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Abstract

High-risk sexual behaviors may result in acquisition of sexually transmitted infections including HIV. Hispanic men who have sex with men (MSM) experience a disproportionate incidence of these infections. Various risk factors, cultural aspects, and relationship factors may influence the sexual behaviors of this subgroup of MSM. The purpose of this study was to describe the sexual behaviors of a sample of foreign-born Hispanic MSM and to compare these sexual behaviors in terms of condom usage, risky sexual behaviors, avoidance of body fluids, and sexual negotiation when stratified by relationship status. Using a cross-sectional, descriptive research design, a convenience sample of 135 foreign-born Hispanic MSM, the majority of whom were Cubans, was recruited and surveyed from the South Florida area. The majority of participants reported engaging in the high-risk sexual behaviors of sex without condoms, substance abuse before or during sex, anal sex, contact with body fluids, and did not negotiate safer sex behaviors. Differences in sexual behaviors when compared by relationship status were found only in terms of certain risky sexual behaviors but not in terms of condom usage, contact with body fluids, or sexual negotiation. Despite participation in a number of high-risk activities and finding few differences among those men in relationships and those not in primary relationships, factors that promote or inhibit participation in high-risk sexual behaviors among Hispanic MSM in various types of relationships need further exploration.

Keywords

Cubans gay men high-risk sex Hispanics

High-risk or unsafe sexual behaviors typically include any sexual behaviors that place an individual at risk for acquisition of sexually transmitted infections (STIs), including HIV infection. High-risk sexual behaviors include engaging in sexual behaviors without the use of condoms, engaging in high-risk sexual behaviors such as anal intercourse, exchanging body fluids during sexual behaviors, and failing to negotiate safer sex behaviors with partners (Centers for Disease Control and Prevention [CDC], 2010b; DiIorio, Parsons, Lehr, Adame, & Carlone, 1992).

Men who have sex with men (MSM) have experienced high rates of STIs, including gonorrhea, syphilis, HIV infection, and lymphogranuloma venereum (CDC, 2008). High rates of STIs and HIV infection are noted among Hispanic MSM, a subgroup of the MSM population. New cases of HIV infection among Hispanics is three times more than that of Caucasians. High-risk sexual behaviors among Hispanic MSM may be associated with a variety of factors including, but not limited to, inconsistent condom use, substance abuse, socioeconomic status, and Hispanic cultural beliefs (CDC, 2010a).

Miami-Dade County, Florida, has a population of nearly 2.5 million. About 62% of the county’s population is Hispanic. Of the Hispanic population, 54% were foreign-born and 59% speak Spanish at home. The county’s Hispanics are 50% Cuban, 11% South American, 9% Central American, 6% Puerto Rican, 3% each of Dominicans and Mexicans, and 18% other (U.S. Census Bureau, 2010). Of the 9,557 cumulative AIDS cases in the county, 73% were among MSM. In Miami-Dade County, Florida, there are 7,020 cases of AIDS among Hispanic MSM and another 444 cases among Hispanic MSM who are intravenous drug users. The majority of cases of AIDS among Hispanic MSM with AIDS are Cubans (47.2%), U.S.-born Hispanics (11.6%), South Americans, (11.1%), Central Americans (7.9%), Caribbean Hispanics excluding Cuba (6.7%), and 15.5% are other or unknown (Miami-Dade County Department of Health, 2011). Miami, Florida, has one of the highest rates of new cases of HIV infection in the United States (Campsmith, Rhodes, Hall, & Green, 2006).

Research has been conducted on the sexual behaviors of MSM; however, fewer studies have focused exclusively on the sexual behaviors of Hispanic MSM (Carballo-Dieguez et al., 2005). Even fewer studies have been conducted on how the sexual behaviors of Hispanic MSM vary by relationship status. The importance of studying the impact of relationship status on the sexual behaviors of MSM is important because relationship partners have a significant influence on an individual’s beliefs and behaviors and may have a positive or negative influence on HIV transmission risk (Eaton, West, Kenny, & Kalichman, 2009).

Because Hispanic MSM are at an increased risk of HIV infection, it is important to further explore the sexual behaviors of the Hispanic MSM population (Zea, Reisen, & Diaz, 2003). The purpose of this study was to describe the sexual behaviors of a sample of Hispanic MSM and to compare the sexual behaviors of Hispanic MSM by relationship status in terms of condom usage, contact with body fluids, sexual negotiation, and risky sexual behaviors.

Review of the Literature

The examination of sexual behaviors in terms of condom use, contact with body fluids, sexual negotiation, and risky sexual behaviors is conceptually based on the work of DiIorio et al. (1992). Sexual behaviors are interrelated and often overlapping. In an effort to differentiate between low- and high-risk sexual behaviors and to focus on a more broad definition of sexual behaviors that included more than just condom use, DiIorio and colleagues categorized sexual behaviors into condom usage, contact with body fluids, sexual negotiation, and risky sexual behaviors.

