Condom Use,Sexual Risk,and Self-Reported STI in a Sample of Older Male Clients of Heterosexual Prostitution in the United States

Abstract

While there is evidence of increasing rates of sexually transmitted infections (STIs) among older men in the United States, there has been little research on older male clients of female sex providers. The purpose of the current study was to understand the sexual risk behaviors and psychosocial correlates among older men hiring sex providers through provider review websites and discussion boards. A convenience sample of 208 male clients ages 60 to 84 completed online surveys about their sexual behavior and psychosocial factors. Participants indicated the most common sexual activities with providers in the past 12 months were receiving condomless fellatio (33.7%) and having penile–vaginal intercourse with a condom (31.7%). Although condomless penile–vaginal sex with a provider in the past 12 months was only reported by 2.9%, about half (51%) of the respondents indicated that they had experienced this at least once during their lifetime. This was associated with a preference for providers who do not require condoms, having been previously diagnosed with an STI, and perceiving one’s HIV risk to be higher, as well as advancing age and having more emotional relationships with providers. Findings demonstrate the need for general and sexual health care practitioners to openly discuss protective measures and strategies for avoiding STIs among their older-to-elderly male patients.

Keywords

male clients female sex workers STIs prostitution older adults

Over the past decade, studies of sexual risk behavior in male clients of female sex providers worldwide have received considerable attention (Belza et al., 2008; Goldenberg et al., 2010; Gomes do Espirito Santo & Etheridge, 2005; Hong, 2008; Jones et al., 2015; Schei & Stigum, 2010; Yang, Attané, & Li, 2014). Conversely, available research on condom use and sexual risk in male clients of independently operating indoor sex providers in the United States was minimal, largely due to the difficulty in accessing this particular client population. In contrast to studies with captive populations drawn from arrest diversion programs and “john schools” primarily targeting customers of outdoor sex providers (see Monto, 1999; Monto & Milrod, 2013), clients of independent indoor sex workers constitute a more elusive group of sex buyers, and gathering data from them requires creative methodological strategies. Probability samples of male clients of female sex providers in the United States do not exist, and in contrast to recent studies of risk factors and sexually transmitted infections (STIs) among sex providers in the United States (e.g., Cohan et al., 2006; Cunningham & Kendall, 2010), decades-old data on sexual health in clients of brothel or street-based sex work have only yielded limited information on condom use (see Elifson, Boles, Darrow, & Sterk, 1999; Leonard, 1990).

The bulk of sex buyer studies worldwide have included data on adult men, with existing literature showing only one study focused specifically on elderly clients (see Santos Ortíz, Laó-Meléndez, & Torres-Sánchez, 1998). Recent large-scale studies of older adults have indicated that men in their 60s and beyond are often active sexually in a variety of contexts and with a variety of partners. Public health studies of older Americans aged 50 years and above have included sexual health items but have not distinguished between paid and unpaid sex (Catania et al., 1995; Lindau et al., 2007; Stall & Catania, 1994). In 2009, data from the National Survey of Sexual Health and Behavior concerning sexual risk drew on a weighted probability subsample of adults aged 50 to 94 years (M = 61.94, SD = 9.00). Results indicated that although 57.2% of the men reported that their last sexual encounter occurred with a steady relationship partner, 10.8% of participants reported sex with a new acquaintance, and 4.1% (or 15 of 369) had engaged in “transactional sex.” Of those 15 men, 3 met criteria for being at “at risk” of STIs, and 2 of the 3 reported using a condom during their most recent sexual event (Schick et al., 2010). Rates of heterosexually acquired STIs are increasing among the elderly; in 2006, adults older than 50 years accounted for 10% of all new HIV infections in the United States. Individuals diagnosed with AIDS in this age group increased from 24% in 2003 to 34% in 2007, thereby accounting for 21% of all AIDS diagnoses during this time period (see Minichiello, Hawkes, & Pitts, 2011).

With these sexual health concerns in mind for an aging population, the objective of the present study was to understand the sexual behavior and protective measures of older-to-elderly male clients who solicit female sex providers online through nationwide review websites and discussion boards. In particular, condom use and factors associated with sexual risk taking were examined in this hidden group of sex buyers in the United States. Drawing on previous research on clients who solicit female sex providers online (Milrod & Monto, 2012), a set of variables were investigated as possible predictors of sexual risk taking, among them the degree to which the men had formed emotional relationships with providers, a preference for sex providers willing to engage without protection, and the total number of reported sexual partners over the previous 12 months.

Hobbyists and the Girlfriend Experience

In the United States, a portion of long-term sex buyers define themselves as “hobbyists” and dedicate themselves to “the hobby,” a euphemism for prostitution (Milrod & Monto, 2012; Milrod & Weitzer, 2012). The behaviors, preferences, and experiences of hobbyists are shared and communicated through various online forums and discussion boards dedicated to reviews of paid sexual experiences and contacts with independently operating sex providers, for example, The Erotic Review.com, ECCIE.net, and the now defunct myRedBook.com. Many hobbyists seek “the girlfriend experience,” popularly known as the GFE. As part of the GFE, the provider offers not only conventional sex acts but also affectionate behaviors such as hugging and kissing in a putative context of emotionally intimate companionship. Often included in a multihour arrangement, the GFE is seen by clients as elevating a pecuniary transaction into a more normative sexual experience that differs little from a conventional “date” where both parties find sexual satisfaction and derive enjoyment from the encounter (Bernstein, 2007; Huff, 2011; Milrod & Monto, 2012; Milrod & Weitzer, 2012; Pettinger, 2011).

