Two payment options were available, one of which allowed men to maintain complete anonymity (PayPal) and one of which required them to provide a name and mailing address to receive payment (check). A total of 13.3% of the men participating in the study declined the $35. Approval of the research protocol was given by the institutional review boards at Morgan State University (approval number 07/12-0145), where the principal investigator and one of the research assistants were affiliated, and George Mason University (approval number 5659), where the other research assistant was located.

Measures Used

The main outcome measure (i.e., dependent variable) used in this particular article indicates the percentage of sex acts that involved the use of protection. It is a continuous measure based on participants’ self-reported sexual practices during the 30 days prior to interview. Separate questions were asked about the number of times that the man had engaged in receptive oral sex, insertive oral sex, receptive anal sex, and insertive anal sex, and then for each of these behaviors, how many of these times a condom had been used.

Numerous measures examining demographic characteristics were examined. These included age (continuous), race/ethnicity (categorical), sexual orientation (gay vs. bisexual), relationship status (involved in a marital-type relationship vs. not involved), educational attainment (continuous), sexual role identity¹ (top, versatile top, versatile, versatile bottom, bottom), HIV serostatus (positive, negative, unknown), and knowing anyone currently living with AIDS (yes/no).

Four items measuring men’s sex-related preferences were examined. These were how rough they preferred their sex to be (continuous), how long they most liked their sexual sessions to last (continuous), how much they liked having sex in public venues (continuous), and how much they liked having sex that was “wild” or “uninhibited” (continuous).

The Childhood Trauma Questionnaire (Bernstein & Fink, 1998) was used to examine childhood maltreatment experiences. Six measures, all of which asked men about their experiences prior to the age of 18, were used: sexual abuse (Cronbach’s α = .93), physical abuse (Cronbach’s α = .85), emotional abuse (Cronbach’s α = .89), physical neglect (Cronbach’s α = .71), emotional neglect (Cronbach’s α = .93), and total amount of childhood maltreatment experienced (Cronbach’s α = .94). Each of the five main constructs was composed of five measures, and respondents indicated whether each behavior had happened to them “never,” “rarely,” “sometimes,” “often,” or “very often” before they turned 18 years of age.

The substance use/abuse domain was assessed with three measures: currently a user of illegal drugs (yes/no), number of drug problems experienced (continuous scale measure, Cronbach’s α = .87), and total amount of illegal drug use reported during the preceding 30 days (continuous measure of quantity × frequency of recent use, summed across nine drug types). The specific illegal drugs inquired about were marijuana, powdered cocaine, crack cocaine, heroin or other opiates, hallucinogens, Ecstasy, club drugs other than Ecstasy (e.g., ketamine, gamma-hydroxybutyrate [GHB]), methamphetamine, and sedatives or depressants that were not prescribed by a doctor.

Attitudes toward condom use were assessed via a 17-item scale that was found to be highly reliable (Cronbach’s α = .91). Individual items were scored on a 5-point Likert-type scale (with responses ranging from strongly disagree to strongly agree); higher scores on the scale corresponded with attitudes that were more conducive of condom use. The scale was derived from the work of Brown (1984). Only items that were relevant to MSM and their sexual practices were used, so that the scale would be applicable to the study population.

Finally, psychological and psychosocial functioning were examined. Measures examined were self-esteem (using the Rosenberg self-esteem scale [Rosenberg, 1965]; Cronbach’s α = .89), depression (using the Center for Epidemiologic Studies Depression scale [CES-D; Radloff, 1977]); Cronbach’s α = .93), optimism about the future (using the Life Orientation Test–Revised [Scheier & Carver, 1985]; Cronbach’s α = .78), current life satisfaction (adapted from the Satisfaction With Life scale [Diener, Emmons, Larsen, & Griffin, 1985]; Cronbach’s α = .83), concerned about potential sex partners’ HIV serostatus (yes/no), perceived accuracy of HIV serostatus information provided verbally by sex partners (ordinal, with five response options ranging from not at all accurate to very accurate), and perceived accuracy of online HIV serostatus information (ordinal, with five response options ranging from not at all accurate to very accurate).

Analysis

The analysis for this research took place in several steps. Initially, bivariate analyses were conducted to examine which of the independent measures were related one-on-one to the dependent measure in question. Whenever the independent variable was dichotomous (e.g., race, sexual orientation), Student’s t tests were used. Whenever the independent variable was ordinal with five or more response options or continuous in nature (e.g., extent of sexual abuse, level of self-esteem), simple regression was used to test the bivariate relationships.

