CSIRO PUBLISHING
Sexual Health, 2015, 12, 217–223 http://dx.doi.org/10.1071/SH14229
Seeking sex online: social and sexual risk factors among adolescent and young gay and bisexual men Guy Shilo A,C and Zohar Mor B A
Bob Shapell School of Social Work, Tel Aviv University, Ramat Aviv, Tel-Aviv 69978, Israel. Ramla Department of Health, Ministry of Health, Danny Mass Street, Ramla 72100, Israel. C Corresponding author. Email: [email protected] B
Abstract. Background: With the increased use of the Internet to seek sex, research has documented its associated sexual risk behaviours, especially among gay and bisexual men. Only a few studies to date have been conducted among adolescent and young men, and these have focussed on behavioural components to do with seeking sex online, without considering the role of same-sex identity formation processes. The current study aimed to identify behavioural and identity formation variables associated with seeking sex online among adolescents and youth. Methods: A web sampling of young Israeli gay and bisexual men aged 12–30 years (n = 445) was used to assess their seeking sex online characteristics, mental health, sexual risk behaviours, substance use, same-sex disclosure and acceptance and coping resources. Results: Nearly half of the sample used the Internet to seek sex, which was correlated with substance use and sexual risk behaviour. Young adults seek for sex online more commonly than adolescents. Higher numbers of: sexual partners, level of outness, levels of friends support and stronger connectedness to the gay community predicted seeking sex online. Seeking sex online was found to be more of predictor for sexual risk behaviour than any other predictor. Conclusions: Seeking sex online is influenced by the gay sub-culture climate and peer group relationships, rather than by social stressor variables related to sexual orientation formation processes, or by the subject’s general mental health condition. These results underscore the possible risks pertaining to seeking sex among gay and bisexual men and the possible use for this venue to convey safe-sex messages to adolescents and young adults. Additional keywords: Internet, minority stress, sexual risk behaviour. Received 22 June 2014, accepted 21 December 2014, published online 10 March 2015
Introduction Over the past 20 years, the Internet has become a popular medium for seeking sexual partners, especially among gay and bisexual men (GBM). Recent studies1–3 have found that 40% of GBM, on average, use the Internet to seek for sex. A growing number of studies have demonstrated that seeking sex online is associated with elevated sexual risk behaviours, including unprotected anal sex (UAI) and alcohol/substance use during sex.4,5 However, studies of Internet users and sexual risk behaviour have often focussed on general behavioural components related to seeking sex online, without taking into account the role of same-sex identity formation processes, such as self-acceptance of same-sex orientation and disclosure of same-sex identity (‘coming out’).6 These processes and their social correlates, such as the lack of social support and fewer connections with the gay community, create unique minority stressors that adversely affect mental and physical health among sexual minorities.7–9 Journal compilation CSIRO 2015
With adolescents and young adults being ‘early adopters’ of new technologies such as the Internet, surprisingly only a few studies have examined how the Internet affects their sexual behaviour, and fewer still, to our knowledge, have examined this specifically in relation to adolescents younger than 18 years of age.5,10,11 Few qualitative studies of young GBM (YGBM) who engage in seeking sex online have examined key characteristics of the Internet, such as anonymity, accessibility and its usefulness in exploring issues related to sexual orientation,12–14 suggesting that seeking sex online may be linked to the early stages of sexual identity formation processes. Recent studies show that lesbian, gay and bisexual (LGB) youth and young adults in Israel, a developed country characterised by a relatively openly gay society, disclose their sexual orientation at the mean age of 16.5 years to both friends and family members,15 and that 67.5% of gay men reported their first male sexual debut before the age of 18 years.16 The annual incidence of newly diagnosed HIV infections www.publish.csiro.au/journals/sh
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among GBM in Israel has tripled between 1999 and 2010,17 and 92% of Israelis aged 30 years or younger have access to the Internet and use it on daily basis.18 Together, these statistics suggest that a growing number of Israeli YGBM seek sex online. Given the limited data on the psychosocial processes underlining seeking sex online among YGBM, and the growing concern over the increase of sexual risk behaviour and Internet use among GBM, the present study aimed to: (i) assess the level of risk behaviours among adolescents (under the age of 18 years) and young adult (18–30 years old) GBM in Israel who engage in seeking sex online; and (ii) appraise Internet use characteristics related to sexual orientation formation process of YGBM who conduct their sex seeking online; we would also gauge the association between seeking sex online and sexual risk behaviour beyond demographics, risk behaviours, psychosocial characteristics and mental health. Methods Procedures Study participants were recruited between July and October 2010 and were asked to complete an anonymous electronic questionnaire hosted on a secure web page. In view of the difficulty of sampling GBM in a representative fashion, an online venue-sampling was used,19 and eight LGB groups on Facebook and six additional young LGB web forums offered the questionnaire to their members. Web forums and Facebook groups were excluded from our sampling frame if they were likely to over-represent people seeking for sexual encounters, thus reducing possible selection bias. Eligibility criteria included being a Jewish male between the ages of 12 and 30 years, living in Israel, self-identifying as gay or bisexual and sexually active. The lower limit of 12 years of age was used to align with the lower age range of first sexual debut found in previous studies.20,21 