A perennial topic of discussion on some review sites and GFE-related forums is the emotion management that sometimes occurs in hobbyist–provider relations. Such discussion threads revolve around clients who appear convinced that there are authentic emotional aspects of their relationship with a provider. Clients who repeatedly see an “all-time favorite”(ATF) often develop what they perceive to be a deepened emotional connection with their provider of choice. The men also believe that their feelings are experienced and reciprocated by the provider and seek to replicate aspects of nonremunerative relationships that lead to deepened physical and emotional intimacies (Milrod & Weitzer, 2012). Meanwhile, condomless penile–vaginal or anal sex is frowned on in discussions or reviews, and prospective clients considering the purchase of sex are exposed to a set of fairly stringent standards concerning appropriate conduct. In fact, reviews that allude to condomless intromissive sex acts or “barebacking” are usually reported by other posters to moderators who intend to encourage compliance with behavioral expectations and reasonable protective strategies during the encounter. Hobbyists who persist in disclosing barebacking in their sexual activities with providers are usually censored, put on moderation with monitored posting privileges, or banned from membership on the various sites (Milrod & Monto, 2012, Milrod & Weitzer, 2012).

Objectives and Research Questions

Although recent research on condom use in clients of sex providers has included adult men of all ages in a variety of settings (e.g., Belza et al., 2008; Hong, 2008; Yang et al., 2014), the present study focuses on hobbyists between the ages of 60 and 84 who solicited U.S.-based independently operating sex providers online through sex provider review websites and discussion boards. The primary purpose of this study was to assess condom use and predictors of sexual risk taking among a population of older male clients of heterosexual prostitution. Participants were not expected to be representative of aging sex buyers in the United States or worldwide. However, their answers were expected to provide an important insight into the sexual health and sexual risk taking in a population of elderly men who regularly solicit female sex providers online.

The study gathered a convenience sample of 208 men drawn from a variety of hobbyist discussion boards and sex provider review websites. In particular, the following questions were explored:

What physical and sexual health issues are faced by older hobbyists?

What sexual behaviors do older hobbyists report?

What are the predictors of sexual risk taking among older hobbyists?

How do older hobbyists perceive their own risk for exposure to STIs?

Method

Participants

The sample consisted of adult men older than 60 years (N = 208) who were registered users of various sex provider review websites and/or discussion forums, and who posted or read reviews/comments of sexual encounters with U.S.-based sex providers on these sites. Participants appeared motivated by curiosity as well as by courtesy toward the first author, known to some participants as a credible researcher who had previously published data on the American online hobbyist community.

Procedures

Participants were solicited during a 60-day period through invitational postings placed by the first author on two fee-based sites dedicated mainly to provider reviews, a blog by a former sex worker, and on five free nationwide commercial sex forums related mostly to discussions and commentaries on “the hobby.” Solicitations were placed on a total of eight sites. The sites were selected based on having their own nationwide review databases and/or ease of registration and access to obtain posting and messaging rights. The first author registered under a username on each site. Postings with requests for participation contained information about the purpose of the study, and for those eligible to send a private message to the first author through the message system of each site. Once a request for the questionnaire was received, the first author verified through a simple site search that reviews or previous comments had been posted under the username. This ensured that female sex providers would not respond to the survey. Occasionally, the first author communicated briefly with participants, in order to confirm they met the minimum age requirement prior to distributing the questionnaire. A link was then sent by private message to each qualified participant who accessed the questionnaire at a dedicated website. Two early participants volunteered to post their own commentary and messages in order to promote the study and gather additional participants. One informant chose to post messages on a discussion board to which the first author did not have access; another informant posted requests for participation on a nationwide forum with discussion boards dedicated to a variety of erotic or indoor sex industry activities in each major U.S. city. Participation was anonymous and voluntary, and was not compensated. No IP addresses were recorded or made available at any time. The dedicated website hosting the survey instrument was configured for onetime only use, with no access to reenter or complete the questionnaire once exiting the survey site. All participants were provided with an informed consent statement before answering the questionnaire. Data gathering procedures were reviewed and approved to ensure their consistency with the ethical principles required by the institutional review board of the second author’s affiliated institution. Two hundred and nineteen respondents opened the survey, but five respondents reported ages under 60 and were excluded from the tabulation of responses. Six participants exited the survey site before completing the questionnaire.

Measures

All measures were drawn from a 129-item questionnaire intended to provide comprehensive information on older male clients of female providers. Many questions were drawn from existing studies (Atchison, 2010; Lindau et al., 2007; Milrod & Monto, 2012; Smith, Marsden, & Hout, 2010). Additional questions developed specifically for the current study focused on physical and sexual health, condom use, and strategies for avoiding STI. In contrast to studies that have used only one or two measures to assess condom use and STI risk (Regan & Morisky, 2013; Voeten, Egesah, Ondiege, Varkevisser, & Habbema, 2002; Wee, Barrett, Lian, Jayabaskar, & Chan, 2004), the present study assessed sexual risk using four distinct strategies: asking about sexual protection during paid encounters in general, asking sexual protection use for specific sexual activities that pose STI risk, asking whether buyers had asked providers to omit condoms for specific activities that pose STI risk, and asking whether the buyers had ever had condomless penile–vaginal sex with a provider.

