Abstract
A sexual agreement is an explicit mutual understanding made between two partners about which sexual and relational behaviors they agree to engage in within and/or outside of their relationship. Factors that prompt male couples to form a sexual agreement and under what circumstances remain underinvestigated, yet are important considerations for development of couples-based sexual health and HIV prevention interventions. By using thematic analysis with qualitative dyadic data from a convenience sample of 29 HIV-negative male couples, the present study sought to describe the timing and investigate the context and circumstances that led male couples to establish a sexual agreement in their relationship at both the individual and couple levels, and by agreement type. Themes identified for when a sexual agreement was formed included within the first 6 months, and after 6 months in the relationship. Themes related to context and circumstances of couples’ sexual agreement formation were as follows: (a) desire for sexual exploration, (b) arisen circumstances or events with other men, (c) influences from past relationship(s) and/or other couples (i.e., peers), (d) to protect against HIV, and (e) purposeful conversations versus understood. Findings suggest HIV prevention efforts should include skill-building exercises to help improve communication and promote sex positivity within male couples’ relationships.
Studies have reported that between one and two thirds of gay, bisexual, and other men who have sex with men (MSM) in the United States acquire HIV from their primary relationship partners (i.e., male couples; Goodreau et al., 2012; Sullivan, Salazar, Buchbinder, & Sanchez, 2009). Within the context of HIV-negative male couples’ relationships, HIV transmission is driven by a nexus of factors, including the lack of confirmation of both partners’ HIV status (as negative) before having condomless anal sex (CAS), higher number of anal sex acts, more frequent receptive roles, and lower rates of condom use during anal sex (Goodreau et al., 2012; Sullivan et al., 2009). While studies have noted that more than 80% of HIV-negative male couples in the United States practice CAS within their relationships (Chakravarty, Hoff, Neilands, & Darbes, 2012; Mitchell, 2014a; Mitchell, Harvey, Champeau, & Seal, 2012a), CAS is not necessarily a risk factor for HIV acquisition if both men have multiple consecutive HIV-negative test results and practice monogamy (Crawford, Rodden, Kippax, & Van de Ven, 2001; Kippax et al., 1997) or are adherent to their use of preexposure prophylaxis, a biomedical HIV prevention medication taken daily for those who are uninfected with HIV (Grant et al., 2010; McCormack & Dunn, 2015; Molina et al., 2015). HIV-negative male couples’ risk for HIV may increase if HIV-negative status is merely assumed, when one of the partnered men has CAS with a casual MSM partner—either with or without the knowledge of their main partner—and CAS is subsequently practiced within the primary relationship, and/or preexposure prophylaxis is not being used (Chakravarty et al., 2012; Davidovich, de Wit, & Stroebe, 2000; Mitchell, 2014b; Mitchell, Harvey, Champeau, Moskowitz, & Seal, 2012b).
The presence or absence of an explicit sexual agreement may also affect male couples’ risk of HIV acquisition. A sexual agreement is an explicit mutual understanding made between two male partners about the sexual and relational behaviors within and/or outside of their relationship in which they agree to engage in (Hoff & Beougher, 2010; Mitchell, 2014a). Prior research with male couples has noted that many male couples establish a sexual agreement (Gass, Hoff, Stephenson, & Sullivan, 2012; Hoff & Beougher, 2010; Hoff, Beougher, Chakravarty, Darbes, & Neilands, 2010; Mitchell et al., 2012a). While one aim of establishing and adhering to a sexual agreement is to help couples manage their risk for HIV and other sexually transmitted infections, agreements also help them enhance their sexual pleasure, intimacy, communication, and trust within the relationship (Hoff & Beougher, 2010; Mitchell, 2014a). However, couples’ adherence to their sexual agreement may be compromised while under the influence of substances and/or being spontaneous (e.g., in the heat of the moment) with other MSM (Hoff et al., 2009; Mitchell, 2014a), which in turn, may adversely affect their risk for HIV.
