809
ORIGINAL RESEARCH—ERECTILE DYSFUNCTION Australian Gay and Bisexual Men’s Use of Erectile Dysfunction Medications During Recent Sexual Encounters Garrett Prestage, PhD,*† Fengyi Jin, PhD,* Benjamin Bavinton, BA, MPH,* Andrew Grulich, PhD,* Graham Brown, PhD,†‡ Marian Pitts, PhD,† and Michael Hurley, PhD† *Kirby Institute, University of New South Wales, Kensington, NSW, Australia; †Australian Research Centre in Sex Health and Society, La Trobe University, Melbourne, Vic., Australia; ‡Western Australian Centre for Health Promotion Research, Curtin Health Innovation Research Institute, Curtin University, Perth, WA, Australia DOI: 10.1111/jsm.12407
ABSTRACT
Aim. Use of erectile dysfunction medications (EDMs) is relatively common among gay and bisexual men and has been associated with human immunodeficiency virus sexual risk behavior. We aimed to determine what factors were related to EDM use on occasions when participants engaged in protected anal intercourse (PAIC) and when they engaged in unprotected anal intercourse (UAIC) with casual partners. Methods. An online cross-sectional survey was conducted, resulting in a sample of 1,376 Australian gay and bisexual men who reported an occasion of anal intercourse with casual male partners in the previous year. Main Outcome Measure. The main outcome measure was the use of EDM during most recent occasions of PAIC and UAIC. Results. Men were as likely to use EDM on occasions when they were using condoms (11.6%) as they were on occasions when they did not use condoms (13.0%). There was no association between use of EDM and self-esteem, nor was there an association between sexual risk behavior and self-esteem. Men who used EDM were more sexually active overall and appeared to often use EDM to enhance and extend their sexual experiences. Conclusions. Men did not appear to use EDM specifically for the purposes of risk-taking and mainly used EDM to enhance sexual pleasure. Mental health issues were not indicated by use of EDM. Prestage G, Jin FY, Bavinton B, Grulich A, Brown G, Pitts M, and Hurley M. Australian gay and bisexual men’s use of erectile dysfunction medications during recent sexual encounters. J Sex Med 2014;11:809–819. Key Words. HIV; Sexual Risk; Gay Men; Self-Esteem; Erectile Dysfunction Medication; PDE 5 Inhibitors; Men Who have Sex with Men; Sexuality; Sexual Behavior
Introduction
E
rectile dysfunction medications (EDMs), mainly phosphodiesterase type 5 inhibitors, are commonly used for therapeutic purposes to treat erectile dysfunction [1]. However, some men use EDM to enhance and extend their sexual pleasure, and among gay and bisexual men (GBM), such “recreational” use of EDM is relatively common [2–5]. Erectile dysfunction can profoundly impact men’s sense of masculinity and self-esteem [6,7], although it is arguable that the “dysfunction” may often be due to an overemphasis on erectile func-
© 2013 International Society for Sexual Medicine
tion as a core component of masculinity [8–11]. Also, among more sexually active GBM, use of EDM may be as much about enhanced sexual performance and practical methods of maximizing pleasure as it is about addressing perceived problems of erectile dysfunction [12]. The prospect of recreational use of EDM among GBM has raised concerns about the possibility of increases in “unsafe sex” [13]. Use of EDM among GBM is often associated with participating in highly sexually active networks and with having engaged in unprotected anal intercourse (i.e., not including ‘with casual partners’) [14–18]. It is often accompanied by the use of J Sex Med 2014;11:809–819
810 club drugs such as methamphetamine [3,14,19– 22]. This phenomenon has been described as “intensive sex partying” and isassociated with “sexually adventurous” gay subcultures [4,23]. The use of both EDM and club drugs have been identified as risk factors in human immunodeficiency virus (HIV) sexual risk behavior and HIV infection, particularly when used in combination [4,14,16–18,21,24–30]. Elsewhere, it has been noted that GBM increase their use of these drugs, including EDM, in the context of partying when they believe that other men also intend to use them [31]. In this context, we have argued that while some EDM use may be due to some erectile dysfunction, the primary purpose appears to be recreational—to enhance and extend sexual experience [4,23]. In an earlier study of GBM who engaged in group sex, we found that they were very likely to engage in sexual risk behavior and to use EDM [17]. Moreover, the