More precisely, the first measure of sexual risk asked “How often do you use sexual safety protection such as condoms, female condoms, dental dams, or medical gloves when you engage sexually with a provider?” along with the responses “never,” “seldom,” “sometimes,” “a lot of the time (50% to 74%),” “almost every time (75% to 99%),” and “all the time for all sexual activities.” The second measure employed a checklist asking participants to select the sexual behaviors for which they did not use sexual safety protection, such as condoms, female condoms, dental dams, or medical gloves. Responses to four of these items were summed (genital-to-genital rubbing, fellatio, vaginal intercourse, and anal intercourse) to create a 5-point index (0-4) of sexual risk behavior (M = 1.61; SD = 0.90). Lower risk activities, such as being manually masturbated, were not included. The third strategy asked participants to identify and check activities for which they had ever requested that a provider omit protection. Using the same four items as in measure three, responses were summed to create a 5-point index (M = 0.852; SD = 1.064). For the fourth measure, participants were asked whether they had ever engaged with a provider at least once in sexual activity involving “penis in vagina without condom.”

Participants were asked to rate their perceived risk of contracting HIV, for which they could answer “high,” “medium,” “low,” or “none at all.” Participants were asked if they had a regular, nonpaid sexual partner, to which they could answer yes or no. A dummy variable was created to indicate whether they checked “willingness to go bareback without a condom” when asked about qualities they sought in providers. Participants were also asked to indicate on a checklist whether they had ever been diagnosed with a STI. From this checklist, a dummy variable was created to indicate whether they had ever been diagnosed with any STI. Participants were evaluated on whether they had formed emotional relationships with providers by summing four dichotomous variables: (1) whether they had ever fallen in love or become emotionally attached to a provider, (2) whether they had a specific provider who they frequented on an exclusive basis, (3) whether they had provided gifts to a provider unrelated to sexual exchanges, and (4) whether they could marry or become a partner of an actively working provider. Participants were also asked about how many sexual partners they had had over the previous 12 months on a 10-point scale with responses ranging from “none” to “50 or more.”

Statistical Analyses

Data were managed and statistics were calculated using SPSS version 20.0 (IBM, Armonk, NY). Simple frequencies were used to describe the background characteristics, sexual behavior, STI risks, and self-reported STI history of participants. Each of the four measures of sexual risk behavior was treated as the dependent variable in a linear regression analysis, or for the dichotomous variable (condomless penile–vaginal sex), a logistic regression analysis (Cox & Snell, 1989). For each of the four regression analyses, seven variables were included as predictors: (1) the degree to which they had formed emotional relationships with providers, (2) their perceived HIV risk, (3) whether they reported having a regular nonpaid sexual partner, (4) whether they reported a preference for providers willing to go without protection, (5) whether they had ever been diagnosed with an STI, (6) their total number of reported sexual partners over the previous 12 months, and (7) the age of the respondent. Predictors 3, 4, and 5 were coded as dummy variables, with 1 indicating affirmative responses and 0 indicating negative responses.

For each of the three dependent variables in the linear regression analyses, all variables were entered simultaneously, as well as with forward, backward, and stepwise elimination of the independent variables. The results of the backward elimination are reported; however, all selection strategies yielded identical results. The analyses reported (Table 3) include both the full models and the selected models, which includes only statistically significant predictors (α < .05). For the logistic regression, the analyses reported here (Table 4) include the full model, as well as a model including only significant predictors (α > .05), based on backward elimination using the Wald test, which yielded results identical to other selection strategies.

Results

Participants (N = 208) were overwhelmingly White non-Hispanic (n = 201) and 97.1% (n = 202/208) heterosexual. Age ranged from 60 to 84 years (M = 64.1) and was skewed toward the younger ages, with about 60% (n = 125/208) between 60 and 64, and 28% (n = 58) aged 65 to 69 years. About 68% (n = 142/208) reported being married. Stated incomes were above the nationwide mean for U.S. households (M = $135,560, Mdn = $100,000, SD = $120,423). Over 52% (n = 108/207) were still working full-time, but about 35.3% (n = 73) were retired. Almost half (47.6%; n = 99/208) reported having between 5 and 10 sexual partners within the past 12 months, with 21.6% (n = 45) reporting fewer and 30.8% (n = 64) reporting more. About a quarter (26.1%; n = 54/207) reported having sex less than 12 times during the previous year, with 33.2% (n = 69) reporting 13 to 24 times, and the remainder reporting sex over 25 times. About half (51.5%; n = 106/206) report that one of their sexual partners was a spouse or regular nonpaid sexual partner (see Table 1).

Table 1.

Sample Characteristics—Men 60 Years or Older Who Solicit Sex Online.