The types of sexual agreements that male couples form vary. Some couples from a “closed agreement” in which partners only have sex with each other (e.g., CAS within the relationship), whereas other couples may form an “open agreement” that allows partners to engage in sexual behaviors within and outside the relationship, with or without specific guidelines (Gass et al., 2012; Hoff et al., 2010; Mitchell, 2014a; Mitchell et al., 2012b ; Parsons, Starks, DuBois, Grov, & Golub, 2013). As noted by some studies, couples’ sexual agreements may also change over time such that the type of agreement they originally establish may differ as their relationship progresses (e.g., closed to open or open to closed; Gass et al., 2012; Mitchell, 2014b; Prestage et al., 2008). As a result of this variation in agreement types and potential change in agreement type over time, the types of behaviors that couples allow to occur per their agreement also varies (e.g., CAS vs. using condoms for anal sex with casual MSM partners) (Gass et al., 2012; Mitchell, 2014a) and have direct implications for HIV prevention. For instance, prior studies have reported that HIV-negative male couples who have established and adhered to a sexual agreement are less likely to engage in HIV risk–related behaviors (e.g., CAS with a casual MSM partner) than male couples who do not form an agreement or adhere to one (Darbes, Chakravarty, Neilands, Beougher, & Hoff, 2014; Mitchell et al., 2012b).
The contexts and circumstances that lead male couples to establish a sexual agreement have yet to be explored and understanding these contexts from both relationship partners (i.e., at the dyadic level) is crucial. The establishment of an explicit mutually understood sexual agreement is dyadic because it requires the interaction and participation of both partners of the couple. The interdependence theory posits that behaviors within couples’ relationships are interdependent because each partner has a certain amount of control and influence on the outcome in the behavioral interaction they have together (Kelley & Thibaut, 1978). This outcome is dependent on each partner’s option, value, and assessment of the particular behavior and whether that behavior is important to their relationship. With respect to establishment of a sexual agreement, each partner’s willingness to form a sexual agreement will depend on his value toward forming a sexual agreement in the relationship and whether he believes this is important to him and the relationship. As such, research which investigates the contexts and circumstances under which HIV-negative male couples establish a sexual agreement is noteworthy to investigate to assess how best to encourage male couples without a sexual agreement to form a tailored one to their own needs as well as the needs of their relationship. This dyadic perspective is necessary for health promotion (e.g., formation of sexual agreements) and development of future dyadic HIV prevention programs that aim to involve both partners of the male couple.
While there is a fairly thorough understanding about what motivates male couples to establish a sexual agreement (Gass et al., 2012; Hoff & Beougher, 2010; Mitchell et al., 2016), the actual process and context of how this formation occurs is lacking in the literature. By using qualitative dyadic data from 29 concordant HIV-negative male couples residing in either the Atlanta, Georgia or Detroit, Michigan metro areas, the present study sought to (a) report when the sexual agreement in the relationship was formed at the individual and couple levels; (b) investigate the context and circumstances that led couples to establish a sexual agreement (i.e., the process) at the individual and couple levels; and (c) describe whether the timing, contexts, and circumstances that led couples to form a sexual agreement differed by their agreement type.
Method
Recruitment and Eligibility
The University of Michigan and Emory University Institutional Review Boards approved all procedures for this study. Data for this study were drawn from interviews conducted with 29 HIV-negative male couples from Atlanta and Detroit in early 2014. Participants were recruited via the distribution of flyers at local gay-identified events and venues, ads on e-mail listservs, and business card distribution through places that provide services and/or activities to gay men and other MSM, including local AIDS service organizations and community-based organizations, bars, and coffee shops in Detroit and Atlanta metro areas. Placement of ads on Facebook was also used to target Facebook members whose profile webpage lists that they are male, 18 years of age or older, living in either of these metro areas, interested in men, and in a relationship (gender of relationship partner was clarified during the screening process). Interested men either clicked on the Facebook ad or called the number listed on the recruitment materials to learn more about the study; they were then directed to a confidential online screener. Eligible men (aged >18, resident in Atlanta or Detroit, self-reported as being HIV-negative; had been practicing CAS in their relationship for >6 months; have reported no recent history [<1 year] of intimate partner violence or coercion; have formed and kept their sexual agreement for >6 months) were then directed to an electronic version of the informed consent document. Once consented, participants were prompted to electronically input their first name, phone number, and e-mail address along with their partner’s first name, e-mail address and/or phone number so that their partner could be screened for eligibility and provide consent to participate. Both members of the male couple had to meet all inclusion criteria to enroll in the study.