Condom Usage

High rates of unprotected anal intercourse (UAI), or anal intercourse without condoms, are common among the this subpopulation of men (Griffin, Snook, Hoff, Cai, & Russell, 2006; Parsons & Bimbi, 2007; Rhodes, McCoy, Hergenrather, Omli, & Durant, 2007; Shernoff, 2006). Fewer studies, however, have focused on Hispanic MSM. Rhodes, Yee, and Hergenrather (2006) conducted a study that surveyed African American, Caucasian, and Hispanic MSM. The researchers found that Hispanic MSM were more likely to report inconsistent condom usage during anal intercourse and were less likely than the other groups of MSM to be tested for HIV infection. Another study of English-speaking Hispanic MSM (n = 159) found that 22% reported UAI with a nonprimary partner in the past 30 days, and 51% reported UAI within the past year. Of those who reported UAI in past 30 days, 67% had engaged in UAI with a primary partner, whereas 44% had engaged in UAI with a nonprimary partner (Diaz, Stall, Hoff, Daigle, & Coates, 1996). A third study reported that factors associated with UAI among Hispanic MSM included a diagnosis of HIV infection, drug abuse, a greater number of sexual partners, psychosocial distress, and higher levels of acculturation (Akin, Fernandez, Bowen, & Warren, 2008).

Contact With Body Fluids

Studies that have documented contact with semen during sexual activity among Hispanic MSM are nonexistent. Two studies, however, have documented explanations for the exchange of semen during sexual activity among the general population of MSM. The exchange of semen is associated with intimacy, identity, and pleasure. This exchange of bodily fluids is viewed as a cultural construct of sexuality in the MSM community (Schilder et al., 2008) and is influenced by perceived levels of risk, gratification, and safety (Vincke, Bolton, & De Vleeschouwer, 2001).

Sexual Negotiation

Sexual negotiation includes discussions between sexual partners regarding issues and behaviors to promote the well-being, self-esteem, or security of both partners. A number of studies have been conducted that focused on sexual negotiation in terms of practicing safer sex behaviors (Davidovich, de Wit, & Stroebe, 2000; Kippax et al., 1997; Semple, Patterson, & Grant, 2000); however, only one study could be located that investigated sexual negotiation among Hispanic MSM. This study focused on sexual negotiation and disclosure of HIV status among Hispanic MSM who used the Internet to locate sexual partners. The participants were more likely to engage in sexual negotiation and discussion of HIV status via the Internet than in person. MSM who participated in sexual negotiation were more likely to use condoms during anal sex. The researchers concluded that the Internet as a form of sexual networking may be useful in assisting men with sexual negotiation and HIV status disclosure strategies (Carballo-Dieguez, Miner, Dolezal, Rosser, & Jacoby, 2006).

Risky Sexual Behaviors

The majority of the available research on risky sexual behaviors includes substance abuse during sexual activity as a high-risk behavior. In addition to the study by Akin and colleagues (2008) that noted that substance abuse was related to UAI, a study by Dolezal, Carballo-Dieguez, Nieves-Rosa, and Diaz (2000) found that substance abuse among Hispanic MSM was related to UAI, especially with casual or nonprimary partners. When country of origin, acculturation, partner type, and personality traits were controlled, the relationship of substance abuse and UAI remained statistically significant. Substance abuse during sexual activity was used as a means to cope with sexual identity, to identify with the mainstream gay community, and to decrease sexual inhibitions (Bauermeister, 2008).

Relationship Status

The relationship between sexual behaviors and relationship status has been documented, but the results are conflicting. As reported in the research literature, casual sexual relationships outside primary relationships are common among the general population of MSM (Crawford et al., 2003; Hickson & Davies, 1992). MSM with HIV infection involved in primary relationships reported more high-risk sexual behaviors with primary sexual partners as well as casual sexual partners (Niccolai, D’Entremont, Pritchett, & Wagner, 2006; Theodore, Duran, Antoni, & Fernandez, 2004). MSM involved in relationships where both partners are either infected with HIV or not infected with HIV (termed seroconcordant relationships) were more likely to engage in unprotected sexual activity with primary partners than men in serodiscordant relationships. Concern about contracting HIV resulted in fewer high-risk sexual behaviors (Crawford et al., 2003).

However, a study by Klausner, Pollack, Wong, and Katz (2006) found that MSM in primary relationships had fewer sexual partners, fewer casual partners, and lower rates of UAI with casual partners compared with MSM not in primary relationships. Bricker and Horne (2007) reported that 73% of the sample (n = 179) reported involvement in primary relationships. Men in these relationships reported fewer sexual partners, fewer numbers of lifetime sexual partners, and higher levels of attachment to the relationship. In these studies, primary relationships were protective against STIs and HIV. Studies that examined the influence of relationships on the sexual behaviors of Hispanic MSM are nonexistent.

Demographic Variables

Evidence of the influence of certain demographic variables on sexual behaviors among the general population of MSM can be found in the literature. Ross, Henry, Freeman, Caughy, and Dawson (2004) reported that MSM who were younger in age and had lower levels of education were more likely to participate in high-risk sexual behaviors. Income, however, does not have any influence on sexual behaviors among MSM (Santelli, Lowry, Brener, & Robin, 2000).