Item	Percentage (N)
Ethnicity	(208)
White	96.6% (201)
Hispanic, Chicano, or Latino	0.5% (1)
East Asian	1.9% (4)
Multiracial/other	1.0% (2)
Education level	(207)
High school or GED	1.9% (4)
Some college or vocational training	15.5% (32)
Bachelor’s degree	34.8% (72)
Graduate degree	47.8% (99)
Marital status	(208)
Married	68.3% (142)
Divorced	14.4% (30)
Separated	1.4% (3)
Partnered	2.9% (6)
Widowed	7.2% (15)
Single	5.8% (12)
Income	(205)
$0-35,000	9.8% (20)
$36,000-70,000	20.5% (42)
$71,000-100,000	27.3% (56)
$101,000-150,000	18.0% (37)
$151,000-250,000	12.7% (26)
$250,000+	11.7% (24)
Age (years)	(208)
60-64	60.1% (125)
65-69	27.9% (58)
70-74	8.2% (17)
75-79	2.9% (6)
80-84	1.0% (2)
Total sex partners (12 months)	(208)
1-4	21.6% (45)
5-10	47.6% (99)
11-20	19.7% (41)
21-30	6.3% (13)
31 or more	4.8% (10)
How often sex (12 months)	(207)
None	1.0% (2)
1	0.5% (1)
2-6	8.7% (18)
7-12	15.9% (33)
13-24	33.2% (69)
25-50	24.6% (51)
Over 50	15.9% (33)
Sex with wife or regular partner (Yes)	51.5% (106/206)

More than half the participants reported that they had purchased sex between 13 and 24 times (33.2%; n = 69/208) or more (23.6%; n = 49) during the past 12 months. The sexual activities they reported engaging in most often with providers were fellatio without a condom (33.7%; n = 70/208) and penile–vaginal sex with a condom (31.7%; n = 66). Oral sex performed by the client on the provider (11.5%; n = 24), receiving a “hand job” without a condom, that is, being manually masturbated by the provider (9.1%; n = 19), and deep kissing (5.8%; n = 12) followed.

When asked which activities they had ever engaged in with providers, fellatio without a condom (97.1%; n = 202), hand jobs without condoms (94.2%; n = 196), penile–vaginal sex with a condom (96.6%; n = 201), and deep kissing with tongue (94.7%; n = 197) were all reported by over 90% of participants. Fellatio with a condom (86.5%; n = 180) was also common. Condomless penile–vaginal sex was reported by about half of all participants (51.4%; n = 107), and hand jobs with a condom were reported by 29.3% (n = 61) of all participants. Fewer than half of participants (40.8%; n = 201) reported using protection all the time for all sexual activities. When separately asked to identify activities from a checklist for which they “do not use sexual safety protection . . . ,” more than half of participants listed hand jobs (95%; n = 192/202), fellatio (91.0%; n = 184), cunnilingus (87.1%; n = 176), or manually masturbating the provider (83.7%; n = 169). Genital-to-genital rubbing (49.5%; n = 100), penile–vaginal intercourse (13.9%; n = 28), and anal intercourse (6.4%; n = 13) were listed less frequently (see Table 2).

Table 2.

Sexual Behaviors and STI Risk and Testing Among Older Clients.

Item	Percentage (N)
How often sexual contact with provider (12 months)	(208)
None	1.9% (4)
1 Time	1.9% (4)
2-6 Times	17.3% (36)
7-12 Times	22.1% (46)
13-24 Times	33.2% (69)
25-50 Times	18.3% (38)
Over 50 times	5.3% (11)
Most common activity with provider	(208)
Fellatio without condom	33.7% (70)
Penis in vagina with condom	31.7% (66)
Cunnilingus	11.5% (24)
Hand job without condom	9.1% (19)
Deep kissing with tongue	5.8% (12)
Penis in vagina without condom	2.9% (6)
Fellatio with condom	1.4% (3)
Being dominated/spanked/tied	1.0% (2)
Using sex toys	1.0% (2)
Anal sex	0.5% (1)
Other	1.4% (3)
Ever done the following with a provider	(208)
Fellatio without condom (Yes)	97.1% (202)
Penis in vagina with condom (Yes)	96.6% (201)
Manual masturbation by provider (Yes)	94.2% (196)
Fellatio with condom (Yes)	86.5% (180)
Penis in vagina no condom (Yes)	51.4% (107)
Anal sex (protection not specified; Yes)	47.6% (99)
Group sex (Yes)	13.5% (28)
Currently have an ATF exclusive (Yes)	28.0% (56/200)
Preference for bareback provider (Yes)	14.4% (29/202)
Ever told by health care professional you have any of the following:
Syphilis	1.0% (2/207)
Hepatitis B/C	2.0% (4/205)
Trichomonas	2.4% (5/207)
Chlamydia	5.3% (11/207)
Herpes	7.8% (16/205)
HPV	10.1% (21/208)
Gonorrhea	10.2% (21/206)
“Yes” for any above	31.5% (62/197)
Told you have any STI in the past 12 months (Yes)	4.1% (8/197)
Talked with doctor about sex since turning 60 years (Yes)	57.2% (119/208)
Who started the discussion about sex?	(118)
Participant	82.2% (97)
Physician	7.6% (9)
Both (multiple discussion)	10.2% (12)
Has doctor recommend HIV test (Yes)	12.5% (26/208)
Ever been tested for HIV (Yes)	62.0% (129/208)
If not HIV tested, why?	(79)
Not at risk	73.4 (58)
Never occurred to me	13.9 (11)
Nervous	11.4 (9)
Other	12.7 (10)
Perceived chance of getting infected with HIV	(208)
High	0.5% (1)
Medium	3.4% (7)
Low	77.4 (161)
None at all	18.8 (39)
How often use protection, such as condoms, gloves, dental dams, female condoms, when with a provider	(201)
Never	4.0% (8)
Seldom	8.5% (17)
Sometimes	7.0% (14)
A lot (50-74%)	12.9% (26)
Almost all (75-99%)	26.9% (54)
Always	40.8% (82)
Ever done the following with provider without condom
Fellatio	97.1% (202/208)
Hand job	94.2% (196/208)
Vaginal	51.4% (107/208)
You omit sexual safety protection for the following
Hand job	95.0% (192/202)
Fellatio	91.0% (184/202)
Cunnilingus	87.1% (176/202)
Fingering her	83.7% (169/202)
Genital to genital rubbing	49.5% (100/202)
Vaginal	13.9% (28/202)
Anal	6.4% (13/202)
Why omit condom during penile-vaginal sex
Diminished sensation	25.2% (51/202)
Loss of erection	17.3% (35/202)
Does not feel intimate	12.9% (26/202)
Material too thick	4.0% (8/202)
Condom is too tight	1.5% (3/202)
Other (too small, allergy, do not know how)	2.5% (5/202)