Items that were found to be related either significantly (p < .05) or marginally (.15 > p > .05) to the dependent measure in these bivariate analyses were entered into a multivariate equation, and then removed in stepwise fashion until a best fit model containing only statistically significant measures remained. This approach was used for the main outcome measure (i.e., percentage of protected sex) and for each of the relevant endogenous measures (e.g., condom-related attitudes, level of self-esteem).

As a final analytical step, the relationships depicted in Figure 2 (which portrays the results of the analyses just described) were subjected to a structural equation analysis. This was undertaken to determine whether the way the relationships depicted there is an appropriate and effective representation of the study data. SAS’s PROC CALIS procedure was used to assess the overall fit of the model to the data. When conducting a structural equation analysis, several specific characteristics are examined and sought: (a) a goodness-of-fit index as close to 1.00 as possible but no less than .90, (b) a Bentler–Bonett normed fit index value as close to 1.00 as possible but no less than .90, (c) an overall chi-square value for the model that is statistically nonsignificant, preferably as far from attaining statistical significance as possible, and (d) a root mean square error of approximation value as close to 0.00 as possible but no greater than .05. If these conditions are met, then the structural relationships depicted are considered to indicate a good fit with the data (Browne & Cudeck, 1993; Byrne, 1994; Schumacker & Lomax, 2004; Steiger, 1990). Throughout all the analyses, results are reported as statistically significant whenever p < .05.

Figure 2.

Factors associated with engaging in protected sex

Results

Sample Characteristics

In total, 332 men participated in the study. They ranged in age from 18 to 72 years (mean = 43.7 years, SD = 11.2, median = 43.2). Racially, the sample is a fairly close approximation of the American population (U.S. Census Bureau, 2001), with 74.1% being Caucasian, 9.0% each being African American and Latino, 5.1% self-identifying as biracial or multiracial, 2.4% being Asian, and 0.3% being Native American. The large majority of the men (89.5%) considered themselves to be gay and almost all the rest (10.2%) said they were bisexual. On balance, men participating in The Bareback Project were fairly well educated. About 1 man in 7 (14.5%) had completed no more than high school; 34.3% had some college experience without earning a college degree; 28.9% had a bachelor’s degree; and 22.3% were educated beyond the bachelor’s level. The sample, like the American population in general, tended to be skewed toward people residing in more densely populated areas (U.S. Census Bureau, 2000). One fifth of the men (20.0%) lived in an area with fewer than 250 persons per square mile. At the other end of the spectrum, 37.8% of the men resided in an area with more than 5,000 persons per square mile, and half of these men (19.8% of the total sample) lived in an area with more than 10,000 persons per square mile. Slightly more than half of the men (59.0%) reported being HIV-positive; most of the rest (38.6%) were HIV-negative. Although the proportion of participants who were HIV-positive is very high, this is not unexpected when one considers that this study population was defined by its active searching online for partners for unprotected sex.

Bivariate and Multivariate Analysis: Protected Sex

Demographic variables

Caucasian men used condoms about one third as much as their nonwhite counterparts (5.5% vs. 15.0%, t = 3.90, p < .001). HIV-positive men used condoms less than half as often as their HIV-negative and serostatus-unknown counterparts (5.2% vs. 12.1%, t = 3.13, p < .01). There was a tendency for unprotected sex to be lower when men knew more people who were living with AIDS (8.8% vs. 4.9%, t = 1.60, p < .15). Educational attainment, age, sexual orientation, relationship status, and sexual role identity (top/bottom/versatile) were not found to be related to the frequency of condom use.

Sex-related preferences

The more that men preferred their sex to be “wild” or “uninhibited,” the less likely they were to use condoms (F_1,292df = 8.10, p < .01). The other measures examined here were not related to the tendency to engage in protected sex.

Childhood maltreatment

None of the childhood maltreatment measures was found to be related to the proportion of men’s sex acts involving the use of condoms.

Substance use/abuse

The more drug-related problems men experienced, the more unprotected sex they reported (F_1,292df = 6.53, p < .05). How much illegal drug use they reported during the month prior to interview and whether or not they were active users of illegal drugs were not predictive of their extent of condom use.

Attitudes toward condom use

The more favorable their attitudes toward condom use were, the more likely they were to engage in protected sex (F_1,291df = 39.33, p < .001).