Study Sample
Table 1 provides demographics of the study sample. In total, 29 male couples participated in the interviews: 15 from the Detroit metro area and another 14 from the Atlanta metro area. All couples had a sexual agreement for a minimum of 6 months and had adhered to it at the time of study enrollment. Fifteen couples had an open sexual agreement, whereas 14 male couples had a closed agreement. The mean age of the participants was 33 years (range: 19-65) and the average age difference between partners was 6.1 years (range: 0-38). Fourteen percent of couples (N = 4) had been in their relationship between 6 and 12 months, 34% (N = 10) between 1 and 2 years, 17% (N = 5) between 2 and 5 years, 24% (N = 7) between 5 and 10 years, and 10% (N = 3) had been in their relationship for over 10 years. Most men identified as non-Hispanic and/or White; 28% of the couples as mixed race (N = 8).
Demographic Characteristics of Partnered Men Who Participated in the Interviews.
Procedure
At the appointment, each partner was provided a copy of the consent document. Partners of each couple were interviewed simultaneously yet apart from one another (by different interviewers). Development of the semistructured individual-level interview guide was informed by findings from prior studies conducted about male couples’ sexual agreements (Mitchell, 2014a; 2014b; Mitchell et al., 2012a;2012b ). Specifically, men were asked, “Can you tell me a little bit about when and how your sexual agreement was formed in your current relationship?” To help participants elaborate and expand on their responses, different follow-up prompts were used, including the following: “What prompted you and your partner to form an agreement?” “Did something happen?” and “At what stage of your relationship did this event and/or forming an agreement happen?” All interviews were conducted by one of the three trained research team members, all of whom received training in conducting informative interviews by the project principal investigator. All interviews occurred in private spaces. Data collection ceased once saturation was reached. All interviews were digitally recorded, transcribed verbatim, and de-identified.
Analytic Plan
Thematic analysis (Braun & Clarke, 2006) was conducted to identify patterns (themes) about the contexts and circumstances under which male couples formed their sexual agreement, and whether differences in these contexts and circumstances of establishing a sexual agreement existed by couples’ agreement type. Using a step-by-step iterative process (Frost, McClelland, Clark, & Boylan, 2014), each of three research team members read the transcripts, took notes, and manually identified any overarching themes using a color-coded highlighting scheme. These three members then met to compare and discuss their color-coding for these themes and made adjustments as needed before creating the codebook, which provided a description of the themes for coding along with their corresponding definitions. Each team member then used the codebook to color-code the transcripts once again. This process was applied for all transcripts; each team member reviewed one another’s coding of the transcripts to ensure consistency for the themes identified. All coding was done manually, and analysis of participants’ responses was conducted at both the individual and couple levels (i.e., between the two relationship partners). A sum count of each individual-level response per theme was calculated. Tables were then created to help visualize the concurrence and discordance in thematic responses within and between couples (i.e., at the couple level).
Results
The current study presents qualitative data from an individual and dyadic perspective of (a) when couples formed a sexual agreement and (b) the context and circumstances that led them to establish a sexual agreement (i.e., the process) in their relationship. Exemplary quotes from those who formed a closed agreement and those who formed an open agreement are presented for both of these perspectives to highlight and describe the themes that emerged from the interviews conducted. When relevant, whether themes were more common (or not) by couples’ agreement type formed are noted for each of these perspectives.
When Male Couples Formed Their Sexual Agreement in Their Relationship
The timing of when couples formed their agreement appeared to occur either within the first 6 months or sometime after the sixth month of their relationship. Of the participants who shared that they formed their agreement within the first 6 months of their relationship, two thirds indicated that they had formed their agreement with their partner at the very beginning and/or within the first few dates; the other third formed their agreement sometime between 3 and 6 months after their relationship began. For instance, one participant shared, “ . . . by our third date, we realized that we wanted to be together and in a long-term relationship” (28 years, closed agreement). Whereas another noted that his experience of forming an agreement occurred several months after his relationship began: Probably 4 or so months into the actual relationship. We had talked about our status and I had actually just been tested prior to meeting him for the first time. He had been tested. So we talked about that and shared our results. So our agreement kind of came out of that. (26, closed agreement)
Conversely, one participant shared his experience in forming a sexual agreement later in the relationship: It was probably about . . . 6 months to a year in before we moved in together . . . we really were kind of exploring . . . what it meant to be sexual with each other and, you know, we really wanted to make it a long-term commitment thing, and I really hadn’t been with that many people—I’d been with one person before him, and, so we really wanted to . . . make it so that our relationship would last. (27, open agreement)
As noted in Table 1, in both Detroit and Atlanta, two thirds of couples concurred about when they formed their agreement in the relationship, whereas one third of couples disagreed. Among the couples who concurred, most had done so within the first 6 months of their relationship. Many couples with closed agreements formed their agreements at the very beginning (e.g., first few dates) of their relationship, whereas couples with open agreements tended to vary in time while in their relationship for when they established their sexual agreement.