The study was approved both by the Institutional Review Boards of Tel Aviv University and E. Wolfson Medical Center. Measures Internet use for sex was defined by the frequency of use of the Internet to look for sexual partners. Response choices ranged from 1 (‘Never’) to 5 (over 5 h a day). In order to calculate the odds ratios and threshold effect22,23 related to Internet use for sex, outcomes were dichotomised into those that go online to seek for potential sexual partners v. those who find their sexual partner by other venues. Substance use was assessed by four questions,24 pertaining to the daily use of alcohol above one portion, club drugs, chemical stimulants or hallucinogens in the previous 6 months. Items were scored dichotomously: 0 (‘Never used the specific substance’) or 1 (‘used the specific substance one or more times’). Scores were calculated as the sum of the items; the higher the score, the greater the substance use (on a scale from 0 to 5; Cronbach’s a = 0.79). Sexual risk behaviour was assessed by three questions,24 concerning the practise of unprotected anal intercourse and the use of drugs or alcohol, before or during sexual intercourse within the previous 6 months. Items were scored
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dichotomously: 0 (‘Never engaged in the specific risk behaviours’) or 1 (‘Performed one or more episode of the specific risk behaviours’). Scores were calculated as the sum of the items; the higher the score, the greater the extent of sexual risk behaviour (on a scale from 0 to 3; Cronbach’s a = 0.76). Mental health was assessed by the Mental Health Inventory25 –a 38-item measure of mental distress (25 items) and psychological wellbeing (13 items). Items were rated on a 6point scale ranging from 1 (‘Strongly agree’) to 6 (‘Strongly disagree’). In the present study, Cronbach’s a was 0.92 for the distress scale and 0.93 for the wellbeing scale. Scores were calculated as the sum of the item measures of each index; the higher the score, the greater the distress or wellbeing. Acceptance of sexual orientation was assessed using the LGB Self-Acceptance Questionnaire.26 It comprised 10 questions concerning the respondents’ degree of acceptance of their sexual orientation, with responses on a five-point scale ranging from 1 (‘Not at all’) to 5 (‘Very much’). In the present study, Cronbach’s a was 0.84. Scores were calculated as the mean of the index items; the higher the score, the greater self-acceptance of sexual orientation. Level of outness was assessed by the means of seven items, establishing the extent to which the subject had ‘come out’ to close friends, family members and friends and faculty or teachers at school, university, army and work, respectively (adapted from D’Augelli27), on a five-point scale ranging from 1 (‘No one’) to 5 (‘All’). In the present study, Cronbach’s a was 0.81. Scores were calculated as the mean of each item; the higher the score, the greater the level of outness. Support by family and friends was rated on a 13-items scale28 that measured perceived social support from the individual’s close family and friends. Items were rated on a five-point scale (1 = ‘Not at all,’ 5 = ‘A great deal’). In this study, Cronbach’s a = 0.91 for social support from friends and a = 0.86 for social support from family. Scores were calculated as the mean of the constituent items; the higher the score, the greater the support from each support provider. Connectedness to the LGB community was assessed by means of an eight-item questionnaire15 relating to key social activities available to LGB youth and young adults in Israel. In each case, participants were asked to rate their social contact on a five-point scale, ranging from 1 (‘Never’) to 5 (‘Usually’). In this study, Cronbach’s a was 0.82. Scores were calculated as the mean of the constituent items; the higher the score, the greater the individual’s connectedness to the LGB community. For demographics and social characteristics, participants indicated their age; sexual orientation; number of sexual partners in the previous 6 months; the venue in which they usually find their sexual partners from a list of five venues, including four non-electronic venues (Internet, club/bar, sauna, public areas or through friends); whether they had a steady partner (defined as a steady relationship lasting longer than 1 year); if they had sex exclusively with their steady partner; and whether they and their partner had been tested for HIV in the previous 6 months. Based on the typical age of high school graduation and compulsory military service in Israel, participants were classified as either an adolescent (age 18 years) or a young adult (aged 19 years and above).
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Statistical analysis Respondents who engaged in seeking sex online were compared with those who did not, in terms of demographics, substance use, sexual risk behaviour, mental health, gay identity formation, social support and connectedness to LGB community, by means of the c2 test for categorical variables or an independent two-tailed Student’s t-test for continuous variables for normally distributed variables, using SPSS for Windows software, version 18 (Chicago, IL, USA). All independent variables were included in a logistic regression model to identify predictors of sexual risk behaviour, generating an adjusted odds ratio (OR) and 95% confidence intervals (CI). Results Sample characteristics The questionnaire was completed by 490 YGBM, who met the eligibility criteria; however, only 445 participants completed the questionnaires with no missing data and were included in the analyses. The mean age of the participants was 22.5 years (s.d. = 4.7; range: 12–30 years). Of these, 87.6% self-identified as gay, 8.8% as bisexual and 3.4% as questioning. Most participants (n=396, 89.2%) described themselves as secular, while 48 (10.8%) described themselves as ‘traditional’ or ‘religious’. Collectively, participants resided in 104 cities and towns, representing all seven social demographic clusters in Israel.18 Of all study participants, 22% were high school students, 35.7% were attending university, 10.8% were in military service and 57.8% were employed, while 35.1% were both students (at high school or university) and concomitantly employed.