majority of the men who also used drugs, including EDM, on an occasion of group sex, indicated that they did so specifically to enhance and extend the sexual experience, and for some, to permit them to engage in more sex, with more partners, than they might otherwise find possible. Half of the men in that study who reported using EDM during group sex also indicated that they used amyl nitrite on this same occasion, despite it being specifically contraindicated [32]. A similar proportion also reported that, on the same occasion, they used methamphetamine, which commonly has the effect of reducing men’s capacity to achieve and sustain erections [33,34]. EDM can help counteract these effects [35]. Use of EDM in this context is not so much about preexisting erectile dysfunction as it is about enabling the use of other drugs to ensure that the sought-after heightened sexual experience can be achieved. These same behaviors have also been associated with men’s sense of their own masculinity, of which sexual performance is perceived to be an important component [30,36–40]. In our previous work among GBM who engaged in group sex, a masculine self-belief was often particularly important [37]. For many, their concept of masculinity involved being highly sexually active and being able to demonstrate sexual performance within the group sex setting. The term “sexpig”—or more simply “pig”—has been used to describe GBM who seek “as much sex as [they] can get with as many different men as possible, often in the form of group sex that includes barebacking, water sports, fisting, and S/M” [41]. For many GBM who describe themJ Sex Med 2014;11:809–819
Prestage et al. selves as sexpigs, their sexuality is often represented as hypermasculinized, although masculine status is often acquired through “voracious bottoming” (taking the receptive position during anal sex with multiple partners) [41]. “Sexual sensation seeking,” which certainly includes attitudes to sexual performance among its component items, has also been similarly associated with indicators of being more sexually adventurous, HIV sexual risk behavior, and the use of EDM [3,38,42,43]. Whereas men who self-identify as “sexpigs” positively assert their own (hyper)sexuality, the measure of sexual sensation seeking is used to identify men who are psychologically predisposed toward multiple partners and more adventurous sexual behaviors; men who can be described as “sensation seekers” exhibit desires and behaviors that are often assumed to be pathological in nature. Aims
We investigated the use of EDM in relation to social, community, and sexual identity and engagement, self-esteem, sexual desire, and risk behavior during encounters involving protected anal intercourse with casual partners (PAIC) and encounters involving unprotected anal intercourse with casual partners (UAIC) among Australian GBM. We sought to identify variables that were independently associated with EDM use during both PAIC and UAIC occasions. Methods
Procedures This was a cross-sectional study of Australian GBM conducted in 2009 using an anonymous online survey to investigate their beliefs about HIV and the risks of HIV transmission [44]. No identifying details, including IP addresses or cookies, were collected. No compensation for participation was provided. All participants were provided with information about what participation entailed prior to direct access to the survey questionnaire. As this was an anonymous survey, completion of the survey questions was taken as consent, in accordance with National Health and Medical Research Council guidelines, and with the approval of the Human Research Ethics Committee of the University of New South Wales and of La Trobe University. Participants Men were eligible for the study if they were aged 18 or above, gay- or bisexual-identified, or had had
811
Gay Men’s Use of Erectile Dysfunction Medications sex with another man in the previous year, and lived in Australia. Participation in the study was promoted through distribution of advertising material at gay community events and venues, and online via weblinks and banner ads on gay community websites, gay dating websites, and through gay community online media. Online promotions had a direct link to the study site. Enrollment occurred online. Two thousand three hundred six men provided useable complete responses. Among these 2,306 men, 1,376 reported either an occasion involving either PAIC or UAIC in the previous year. Analyses reported here were of these 1,376 men.