The Contexts and Circumstances Under Which Male Couples Formed Their Agreement
A number of themes were identified about the contexts and circumstances that led to male couples establishing a sexual agreement in their current relationship, including (a) discussions prompted by desire for sexual exploration, (b) circumstances or events with other men, (c) influences from past relationship(s) and/or other couples (i.e., peers), (d) to protect against HIV, and (e) purposeful conversations versus “understood” comments. Table 2 lists the themes, by sexual agreement type.
When the Discussion of a Sexual Agreement Was Prompted, at the Couple Level: Differences and Similarities Between the Two Relationship Partners.
Note. Seven couples were discordant on when they discussed forming a sexual agreement. Four couples were from Detroit and the remaining three couples were from Atlanta.
Desire for Sexual Exploration
A number of participants, predominantly those who formed an open sexual agreement, expressed their desire for sexual exploration. Two subthemes were included in men’s expressed desire for sexual exploration: (a) feeling restricted or not wanting to hold their partner back and (b) having a sex-positive outlook. Some men were cognizant of their sexual needs and felt comfortable expressing them to their partner without feeling ashamed. These men also perceived that their partner had the same or similar outlook about sex and, therefore, were able to come to an agreement about it. For example, this participant shares how he and his partner were able to separate sex from having an emotional attachment when it comes to engaging in sexual behaviors with others (outside the relationship): So the specific questions that I can remember are. . . . “And is there something that you want to do . . . or something that you want to sort of experiment with?” For us it was a pretty easy conversation, ‘cause we’re both not necessarily modest. But we both can sort of look at things from—and I don’t wanna use this term as strictly as it is, but we can look at things sort of clinically and not necessarily always attach a lot of feeling to it. (42, open agreement)
In addition, participants also noted how they did not want to feel restricted or want to restrict their partner from being able to explore their sexual needs or desires. For some men, this feeling of restriction was sometimes difficult to express or immediately recognize; yet when they did overcome this tension in their relationship, they were able to come to an understanding about permitting an openness about sex. For example: We were just at a really stagnant point in our relationship and there were these underlying issues and we were trying to figure out what was going on and we finally hit a point where we felt this restriction. At that point, we didn’t want to end our relationship because we knew how well we were together. But it took us a while to figure out where we were going to go. So we finally came to the point that if need be, we have that openness available and it is something that we could both consent to. (26, open agreement)
Circumstances or Events With Other Men
A number of men, most of whom had an open sexual agreement, shared that forming a sexual agreement was prompted by a circumstance or event involving a third party. Some men reported a one-sided involvement with a third party, either being involved themselves or finding out about their partners’ outside involvement (e.g., with a casual MSM sex partner). Some couples had misunderstandings of each other’s perceptions of sexual exclusivity, leading a partner of the couple to engage in behaviors that the other partner did not know about or agree to. These situations and misunderstandings often prompted the couple to discuss and come to agreement about having sex (or not) with others. In this example, one participant shared that his partner found out about him having sex with someone else (without him), which led them to decide to only having sex with others while together: Yeah, I hooked up with someone else and he decided that the emotional stress that he felt over the occasion wasn’t, well obviously if he felt emotional stress, I didn’t think it was worth it either in the end. You know, he made it known that he didn’t want [that]. (23, open agreement)
Conversely, other men revealed a two-sided involvement, with both partners of the couple being involved with outside partners. These men commonly shared that their discussion to form a sexual agreement was prompted by wanting to clarify boundaries. One participant shared: My partner and I are in a polyamorous relationship. We have agreed that it is okay to have sexual relations outside of the partnership between he and I. . . . There’s not any guidelines, except common sense. . . . You know, stay safe. If you don’t trust the guy, don’t do anything that would endanger yourself or- or anything else. It’s not a thing where you have to obtain permission beforehand; if you feel that it’s right, go ahead, have fun. (31, open agreement)
This participant expressed that the agreement came naturally for them, as they began their relationship long distance, and both partners wanted to fulfill their sexual needs and desires outside of the relationship from the very beginning. Discussing and adjusting boundaries per their agreement helped this participant and his partner feel more comfortable about being honest with each other.