Using the Internet to seek sexual partners Of all YGBM in this study, 201 (45.2%) reported that they used the Internet to seek sexual partners. Those who seek sexual partners on the Internet were more likely to be young adults, single, used substances, reported having more sexual partners in the previous 6 months, had a stronger support of friends and were more connected to the LGB community compared with those who did not search for sexual partners online (Table 1). Almost all participants who used the Internet to seek sexual partners (97.0%) reported that the Internet was the most common venue in which they finally met their sexual encounters. No significant differences were found between those who used the Internet to seek sexual partners and those who did not in terms of other venues in which they met their sexual partners. Meeting sexual partners through friends (45.9%) and in a bar/club (43.1%) were the most common venues reported by participants who did not use the Internet for sex-seeking. In addition, no significant differences were found between the two groups in terms of gay identity formation (self-acceptance, level of outness), mental health (wellbeing, mental distress) or family support. In multivariate regression analysis aimed at identifying variables predicting online sex seeking, it was found that being a young adult, single, having higher numbers of sexual partners, reporting higher levels of outness and higher levels of support from friends and a stronger connectedness to the LGB community predicted seeking sex online (Table 2). Risk behaviours and seeking sex online To further characterise behavioural variables related to seeking sex online, we compared the substance-use and sexual risk
Table 1. Characteristics of gay and bisexual males seeking sexual partners online v. those who do not (n = 445) *P < 0.01; **P < 0.001. LGB, lesbian, gay and bisexual. Results are presented as mean number of variables Variable
Adolescent ( 18 years) In a steady relationship Substance use Usually meeting sexual partners in: Bar/club Through friends Public places/gardens Internet Sauna No. of sexual partners in the previous 6 months Well-being Mental distress Self-acceptance Level of outness Family support Friends’ support Connectedness to the LGB community
Seeks sexual partners online 45.2% (n = 201) % (N)
Does not seek sexual partners online 54.8% (n = 244) % (N)
c2
21.4 (43) 18.9 (38) 67.2 (133)
33.2 (81) 43.9 (107) 53.8 (129)
7.64* 31.2** 8.13**
34.3 37.3 2.9 97 5.5
43.1 45.9 2.5 6.1 2.3
(69) (75) (6) (195) (11)
Mean (s.d.) 8.12 (10.9) 45.93 66.11 1.58 3.46 3.94 4.30 2.73
(13.39) (21.85) (0.61) (1.10) (0.78) (0.48) (0.77)
219
(105) (112) (6) (15) (6)
Mean (s.d.) 2.12 (1.98) 45.73 64.25 1.56 3.29 3.94 4.15 2.52
(12.53) (21.73) (0.54) (1.15) (0.73) (0.58) (0.84)
3.51 3.34 0.12 365.15** 2.72 Student’s t-test 7.24** 0.17 0.89 0.32 1.54 0.09 2.94* 2.84*
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behaviour patterns of participants who reported using the Internet for sex seeking with those who did not. To avoid the bias of participants who had a steady boyfriend with whom they had exclusive sex and where both had been tested for HIV, we excluded these participants (n=42) from the analyses of sexual risk behaviours. As shown in Table 3, participants who engaged in seeking sex online used more marijuana, stimulants and nitrite inhalants (e.g. ‘poppers’) compared with participants who did not use the Internet to seek sexual partners. In addition, online sex-seekers reportedly engaged in risky sexual behaviours, including UAI, using the drugs and alcohol shortly before or during sexual intercourse, compared with participants who did not engage in seeking sex online. Multivariate analyses predicting sexual risk behaviour To determine the independent variables predicting sexual risk behaviour, we performed a sequential logistic regression, in which age group and being in a steady relationship were entered in the first step as a priori control variables. In the Table 2. Multivariate analysis predicting Internet use for seeking sex (n = 445) CI, confidence interval for adjusted odds ratio (OR); B, undstandardised beta coefficient; SE, standard error. *P< 0.01; **P< 0.001. Results are presented as mean numbers of variables Variable Young adults (19–30 years) No steady boyfriend Substance use Sexual partners in previous 6 months Well-being Mental distress Self-acceptance Level of outness Family support Friends’ support Connectedness to the LGB community
B
SE
OR
95% CI
0.93* 1.79** 0.34
0.42 0.31 0.33
2.56 5.88 1.40
1.23–3.58 2.35–6.26 0.74–2.66
0.33** –0.01 0.01 0.02 0.39* –0.12 0.70*
0.33 0.02 0.01 0.33 0.18 0.21 0.32
1.39 0.99 1.01 1.02 1.47 0.88 2.01
1.23–1.57 0.97–1.03 0.99–1.03 0.53–1.95 1.42–1.97 0.58–1.34 1.07–3.79
0.19*
0.19
1.21
1.15–1.76
second step, the number of sexual partners, substance use, and the variables of mental health, gay identity formation, social support and connection to the LGB community were entered and finally, seeking sex online was added in the final step (Table 4). Being an adolescent and having a steady boyfriend were both found to have a negative association with sexual risk behaviour. After controlling for these variables, lower levels of wellbeing, higher levels of outness, greater friends’ support, and stronger connectedness to LGB community were predictors significantly influencing risky sexual behaviour. In addition, substance use was also a predictor of sexual risk behaviour; participants who used high levels of substances were 4.41-fold more likely to engage in sexual risk behaviour, compared with those with a lower incidence of substance use. Finally, online sex seeking predicted risky sexual behaviour, even after controlling for demographic factors, social variables, mental health and substance use. Discussion This is the first study to focus on Jewish YGBM in Israel who engage in seeking sex online and one of the only studies to include participants as young as 12 years old.29 In this study, approximately half of all YGBM used the Internet to search for sex; a finding consistent with previous studies in Western countries, and one that underlines the increasing prevalence of online sex in this population.2,3 Indeed, this study demonstrated that most (97%) of the participants who seek sex online met their sexual partners via Internet seeking, while meeting sexual partners in bar/clubs or through friends were the most common ways reported by participants who did not use the Internet for sex-seeking. In addition, seeking sex online was correlated with other risk behaviours; YGBM who seek sex online used substances more commonly and reported UAI, compared with those who do not search for sex online. This is in line with previous studies,4,30 indicating the associated risk factors involved in seeking sex online. Although causality between Internet use and sexual risk behaviours may be difficult to ascertain given the crosssectional nature of this study, it does show that seeking sex online attracts YGBM who engage in other risky behaviours. We cannot rule out the possibility that a third