A number of research studies with Hispanics have focused on acculturation (Marin & Gamba, 1996; Marin & Marin, 1991) or the components of acculturation such as length of time in the United States, language preference, and language fluency (Unger, Ritt-Olson, Wagner, Soto, & Baezconde-Garbanati, 2007). Foreign-born Hispanic MSM experience distinct challenges related to foreign-birth. Studies have shown that limited English proficiency (Guilamo-Ramos, Jacard, Pena, & Goldberg, 2005) and recent immigration (Blake, Ledsky, Goodenow, & O’Donnell, 2001) were associated with high-risk sexual behaviors in the general population of Hispanics. In contrast, foreign-born Hispanic MSM engaged in less high-risk sexual behaviors when compared with U.S.-born Hispanic MSM (De Santis, Vasquez, Weidel, Watson, & Sanchez, 2009). With the limited studies to examine the differences between foreign-born and U.S.-born Hispanic MSM in terms of sexual behaviors, it is unclear at this point if foreign-birth is a risk or protective factor for participation in high-risk sexual behaviors.

This study provides data that contribute to the knowledge base of high-risk sexual behaviors among foreign-born Hispanic MSM. From the relevant literature, significant gaps in the literature were noted in terms of comparing sexual behaviors by relationship status among these Hispanic MSM.

Method

Design, Sample, and Setting

A descriptive cross-sectional research design was used. The university’s institutional review board granted approval for the study and waived the signed informed consent requirement. Participants were provided with a letter that described the study and informed participants that by completing the study questionnaire, consent was provided to participate in the study.

The sample was collected from the population of community-dwelling Hispanic MSM who reside in South Florida. Community-dwelling Hispanic MSM are those who are not institutionalized and who reside independently in the community. Before data collection began, an a priori minimum sample size of 102 (or at least 52 participants in a relationship with another man and at least 51 participants not in a relationship with another man) was calculated using an alpha of .05, a power of .80, and a medium effect size of 0.5 (Soper, 2010).

This study is an analysis of unpublished data from a larger study that focused on the relationship of depressive symptoms, self-esteem, and sexual behaviors among a community-dwelling sample of MSM (n = 205; De Santis, Colin, Vasquez, & McCain, 2008). This study comprises the unpublished data on the sexual behaviors of the foreign-born Hispanic MSM (n = 135).

To participate in the study, participants were required to (a) be 18 years of age or older, (b) self-identify as Hispanic or Latino, and (c) self-identify as gay or bisexual, or report sexual activity with another man at some point during the lifetime. Recruitment of participants was conducted at various community sites such as bars/clubs, parties/social events, and places of worship. Participants were recruited from bars/clubs (n = 45; 33.3%), followed by clinics (n = 22; 16.3%), and private parties/social events (n = 17; 12.6%). An additional 51 participants (37.8%) were recruited using snowball sampling, where participants who have completed the study referred additional participants to the researcher (Creswell, 1994). Those participants who were recruited via snowball sampling completed the survey in their home setting.

Because of the unique demographic composition of South Florida, the survey was available in both English and Spanish. The majority of the participants (n = 104; 77%) elected to complete the survey in Spanish.

The participants ranged in age from 21 to 58 years with a mean of 37.53 years (SD = ±8.12). Reported length of time in the United States ranged from less than 1 year to 44 years (M = 13.61; SD = ±10.69). Slightly more than half of the foreign-born men were Cubans (56.3%; n = 76). The remainder were South American (n = 31; 23.0%), Caribbean Islanders excluding Cuba (n = 16; 11.8%), Central Americans (n = 10; 7.4%), and Europeans (n = 2; 1.5 %). Total income in U.S. dollars ranged from $0 to $104,000 per year (M = $36,705.48; SD = $23,191.67). Almost all (n =123; 91.1%) were employed full-time. In terms of highest educational level obtained, 28 participants (20.8%) had a high school diploma or less; 75 (55.5%) had an associate’s or bachelor’s degree; and 32 (23.7%) had a master’s degree or higher. The majority of the participants (n = 82; 60.7%) were involved in a primary relationship.

Instruments

The Safer Sex Behavior Questionnaire (SSBQ; DiIorio et al., 1992) was used in this study as well as a demographic questionnaire. This instrument and the demographic questionnaire were translated into Spanish, translated back into English, and compared with the original translation for accuracy using the process of back translation (Chen & Boore, 2009).

The SSBQ is a measure of sexual behaviors. The SSBQ contains 27 items on a 4-point Likert-type scale ranging from 1 (never) to 4 (always). Total scores range from 27 to 108 with higher scores indicating participation in safer sex behaviors. The SSBQ includes subscales that measure condom usage, contact with body fluids, sexual negotiation, and risky sexual behaviors. Possible scores on the subscale of condom usage range from 7 to 28, contact with body fluids range from 2 to 8, sexual negotiation range from 10 to 40, and risky sexual behaviors range from 7 to 28. An example of an item on the condom usage subscale is “I insist on condom use when I have sex.” An example of an item on the contact with body fluids subscale is “I avoid contact with my partner’s semen.” An example of an item on the sexual negotiation subscale is “If my partner insists on sexual intercourse without a condom, I refuse to have sexual intercourse.” An example of an item on the risky sexual behaviors subscale is “I engage in anal intercourse without a condom.”