Influence From Past Relationship(s) and/or Peers
Another theme pertained to the influence that men’s past relationship(s) and/or coupled peers had toward them initiating a discussion about forming a sexual agreement. Usually, these men shared they had experienced unfavorable outcomes in their past relationships, and learned that expressing their expectations to their partners early in the relationship was important. For instance, one participant shared how his past relationship experiences influenced him to be more open and communicate in his current relationship, particularly about expectations and agreements: I mean, I’ve heard so many stories. Even in my one of my past relationships I’ve had problems with the boyfriend cheating or even thinking it’s okay to do things with other guys. And I like to put it out there; I just want it known right away that that’s not okay with me. (24, closed agreement)
Other men revealed that they received advice from couples’ about their experiences with establishing an open or closed agreement. Furthermore, many who endorsed this theme shared that they were happier with their sex lives after taking their peers’ advice. One participant expressed: We went to a gay rodeo and we played separate for the first time and I wasn’t okay with it at first and that’s when we started discussing it. . . . Yeah we had some conversations with a few close friends of ours [other male couples] that know a little bit more about open relationships than I do and we decided to open it up after that. (47, open agreement)
Commonly, those who endorsed this theme shared that their experiences with opening or closing their relationship not only improved their relationship sexually but also helped alleviate the stress of not being able to express to their partner about their sexual needs or expectations.
To Protect Against HIV
Some men reported that they introduced the discussion about sexual agreements to their partners because of their desire to remain protected against HIV. These discussions—or context of how the agreement was formed—primarily revolved around two areas of HIV prevention: condom use with outside partners and monogamy. For couples who wanted to form an open sexual agreement, their desire to remain protected against HIV [within the relationship], typically centered on resolving any questions about condom use with outside partners. One participant shared his experience: I guess like-like 3 months in I would assume that we kind of just made a decision, like, that we wouldn’t—that we would have—put parameters like, and we would have rules. . . . Well we started out with . . . I guess, obviously like if we had, like, sex with someone else it w-we would use protection. (24, open agreement)
In contrast, other men voiced their concerns about HIV by indicating their desire to form a closed agreement as a way for them and their partners to remain HIV-negative. One participant shared that being sexually monogamous with his partner, rather than establishing condom use with outside partners, was the only form of HIV prevention that he was interested in establishing with his partner: I’m a health care professional and so part of me is my health and I have a very kind of strict or no tolerance policy for any type of cheating . . . I’m looking for a monogamous relationship and I let that be known to him and . . . I guess that’s how that conversation got started. I mean I let it verbally known that hey if there’s any point in the relationship that if you’re not feeling it or I’m not feeling it don’t go behind my back; just tell me and it’s done. (34, closed agreement)
For this partner, having a closed sexual agreement was the only option he was interested in for HIV prevention as well as for what he wanted to have as a relationship.
Establish Monogamy
One context in which couples formed a sexual agreement pertained to their desire to be in a monogamous relationship. Many of these situations had an applied approach such that they did not explicitly discuss the details of their agreement when it was formed in the relationship. Most of those who endorsed this theme knew from the very beginning that they wanted to be monogamous with their partner. For example, one participant shared: It was actually formed when we first met because that was actually one of the first things we talked about within the first few dates. It was like you know, when we date we want to be monogamous, committed to each other, and, you know, not anybody else. We were actually both seeing other people when we first started dating but we completely cut all of them out and just focused on each other. (24, closed agreement)
Understood Versus Purposeful Conversation
Last, an important distinction was found between those who had purposeful conversations about sexual agreements and those who made “understood” remarks throughout their relationship, particularly within the first year. Those who had purposeful conversations made it explicitly clear to their partner about their desires, needs, and boundaries regarding sexual and related behaviors within and outside the relationship. For example, one participant shared: . . . it was very early within that first week or two that once we started kinda goin’ down that road we just wanted to make sure that there was an understanding of we weren’t goin’ outside of the relationship for any sexual activity. (30, closed agreement)
Conversely, those who made “understood” remarks throughout their relationship did not communicate explicitly about their desires, needs, or boundaries within and outside the relationship. One participant revealed his nonexplicit, open agreement he had with his partner: We never really sat down and had like an actual official conversation about it, just kind of more like incidentals come up over time and just . . . kinda, yeah, I don’t know, there was no real just no real “set in stone” anything. It was just kinda—it’s definitely like understood that we talk about it, you know, beforehand or anything like that . . . I mean every now and then like there’d be a—talk about like, someone who is interested in one or the other, or things like that and so we’d just talk about it. (25, open agreement)
Although several themes emerged about partnered men’s contexts and circumstances that led them to form a sexual agreement in their relationship, not all themes were equally distributed by agreement type within this convenience sample of male couples.