Table 3. Substance use and sexual risk behaviours among gay and bisexual males seeking sexual partners via the Internet v. those not seeking sexual partners via the Internet Note: numbers reflect the participants reporting use of the relevant substance or conducting the relevant behaviour. *P < 0.01; **P < 0.001
Substance use Alcohol Marijuana Club drugs Stimulants Inhaled nitrites Sexual risk behaviour Anal intercourse without condom Drug use before/during intercourse Alcohol use before/during intercourse
Using the Internet to seek sexual partners 45.2% (n = 201) n % 104 57 10 23 30
51.7 28.4 5.0 11.4 14.9
49.9% (n = 201) 62 30.8 35 17.4 89 44.2
Not using the Internet to seek sexual partners 54.8% (n = 244) n % 109 44 6 10 17
c2
44.7 18.0 2.5 4.1 7.0
2.21 6.7* 2.01 8.66** 7.39**
50.1% (n = 202) 35 17.3 7 3.5 50 24.8
10.08** 20.99** 17.00**
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Table 4. Hierarchical logistic regression predicting sexual risk behaviour (n = 445) Note: CI, confidence interval for adjusted odds ratio (OR); B, unstandardised beta coefficient; SE, standard error. *P < 0.01; **P < 0.001. Results are presented as mean number of variables Variable Step 1 Young adults (19–30) Single Step 2 Sexual partners in previous 6 months Wellbeing Mental distress Self-acceptance Level of outness Family support Friends’ support Connectedness to the LGB community Substance use Step 3 Seeking sexual partners online
B
SE
OR
95% CI
0.24* 1.09**
0.27 0.24
1.51 2.94
1.23–1.56 1.89–2.35
0.03 –0.05** 0.17 0.01 0.30* 0.16 0.69* 0.45* 1.48**
0.02 0.02 0.01 0.29 0.16 0.19 0.30 0.17 0.29
1.03 0.95 1.02 0.99 1.35 1.17 2.00 1.54 4.41
0.99–1.06 0.92–0.98 0.99–1.04 0.56–1.79 1.13–1.84 0.79–1.71 1.11–3.59 1.36–1.59 2.47–7.87
1.19**
0.27
3.30
1.96–5.56
c2 24.53**
107.41**
factor associates Internet use to seek sex and risk behaviours, like a sensation-seeking personality. It should be noted that in terms of behaviour variables, no differences were found between participants who used the Internet for sex-seeking and those who did not in the frequency of meeting sexual partners in other venues. Yet, with the convenience of Internet sex-seeking and high frequency of this sex-seeking tool, even those who do not engage in such risk behaviours are exposed, during their online sex seeking, to sexual encounters that puts them at risk for sexually transmissible infections, including HIV. Previous research explained seeking sex online among YGBM in terms of the characteristics of same-sex identity formation and social stressors that put YGBM in the vulnerable mental situation of concealing their sexual identity and looking for anonymous places to meet other MSM.31 However, the findings of the present study offer a different explanation; namely, that YGBM who engage in seeking sex online are no different from those who do not, in terms of mental health and personal acceptance of their sexual identity, while, in contrast, they do report higher levels of outness, friends’ support and connectedness to the LGBT community. These findings suggest that seeking sex online behaviour might be influenced by other reasons rather than by societal stressors related to sexual orientation identity formation. In addition, although lower levels of mental health were found to predict risky sexual behaviour among YGBM, which is in keeping with the social stress hypothesis,7 high levels of outness, connectedness to the LGB community and friends’ support were associated with increased incidence of sexual risk behaviour. Qualitative research conducted among gay men suggested that using the Internet for sex-seeking allows participants to express their desires, manage their identity, facilitates HIV status disclosure and allows sexual exploration.30 In addition, with the convenience of using the Internet for sex-seeking, the popularity of geo-social networks (e.g. Grindr) among GBM33 and the motivation of facilitating social connections through the Internet, may explain the findings that high levels of outness, friends’
134.50**
support and connectedness to the LGBT community were predictors of Internet sex-seeking. It should be noted that our findings demonstrated that seeking sex online was strongly associated with risky sexual behaviour, even after discounting personal variables, social characteristics and mental health status. This suggests that although there are potential positive social aspects of electronic networks between YGBM, the Internet also exposes participants to risky sexual behaviours. Young GBM are an under-studied population at risk for HIV. This study shows that adolescents (aged below 18 years) were less likely to use the Internet for sex-seeking, while being a young adult (18–30 years) was correlated with increased risky sexually behaviour. It is probable that young adults enjoy better access to gay community venues, and are thus exposed more to the gay lifestyle and are able to adopt risky sexual behaviour and other risk behaviours.9 Although young adults in the survey were found to engage in seeking sex online more often than their adolescent counterparts, it should be noted that one-fifth of the adolescent respondents reported this practice. Although the legal age restriction of 18 years is required to register and use sex-seeking websites in Israel, our findings suggest that adolescents can find a way to get around legal restrictions and parental control. The increased incidence of HIV infection among YGBM, both in Western countries and in Israel,13,17 coupled with the average age of 16 years for ‘coming out’ to friends and families, makes the fact that online sex seeking, practised by GBM as young as 12 years old, a risky behaviour and a target for intervention at younger ages. Being in a steady same-sex relationship was found to be a protective factor for both seeking sex online and sexual risk behaviour.16 Our study shows that YGBM in steady relationships tend not to engage in seeking sex online, which is not surprising, but it does run counter to the common assumption30 or prejudice that GBM are constantly looking for sexual relations irrespective of their personal relationship status.32 These findings underline the importance of social support and legalisation for same-sex relationships as a