An alpha coefficient of .82 was reported on the SSBQ. The SSBQ is correlated with instruments that measure self-expression, assertiveness, and risk-taking behaviors (DiIorio et al., 1992). A reliability coefficient of .86 was noted in this sample of Hispanic MSM, which is comparable to DiIorio et al.’s (1992) original study.

The SSBQ was chosen as the instrument to measure sexual behaviors in this study because of the comprehensive examination of sexual behaviors. Other instruments focus only on a few sexual behaviors such as condom use and do not include contact with body fluids, sexual negotiation, and other risky sexual behaviors. Also, the SSBQ is a standardized instrument with good reliability and validity (DiIorio et al., 1992) and performs well with this population of men based on the high reliability coefficient of .86 for this sample. The majority of studies that focus on the sexual behaviors of Hispanic MSM have not used standardized instruments to measure sexual behaviors of these men (Akin et al., 2008; Carballo-Dieguez et al., 2006; Diaz et al., 1996; Rhodes et al., 2006).

The demographic questionnaire provided information about the study’s participants. Items included in the demographic questionnaire were age, country of origin, number of years living in the United States, employment status, income, relationship status, educational level, and language preference.

The self-administered survey was completed in 15 to 20 minutes by all the participants. The survey was administered by the author. Before the survey was administered, literacy was assessed by having the participants read a brief explanation of the study in their preferential language. The survey was then self-administered.

Data Collection and Recording

At the various sites, participants were approached and invited to participate in the study. Participants who met inclusion criteria and agreed to participate were enrolled in the study. Attempts were made to offer privacy within study site confines, such as providing clipboards with cover sheets to protect responses to the questionnaire. After completion of the questionnaire, participants were instructed to place it in a sealed envelope. Participants received a gift card worth US$5 compensation for time spent completing the questionnaire.

Data Analysis Plan

Questionnaires were checked for completeness before data entry. A plan was developed to exclude any questionnaires with more than 30% missing data from data entry and data analysis (Tsikriktsis, 2005); however, none of the surveys contained more than 30% missing data. Data were managed and analyzed using the Statistical Package for the Social Sciences 17.0 (SPSS) software.

To determine the specific sexual behaviors that this sample of Hispanic MSM engaged in, individual items on the SSBQ were examined. Descriptive statistics were used to describe the sexual behaviors of this sample of Hispanic MSM.

To compare the sexual behaviors of Hispanic MSM by relationship status, relationship status was treated as a nominal variable and the total scores on the SSBQ and the total scores on the SSBQ subscales of condom use, contact with body fluids, sexual negotiation, and risky sexual behaviors were treated as continuous variables. Descriptive statistics and t tests were used to compare the total SSBQ scores and the subscale scores of the two groups of Hispanic MSM. When significant differences were found on the SSBQ subscales, individual items of the subscales were also compared by relationship status.

Results

Data were analyzed in three steps. The first step involved the use of descriptive statistics to examine the individual items of the SSBQ to describe the numbers of the entire sample engaging in specific high-risk sexual behaviors.

The second step in data analysis involved using correlation coefficients to examine the relationships between the subscales of the SSBQ (condom use, contact with body fluids, sexual negotiation, and risky sexual behaviors). The examination of the relationships between the subscales is necessary to show the interrelatedness and possible overlap of sexual behaviors.

The third step of data analysis involved the use of t tests to compare the total SSBQ scores and the subscale scores when the two groups of Hispanic MSM were stratified by relationship status. To compare the participants by relationship status, participants were asked a single question regarding relationship status (Are you in an intimate relationship with another man? Tiene Ud. un relacion intima con otro hombre?). Relationship status was dichotomized as x = 0 for those men not reporting a relationship; and x = 1 for participants reporting a relationship. This allowed for comparisons to be made by relationship status.

Sexual Behaviors of Hispanic MSM

An analysis of the individual items on the SSBQ provided an in-depth description of the sexual behaviors of this sample of Hispanic MSM. The majority of the participants reported engaging in anal sex, having sexual activity without condoms, using substances such as alcohol and drugs before or during sexual activity, contact with the body fluids of partner(s), and neglecting to negotiate safe-sex behaviors with partner(s). The sexual behaviors of this sample of Hispanic MSM are detailed in Table 1.

Table 1.

Sexual Behaviors of Hispanic Men Who Have Sex With Men (N = 135)