Psychological/psychosocial functioning

The more accurate men perceived their sex partners to be with regard to HIV serostatus information when they discussed it, the less likely they were to use condoms during sex (F_1,279df = 16.51, p < .001). Self-esteem, depression, optimism about the future, current life satisfaction, being concerned about sex partners’ HIV serostatus, and the extent to which men perceived online-provided HIV serostatus information to be accurate were unrelated to the proportion of sex acts involving the use of protection.

Multivariate analysis

Six items were found to be related to the overall understanding of the proportion of sex acts that involved the use of protection. These were (a) attitudes toward condom use (β = .29, p < .001), (b) HIV serostatus (β = .17, p < .01), (c) race/ethnicity (β = .17, p < .01), (d) perceiving HIV serostatus information to be accurate (β = .15, p < .01), (e) knowing people who are living with AIDS (β = .12, p < .05), and (f) knowing people who died from AIDS (β = .12, p < .05). Together, these items explained 23.6% of the total variance.

Bivariate and Multivariate Analysis: Attitudes Toward Condom Use

Demographic variables

African American men had better attitudes toward using condoms than their counterparts belonging to other racial/ethnic groups (t = 3.60, p < .001). HIV-positive men were more opposed to condom use than their HIV-negative counterparts (t = 2.55, p < .05). There was a tendency for educational attainment and attitudes toward condom use to be related inversely to one another (F_1,328df = 2.19, p < .15). Men who were involved in a relationship had slightly more favorable attitudes toward condom use than their single counterparts (t = 1.54, p < .15). Men who considered themselves to be sexual bottoms had somewhat more negative attitudes toward condom use than their versatile and top counterparts (t = 1.70, p < .15). Knowing people who are living with AIDS, age, and sexual orientation were not found to be related to men’s attitudes toward condom use.

Sex-related preferences

The longer that men preferred their sexual sessions to last, the more opposed to condoms they were (F_1,326df = 4.04, p < .05). The more that men preferred their sex to be “wild” or “uninhibited,” the less likely they were to favor the use of condoms (F_1,327df = 32.99, p < .001). The more that men liked having sex in public venues, the more they tended to dislike using protection (F_1,323df = 6.17, p < .05). There was a tendency for men who liked their sex to be on the physically rougher side to have worse attitudes toward using condoms when compared with their peers who preferred their sex to be gentler (F_1,327df = 2.46, p < .15).

Childhood maltreatment

The more emotional abuse that men experienced during their formative years, the worse their attitudes toward using condoms were as adults (F_1,327df = 5.80, p < .05). Additionally, the more emotional neglect (F_1,327df = 2.66, p < .15) or physical neglect (F_1,327df = 8.85, p < .01) they had experienced while growing up, the more negative their condom-related attitudes were as adults. The total amount of childhood maltreatment was found to be related inversely to men’s attitudes regarding condom use (F_1,327df = 4.88, p < .05). Sexual abuse and physical abuse were not found to be related to men’s attitudes toward the use of condoms.

Substance use/abuse

The more drug-related problems men experienced, the more negative men’s condom-related attitudes were (F_1,328df = 8.15, p < .01). Similarly, condom attitudes were more negative among active users of illegal drugs than among nonusers (t = 2.13, p < .05). The more illegal drug use they reported during the month prior to interview, the more negative their attitudes toward condoms were (F_1,328df = 5.63, p < .05).

Psychological/psychosocial functioning

The more accurate men perceived their sex partners to be with regard to HIV serostatus information when they discussed it, the more negative their attitudes toward using condoms were (F_1,315df = 7.62, p < .01). Condom attitudes were more favorable among people with higher levels of self-esteem (F_1,328df = 11.13, p < .001), lower levels of depression (F_1,327df = 5.78, p < .05), greater feelings of optimism about the future (F_1,328df = 7.55, p < .01), and greater life satisfaction (F_1,328df = 4.37, p < .05). Men who said that they were not concerned about their sex partners’ HIV serostatus were more negative in their feelings about using condoms than were their counterparts who specifically identified an HIV serostatus in desired sex partners (t = 3.48, p < .001). The more that men perceived online-provided HIV serostatus information to be accurate, the worse their attitudes toward condom use were (F_1,327df = 4.16, p < .05).