Measures The online questionnaire included demographic items, and questions on sexuality and social engagement with gay men, sexual behavior and desire, and condom use [44]. We asked men when was their most recent occasion of PAIC and to describe both what had occurred and their partners on that occasion. Then, we asked similar questions about their most recent occasion of UAIC. Men were asked whether they had used any drugs, including EDM, during these occasions of PAIC and UAIC. All other drugs listed were illicit drugs. We included the Rosenberg measure of global self-esteem [45], which consists of 10 items with responses on a four-point scale ranging from “strongly agree” to “strongly disagree.” Strong internal consistency was found in this sample: α = 0.889; mean = 18.39; standard deviation (SD) = 4.99. We also included a previously used measure of social engagement with gay men consisting of two items: proportion of friends who are gay, with responses on a five-point scale ranging from “none” to “all,” and time spent with gay friends with responses on a four-point scale ranging from “none” to “a lot” [46]. Strong internal consistency was found in this sample: α = 0.804; mean = 5.87; SD = 1.60. The Kalichman measure of sexual sensation seeking was also included, with the mean score derived from 11 items each with responses on a four-point scale ranging from “not at all” to “very much” [47]. Strong internal consistency was found in this sample: α = 0.759; mean = 30.70; SD = 5.25. HIV serostatus was by self-report. Participants were asked about their HIV testing history and test results, and what they believed was their own HIV serostatus. They were also asked the extent to which they identified with various sexual identities, including the term “sexpig,” with responses
scored as 1 = “not at all,” 2 = “somewhat,” and 3 = “very much.” We have confined these analyses to the “sexpig” identity as a marker of highly sexually active GBM, often linked to concepts of masculinity [35,36,40]. In terms of masculinity, men who did not rate themselves as masculine were scored as “0,” somewhat masculine was scored as “1,” and very masculine as “2.”
Analysis Data were analyzed with SPSS™ version 21 software (SPSS, Inc., Chicago, IL, USA). Items in our analyses included age, education, cultural (or ethnic) background, HIV serostatus, number of male partners in previous 6 months, group sex (involving three or more partners), social engagement with gay men, self-esteem scores, sexual identification as a “sexpig,” self-rating of masculinity, and sexual sensation seeking. These items were considered in relation to use of EDM. For univariate analyses, comparing men who reported UAIC with men who did not report UAIC, and comparing men who used EDM with men who did not use EDM, categorical variables were analyzed using Pearson’s chi-square test and t-tests were used for continuous variables. We used Type I error of 5% for these analyses. To estimate statistical associations with use of EDM, we used logistic regression models and presented adjusted odds ratios and 95% confidence intervals (CIs). Associations with a P value of less than 0.1 in univariate analyses were included in the multivariate analyses. Descriptive Statistics and Comparison between PAIC and UAIC
Among the 1,376 men included in these analyses, 1,302 men reported a sex encounter involving PAIC in the previous year, and 617 reported a recent sex encounter involving UAIC; 543 men reported both a PAIC occasion and a UAIC occasion. Nearly half (48.1%) of the men in the sample were in (nonmonogamous) regular relationships. Mean age was 36.1 years. However, 402 men declined to report their age: There was no difference on any of the demographic, sexuality, or behavioral indicators between those who reported their age and those who did not. The majority (56.6%) of men were university educated. The majority identified “very much” (59.6%) or “somewhat” (32.2%) with the term “gay”; of the remaining 119 men, 55 nonetheless described themselves as “gay” or “homosexual.” J Sex Med 2014;11:809–819
812
Prestage et al.
Table 1 Profile of men who reported any UAIC encounters in the previous year and those who reported only PAIC encounters PAIC encounter only in the previous year (N = 759) Categorical variables N (%) Education Less than university level University level Ever tested for HIV Yes, tested Never tested Belief about own HIV status HIV positive HIV negative Unknown Ethnicity Anglo-Celtic Australian Other European Asian Other Sexual identity Gay/homosexual Bisexual Other Identification as “sexpig” Not at all Somewhat Very much Self-rated masculinity Not masculine Somewhat masculine Very masculine Use of erectile medications Did not use Did use Continuous variables Mean age in years (SD) Scales Mean scores (SD) Global self-esteem Sensation seeking Gay social engagement