SSBQ Subscale	Sexual Behavior	Number (%)
Condom use	Consistently insists on condom usage during sex	77 (57.0)
	Consistently stops foreplay long enough to put on a condom	70 (51.9)
	Consistently carries condoms in preparation for sexual activity	86 (63.7)
	Consistently engages in oral sex without barriers	102 (75.6)
	Consistently uses rubber gloves if cuts on hands are present	27 (20.0)
	Consistently would have sex without a condom if “swept away” in the moment	85 (62.9)
	Has anal sex without condoms	54 (40.0)
Contact with body fluids	Consistently has contact with semen	72 (53.3)
	Consistently has contact with partner(s) blood	13 (9.6)
Sexual negotiation	Consistently asks sexual history of partner(s)	27 (20.0)
	Consistently asks partner(s) about gay/bisexual history	28 (20.7)
	Consistently abstains from sex when sexual history of partner(s) is not known	30 (22.2)
	Consistently examines partners for sores/irritation before sex	60 (44.4)
	Consistently states point of view about sex with partner(s)	93 (68.9)
	Consistently asks partners about history of intravenous drug use	36 (26.7)
	Consistently has a plan to practice safer sex	87 (64.4)
	Consistently refuses to have sex if partner(s) wants sex without a condom	78 (57.8)
	Has difficulty discussing sex with partner(s)	54 (40.0)
	Consistently initiates safer sex topics with partner(s)	65 (48.1)
Risky sexual behaviors	Uses cocaine or other drugs during sex	18 (13.3)
	Has sex with someone who uses intravenous drugs	7 (5.1)
	Engages in sex on the first date	85 (62.9)
	Consistently avoids sex when genital irritation or sores are present	111 (82.2)
	Engages in anal sex	127 (94.1)
	Has sex with gay or bisexual men	121 (89.6)
	Drinks alcohol before or during sexual activity	90 (66.7)

Note. SSBQ = Safer Sex Behavior Questionnaire.

Demographic Variables

Demographic data of the two groups of Hispanic MSM, those in a primary relationship (n = 82) and those not in a primary relationship (n = 53) were compared. Continuous-level data (age, number of years in the United States, income, and number of years of education) were compared using the t test. Categorical data (employment status and language preference) were compared using the chi-square test.

Concerning the variables that were at the continuous level of measurement, significant differences were found in income only, as men in relationships reported a higher mean income (M = $38,380.98, SD = ±$25,631.93) than men not in relationships (M = $34,113.21, SD = ±$18,743.88; t = −1.04, p = .021). Significant differences between the two groups were not found in terms of age (t = −0.917, p = .149), number of years in the United States (t = −1.45, p = .531), or number of years of education (t = −0.295, p = .940). Significant differences in the two groups of men were not found in terms of the categorical variables of employment status (χ² = .032, df = 1, p = .859) or language preference (χ² = 1.41, df = 1, p = .237).

Relationships Between the SSBQ Subscales

Correlation coefficients were examined to determine the relationships between the four SSBQ subscales: condom use, contact with body fluids, sexual negotiation, and risky sexual behaviors. Statistically significant relationships were found between all the subscales of the SSBQ. The results of the relationships between the four SSBQ subscales are found in Table 2.

Table 2.

Bivariate Correlations Between the SSBQ Subscales in a Sample of Hispanic MSM (N = 135)

	Condom Usage	Contact With Body Fluids	Sexual Negotiation	Risky Sexual Behaviors
Condom usage	—
Contact with body fluids	.427**	—
Sexual negotiation	.582**	.469**	—
Risky sexual behaviors	.263**	.256**	.261**	—

Note. SSBQ = Safer Sex Behavior Questionnaire; MSM = men who have sex with men.

p ≤ .01 level (two-tailed).

Sexual Behaviors

The total SSBQ scores for this sample of Hispanic MSM ranged from 46 to 104 (M = 79.61, SD = ±12.94). Significant differences (t = 1.09, p = .328) were not found in the mean scores of men in relationships (M = 78.63, SD = ±12.44) when compared with men not in primary relationships (M = 81.11, SD = ±13.67). This indicates that the two groups of Hispanic MSM did not differ in total SSBQ scores.

Condom use

Total scores on the condom use subscale of the SSBQ for this sample of Hispanic MSM ranged from 7 to 28 (M = 20.24, SD = ±5.30). When compared by relationship status, the mean score on the condom use subscale for men in a relationship was 19.74 (SD = ±5.40) and the mean score for men not in a relationship was 21.00 (SD = ±5.08). The differences in mean scores on the condom use subscale of the SSBQ were not significant (t = 1.35, p = .920). This indicates that no differences were found in the use of condoms during sexual activity between Hispanic MSM in relationships and those not in relationships.

Contact with body fluids

Total scores on the contact with body fluids subscale of the SSBQ for this sample of Hispanic MSM ranged from 2 to 8 (M = 6.80, SD = ±1.49). When compared by relationship status, the mean score on the contact with body fluids subscale for men in a relationship was 6.67 (SD = ±1.55) and the mean score for men not in a relationship was 7.00 (SD = ±1.39). The differences in mean scores on the contact with body fluids subscale of the SSBQ were not significant (t = 1.26, p = .488). This indicates that no differences were found in contact with body fluids during sexual activity between Hispanic MSM in relationships and those not in relationships.

Sexual negotiation

Total scores on the sexual negotiation subscale of the SSBQ for this sample of Hispanic MSM ranged from 13 to 40 (M = 28.46, SD = ±6.39). When compared by relationship status, the mean score on the sexual negotiation subscale for men in a relationship was 28.01 (SD = ±6.22) and the mean score for men not in a relationship was 29.15 (SD = ±6.65). The differences in mean scores on the sexual negotiation subscale of the SSBQ were not significant (t = 1.01, p = .587). This indicates that no differences were found in sexual negotiation practices between Hispanic MSM in relationships and those not in relationships.