Note. STI = sexually transmitted infection; ATF = all-time favorite; HPV = human papillomavirus; HIV = human immunodeficiency virus.

When asked to rate their likelihood of becoming infected with HIV, 18.8% (n = 39/208) of all participants said “none” and 77.4% (n = 161) replied “low.” About 38% (n = 79) had never been tested for HIV. The most common reason for not testing was considering oneself at low risk (73.4%; n = 58/79). The majority of participants (68.5%; n = 135/197) reported never having been diagnosed with any STI to date. Lifetime diagnoses of gonorrhea (10.2%; n = 21/206) and genital warts (10.1%; n = 21/208) were reported most frequently, followed by genital herpes (7.8%; n = 16/205) and chlamydia (5.3%; n = 11/208).

Regression analyses reveal different predictors for different measures of sexual risk behavior (see Table 3). Using the single-item measure of sexual risk behavior (“How often do you use sexual safety protection . . . ”), three items—age of respondent, perceived likelihood of HIV risk, and preferring providers who do not require condoms—were negatively associated with use of protection in both the full (R² = .151; p < .001) and selected (R² = .149; p < .001) models.

Table 3.

Multiple Regression Analyses Predicting Three Indicators of Sexual Risk Behavior.

Predictors	Number of acts without protection			Number of acts request no protection			How often use protection
Predictors	Β	SE Β	β	Β	SE Β	β	Β	SE Β	β
Full model
(Constant)	−1.697	0.918		−0.986	1.184		9.498	1.635
Emotional relationships with providers	0.143	0.049	.185**	0.083	0.063	.091	−0.160	0.087	−.131
Perceived HIV risk	0.275	0.126	.133*	0.238	0.163	.098	−0.459	0.224	−.141*
Have nonpaid partner	0.030	0.113	.017	0.117	0.146	.055	−0.045	0.201	−.016
Prefer no condom providers	1.079	0.161	.416***	1.169	0.207	.384***	−1.191	0.289	−.286***
Ever diagnosed with STI	0.241	0.120	.123*	0.180	0.155	.078	−0.030	0.214	−.010
Total sex partners (12 months)	0.070	0.039	.108	0.032	0.051	.043	0.010	0.070	.010
Age of participant	0.029	0.014	.132*	0.012	0.017	.047	−0.054	0.024	−.155*
	R² = .322***			R² = .182***			R² = .151***
Selected model
(Constant)	−1.333	0.887		0.677	0.077		9.597	1.570
Emotional relationships with providers	0.139	0.048	.179**	—	—	—	—	—	—
Perceived HIV risk	0.301	0.126	.146*	—	—	—	−0.482	0.221	−.148*
Have nonpaid partner	—	—	—	—	—	—	—	—	—
Prefer no condom providers	1.082	0.160	.417***	1.286	0.202	.422***	−1.288	0.283***	−.310***
Ever diagnosed with STI	0.238	0.120	.121*	—	—	—	—	—	—
Total sex partners (12 months)	—	—	—	—	—	—	—	—	—
Age of participant	0.029	0.013	.134*	—	—	—	−0.058	0.024	−.168*
	R² = .317***			R² = .174***			R² = .149***

Note. SE = standard error; STI = sexually transmitted infection.

When predicting the number of acts (penile–vaginal, anal, fellatio, and genital-to-genital rubbing) for which they reported using not using condoms or other protection, five items emerged as significant, explaining about a third of the variance in both the full (R² = .322; p < .001) and selected (R² = .317; p < .001) models. A preference for providers who do not require condoms was positively associated with unprotected sex acts. Having been previously diagnosed with an STI and perceiving one’s HIV risk to be higher were also associated with more acts without protection. Advancing age and having more emotional relationships with providers were also positively associated with unprotected sex acts.