Multivariate analysis

Seven items were found to be related to the overall understanding of men’s attitudes regarding the use of protection. These were (a) having a preference for “wild” or “uninhibited” sex (β = .25, p < .001), (b) self-esteem (β = .17, p < .01), (c) perceiving HIV serostatus information to be accurate (β = .15, p < .01), (d) not caring about potential sex partners’ HIV serostatus (β = .15, p < .01), (e) the number of drug problems experienced (β = .13, p < .01), (f) race/ethnicity (β = .13, p < .01), and (g) educational attainment (β = .13, p < .01). Together, these items explained 20.7% of the total variance.

Bivariate and Multivariate Analysis: Self-Esteem

Demographic characteristics

African American men had higher levels of self-esteem than their counterparts belonging to other racial/ethnic groups (t = 2.36, p < .05). The more education men had, the higher their levels of self-esteem were overall (F_1,328df = 12.54, p < .001). The older men were, the better they tended to feel about themselves (F_1,327df = 7.48, p < .01). One factor not examined in the other analyses, but relevant here, was body mass index, with lower self-esteem being reported by men who were more overweight (F_1,328df = 5.72, p < .05). HIV serostatus, relationship involvement status, and sexual orientation were not found to be associated with men’s levels of self-esteem.

Childhood maltreatment

For emotional abuse (F_1,327df = 24.69, p < .001), emotional neglect (F_1,327df = 36.34, p < .001), physical neglect (F_1,327df = 29.69, p < .001), and overall amount of maltreatment experienced during their formative years (F_1,327df = 22.70, p < .001), more maltreatment corresponded with lower levels of self-esteem in adulthood. Physical abuse and sexual abuse were not related to men’s levels of self-esteem.

Substance use/abuse

There was a tendency for greater drug use to correspond with higher self-esteem (F_1,328df = 3.81, p < .15) and for more drug-related problems to correlate with reduced self-esteem (F_1,328df = 2.47, p < .15). Users of illegal drugs and nonusers reported comparable levels of self-esteem.

Multivariate analysis

Five items were identified as contributing uniquely and significantly to men’s overall levels of self-esteem. These were (a) emotional neglect during one’s formative years (β = .27, p < .001), (b) race/ethnicity (β = .14, p < .01), (c) educational attainment (β = .14, p < .01), (d) body mass index (β = .12, p < .05), and (e) age (β = .10, p < .05). Together, these items explained 16.0% of the total variance.

Structural Equation Model

The results of the analyses presented above were placed into diagram form to facilitate a visual presentation of the findings, and then subjected to a structural equation analysis to ascertain whether this way of visualizing and interpreting the data is supported by the data. Figure 2 presents this diagram and the results of the analysis. Standardized coefficients (i.e., beta values) are shown on the chart, so that effect sizes can be compared.

Analysis revealed that this is an excellent way of conceptualizing the relationships at hand. First, when undertaking a structural equation analysis, it is desirable to obtain a goodness-of-fit coefficient that is greater than .90 and as close to 1.00 as possible. Here, it was found to be .99. Second, in a structural equation analysis, we want the chi-square test for the equation to be statistically nonsignificant. Here, with a chi-square value of 28.54 (22 df), the probability level was p = .21. Third, the root mean square error of approximation should be no greater than .05, and as close to 0.00 as possible. Here, it was .03. Fourth, we look for a Bentler–Bonett normed fit index value that is greater than .90 and as close to 1.00 as possible. Here, this coefficient was .95 All the desired structural equation properties were met, indicating that the model is an appropriate way of depicting the relationships under study.

Discussion

Overall, the present study yielded findings that support the utility of a syndemics theory approach for understanding (un)protected sex practices among men who use the Internet to identity potential partners for unprotected sex. The conceptual model shown in Figure 1 hypothesized that condom-related attitudes would be one of the key factors contributing to our understanding of involvement in unprotected sex. The data supported this contention and, indeed, identified attitudes toward condom use as the single strongest predictor of men’s involvement in risky sex. Moreover, the conceptual model depicted this relationship as one that would be influenced by other factors, such as demographic differences, psychological/psychosocial functioning, substance use/abuse, childhood maltreatment experiences, and sex-related preferences. Although all these factors were not found to be influential in the overall determination of men’s attitudes toward condom use, several of them were. Other studies have addressed the importance of understanding and recognizing how MSM feel about using condoms, and the need to address these condom-related attitudes if one wishes to bring about reductions in HIV risk in this population (Ostrow et al., 2008; Peterson & Bakeman, 2006). Generally speaking, though, less attention has been paid by previous scholars about the specific factors that underlie attitudes toward condom use in this population. The present study, consistent with the syndemics theory approach used to guide this research, highlights the importance of considering the multiplicity of factors that interact with one another to affect how men feel about using condoms.