Any UAIC encounter in the previous year (N = 617)
Total (N = 1,376)
P value
0.001 300 (39.5) 459 (60.5)
297 (48.1) 320 (51.9)
597 (43.4) 779 (56.6)
668 (88.0) 91 (12.0)
552 (89.5) 65 (10.5)
1,220 (88.7) 156 (11.3)
47 (6.2) 712 (93.8) 0 (0.0)
115 (18.6) 500 (81.0) 2 (0.3)
162 (11.8) 1,212 (88.1) 2 (0.1)
463 189 44 63
429 115 28 45
0.218
ORIGINAL RESEARCH—ERECTILE DYSFUNCTION Australian Gay and Bisexual Men’s Use of Erectile Dysfunction Medications During Recent Sexual Encounters Garrett Prestage, PhD,*† Fengyi Jin, PhD,* Benjamin Bavinton, BA, MPH,* Andrew Grulich, PhD,* Graham Brown, PhD,†‡ Marian Pitts, PhD,† and Michael Hurley, PhD† *Kirby Institute, University of New South Wales, Kensington, NSW, Australia; †Australian Research Centre in Sex Health and Society, La Trobe University, Melbourne, Vic., Australia; ‡Western Australian Centre for Health Promotion Research, Curtin Health Innovation Research Institute, Curtin University, Perth, WA, Australia DOI: 10.1111/jsm.12407
ABSTRACT
Aim. Use of erectile dysfunction medications (EDMs) is relatively common among gay and bisexual men and has been associated with human immunodeficiency virus sexual risk behavior. We aimed to determine what factors were related to EDM use on occasions when participants engaged in protected anal intercourse (PAIC) and when they engaged in unprotected anal intercourse (UAIC) with casual partners. Methods. An online cross-sectional survey was conducted, resulting in a sample of 1,376 Australian gay and bisexual men who reported an occasion of anal intercourse with casual male partners in the previous year. Main Outcome Measure. The main outcome measure was the use of EDM during most recent occasions of PAIC and UAIC. Results. Men were as likely to use EDM on occasions when they were using condoms (11.6%) as they were on occasions when they did not use condoms (13.0%). There was no association between use of EDM and self-esteem, nor was there an association between sexual risk behavior and self-esteem. Men who used EDM were more sexually active overall and appeared to often use EDM to enhance and extend their sexual experiences. Conclusions. Men did not appear to use EDM specifically for the purposes of risk-taking and mainly used EDM to enhance sexual pleasure. Mental health issues were not indicated by use of EDM. Prestage G, Jin FY, Bavinton B, Grulich A, Brown G, Pitts M, and Hurley M. Australian gay and bisexual men’s use of erectile dysfunction medications during recent sexual encounters. J Sex Med 2014;11:809–819. Key Words. HIV; Sexual Risk; Gay Men; Self-Esteem; Erectile Dysfunction Medication; PDE 5 Inhibitors; Men Who have Sex with Men; Sexuality; Sexual Behavior
Introduction
E
rectile dysfunction medications (EDMs), mainly phosphodiesterase type 5 inhibitors, are commonly used for therapeutic purposes to treat erectile dysfunction [1]. However, some men use EDM to enhance and extend their sexual pleasure, and among gay and bisexual men (GBM), such “recreational” use of EDM is relatively common [2–5]. Erectile dysfunction can profoundly impact men’s sense of masculinity and self-esteem [6,7], although it is arguable that the “dysfunction” may often be due to an overemphasis on erectile func-
© 2013 International Society for Sexual Medicine
tion as a core component of masculinity [8–11]. Also, among more sexually active GBM, use of EDM may be as much about enhanced sexual performance and practical methods of maximizing pleasure as it is about addressing perceived problems of erectile dysfunction [12]. The prospect of recreational use of EDM among GBM has raised concerns about the possibility of increases in “unsafe sex” [13]. Use of EDM among GBM is often associated with participating in highly sexually active networks and with having engaged in unprotected anal intercourse (i.e., not including ‘with casual partners’) [14–18]. It is often accompanied by the use of J Sex Med 2014;11:809–819
