BRIEF REPORT–EPIDEMIOLOGY AND SOCIAL SCIENCE A Descriptive Analysis of HIV Risk Behavior Among Men Having Sex With Men Attending a Large Sex Resort Richard Crosby, PhD*† and Aaron Mettey, MPH* study of MSM attending a bathhouse in Portland Oregon.4 Un- Summary: This study assessed the prevalence of various HIV-
fortunately, studies of MSM specifically attending sex resorts associated risk behaviors among men who have sex with men (MSM) (as opposed to bathhouses) have not been reported.
attending a popular sex resort in the southern United States. One hun- Sex resorts are an extension of the bathhouse concept.
dred fifty men completed an anonymous self-administered question- Sex resorts, unlike bathhouses, are designed for couples and naire (91% response rate). Men currently resided in 14 states. Onesixth reported being HIV-positive. During a typical resort visit, men groups as well as singles. MSM congregate for extended stays averaged 4 sex partners. About two thirds of the men had anal sex (staying in private rooms for 1 or several days and nights) during a typical resort stay; of these, 21% reported never using con- within the context of a self-contained environment that sup- doms and 41% reported always using condoms. HIV risk behavior ports cruising (ie, a physical and social environment that is over the past few months was also assessed. Men averaged 10 sex highly conducive to meeting sex partners). This study assessed partners. Meeting partners by means of the Internet (57%) and bath- the prevalence of various HIV-associated risk behaviors houses—excluding sex resorts—(40%) was common. Most men among MSM attending a popular sex resort in the southern (62%) reported having group sex. About one half (49%) engaged in unprotected anal sex. Significant differences in recent frequency ofunprotected anal sex between HIV-positive and HIV-negative menwere not found (P = 0.74). Among those using condoms, 20% re- ported not using condoms from start to finish of sex, 7% reported Study Sample
breakage, and 6% reported slippage. Twenty-three percent had anal During Saturdays from May through November of 2002, sex without lubrication. Fisting and the use of nonprescription silde-nafil citrate (Viagra) was reported by about one sixth of the men. The 164 men attending a sex resort located in the Southeast were findings suggest that MSM attending sex resorts may experience sub- randomly approached by trained male research staff and asked stantial risk of HIV infection. Sex resorts may be an important venue to participate in a brief survey about men’s sexual health. Of these, 150 completed a self-administered questionnaire (91%response rate). Incentives were not provided. The Emory Uni- Key Words: gay men, HIV, prevention
versity Institutional Review Board approved the study proto- (J Acquir Immune Defic Syndr 2004;37:1496–1499) The sex resort selected for this study was one of the larg- est in the southeastern United States. The resort was a 65-room In the United States, men who have sex with men (MSM) complex enclosed by a privacy fence and a gated entrance.
experience a substantial and disproportionate risk of infec- Depending on the season, between 50 and 100 men typically tion with HIV.1,2 Based on their recent resurgence, bathhouses registered at the resort each week. Cost was comparable to that and sex clubs are potential venues for programs that promote of a hotel room. The resort provided men with a steam room, safer sex practices among MSM at risk of either acquiring or hot tub, maze, dungeon, and outdoor pool and patio area. Pa- transmitting HIV; yet, few studies of men attending bath- trons were 18 years of age or older and were admitted to the houses have been reported.3 A notable exception is a recent resort based on membership requirements. Most patronsstayed at the resort for at least 2 days. The social environmentsupported the meeting of men for the purpose of having sex.
Received for publication January 21, 2003; accepted April 7, 2003.
Clothing was optional in specified areas.
From the *Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA; and †EmoryCenter for AIDS Research, Emory University, Atlanta, GA.
Data Collection
Reprints: Richard Crosby, Division of Public Health, Kentucky School of Men were recruited during their leisure time spent on the Public Health, 121 Washington Ave., Room 111C, Lexington, KY 40506- patio or near the pool area. Men providing informed consent Copyright 2004 by Lippincott Williams & Wilkins subsequently completed a brief questionnaire. Men were free J Acquir Immune Defic Syndr • Volume 37, Number 4, December 1 2004 J Acquir Immune Defic Syndr • Volume 37, Number 4, December 1 2004 to complete the questionnaire in a semiprivate area (eg, at ever, 34% reported attending with a lover, 19% reported at- tables within the patio area or near the pool) or a private area tending with a friend, and the remainder reported attending in (eg, in their rented rooms). Men were also provided with ma- groups of 3 or more. During a typical visit to the resort, men nila envelopes and instructed to seal the completed question- reported having sex with an average of 4.2 partners (SD = 6.1, median = 3.0, range: 0–56 partners).
Sex was clearly defined in the questionnaire as including Measures
anal-genital or oral-genital contact. About two thirds (65.3%) Two sets of measures were used. The first asked men to of the men indicated engaging in anal sex during a typical visit provide responses to questions that specifically assessed be- to the resort. Of these, 41% reported using condoms for every haviors that occurred while attending the sex resort. The sec- act of anal sex, 19% for at least 75% of the acts, 11% for at least ond set of measures assessed the prevalence of HIV-associated 50%, 8% for at least 25%, and 21% reported never using con- risk behaviors during the past 3 months.
doms while engaging in anal sex at the resort. HIV-positivemen (64.7%) were as likely as HIV-negative men (58.0%) to report inconsistent (less than 100%) condom use while stayingat the resort (P = 0.61).