Risky sexual behaviors

Total scores on the risky sexual behaviors subscale of the SSBQ for this sample of Hispanic MSM ranged from 11 to 28 (M = 21.63, SD = ±2.80). When compared by relationship status, the mean score on the risky sexual behaviors subscale for men in a relationship was 21.73 (SD = ±2.30) and the mean score for men not in a relationship was 21.47 (SD = ±3.44). The differences in mean scores on the risky sexual behaviors subscale of the SSBQ were significant (t = −0.526, p = .001). This indicates that Hispanic MSM not in relationships reported engaging in more risky sexual behaviors than those men in relationships.

Because the risky behaviors subscale was the only subscale of the SSBQ on which Hispanic MSM in relationships differed significantly from Hispanic MSM not in relationships, it was necessary to review the seven items of this subscale to determine if significant differences could be found on the individual items when stratified by relationship status. No differences were found between the two groups in terms of using drugs prior to or during sexual activity (t = −1.02, p = .308), engaging in sexual intercourse on the first date (t = −0.021, p = .984), engaging in anal intercourse (t = 1.51, p = .133), having sexual relationships with men who are gay/bisexual (t = 0.794, p = .429), or consuming alcohol prior to or during sexual activity (t = 0.400, p = .690).

Significant differences were found between the two groups in terms of having sexual partners who are injecting drug users and avoidance of sexual activity when sores or irritation are present in the genital area. Hispanic MSM who are in primary relationships were more likely to have sex with a partner who is an injecting drug user (t = −1.02; 95% CI = 0.092-0.290; p = .015) and were more likely to avoid sexual activity when genital irritation or sores are present (t = −2.19; 95% CI = −0.662 to −0.033; p = .031) when compared with Hispanic MSM not in primary relationships.

Discussion

The results of this study close some of the gaps in the research knowledge base concerning the sexual behaviors of foreign-born Hispanic MSM residing in South Florida. First, this study provides a comprehensive examination of sexual behaviors of this group of Hispanic men, including condom usage, risky sexual behaviors, contact with body fluids, and sexual negotiation in one study. Second, this study provided a more comprehensive investigation of sexual behaviors in this sample of Hispanic MSM when stratified by relationship status. At this point, the influence of relationship status on the sexual behaviors of the general population of MSM is unclear (Crawford et al., 2003; Klausner et al., 2006). This study provides the foundation for further study on relationships and sexual behaviors of foreign-born Hispanic MSM.

Differences in the sexual behaviors of Hispanic MSM in primary relationships and those not in primary relationships were found only in terms of risky sexual behaviors. The only differences noted in risky sexual behaviors were sexual activity with intravenous drug users and avoidance of sexual activity when genital irritation or sores are present. No other differences were found between the two groups of Hispanic MSM in this study. One may assume that Hispanic MSM not in primary relationships would be more likely to have more sexual partners and, therefore, would be at an increased risk of STIs and HIV. Conversely, men in primary relationships would have fewer sexual partners and would be more likely to know their partner’s STI/HIV status. Men who are aware of their partner’s status and who are in seroconcordant relationships may be more likely to participate in high-risk sexual behaviors such as not using condoms and exchanging body fluids based on negotiation and trust within the relationship (Bricker & Horne, 2007). The fact that there were few differences between these two groups of MSM requires additional research.

The results of this study that explored the high-risk sexual behaviors of Hispanic MSM provide implications for the clinical care and STI/HIV prevention intervention programs targeted to this population of men. In terms of clinical care implications, the results of the study indicate that health care providers need to continue to provide education to Hispanic MSM focused on safer sex behaviors that could reduce the high rates of STIs and HIV infection in this population, as the high rates of these infections are directly related to participation in high-risk sexual behaviors (CDC, 2010b). Reinforcement of safer sex behaviors provided by health care providers may be helpful in focusing attention on this issue. Continually repeated and reinforced messages by health care providers regarding the importance of safer sex behaviors may stimulate these men to consider changing behavior and to substitute high-risk sexual behaviors with safer sex behaviors.

Health care providers should inquire about the relationship status of men during each health care encounter. A more in-depth exploration of relationship status is necessary to ascertain safer-sex practices both within and outside the primary relationship. Information needs to be provided that informs men about the significant risk of STI/HIV infection that could exist if one or both partners are involved in high-risk sexual behaviors either in the primary relationship or outside. A study by Myers and colleagues (1999) found that a range of behaviors occur in MSM relationships. In some relationships, high-risk behaviors are avoided in the primary relationship but practiced outside the primary relationship. In other instances high-risk behaviors were practiced within the primary relationship but avoided outside the primary relationship. Health care providers working with the MSM population need awareness of the range of sexual behaviors both within and outside the primary relationship and need to continue to reinforce safer sex messages to members of the population, regardless of relationship status.

The low rates of condom use during oral and anal sex are important to note. About 76% (n = 102) of the participants engaged in oral sex without condoms or barriers. This is of less concern than the number of participants (n = 81; 60.1%) who consistently did not use condoms during anal sex. The risk of HIV transmission via oral sex is lower than other sexual behaviors, however, other STIs can be easily contracted via oral sex. Since the major risk factor for HIV transmission is unprotected anal sex (CDC, 2010b), and it was found that 94.1% (n = 127) of the participants engaged in anal sex, the participants in this study are at risk for HIV infection.