Additionally, the conceptual model illustrated an expectation that psychological and psychosocial functioning would play a central role in the overall understanding of men’s involvement in risky sex. Indeed, the data supported this hypothesis while illustrating just how complicated these relationships are. Several of the psychological/psychosocial functioning measures were found to be relevant in the overall structural model explaining men’s practice of unprotected sex, namely, self-esteem, being unconcerned about potential sex partners’ HIV serostatus, and the amount of accuracy in HIV serostatus information perceived to be inherent in personal discussions with one’s sex partners. Of these measures, self-esteem was identified as the most centrally relevant psychological functioning measure, but even it was not found to have direct effects on engaging in (un)protected sex. Rather, the data revealed that self-esteem operates by affecting men’s feelings about using condoms, and those in turn directly affect how they act with regard to the (non)use of sexual protection. Moreover, the data showed that self-esteem is subject to other types of influence that are central to the syndemics theory model, including demographic differences and childhood maltreatment experiences. Once again, a few previous studies have spoken about the relationship between self-esteem and involvement in HIV risk practices (Gullette & Lyons, 2006; Rosario, Schrimshaw, & Hunter, 2006; Stein, Rotheram-Borus, Swendeman, & Milburn, 2005). But on the whole, previous studies have devoted little attention to “the bigger picture” regarding the factors associated with self-esteem and the myriad ways in which it has its effects on people’s behaviors. The syndemics theory approach proffered by the present study can provide an important intellectual backdrop against which to develop a fuller understanding of this phenomenon.

The conceptual model shown in Figure 1 hypothesized that substance use or abuse would play a key role in the overall understanding of men’s involvement in risky sexual practices as well. Ultimately, it was shown to be relevant in the overall equation, but it was not as centrally important as initially hypothesized. Despite the relevance of substance use and abuse in the bivariate analyses examining unprotected sex, attitudes toward condom use, and self-esteem, overall, the effects of the substance use/abuse measures was retained in only one form in the final analysis. Specifically, the more drug-related problems men were experiencing, the poorer their attitudes toward condom use were. As with self-esteem, therefore, the effects of substance abuse on risk practices appear to be more indirect than direct, operating principally through their impact on condom-related attitudes. Although most published studies have shown that substance abuse leads to increases in risky sex among MSM (Berg, 2009; Carey et al., 2009; Wheeler, Lauby, Liu, Van Sluytman, & Murrill, 2008), the present study suggests that this relationship may be more complex than is often contended. Balan, Carballo-Dieguez, Ventuneac, and Remien (2009) commented on this very topic in their work, noting that while most of their Latino MSM Internet users used alcohol and/or other drugs in conjunction with their barebacking sexual behaviors, substance use did not appear to be propelling unprotected sex among participants in their study. As one example of this, more research is needed to understand how the use of understudied substances such as amyl nitrate (i.e., poppers) may be related to involvement in unsafe sex. Some research has suggested that the use of this substance, which is often used by MSM to make anal sex more comfortable, may be related to greater involvement in HIV risk practices (Carey et al., 2009; Choi et al., 2005; Purcell, Moss, Remien, Woods, & Parsons, 2005). More research needs to be done to examine how, exactly, substance use and abuse behaviors interact with psychological/psychosocial functioning and attitudes toward condom use to affect HIV risk practices. A syndemics theory approach may be useful to such endeavors, as they try to evaluate the complicated, intertwined nature of the effects of substance use/abuse, psychological/psychosocial functioning, safety-related attitudes, childhood maltreatment experiences, and so forth.

This study’s findings pertaining to childhood maltreatment experiences also speak to the value that may be found in adopting a syndemics theory approach to studying risk taking among Internet-using MSM. Although most published studies have reported an elevated likelihood of HIV risk involvement among MSM who have been victimized early in life (Arreola, Neilands, & Diaz, 2009; Catania et al., 2008; Rosario et al., 2006), the present study did not find such an association. This is not to say, however, that childhood maltreatment experiences were irrelevant to understanding their involvement in engaging in unprotected sex. As Figure 2 shows, the relationship appears to be an indirect and rather complicated one. What appears to be happening is this: Childhood maltreatment, particularly when it takes the form of emotional neglect, leads men to suffer from lower self-esteem. The lower self-esteem, in turn, increases the chances that men will have negative attitudes toward using condoms. (This follows logically, when one considers that using condoms is a self-protective behavior, and people who do not have good opinions of themselves are not as likely to take good or proper care of themselves as people who think more highly of themselves.) Negative attitudes toward condom use, in turn, are related quite closely to the failure to use these devices. It is the specific interplay of these types of factors—childhood maltreatment, psychological functioning, attitudes toward personal safety—that has an impact on the likelihood of engaging in (un)protected sex. Studies such as those conducted by Catania et al. (2008) and Rosario et al., (2006) have documented just how complicated the effects of childhood maltreatment can be, particularly when trying to link them to adulthood involvement in HIV risk behaviors. The syndemics theory approach seems to be valuable, and applicable, as a way of conceptualizing how these various factors may work together to affect risk outcomes.