Only one variable—a declared preference for providers who do not require condoms—significantly predicted the number of acts (penile–vaginal, anal, fellatio, and genital-to-genital rubbing) for which participants requested to omit protection. Results were consistent in regressions using the full model (R² = .182; p < .001) and selected (R² = .174; p < .001) models.

For the logistic regression analysis predicting whether participants reported ever having had condomless penile–vaginal intercourse, four items had significant coefficients in the full model (R² = .269; p < .001) and one more became significant in the selected model (R² = .269; p < .001; see Table 4). Emotional relationships with providers and preferring providers who do not require condoms were positively associated with condomless sex. Having been diagnosed with an STI and higher perceptions of HIV risk were also associated with condomless penile–vaginal intercourse. For the selected model, older age was also associated with more condomless penile–vaginal sex.

Table 4.

Logistic Regression Analysis Predicting Having Unprotected Penile–Vaginal Sex With a Provider.

Predictor	Β	SE	Wald	df	Exp(Β)
Full model
(Constant)	−9.170	3.258	7.923	1
Emotional relationships with providers	0.538	0.157	11.807	1	1.712**
Perceived HIV risk	0.856	0.410	4.369	1	2.354*
Have nonpaid partner (1)	−0.044	0.355	0.015	1	0.957
Prefer no condom provider (1)	2.617	0.800	10.688	1	13.690**
Ever diagnosed with STI (1)	1.077	0.385	7.837	1	2.936**
Total sex partners past year	0.054	0.126	0.183	1	1.056
Age of participant	0.092	0.047	3.748	1	1.096
	Pseudo R² = .269***
Selected model
(Constant)	−9.050	3.184	8.076	1
Emotional relationships with providers	0.540	0.155	12.180	1	1.716**
Perceived HIV risk	0.880	0.406	4.706	1	2.411*
Have nonpaid Partner (1)	—	—	—	—	—
Prefer no condom provider (1)	2.587	0.790	10.726	1	13.291**
Ever diagnosed with STI (1)	1.055	0.379	7.729	1	2.871**
Total sex partners past year	—	—	—	—	—
Age of participant	0.094	0.047	4.008	1	1.099*
	Pseudo R² = .269***

Note. df = degrees of freedom; SE = standard error; STI = sexually transmitted infection; HIV = human immunodeficiency virus. Cox and Snell pseudo R².

p < .05. **p < .01. ***p < .001.

Discussion

The present study of sexual safety protection use, sexual risk, and self-reported STI in a sample of older White, married, heterosexual purchasers of sex from U.S.-based providers revealed a number of unexpected findings. Compared with other, more inclusive samples of men who have purchased sexual services (Milrod & Monto, 2012; Monto, 1999; Monto & Milrod, 2013), the men in this Internet hobbyist sample were much more active in purchasing sex, with more than half reporting that they had purchased sex between 13 and 24 times (33.2%) or more (23.6%) during the past 12 months. In fact, the older the participant, the more frequent his sex purchases during the past 12 months. In contrast, among samples using arrested customers aged 18 to 84 years (M = 38) who purchased sex in outdoor settings, about two thirds reported paying for sex less than once per month (Milrod & Monto, 2012; Monto, 1999; Monto & Milrod, 2013). Almost every participant in the study had experienced condomless receptive fellatio, and condomless penile–vaginal intercourse had been experienced at least once by slightly over half the sample. In fact, less than half of the participants reported using protection for all sexual activities and an overwhelming majority avoided protection for manual masturbation or fellatio. And while the majority of participants had never been diagnosed with an STI to date, 1 in 10 had been diagnosed with gonorrhea and/or genital warts during their lifetime. None of the participants reported having been diagnosed with HIV, though only 62% (n = 129) reported having been tested, and the majority rated the likelihood of becoming infected with HIV as “low.” This belief appears to be consistent with those of sex buyers in countries where information technology and medical access are readily available to the general population (Chetwynd & Plumridge, 1994; Moore, 1999). The results indicated that consistent with the patterns of sexual activity described above, patterns of condom use among the participants reflected a general awareness of the sexual activities that would most likely result in the transmission of infection. It is interesting to note that these particular men of above-average socioeconomic status share similarities in their sexual risk taking with client populations of comparatively lesser means and limited access to health care such as middle-class sex purchasers in Africa or East Asia (Hong, 2008; Lau, Siah, & Tsui, 2002; Voeten et al., 2002). These similarities were identified among a set of factors influencing condom use and unprotected sex acts among the older “hobbyists.” Age and an emotional attachment to the provider were both positively associated with condomless penile–vaginal intercourse. Repeated intercourse on a long-term basis with a familiar provider could be interpreted as a relaxation of boundaries, based on mutual trust; the client often believes that his presumably exclusive relationship with the provider is the only one in which condoms are omitted, based on the provider’s approval (Hong, 2008; Vanwesenbeeck, de Graaf, van Zessen, & Straver, 1993; Voeten et al., 2002). In addition, the illusion of mutual intimacy inherent in the GFE as well as the possibility of being viewed as an elderly low-risk client who pays for sex with only one or a very limited number of providers may contribute to a false sense of security in avoiding infection, and therefore these older men may be held to a paradoxically lower standard of sexual safety required by the provider during the encounter.