810 club drugs such as methamphetamine [3,14,19– 22]. This phenomenon has been described as “intensive sex partying” and isassociated with “sexually adventurous” gay subcultures [4,23]. The use of both EDM and club drugs have been identified as risk factors in human immunodeficiency virus (HIV) sexual risk behavior and HIV infection, particularly when used in combination [4,14,16–18,21,24–30]. Elsewhere, it has been noted that GBM increase their use of these drugs, including EDM, in the context of partying when they believe that other men also intend to use them [31]. In this context, we have argued that while some EDM use may be due to some erectile dysfunction, the primary purpose appears to be recreational—to enhance and extend sexual experience [4,23]. In an earlier study of GBM who engaged in group sex, we found that they were very likely to engage in sexual risk behavior and to use EDM [17]. Moreover, the majority of the men who also used drugs, including EDM, on an occasion of group sex, indicated that they did so specifically to enhance and extend the sexual experience, and for some, to permit them to engage in more sex, with more partners, than they might otherwise find possible. Half of the men in that study who reported using EDM during group sex also indicated that they used amyl nitrite on this same occasion, despite it being specifically contraindicated [32]. A similar proportion also reported that, on the same occasion, they used methamphetamine, which commonly has the effect of reducing men’s capacity to achieve and sustain erections [33,34]. EDM can help counteract these effects [35]. Use of EDM in this context is not so much about preexisting erectile dysfunction as it is about enabling the use of other drugs to ensure that the sought-after heightened sexual experience can be achieved. These same behaviors have also been associated with men’s sense of their own masculinity, of which sexual performance is perceived to be an important component [30,36–40]. In our previous work among GBM who engaged in group sex, a masculine self-belief was often particularly important [37]. For many, their concept of masculinity involved being highly sexually active and being able to demonstrate sexual performance within the group sex setting. The term “sexpig”—or more simply “pig”—has been used to describe GBM who seek “as much sex as [they] can get with as many different men as possible, often in the form of group sex that includes barebacking, water sports, fisting, and S/M” [41]. For many GBM who describe themJ Sex Med 2014;11:809–819
Prestage et al. selves as sexpigs, their sexuality is often represented as hypermasculinized, although masculine status is often acquired through “voracious bottoming” (taking the receptive position during anal sex with multiple partners) [41]. “Sexual sensation seeking,” which certainly includes attitudes to sexual performance among its component items, has also been similarly associated with indicators of being more sexually adventurous, HIV sexual risk behavior, and the use of EDM [3,38,42,43]. Whereas men who self-identify as “sexpigs” positively assert their own (hyper)sexuality, the measure of sexual sensation seeking is used to identify men who are psychologically predisposed toward multiple partners and more adventurous sexual behaviors; men who can be described as “sensation seekers” exhibit desires and behaviors that are often assumed to be pathological in nature. Aims
We investigated the use of EDM in relation to social, community, and sexual identity and engagement, self-esteem, sexual desire, and risk behavior during encounters involving protected anal intercourse with casual partners (PAIC) and encounters involving unprotected anal intercourse with casual partners (UAIC) among Australian GBM. We sought to identify variables that were independently associated with EDM use during both PAIC and UAIC occasions. Methods
Procedures This was a cross-sectional study of Australian GBM conducted in 2009 using an anonymous online survey to investigate their beliefs about HIV and the risks of HIV transmission [44]. No identifying details, including IP addresses or cookies, were collected. No compensation for participation was provided. All participants were provided with information about what participation entailed prior to direct access to the survey questionnaire. As this was an anonymous survey, completion of the survey questions was taken as consent, in accordance with National Health and Medical Research Council guidelines, and with the approval of the Human Research Ethics Committee of the University of New South Wales and of La Trobe University. Participants Men were eligible for the study if they were aged 18 or above, gay- or bisexual-identified, or had had
811
Gay Men’s Use of Erectile Dysfunction Medications sex with another man in the previous year, and lived in Australia. Participation in the study was promoted through distribution of advertising material at gay community events and venues, and online via weblinks and banner ads on gay community websites, gay dating websites, and through gay community online media. Online promotions had a direct link to the study site. Enrollment occurred online. Two thousand three hundred six men provided useable complete responses. Among these 2,306 men, 1,376 reported either an occasion involving either PAIC or UAIC in the previous year. Analyses reported here were of these 1,376 men.