Potential Limitations

As with any research study, the present study has a few potential limitations. First, the response/participation rate was low,² which could raise concern of selection bias and, therefore, the representativeness of the sample. Although it is difficult to be certain that the men who participated represent the men who did not, there is compelling evidence to suggest that differences between the two groups are minimal. Before The Bareback Project was started, the principal investigator conducted a large-scale content analysis with a random national sample of one of the main websites used by men to meet other men seeking unprotected sex partners (for additional information, see Klein, 2008a, 2008b, 2009, 2010). The demographic composition of that sample and the one obtained in The Bareback Project closely match one another in terms of age representation, racial group composition, sexual orientation, and rural/suburban/urban location of residence. The two samples also resemble one another closely in terms of the types of sexual practices that men sought. The similarity of the two samples suggests that men who chose to participate in the present study represent those who did not in terms of identifiable characteristics that are likely to be the best indicators of selection bias. Also, the demographic composition of men in The Bareback Project and in the male adult population-at-large are a fair approximation of one another in terms of their age breakdown (U.S. Census Bureau, 2001), racial composition (U.S. Census Bureau, 2001), and rural/suburban/urban location of residence (U.S. Census Bureau, 2000). The present sample is better educated than men in the general population (U.S. Census Bureau, 2001) and more likely to be HIV-positive (which is to be expected when one considers the population targeted in the present research).

Second, as with most research data on sexual behaviors, the data in this study are based on uncorroborated self-reports. Therefore, it is unknown whether participants underreported or overreported their involvement in risky behaviors. The self-reported data probably can be trusted, however, as noted by other authors of previous studies with similar populations (Schrimshaw, Rosario, Meyer-Bahlburg, & Scharf-Matlick, 2006). This is particularly relevant for self-reported measures that involve relatively small occurrences (e.g., number of times having a particular kind of sex during the previous 30 days), which characterize the substantial majority of the data collected in this study (Bogart et al., 2007). Other researchers have also commented favorably on the reliability of self-reported information in their studies regarding topics such as condom use (Morisky, Ang, & Sneed, 2002).

A third potential limitation is the possibility of recall bias. For most of the measures used, respondents were asked about their beliefs, attitudes, and behaviors during the past 7 or 30 days. These time frames were chosen specifically to (a) incorporate a large enough time frame in order to facilitate meaningful variability from person to person and (b) minimize recall bias. Although the author cannot determine the exact extent to which recall bias affected the data, other researchers who have used similar measures have reported that recall bias is sufficiently minimal and that its impact on study findings is likely to be negligible (Kauth, St. Lawrence, & Kelly, 1991). This seems to be especially true when the recall period is small (Fenton, Johnson, McManus, & Erens, 2001; Weir, Roddy, Zekeng, & Ryan, 1999), as was the case for most of the main measures used in the present study.

Summary

In summary, the present study found considerable evidence to support the utility of a syndemics theory approach to understanding HIV risk practices in high-risk MSM populations. As the theory contends, the present study’s data showed that demographic factors, childhood maltreatment experiences, substance use/abuse, psychological/psychosocial functioning, and attitudes toward risk taking are all relevant to understanding risk taking, and they are interrelated in a highly complex manner. Future HIV prevention and intervention programs might wish to take into account the types of syndemic effects that have been identified in this study and in previous studies. Doing so may help develop a better understanding of risk taking among high-risk MSM, and that, in turn, can lead practitioners to develop more effective prevention and intervention efforts targeting this population.

Footnotes

The author(s) declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

The author(s) disclosed receipt of the following financial support for the research and/or authorship of this article:

This research was supported by a grant from the National Institute on Drug Abuse (5R24DA019805).

Notes

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