Descriptive Comparison, by Agreement Type, of Partnered Men’s Self-Reported Contexts and Circumstances Toward Establishing a Sexual Agreement
As reported in Table 2, some themes about the contexts and circumstances that led couples to establish a sexual agreement were more common among those with open agreements, whereas other themes were more common among those with closed agreements. For example, discussions prompted by desire for sexual exploration and arisen circumstances or events with other men were primarily identified among the participants who had formed an open sexual agreement with their partner. Themes of influences from past relationship(s) and/or other couples (i.e., peers) and desire to establish monogamy were primarily noted among the men who had formed a closed sexual agreement with their partner. No differences by agreement type were noted about purposeful conversations versus “understood” comments and desire to protect against HIV.
Within Couples’ Relationships Descriptive Comparisons on the Contexts and Circumstances of Establishing a Sexual Agreement
Table 3 provides descriptive comparisons within couples’ relationships of the themes pertaining to the contexts and circumstances that led them to establishing a sexual agreement in their relationship. When comparing within-couple responses, concurrency in some themes was more common than in other themes (see Table 4). For example, eight couples had both partners share about their desire for sexual exploration and/or to establish monogamy, whereas two couples had both partners share about wanting to be protected against HIV. The couples with partners who shared different responses illuminate the variety of contexts and circumstances that led them to establish a sexual agreement in their relationship.
Individual-Level Themes of the Context and Circumstances Under Which the Discussion of Forming a Sexual Agreement Was Prompted, by Agreement Type.
Note. Multiple themes were embedded in the participants’ responses. Because of this overlap in responses, the number of partnered men do not equal to 58.
Perceived Context of Forming a Sexual Agreement at the Couple Level: Differences and Similarities Between the Two Relationship Partners.
Note. Our analyses detected that there were multiple themes embedded in the participants’ responses. Because of this overlap in responses, the number of couples do not equal to 29.
Discussion
Few studies have investigated the contexts and circumstances that led male couples to establish a sexual agreement in their relationship. Given the nature of sexual agreements and their relevance for HIV prevention, findings from this study are important to consider for development of couples-based sexual health and HIV prevention interventions, of which, few evidence-based ones currently exist (Burton, Darbes, & Operario, 2010; El-Bassel et al., 2010; Grossman et al., 2011; Herbst et al., 2007).
In this sample, the timing of when a male couple formed their sexual agreement varied though generally fell into two broad groups: within first 6 months and after 6 months. Although most couples reported forming their agreement early in their relationship, several couples did not have a discussion with their partners until 6 months into the relationship, and some, a few years after. One study by Mitchell (2014b) reported as couples’ relationship length increased, the proportion of couples who disagreed about their current agreement type increased. To help prevent misunderstandings and manage expectations regarding allowable behaviors, future work should help encourage male couples have explicit, detailed conversations about their sexual agreements, and to consider forming a sexual agreement sooner rather than later in their relationship–with the understanding that agreements are not static and can be altered based on changing circumstances or naturally over time. Furthermore, prior studies have also reported that some male couples have broken their sexual agreements with most break ups being circumstantial or because one or both partners’ sexual needs were unmet (Gomez et al., 2012; Hoff et al., 2009; Mitchell, 2014a), and that few partners disclose these break ups within their relationships (i.e., to their primary partners; Gass, et al., 2012; Hosking, 2013; Mitchell, 2014a). Another component for helping male couples form an explicit sexual agreement earlier in their relationships should include helping them obtain skills and the tools needed to help identify and express when their needs are not being met and what to do when certain circumstances arise that may be conducive to one or both partners breaking their agreement.
In addition, given the role that peer support emerged from the data, it is possible that male couples with a sexual agreement could provide social support to those who have yet to form an agreement as well as to those who are thinking about changing their agreement type. This type of dyadic community engagement may help facilitate agreement formation sooner within male couples’ relationships. To explore this possibility, future research could investigate whether social support by male couples positively influences how other male couples manage their expectations about sex within the context of their relationship.