The use of substances during sexual activity could explain the low rates of condom use. Large numbers of participants reported substance abuse before and during sexual activity. Substance abuse included cocaine and/or other drugs (n = 18; 13.1%) and/or alcohol (n = 90; 66.7%). Given the fact that alcohol and other substances impair judgment and decrease inhibitions, this could offer one possible explanation for the low rates of condom use among the men in this study.

An unexpected finding concerning substance abuse is that Hispanic MSM in relationships were more likely to have partners who are injection drug users. This finding represents a significant risk of HIV infection for both partners (CDC, 2010b). Other than the fact that this represents an additional risk factor for HIV infection, it is difficult to interpret this finding because participants were not asked to report HIV status. If both partners have HIV infection, there may be a risk of transmitted resistant strains of HIV infection between partners. If the partners are serodiscordant, where one has HIV infection and one does not, this finding represents an additional risk for HIV infection for the uninfected partner.

Another behavior that places the men in this study at risk for HIV/STIs is contact with the semen of sexual partners. A large number of the participants (n = 72; 53.3%) reported contact with semen. This body fluid contains a high concentration of HIV (CDC, 2010b). A limitation with the use of the SSBQ is that it is not known whether semen made contact with oral mucosa, rectal mucosa, or intact skin, the large number of men in this study who had contact with the semen of their partner(s) represents exposure to HIV and STIs. Exposure to semen on unbroken skin is less risky than contact with oral or rectal tissue. Contact with rectal tissue represents the greatest risk of HIV exposure (CDC, 2010b).

The information regarding sexual negotiation is a significant finding. Discussion of safer sex behaviors appears to be an issue or concern for the men in this study as only a little less than half (48.1%; n = 65) of the participants reported that they consistently initiate safer sex discussions with their partners. More than two thirds of the participants report voicing views on sexual behaviors to partners (68.9%; n = 93). However, despite the fact that the majority of the men reported consistently initiating sexual discussions and statement of views on sexual behaviors, only 22.2% (n = 30) reported asking the sexual histories of their sexual partners and abstaining from sexual behaviors if the partner’s sexual history was not known. This would indicate that although the participants reported initiating safer sex behaviors and stating views on safer sex behaviors, it appears that many have difficulty negotiating safer sex behaviors with their partners. This difficulty with sexual negotiation may offer an additional explanation for the low rates of condom use.

Another possible explanation for the difficulty in discussing safer sex behaviors with partner(s), stating views on sex, and obtaining sexual histories of partner(s) may be related to inequalities in power in the primary relationship. Inequalities in the relationship may be related to physical, psychological, or financial control of one partner by another. The partner who is being controlled may not be able to negotiate safer sex behaviors. This represents a risk for HIV and STIs if either partner is engaging in high-risk sexual behavior outside the primary relationship (Feldman, Diaz, Ream, & El-Bassel, 2007).

Recent immigrants in particular should be targeted for HIV/STI prevention programs. These men are at an increased risk because HIV/STI prevention messages may not have been provided in their countries of origin. In addition, many MSM immigrate to the United States so that they can experience sexual and lifestyle freedoms that may not have been available in the home country. These freedoms combined with substance abuse may place these MSM at an increased risk of HIV/STIs.

Directions for Future Research

Although this study adds to the knowledge base of the sexual behaviors of Hispanic MSM, a few additional gaps in the knowledge base exist that need further exploration. First, more studies need to be conducted that focus on relationships among Hispanic MSM. Research studies that explore the meaning of relationships, expectations, rules, or cultural norms among Hispanic MSM are needed. The results of previous research on relationships among the general population of MSM are conflicting (Bricker & Horne, 2007; Crawford et al., 2003; Hickson & Davies, 1992). This area has not been explored in the population of Hispanic MSM.

Future research could be focused on the various types of relationships that Hispanic MSM could be involved in such as monogamous relationships with other men, open relationships with other men, and even relationships with women. If these men are in open relationships, are there established rules regarding expectations for participation in safer sex behaviors outside the relationship? For men in monogamous relationships, are there expectations of fidelity or have discussions occurred regarding expectations for safer sex behaviors if infidelity occurs? Because these topics have not been explored with Hispanic MSM, at this point this information is not known.

More research is needed regarding condom use in Hispanic MSM. Previous research has shown that Hispanic MSM often do not use condoms because condoms decrease physical and emotional pleasure during anal intercourse (Balan, Carballo-Dieguez, Ventuneac, & Remien, 2009) or because of a dislike or indifference of condoms, low perception of risk of infection, emotional connectedness and trust in partners, unavailability and inconvenience, and a lack of control (Carballo-Dieguez & Dolezal, 1996). Research is needed to address these factors while promoting condom use among Hispanic MSM.

Second, the exchange of bodily fluids, that is, semen, during activity needs further explanation. The reasons for the exchange of semen during sexual activity among members of this population have not been investigated, therefore an explanation for this practice cannot be provided. Until future studies are conducted that examine this phenomenon, it is unknown if the exchange of semen among members of this population is related to intimacy, pleasure, or affirmation of identity (Schilder et al., 2008).