Although the present study provides valuable information on the sexual practices of an under-researched population, there are several limitations that should be considered when evaluating these data. The sample was relatively specific, limited to primarily White, comparatively wealthy older men who frequented online websites for hobbyists and providers. Participation in the sites and discussion boards require at least an interest in communicating in a reasonably literate fashion, both with providers and other hobbyists in a venue that is often marked by some elevated social status, if not outright wealth. The majority of the sites are also biased toward presenting a socially desirable image in their particular avoidance of explicit or derogatory terms on the discussion boards, and restricting details of the sexual encounter to reviews that can only be accessed by paying a fee. The results of the study should not be generalized to all clients of sex providers or even all older clients of the same, especially outside of the United States. Data were self-reported and no biomarkers were collected to verify STI status. The men may not have accurately recalled their sexual behaviors in the past year or lifetime. The regression analyses, using seven predictors with a sample of 208, though informative, may be overspecified. However, because both full and selected models revealed consistent results and because other combinations of variables (not reported) did not change the pattern of results, it was determined that the reported models best captured the patterns in the data.

The psychosocial and behavioral data presented here contribute to a deeper understanding of the sexual practices of older male clients and their relationships with providers. Future quantitative research should aim to explore behavioral and psychosocial factors associated with higher and lower risk encounters with sex providers among a larger and more ethnically diverse sample of older men. The addition of biomarkers in larger scale research would also help supplement self-reported data on sexual health. Qualitative studies with older sex buyers would further investigate clients’ perceptions of their relationships with both paid and unpaid partners and explore the ways in which they negotiate condom use in these encounters. In turn, this research would help inform and improve best practices for sexual health care, since medical and mental health clinicians should not assume that old age is a barrier to paying for sex, particularly among generational cohorts that began engaging in sexual activity prior to the epidemic emergence of the HIV virus. Health screenings of aging males should include specific questions concerning a putative variety of sexual partners and detailed assessments of protective strategies, to reduce the incidence of STIs among this growing population of sexually active older men.

Footnotes

Acknowledgements

We are in debt to Juline Koken, PhD, for her critical discussion and editorial contribution to the original manuscript.

Declaration of Conflicting Interests

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

Funding

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

References

Atchison

(2010). Report of the preliminary findings for Johns’ voice: A study of adult Canadian sex buyers. Retrieved from http://www.johnsvoice.ca/docs/JOHNS_VOICE_GENERAL_RESULTS_EXECUTIVE_SUMMARY_FINAL_DIST.pdf

Belza

M. J.

de la Fuente

Suárez

Vallejo

García

López

. . . Bolea

(2008). Men who pay for sex in Spain and condom use: Prevalence and correlates in a representative sample of the general population. Sexually Transmitted Infections, 84, 207-211.

Bernstein

(2007). Buying and selling the girlfriend experience: The social and subjective contours of market intimacy. In Padilla

Hirsch

Muñoz-Laboy

Sember

Parker

(Eds.), Love and globalization: Transformers of intimacy in the contemporary world (pp. 186-202). Nashville, TN: Vanderbilt University Press. doi:10.1136/sti.2008.029827

Catania

J. A.

Binson

Dolcini

M. M.

Stall

Choi

K. H.

Pollack

L. M.

. . . Moskowitz

J. T.

(1995). Risk factors for HIV and other sexually transmitted diseases and prevention practices among U.S. heterosexual adults: Changes from 1990 to 1992. American Journal of Public Health, 85, 1492-1499.

Chetwynd

Plumridge

(1994). Knowledge, attitudes and activities of male clients of female sex workers: Risk factors for HIV. New Zealand Medical Journal, 107, 351-353.

Cohan

Lutnick

Davidson

Cloniger

Herlyn

Breyer

. . . Klausner

(2006). Sex worker health: San Francisco style. Sexually Transmitted Infections, 82, 418-422.

Cox

D. R.

Snell

E. J.

(1989). Analysis of binary data (2nd ed.). London, England: Chapman and Hall/CRC.

Cunningham

Kendall

T. D.

(2010). Risk behaviours among internet-facilitated sex workers: Evidence from two new datasets. Sexually Transmitted Infections, 86(Suppl. 3), 100-105. doi:10.1136/sti.2010.044875

Elifson

K. W.

Boles

Darrow

W. W.

Sterk

C. E.

(1999). HIV seroprevalence and risk factors among clients of female and male prostitutes. Journal of Acquired Immune Deficiency Syndromes & Human Retrovirology, 20, 195-200.

10.

Goldenberg

Gallardo Cruz

Strathdee

S. A.

Nguyen

Semple

S. J.

Patterson

T. L.

(2010). Correlates of unprotected sex with female sex workers among male clients in Tijuana, Mexico. Sexually Transmitted Diseases, 37, 319-324. doi:10.1097/OLQ.0b013e3181c5334f

11.

Gomes do Espirito Santo

M. E.

Etheridge

G. D.

(2005). Male clients of brothel prostitutes as a bridge for HIV infection between high risk and low risk groups of women in Senegal. Sexually Transmitted Infections, 81, 342-344.

12.