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protective factor for sexually transmissible infections, including HIV.34 The present study had several limitations. First, it was based on a convenience sample, which may not be representative of all YGBM in Israel. However, this is an acceptable method in sensitive data collection, especially among youth.19 Second, the cross-sectional design limits the conclusions that may be drawn regarding causality. Nonetheless, studies of adult MSM have also found that MSM who meet their partners online are at high sexual risk. Third, all the findings are based on self-reporting, which is susceptible to reporting bias, especially concerning sensitive and intimate aspects such as sexual practices and substance use. To minimise this bias, in light of other studies that showed that Internet-based samples among MSM reduce reporting bias and increase validity,19 participants were asked to complete the data anonymously and only with regard to the previous 6 months. Conclusion Young GBM who used the Internet to seek sex were more likely to report sexual risk behaviour and substances use than those who found their sexual partners via other venues. It may be that online sex-seekers are influenced by the gay sub-culture lifestyle and peer group relationships, rather than by social stressor variables related to sexual orientation formation processes, such as concealment of sexual orientation and self-acceptance or mental health condition. With the increasing adoption of new technologies by YGBM, electronic networks can be used as a valuable tool to convey safe-sex messages and to perform online studies. Conflicts of interest The authors are not aware of any conflict of interest, real or perceived, with regard to this article. Acknowledgements The authors would like to thank Uri Shefer, Oren Pizmoni-Levy, Nadav Antebi, Yaron Gal and Ori Kapara for their assistance in forming the study concept and in developing the questionnaire. This study was partially supported by the Israeli Gay Youth Organisation.
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and protective factors, and interventions. J Sex Res 2011; 48: 218–53. doi:10.1080/00224499.2011.558645 Davis M, Hart G, Bolding G, Sherr L, Elford J. Sex and the Internet: gay men, risk reduction, and serostatus. Cult Health Sex 2006; 8: 161–74. doi:10.1080/13691050500526126 Rendina HJ, Jimenez RH, Grov C, Ventueneac A, Parsons JT. Patterns of lifetime and recent HIV testing among MSM in New York City who use Grindr. AIDS Behav 2014; 18: 41–9. doi:10.1007/s10461013-0573-2 Worth H, Reid A, McMillan K. Somewhere over the rainbow: love, trust and monogamy in gay relationships. J Sociol 2002; 38: 237–53. doi:10.1177/144078302128756642 Rosser SB, Oakes J, Horvath K, Konstan J, Danilenko G, Peterson J. HIV sexual risk behavior by men who use the Internet to seek sex with men: results of the Men’s INTernet Sex Study-II (MINTS-II). AIDS Behav 2009; 13: 488–98. doi:10.1007/s10461-009-9524-3 Klausner JD, Pollack LM, Wong W, Katz MH. Same-sex domestic partnerships and lower-risk behaviors for STDs, including HIV infection. J Homosex 2006; 51: 137–44. doi:10.1300/J082v51n04_07
www.publish.csiro.au/journals/sh
Sexual Health, 2015, 12, 217–223 http://dx.doi.org/10.1071/SH14229
Seeking sex online: social and sexual risk factors among adolescent and young gay and bisexual men Guy Shilo A,C and Zohar Mor B A
Bob Shapell School of Social Work, Tel Aviv University, Ramat Aviv, Tel-Aviv 69978, Israel. Ramla Department of Health, Ministry of Health, Danny Mass Street, Ramla 72100, Israel. C Corresponding author. Email: [email protected] B
Abstract. Background: With the increased use of the Internet to seek sex, research has documented its associated sexual risk behaviours, especially among gay and bisexual men. Only a few studies to date have been conducted among adolescent and young men, and these have focussed on behavioural components to do with seeking sex online, without considering the role of same-sex identity formation processes. The current study aimed to identify behavioural and identity formation variables associated with seeking sex online among adolescents and youth. Methods: A web sampling of young Israeli gay and bisexual men aged 12–30 years (n = 445) was used to assess their seeking sex online characteristics, mental health, sexual risk behaviours, substance use, same-sex disclosure and acceptance and coping resources. Results: Nearly half of the sample used the Internet to seek sex, which was correlated with substance use and sexual risk behaviour. Young adults seek for sex online more commonly than adolescents. Higher numbers of: sexual partners, level of outness, levels of friends support and stronger connectedness to the gay community predicted seeking sex online. Seeking sex online was found to be more of predictor for sexual risk behaviour than any other predictor. Conclusions: Seeking sex online is influenced by the gay sub-culture climate and peer group relationships, rather than by social stressor variables related to sexual orientation formation processes, or by the subject’s general mental health condition. These results underscore the possible risks pertaining to seeking sex among gay and bisexual men and the possible use for this venue to convey safe-sex messages to adolescents and young adults. Additional keywords: Internet, minority stress, sexual risk behaviour. Received 22 June 2014, accepted 21 December 2014, published online 10 March 2015
Introduction Over the past 20 years, the Internet has become a popular medium for seeking sexual partners, especially among gay and bisexual men (GBM). Recent studies1–3 have found that 40% of GBM, on average, use the Internet to seek for sex. A growing number of studies have demonstrated that seeking sex online is associated with elevated sexual risk behaviours, including unprotected anal sex (UAI) and alcohol/substance use during sex.4,5 However, studies of Internet users and sexual risk behaviour have often focussed on general behavioural components related to seeking sex online, without taking into account the role of same-sex identity formation processes, such as self-acceptance of same-sex orientation and disclosure of same-sex identity (‘coming out’).6 These processes and their social correlates, such as the lack of social support and fewer connections with the gay community, create unique minority stressors that adversely affect mental and physical health among sexual minorities.7–9 Journal compilation CSIRO 2015
With adolescents and young adults being ‘early adopters’ of new technologies such as the Internet, surprisingly only a few studies have examined how the Internet affects their sexual behaviour, and fewer still, to our knowledge, have examined this specifically in relation to adolescents younger than 18 years of age.5,10,11 Few qualitative studies of young GBM (YGBM) who engage in seeking sex online have examined key characteristics of the Internet, such as anonymity, accessibility and its usefulness in exploring issues related to sexual orientation,12–14 suggesting that seeking sex online may be linked to the early stages of sexual identity formation processes. Recent studies show that lesbian, gay and bisexual (LGB) youth and young adults in Israel, a developed country characterised by a relatively openly gay society, disclose their sexual orientation at the mean age of 16.5 years to both friends and family members,15 and that 67.5% of gay men reported their first male sexual debut before the age of 18 years.16 The annual incidence of newly diagnosed HIV infections www.publish.csiro.au/journals/sh