Several themes emerged from the interviews when examining the contexts and circumstances that led male couples to form a sexual agreement in their relationship. Most couples expressed a desire to identify and/or create boundaries, whether they wanted an open or closed agreement. Some discussions that led to forming an agreement were prompted due to circumstantial events, while others were explicitly and purposefully initiated by one or both of the partners. In contrast, very few of the agreements formed by this sample were “understood” in nature and not explicitly discussed. To establish a sexual agreement requires communication skills of not only being able to identify what one values sexually and about being in a relationship but also being able to express those expectations and needs to their relationship partner and listening to their partners’ expectations and needs. As described in the current findings, couples’ agreement formations were just as much circumstantial as purposeful.
Some partnered men expressed a desire for sexual exploration and either felt restricted within the relationship, felt that they were restricting their partner, or were generally sex positive and wanted to be open-minded about the possibility of having sex outside of the relationship. Sex positivity can be defined as a form of sexual expression aiming to detach any shame about one’s thoughts and/or desires to engage in sexual behaviors [with others], as well as embracing the full benefits of sex as being healthy (Women and Gender Advocacy Center, 2016). Embracing a more sex-positive attitude may help some male couples communicate better and identify what type of sexual agreement they want for their relationship. Future HIV prevention interventions should consider how best to promote and provide support for male couples’ sexual health, and to integrate sexual health into current services, such as couples-based HIV testing and counseling (Rendina et al., 2014; Stephenson et al., 2011; Sullivan et al., 2014) and mental health counseling and therapy (Parsons et al., 2013). In turn, this type of support and encouragement may help male couples identify what sexual and related behaviors they would like to permit per their agreement, and to be open to possibly changing their agreement terms in the future.
Furthermore, some participants expressed that they wanted to identify which sexual behaviors were going to be permitted with casual MSM partners before having sex outside of their relationship, while others shared that these discussions were prompted because of a circumstantial event that already happened with a casual MSM partner. Thus, some of these instances were proactive, while others were reactive in nature or occurring after the fact. From both HIV prevention and relationship health perspectives, these contrasting circumstances indicate the importance of encouraging male couples to discuss and decide which behaviors they would like to allow per their agreement earlier in their relationship before either one of the partners engages in sex with someone else.
Limitations
The study sample resided in either the Detroit or Atlanta metro areas, thus, these findings may not be representative of all male couples who resided in these specific areas or in other areas of the United States. Furthermore, other factors, which were not detected in this sample, could influence the timing, contexts, and circumstances of couples establishing a sexual agreement, including, power dynamics, intimate partner violence, education, religion, and perceptions of masculinity. Although the current sample size was relatively small, it did allow us to identify and expand our understanding about the contexts and circumstances that led to HIV-negative male couples successfully establishing a sexual agreement in their relationship. Furthermore, this sample was diverse in terms of age, relationship length, sexual agreement type, and to a lesser extent, by race and ethnicity. Further research that includes a larger racial, ethnically, and geographically diverse sample and explores how different relationship dynamics may influence couples’ agreement formation is warranted, as well as studies, which include samples of HIV-discordant and concordantly HIV-positive male couples.
Conclusion
Establishment and adherence to a sexual agreement may be beneficial to HIV-negative male couples for helping reduce their risk for HIV while also enhancing dynamics of their relationship (e.g., trust, communication, intimacy). Findings from this study illuminate some of the contexts and circumstances that led to this sample of couples establishing a sexual agreement and when these events had occurred in their relationship. From a broader HIV prevention perspective, the implications of this work suggest male couples without a sexual agreement may need encouragement to help form one, along with tools on how best to express their desires related to sex and values they may have about being in a relationship. With respect to sexual health, future programs should develop and include skill-building exercises (e.g., self-efficacy regarding sexual health communication) to help improve communication and promote sex positivity between primary same-sex partners. For example, practice-based scenarios may provide a platform to encourage future purposeful conversations among male couples (i.e., between primary partners). These suggestions could be leveraged by integrating them into existing or upcoming HIV prevention efforts specifically designed for male couples (e.g., couples-based HIV testing and counseling). In conclusion, further research is warranted to empirically investigate the causal pathways that provide support for sexual health (e.g., sex positivity) and establishment of a sexual agreement (earlier) in the relationship accounts for reducing HIV-negative male couples’ risk for HIV and enhancing other dynamics of their relationship.
Footnotes
Acknowledgements
Special thanks are extended to the participants for their time and effort.
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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Institute of Mental Health under Grant R34 MH102098 (PI Mitchell J).