Third, more research is needed regarding sexual negotiation among Hispanic MSM. Qualitative research studies or focus groups could be conducted to assist in the development of culturally-appropriate methods to teach sexual negotiation skills to Hispanic MSM. In addition, more research is needed regarding cross-cultural sexual negotiation. If Spanish-speaking MSM are engaging in sexual relationships with men who do not speak Spanish, the Hispanic MSM may not have the necessary language skills to negotiate safer sex behaviors. HIV/STI prevention programs and interventions for Hispanic MSM need to focus on providing these men with the basic language skills to negotiate safer sex behaviors with other MSM outside Hispanic culture.

Fourth, more research is needed on the influence of acculturation on the sexual behaviors of MSM, particularly for recent immigrants. Although a lack of assimilation into mainstream U.S. culture is accepted as a protective factor against high-risk behaviors (Marin & Marin, 1991), the influence of acculturation on high-risk sexual behaviors is equivocal, as other studies have reported that a lack of acculturation or assimilation may be a risk factor (Blake et al., 2005; Guilamo-Ramos et al., 2005). More research is needed to identify risk and protective factors for high-risk sexual behaviors among all Hispanic MSM.

Limitations

There are various identified limitations involving the study’s sample and data collection techniques that may limit confidence in the study’s results. The sample was drawn from a convenience sample of Hispanic MSM. An identified weakness of a convenience sample, which is commonly used with hard-to-reach populations such as MSM, is that that the participants may not be truly representative of the population of Hispanic MSM and, therefore, limits generalizability of the results (Creswell, 1994). Since a large number of the participants (n = 59; 38.1%) were recruited using snowball sampling, a possibility exists that all participants in the study are homogenous and not truly representative of the population of Hispanic MSM (Creswell, 1994).

MSM who do not identify as gay, bisexual, or as a man who has sex with men were not included in this study because the goal of the study was to survey self-identified gay and bisexual Hispanic men. Including Hispanic men who do not identify as gay or bisexual would have yielded a more complete description of the sexual behaviors of Hispanic MSM.

Collecting data at sites frequented by members of this population also may limit the generalizability of the results to the population of Hispanic MSM. Those who participated in the study may over-report or underreport behaviors which may not provide an accurate description of the behaviors under investigation.

If this study were to be replicated, a few essential variables should be included. First, it would be helpful if participants were asked to self-report their HIV infection status. Although some evidence suggests that differences in high-risk sexual behaviors between HIV-infected and HIV-uninfected were not found (Crosby & Mettey, 2004), this has not been studied in Hispanic MSM. Second, a measure of HIV knowledge and perceived susceptibility to HIV infection would be helpful. A Dutch study found that both HIV knowledge and perceived susceptibility to HIV infection influenced sexual behaviors among Dutch MSM (Van der Snoek et al., 2006). The influence of power and control in the relationship on sexual behaviors among Hispanic MSM needs further exploration. A study that examined differences in sexual behaviors by HIV status, knowledge of HIV infection, perceived susceptibility to HIV infection, and power and control in all types of relationships among Hispanic MSM has yet to be conducted.

The final and most important limitation of this study involves measurement of relationship status. The survey included a single question on relationship status. Because this is a dichotomous variable, opportunities for Hispanic MSM to provide information on definitions, perceptions, and expectations of intimate relationships is not provided. Also, this study only focused on relationships with other men. It cannot be assumed that the participants in this study do not have intimate relationships with women in addition to men. The use of this question to measure relationship status may have affected the results of the study, and future studies that focus on relationships among Hispanic MSM should either provide more categories of relationships for men to choose from or even provide an open-ended question for men to describe their relationships with other men, women, or both.

Summary

Hispanic MSM continue to be at an increased risk for STI/HIV infection. This study has demonstrated that this sample of men is engaging in high-risk sexual behavior that places them at risk for STI/HIV. The results of this study provide pertinent information regarding the influence of relationship status on sexual behaviors of this subpopulation of MSM.

Despite its limitations, this study makes a unique contribution to the research literature on Hispanic MSM. The study’s findings on the high-risk sexual behaviors that Hispanic MSM engage in provide justification for further research on this subpopulation of MSM.

Footnotes

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

The author(s) received no financial support for the research and/or authorship of this article.

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How Do the Sexual Behaviors of Foreign-Born Hispanic Men Who Have Sex With Men Differ by Relationship Status?

Abstract

Keywords

Review of the Literature

Condom Usage

Contact With Body Fluids

Sexual Negotiation

Risky Sexual Behaviors

Relationship Status

Demographic Variables

Method

Design, Sample, and Setting

Instruments

Data Collection and Recording

Data Analysis Plan

Results

Sexual Behaviors of Hispanic MSM

Demographic Variables

Relationships Between the SSBQ Subscales

Sexual Behaviors

Condom use

Contact with body fluids

Sexual negotiation

Risky sexual behaviors

Discussion

Directions for Future Research

Limitations

Summary

Footnotes

References