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among GBM in Israel has tripled between 1999 and 2010,17 and 92% of Israelis aged 30 years or younger have access to the Internet and use it on daily basis.18 Together, these statistics suggest that a growing number of Israeli YGBM seek sex online. Given the limited data on the psychosocial processes underlining seeking sex online among YGBM, and the growing concern over the increase of sexual risk behaviour and Internet use among GBM, the present study aimed to: (i) assess the level of risk behaviours among adolescents (under the age of 18 years) and young adult (18–30 years old) GBM in Israel who engage in seeking sex online; and (ii) appraise Internet use characteristics related to sexual orientation formation process of YGBM who conduct their sex seeking online; we would also gauge the association between seeking sex online and sexual risk behaviour beyond demographics, risk behaviours, psychosocial characteristics and mental health. Methods Procedures Study participants were recruited between July and October 2010 and were asked to complete an anonymous electronic questionnaire hosted on a secure web page. In view of the difficulty of sampling GBM in a representative fashion, an online venue-sampling was used,19 and eight LGB groups on Facebook and six additional young LGB web forums offered the questionnaire to their members. Web forums and Facebook groups were excluded from our sampling frame if they were likely to over-represent people seeking for sexual encounters, thus reducing possible selection bias. Eligibility criteria included being a Jewish male between the ages of 12 and 30 years, living in Israel, self-identifying as gay or bisexual and sexually active. The lower limit of 12 years of age was used to align with the lower age range of first sexual debut found in previous studies.20,21 The study was approved both by the Institutional Review Boards of Tel Aviv University and E. Wolfson Medical Center. Measures Internet use for sex was defined by the frequency of use of the Internet to look for sexual partners. Response choices ranged from 1 (‘Never’) to 5 (over 5 h a day). In order to calculate the odds ratios and threshold effect22,23 related to Internet use for sex, outcomes were dichotomised into those that go online to seek for potential sexual partners v. those who find their sexual partner by other venues. Substance use was assessed by four questions,24 pertaining to the daily use of alcohol above one portion, club drugs, chemical stimulants or hallucinogens in the previous 6 months. Items were scored dichotomously: 0 (‘Never used the specific substance’) or 1 (‘used the specific substance one or more times’). Scores were calculated as the sum of the items; the higher the score, the greater the substance use (on a scale from 0 to 5; Cronbach’s a = 0.79). Sexual risk behaviour was assessed by three questions,24 concerning the practise of unprotected anal intercourse and the use of drugs or alcohol, before or during sexual intercourse within the previous 6 months. Items were scored
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dichotomously: 0 (‘Never engaged in the specific risk behaviours’) or 1 (‘Performed one or more episode of the specific risk behaviours’). Scores were calculated as the sum of the items; the higher the score, the greater the extent of sexual risk behaviour (on a scale from 0 to 3; Cronbach’s a = 0.76). Mental health was assessed by the Mental Health Inventory25 –a 38-item measure of mental distress (25 items) and psychological wellbeing (13 items). Items were rated on a 6point scale ranging from 1 (‘Strongly agree’) to 6 (‘Strongly disagree’). In the present study, Cronbach’s a was 0.92 for the distress scale and 0.93 for the wellbeing scale. Scores were calculated as the sum of the item measures of each index; the higher the score, the greater the distress or wellbeing. Acceptance of sexual orientation was assessed using the LGB Self-Acceptance Questionnaire.26 It comprised 10 questions concerning the respondents’ degree of acceptance of their sexual orientation, with responses on a five-point scale ranging from 1 (‘Not at all’) to 5 (‘Very much’). In the present study, Cronbach’s a was 0.84. Scores were calculated as the mean of the index items; the higher the score, the greater self-acceptance of sexual orientation. Level of outness was assessed by the means of seven items, establishing the extent to which the subject had ‘come out’ to close friends, family members and friends and faculty or teachers at school, university, army and work, respectively (adapted from D’Augelli27), on a five-point scale ranging from 1 (‘No one’) to 5 (‘All’). In the present study, Cronbach’s a was 0.81. Scores were calculated as the mean of each item; the higher the score, the greater the level of outness. Support by family and friends was rated on a 13-items scale28 that measured perceived social support from the individual’s close family and friends. Items were rated on a five-point scale (1 = ‘Not at all,’ 5 = ‘A great deal’). In this study, Cronbach’s a = 0.91 for social support from friends and a = 0.86 for social support from family. Scores were calculated as the mean of the constituent items; the higher the score, the greater the support from each support provider. Connectedness to the LGB community was assessed by means of an eight-item questionnaire15 relating to key social activities available to LGB youth and young adults in Israel. In each case, participants were asked to rate their social contact on a five-point scale, ranging from 1 (‘Never’) to 5 (‘Usually’). In this study, Cronbach’s a was 0.82. Scores were calculated as the mean of the constituent items; the higher the score, the greater the individual’s connectedness to the LGB community. For demographics and social characteristics, participants indicated their age; sexual orientation; number of sexual partners in the previous 6 months; the venue in which they usually find their sexual partners from a list of five venues, including four non-electronic venues (Internet, club/bar, sauna, public areas or through friends); whether they had a steady partner (defined as a steady relationship lasting longer than 1 year); if they had sex exclusively with their steady partner; and whether they and their partner had been tested for HIV in the previous 6 months. Based on the typical age of high school graduation and compulsory military service in Israel, participants were classified as either an adolescent (age 18 years) or a young adult (aged 19 years and above).