Hong

(2008). Behavior, knowledge, attitude, and other characteristics of men who had sex with female commercial sex workers in Kenya. American Journal of Men’s Health, 2, 17-24.

13.

Huff

(2011). Buying the girlfriend experience: An exploration of the consumption experiences of male customers of escorts. Research in Consumer Behavior, 13, 111-126.

14.

Jones

K. G.

Johnson

A. M.

Wellings

Sonnenberg

Field

Tanton

. . . Mercer

C. H.

(2015). The prevalence of, and factors associated with paying for sex among men resident in Britain: Findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3). Sexually Transmitted Infections, 91, 116-123. doi:10.1136/sextrans-2014-051683

15.

Lau

J. T. F.

Siah

P. C.

Tsui

H. Y.

(2002). Behavioral surveillance and factors associated with condom use and STD incidences among the male commercial sex client population in Hong Kong: Results of two surveys. AIDS Education and Prevention, 14, 306-317.

16.

Leonard

T. L.

(1990). Male clients of female street prostitutes: Unseen partners in sexual disease transmission. Medical Anthropology Quarterly, 4, 41-55. doi:10.1525/maq.1990.4.1.02a00040

17.

Lindau

S. T.

Schumm

L. P.

Laumann

E. O.

Levinson

O’Muircheartaigh

C. A.

Waite

L. J.

(2007). A study of sexuality and health among older adults in the United States. New England Journal of Medicine, 357, 762-774. doi:10.1056/NEJMoa067423

18.

Milrod

Monto

(2012). The hobbyist and the girlfriend experience: Behaviors and preferences of male customers of Internet sexual services providers. Deviant Behavior, 33, 792-810. doi:10.1080/01639625.2012.707502

19.

Milrod

Weitzer

(2012). The intimacy prism: Emotion management among the clients of escorts. Men and Masculinities, 15, 447-467. doi:10.1177/1097184X12452148

20.

Minichiello

Hawkes

Pitts

(2011). HIV, sexually transmitted infections, and sexuality in later life. Current Infectious Disease Reports, 13, 182-187. doi:10.1007/s11908-010-0164-6

21.

Monto

(1999). Focusing on the customers of street prostitutes: A creative approach to reducing violence against women (Summary report). Retrieved from https://www.ncjrs.gov/pdffiles1/nij/grants/182859.pdf

22.

Monto

Milrod

(2013). Ordinary or peculiar men? Comparing the customers of prostitutes with a nationally representative sample of men. International Journal of Offender Therapy and Comparative Criminology, 58, 802-820.

23.

Moore

(1999). Characteristics, attitudes and risk behaviours of Australian men who visit female sex workers. Venereology, 12, 7-14.

24.

Pettinger

(2011). Knows how to please a man: Studying customers to understand service work. Sociological Review, 59, 223-241.

25.

Regan

Morisky

(2013). Perceptions about HIV and condoms and consistent condom use among male clients of commercial sex workers in the Philippines. Health Education & Behavior, 40, 216-222. doi:10.1177/1090198112446809

26.

Santos Ortíz

M. C.

Laó-Meléndez

J. L.

Torres-Sánchez

(1998). Sex workers and the older male client. In Elias

Bullough

Elias

Brewer

(Eds.), Prostitution (pp. 208-220). New York, NY: Prometheus.

27.

Schei

Stigum

(2010). A study of men who pay for sex, based on the Norwegian national sex surveys. Scandinavian Journal of Public Health, 38, 135-140.

28.

Schick

Herbenick

Reece

Sanders

S. A.

Dodge

Middlestadt

S. E.

Fortenberry

J. D.

(2010). Sexual behaviors, condom use, and sexual health of Americans over 50: Implications for sexual health promotion for older adults. Journal of Sexual Medicine, 7, 315-329.

29.

Smith

T. W.

Marsden

P. V.

Hout

(2010). General social survey, 1972-2010 [Cumulative File] (ICPSR31521-v1). Storrs: Roper Center for Public Opinion Research, University of Connecticut. doi:10.3886/ICPSR31521.v1

30.

Stall

Catania

(1994). AIDS risk behaviors among late middle-aged and elderly Americans: The National AIDS Behavioral Surveys. Archives of Internal Medicine, 154, 57-63.

31.

Vanwesenbeeck

de Graaf

van Zessen

Straver

C. J.

(1993). Protection styles of prostitutes’ clients: Intentions, behavior and considerations in relation to AIDS. Journal of Sex Education & Therapy, 19, 79-92.

32.

Voeten

H. A. C. M.

Egesah

O. B.

Ondiege

M. Y.

Varkevisser

C. M.

Habbema

J. D. F.

(2002). Clients of female sex workers in Nyanza province, Kenya: A core group in STD/HIV transmission. Sexually Transmitted Diseases, 29, 444-452.

33.

Wee

Barrett

M. E.

Lian

W. M.

Jayabaskar

Chan

K. W. R.

(2004). Determinants of inconsistent condom use with female sex workers among men attending the STD clinic in Singapore. Sexually Transmitted Infections, 80, 310-314. doi:10.1136/sti.2003.008342

34.

Yang

Attané

(2014). Commercial sex and condom use among involuntary bachelors: An exploratory survey in rural China. American Journal of Men’s Health, 8, 205-216.