Characteristics of the Sample
Men residing in 14 states comprised the sample; 30% HIV Risk During the Past 3 Months
reported residence in the same state where the sex resort was Sex Partners
located. The average age of the men was 40.7 years (SD = 9.4,median = 40 years, range: 19–64 years). Most (93%) self- Men reported having sex with a mean of 10.0 partners in identified as white. The median income annual interval was the past 3 months (SD = 42.0, median = 4). Based on previous $25,000 to $50,000. Thirty-eight percent indicated that they research suggesting a relation between risky sex among MSM were raised in a small town (not close to a city) or a rural area.
and meeting sex partners through specific venues,5–7 we also Most men identified as gay (82%) or bisexual (16%).
asked men if they recently used specific venues as a way to meet One sixth (16.7%) reported they were HIV-positive; 77% of potential sex partners. Use of the Internet was common (57.3%), these men reported taking antiretroviral therapy. Of those in- followed by bathhouses—excluding sex resorts—(40%), pub- dicating a negative serostatus, 26 (21.7%) reported they had lic rest rooms (16.7%), and circuit parties (9.3%). Sixty-two not been tested in the past year. Significant differences relative percent of the men reported recently engaging in group sex.
to unprotected anal sex (UAS) in the past 3 months between Unprotected Sex
these 26 men (60.0% reported UAS) and the remaining men To assess frequency of engaging in unprotected anal re- (46.7% reported UAS) were not found (P = 0.23). Similarly, ceptive sex (UARS), men were asked (using a 3-month recall significant differences in the mean number of recent (past 3 period): “How many times have you been a BOTTOM during months) male sex partners between these 26 men (mean = 5.6) anal sex (another man’s penis in your rectum) WITHOUT a and the remaining men (mean = 11.0) were not found (P = condom being used?” UARS was reported by 26.6% of the men. Among these men, UARS occurred a mean of 18.1 times Men reported having sex with a mean of 29.1 male part- (SD = 81.6; median = 3.0; range: 1–500 times). UARS was ners in the past 12 months (SD = 88.4, median = 10.0). The more likely among HIV-positive men (47.6%) than among distribution had a strong positive skew caused by 12 men re- HIV-negative men (22.9%; P = 0.02). To assess recent fre- porting sex with 100 or more male partners. Fourteen percent quency of unprotected anal insertive sex (UAIS), the same of the men reported having sex with a female partner in past 12 question was provided with the word “TOP” replacing the months. Just greater than one half (51.4%) of the men reported word “BOTTOM.” UAIS was reported by 42.3% of the men.
they were currently involved in a primary relationship. The Among these men, UAIS occurred a mean of 12.3 times (SD = median length of these relationships was 3 to 5 years. Most 51.0, median = 2.5, range: 1–400 times). UAIS was equally (88%) partners were male. Men with a primary partner re- likely among HIV-positive men (52.2%) and HIV-negative ported a mean of 30.8 male sex partners in the past 12 months.
This mean was not significantly different than the mean (27.3) Forty-nine percent of the men reported engaging in any for men without a primary partner (t = 0.23, df = 137, P = 0.82).
UAS (receptive or insertive) during the recall period. Signifi-cant differences in recent frequency of UAS between HIV- HIV Risk Occurring at the Resort
positive and HIV-negative men were not found (P = 0.74).
Men reported a median of 3.0 stays at the resort during a typical year (range: 1–56 stays). The typical length of stay re- Problems With Condom Use
ported ranged from 1 to 5 days (median = 2.0). About 38% of About two thirds of the men (69%) reported discussing the men reported they typically attended the resort alone; how- condom use with sex partners before sex. Sixteen percent of 2004 Lippincott Williams & Wilkins J Acquir Immune Defic Syndr • Volume 37, Number 4, December 1 2004 the men indicated that they had recently attempted to persuade HIV prevention education and corresponding safer practices.
a partner to use condoms but the partner had refused. When Our findings, like those of other studies,10 suggest that preven- asked specifically about times when they had used condoms as tion education should target men attending sex resorts.
an insertive partner, 20% of the men indicated not using con- About 4 of every 10 men reported consistent condom use doms from start to finish of penetrative sex, 7% reported while attending the resort; however, our findings suggest that breakage, and 6% reported slippage. Despite these problems, men attending the resort commonly do not wear condoms from most men (81%) indicated they were “highly confident” in start to finish of penetrative sex. Condom breakage and slip- their ability to use condoms correctly. Associations between page were also relatively common. Thus, in addition to pro- “confidence” and incomplete use, breakage, and slippage were moting consistent condom use among men attending sex re- not significant (P = 0.80, 0.11, and 0.54, respectively).
sorts, programs may also benefit men by teaching skills de-signed to promote the correct use of condoms.