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Statistical analysis Respondents who engaged in seeking sex online were compared with those who did not, in terms of demographics, substance use, sexual risk behaviour, mental health, gay identity formation, social support and connectedness to LGB community, by means of the c2 test for categorical variables or an independent two-tailed Student’s t-test for continuous variables for normally distributed variables, using SPSS for Windows software, version 18 (Chicago, IL, USA). All independent variables were included in a logistic regression model to identify predictors of sexual risk behaviour, generating an adjusted odds ratio (OR) and 95% confidence intervals (CI). Results Sample characteristics The questionnaire was completed by 490 YGBM, who met the eligibility criteria; however, only 445 participants completed the questionnaires with no missing data and were included in the analyses. The mean age of the participants was 22.5 years (s.d. = 4.7; range: 12–30 years). Of these, 87.6% self-identified as gay, 8.8% as bisexual and 3.4% as questioning. Most participants (n=396, 89.2%) described themselves as secular, while 48 (10.8%) described themselves as ‘traditional’ or ‘religious’. Collectively, participants resided in 104 cities and towns, representing all seven social demographic clusters in Israel.18 Of all study participants, 22% were high school students, 35.7% were attending university, 10.8% were in military service and 57.8% were employed, while 35.1% were both students (at high school or university) and concomitantly employed.
Using the Internet to seek sexual partners Of all YGBM in this study, 201 (45.2%) reported that they used the Internet to seek sexual partners. Those who seek sexual partners on the Internet were more likely to be young adults, single, used substances, reported having more sexual partners in the previous 6 months, had a stronger support of friends and were more connected to the LGB community compared with those who did not search for sexual partners online (Table 1). Almost all participants who used the Internet to seek sexual partners (97.0%) reported that the Internet was the most common venue in which they finally met their sexual encounters. No significant differences were found between those who used the Internet to seek sexual partners and those who did not in terms of other venues in which they met their sexual partners. Meeting sexual partners through friends (45.9%) and in a bar/club (43.1%) were the most common venues reported by participants who did not use the Internet for sex-seeking. In addition, no significant differences were found between the two groups in terms of gay identity formation (self-acceptance, level of outness), mental health (wellbeing, mental distress) or family support. In multivariate regression analysis aimed at identifying variables predicting online sex seeking, it was found that being a young adult, single, having higher numbers of sexual partners, reporting higher levels of outness and higher levels of support from friends and a stronger connectedness to the LGB community predicted seeking sex online (Table 2). Risk behaviours and seeking sex online To further characterise behavioural variables related to seeking sex online, we compared the substance-use and sexual risk
Table 1. Characteristics of gay and bisexual males seeking sexual partners online v. those who do not (n = 445) *P < 0.01; **P < 0.001. LGB, lesbian, gay and bisexual. Results are presented as mean number of variables Variable
Adolescent ( 18 years) In a steady relationship Substance use Usually meeting sexual partners in: Bar/club Through friends Public places/gardens Internet Sauna No. of sexual partners in the previous 6 months Well-being Mental distress Self-acceptance Level of outness Family support Friends’ support Connectedness to the LGB community
Seeks sexual partners online 45.2% (n = 201) % (N)
Does not seek sexual partners online 54.8% (n = 244) % (N)
c2
21.4 (43) 18.9 (38) 67.2 (133)
33.2 (81) 43.9 (107) 53.8 (129)
7.64* 31.2** 8.13**
34.3 37.3 2.9 97 5.5
43.1 45.9 2.5 6.1 2.3
(69) (75) (6) (195) (11)
Mean (s.d.) 8.12 (10.9) 45.93 66.11 1.58 3.46 3.94 4.30 2.73
(13.39) (21.85) (0.61) (1.10) (0.78) (0.48) (0.77)
219
(105) (112) (6) (15) (6)
Mean (s.d.) 2.12 (1.98) 45.73 64.25 1.56 3.29 3.94 4.15 2.52
(12.53) (21.73) (0.54) (1.15) (0.73) (0.58) (0.84)
3.51 3.34 0.12 365.15** 2.72 Student’s t-test 7.24** 0.17 0.89 0.32 1.54 0.09 2.94* 2.84*