Measures The online questionnaire included demographic items, and questions on sexuality and social engagement with gay men, sexual behavior and desire, and condom use [44]. We asked men when was their most recent occasion of PAIC and to describe both what had occurred and their partners on that occasion. Then, we asked similar questions about their most recent occasion of UAIC. Men were asked whether they had used any drugs, including EDM, during these occasions of PAIC and UAIC. All other drugs listed were illicit drugs. We included the Rosenberg measure of global self-esteem [45], which consists of 10 items with responses on a four-point scale ranging from “strongly agree” to “strongly disagree.” Strong internal consistency was found in this sample: α = 0.889; mean = 18.39; standard deviation (SD) = 4.99. We also included a previously used measure of social engagement with gay men consisting of two items: proportion of friends who are gay, with responses on a five-point scale ranging from “none” to “all,” and time spent with gay friends with responses on a four-point scale ranging from “none” to “a lot” [46]. Strong internal consistency was found in this sample: α = 0.804; mean = 5.87; SD = 1.60. The Kalichman measure of sexual sensation seeking was also included, with the mean score derived from 11 items each with responses on a four-point scale ranging from “not at all” to “very much” [47]. Strong internal consistency was found in this sample: α = 0.759; mean = 30.70; SD = 5.25. HIV serostatus was by self-report. Participants were asked about their HIV testing history and test results, and what they believed was their own HIV serostatus. They were also asked the extent to which they identified with various sexual identities, including the term “sexpig,” with responses
scored as 1 = “not at all,” 2 = “somewhat,” and 3 = “very much.” We have confined these analyses to the “sexpig” identity as a marker of highly sexually active GBM, often linked to concepts of masculinity [35,36,40]. In terms of masculinity, men who did not rate themselves as masculine were scored as “0,” somewhat masculine was scored as “1,” and very masculine as “2.”
Analysis Data were analyzed with SPSS™ version 21 software (SPSS, Inc., Chicago, IL, USA). Items in our analyses included age, education, cultural (or ethnic) background, HIV serostatus, number of male partners in previous 6 months, group sex (involving three or more partners), social engagement with gay men, self-esteem scores, sexual identification as a “sexpig,” self-rating of masculinity, and sexual sensation seeking. These items were considered in relation to use of EDM. For univariate analyses, comparing men who reported UAIC with men who did not report UAIC, and comparing men who used EDM with men who did not use EDM, categorical variables were analyzed using Pearson’s chi-square test and t-tests were used for continuous variables. We used Type I error of 5% for these analyses. To estimate statistical associations with use of EDM, we used logistic regression models and presented adjusted odds ratios and 95% confidence intervals (CIs). Associations with a P value of less than 0.1 in univariate analyses were included in the multivariate analyses. Descriptive Statistics and Comparison between PAIC and UAIC
Among the 1,376 men included in these analyses, 1,302 men reported a sex encounter involving PAIC in the previous year, and 617 reported a recent sex encounter involving UAIC; 543 men reported both a PAIC occasion and a UAIC occasion. Nearly half (48.1%) of the men in the sample were in (nonmonogamous) regular relationships. Mean age was 36.1 years. However, 402 men declined to report their age: There was no difference on any of the demographic, sexuality, or behavioral indicators between those who reported their age and those who did not. The majority (56.6%) of men were university educated. The majority identified “very much” (59.6%) or “somewhat” (32.2%) with the term “gay”; of the remaining 119 men, 55 nonetheless described themselves as “gay” or “homosexual.” J Sex Med 2014;11:809–819
812
Prestage et al.
Table 1 Profile of men who reported any UAIC encounters in the previous year and those who reported only PAIC encounters PAIC encounter only in the previous year (N = 759) Categorical variables N (%) Education Less than university level University level Ever tested for HIV Yes, tested Never tested Belief about own HIV status HIV positive HIV negative Unknown Ethnicity Anglo-Celtic Australian Other European Asian Other Sexual identity Gay/homosexual Bisexual Other Identification as “sexpig” Not at all Somewhat Very much Self-rated masculinity Not masculine Somewhat masculine Very masculine Use of erectile medications Did not use Did use Continuous variables Mean age in years (SD) Scales Mean scores (SD) Global self-esteem Sensation seeking Gay social engagement
Any UAIC encounter in the previous year (N = 617)
Total (N = 1,376)
P value
0.001 300 (39.5) 459 (60.5)
297 (48.1) 320 (51.9)
597 (43.4) 779 (56.6)
668 (88.0) 91 (12.0)
552 (89.5) 65 (10.5)
1,220 (88.7) 156 (11.3)
47 (6.2) 712 (93.8) 0 (0.0)
115 (18.6) 500 (81.0) 2 (0.3)
162 (11.8) 1,212 (88.1) 2 (0.1)
463 189 44 63
429 115 28 45
0.218