Risky Sexual Practices
The findings also suggest that men attending the sex re- Twenty-three percent of the men recently engaged in sort may commonly engage in practices that facilitate HIV anal sex without using any form of lubrication (a practice that transmission (ie, anal sex without lubrication, fisting, use of may promote condom breakage and slippage or, if condoms Viagra). Thus, HIV prevention programs might also benefit are not used, may facilitate HIV transmission through penile or men by means of education promoting the maintenance of rectal abrasions8,9). Of interest, 48% of the HIV-positive men abrasion-free penile and rectal tissues. Consistent and correct reported not using lubrication compared with 19% of HIV- use of latex condoms should be strongly promoted among men negative men (P = 0.002). Similarly, fisting (reported by 15%) who nonetheless engage in behaviors that lead to abrasions.
may promote rectal abrasions that enhance probabilities ofHIV transmission. We were also interested in learning whether Limitations
men used Viagra for recreational purposes (because increased Findings are limited by several factors, including the in- erection size and longer duration of intercourse could also herent limitations of a cross-sectional study design and the use damage penile and rectal tissue). Fifteen percent of the men of a convenience sample. Clearly, the use of a nonprobability reported they had recently used “nonprescription” Viagra. Fi- sample precludes generalization of the findings. An important nally, men reported using a variety of substances during sexual limitation is reliance on the validity of men’s responses to the encounters. Poppers were used by 48.0% of the men, ecstasy interview questions. More extensive research is needed with by 13.3%, “Whip-Its” by 5.3%, and cocaine by 12.7%.
other samples of men attending similar resorts.
This descriptive study of MSM attending a large sex re- This descriptive study found that MSM attending a sex sort revealed a substantial degree of HIV risk behavior among resort engaged in multiple HIV-associated risk behaviors at the the patrons during their stay at the resort as well as in the past resort and during the past few months. The evidence suggests 3 months. Perhaps most striking was that one sixth of the men that sex resorts may be a point source of HIV infection and that knew they were HIV-positive and continued to practice risky transmission to communities in multiple states may result.
behavior in this sociosexual milieu. Given that men reported Therefore, HIV prevention programs that seek to promote having an average of 10 sex partners in the past 3 months, the safer sex behaviors among men attending these resorts (during potential for HIV to be acquired from the resort and to spread their stay and when they return to their home community) may to a home community (in any of 14 states) is apparent. This be a beneficial response to the ongoing HIV epidemic among potential is particularly emphasized by findings relevant to men having sex with partners they meet via the Internet, bath-houses, public rest rooms, and circuit parties. A substantialportion of the men may also be placing their female sex part- REFERENCES
1. Centers for Disease Control and Prevention. Need for sustained HIV pre- Notably, more than one fifth of the men indicated they vention among men who have sex with men. Available at: www. Accessed November 19, 2001.
were HIV-negative despite lack of recent testing and ongoing 2. Sullivan PS, Chu SY, Fleming PL, et al. Changes in AIDS incidence for risk behaviors. Clearly, in the absence of more frequent test- men who have sex with men, United States 1990–1995. AIDS. 1997;11: ing, self-identifying as HIV-negative is problematic among 3. Woods WJ, Binson DK, Mayne TJ, et al. HIV/sexually transmitted dis- men involved in this high-risk environment. With cautions ease education and prevention in US bathhouse and sex club environ- against negotiated safety, HIV prevention efforts could be de- ments. AIDS. 2000;14:625–626.
signed to increase men’s motivation to learn their serostatus 4. Van Beneden CA, O’Brien K, Modesitt S, et al. Sexual behaviors in an urban bathhouse 15 years into the HIV epidemic. J Acquir Immune Defic and to make HIV testing easily available to men attending sex resorts. These efforts may lay the foundation for subsequent 5. Coates TJ, Acree M, Stall R, et al. Men who have sex with men in public 2004 Lippincott Williams & Wilkins J Acquir Immune Defic Syndr • Volume 37, Number 4, December 1 2004 places are more likely to have unprotected anal intercourse. Presented at 8. Warner DL, Hatcher RA. Male condoms. In: Hatcher RA, Trussell J, the XIth International Conference on AIDS, Vancouver, July 1996.
Stewart F, Cates W, et al, eds. Contraceptive Technology. 17th ed. New 6. Church J, Green J, Vearnals S, et al. Investigation of motivational and York: Irvington Publishers; 1999:325–352.
behavioural factors influencing men who have sex with men in public 9. Royce RA, Sena A, Cates W, et al. Sexual transmission of HIV. N Engl J toilets (cottaging). AIDS Care. 1993;5:337–346.
7. McFarlane M, Bull SS, Rietmeijer CA. The Internet as a newly emerging 10. DiClemente RJ, Wingood GM, del Rio C, et al. Prevention interventions risk environment for sexually transmitted diseases. JAMA. 2000;284: for HIV positive individuals: a public health priority. Sex Transm Infect.
2004 Lippincott Williams & Wilkins


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