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behaviour patterns of participants who reported using the Internet for sex seeking with those who did not. To avoid the bias of participants who had a steady boyfriend with whom they had exclusive sex and where both had been tested for HIV, we excluded these participants (n=42) from the analyses of sexual risk behaviours. As shown in Table 3, participants who engaged in seeking sex online used more marijuana, stimulants and nitrite inhalants (e.g. ‘poppers’) compared with participants who did not use the Internet to seek sexual partners. In addition, online sex-seekers reportedly engaged in risky sexual behaviours, including UAI, using the drugs and alcohol shortly before or during sexual intercourse, compared with participants who did not engage in seeking sex online. Multivariate analyses predicting sexual risk behaviour To determine the independent variables predicting sexual risk behaviour, we performed a sequential logistic regression, in which age group and being in a steady relationship were entered in the first step as a priori control variables. In the Table 2. Multivariate analysis predicting Internet use for seeking sex (n = 445) CI, confidence interval for adjusted odds ratio (OR); B, undstandardised beta coefficient; SE, standard error. *P< 0.01; **P< 0.001. Results are presented as mean numbers of variables Variable Young adults (19–30 years) No steady boyfriend Substance use Sexual partners in previous 6 months Well-being Mental distress Self-acceptance Level of outness Family support Friends’ support Connectedness to the LGB community
B
SE
OR
95% CI
0.93* 1.79** 0.34
0.42 0.31 0.33
2.56 5.88 1.40
1.23–3.58 2.35–6.26 0.74–2.66
0.33** –0.01 0.01 0.02 0.39* –0.12 0.70*
0.33 0.02 0.01 0.33 0.18 0.21 0.32
1.39 0.99 1.01 1.02 1.47 0.88 2.01
1.23–1.57 0.97–1.03 0.99–1.03 0.53–1.95 1.42–1.97 0.58–1.34 1.07–3.79
0.19*
0.19
1.21
1.15–1.76
second step, the number of sexual partners, substance use, and the variables of mental health, gay identity formation, social support and connection to the LGB community were entered and finally, seeking sex online was added in the final step (Table 4). Being an adolescent and having a steady boyfriend were both found to have a negative association with sexual risk behaviour. After controlling for these variables, lower levels of wellbeing, higher levels of outness, greater friends’ support, and stronger connectedness to LGB community were predictors significantly influencing risky sexual behaviour. In addition, substance use was also a predictor of sexual risk behaviour; participants who used high levels of substances were 4.41-fold more likely to engage in sexual risk behaviour, compared with those with a lower incidence of substance use. Finally, online sex seeking predicted risky sexual behaviour, even after controlling for demographic factors, social variables, mental health and substance use. Discussion This is the first study to focus on Jewish YGBM in Israel who engage in seeking sex online and one of the only studies to include participants as young as 12 years old.29 In this study, approximately half of all YGBM used the Internet to search for sex; a finding consistent with previous studies in Western countries, and one that underlines the increasing prevalence of online sex in this population.2,3 Indeed, this study demonstrated that most (97%) of the participants who seek sex online met their sexual partners via Internet seeking, while meeting sexual partners in bar/clubs or through friends were the most common ways reported by participants who did not use the Internet for sex-seeking. In addition, seeking sex online was correlated with other risk behaviours; YGBM who seek sex online used substances more commonly and reported UAI, compared with those who do not search for sex online. This is in line with previous studies,4,30 indicating the associated risk factors involved in seeking sex online. Although causality between Internet use and sexual risk behaviours may be difficult to ascertain given the crosssectional nature of this study, it does show that seeking sex online attracts YGBM who engage in other risky behaviours. We cannot rule out the possibility that a third
Table 3. Substance use and sexual risk behaviours among gay and bisexual males seeking sexual partners via the Internet v. those not seeking sexual partners via the Internet Note: numbers reflect the participants reporting use of the relevant substance or conducting the relevant behaviour. *P < 0.01; **P < 0.001
Substance use Alcohol Marijuana Club drugs Stimulants Inhaled nitrites Sexual risk behaviour Anal intercourse without condom Drug use before/during intercourse Alcohol use before/during intercourse
Using the Internet to seek sexual partners 45.2% (n = 201) n % 104 57 10 23 30
51.7 28.4 5.0 11.4 14.9
49.9% (n = 201) 62 30.8 35 17.4 89 44.2
Not using the Internet to seek sexual partners 54.8% (n = 244) n % 109 44 6 10 17
c2
44.7 18.0 2.5 4.1 7.0
2.21 6.7* 2.01 8.66** 7.39**
50.1% (n = 202) 35 17.3 7 3.5 50 24.8
10.08** 20.99** 17.00**
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Table 4. Hierarchical logistic regression predicting sexual risk behaviour (n = 445) Note: CI, confidence interval for adjusted odds ratio (OR); B, unstandardised beta coefficient; SE, standard error. *P < 0.01; **P < 0.001. Results are presented as mean number of variables Variable Step 1 Young adults (19–30) Single Step 2 Sexual partners in previous 6 months Wellbeing Mental distress Self-acceptance Level of outness Family support Friends’ support Connectedness to the LGB community Substance use Step 3 Seeking sexual partners online
B
SE
OR
95% CI
0.24* 1.09**
0.27 0.24
1.51 2.94
1.23–1.56 1.89–2.35
0.03 –0.05** 0.17 0.01 0.30* 0.16 0.69* 0.45* 1.48**
0.02 0.02 0.01 0.29 0.16 0.19 0.30 0.17 0.29
1.03 0.95 1.02 0.99 1.35 1.17 2.00 1.54 4.41
0.99–1.06 0.92–0.98 0.99–1.04 0.56–1.79 1.13–1.84 0.79–1.71 1.11–3.59 1.36–1.59 2.47–7.87
1.19**
0.27
3.30
1.96–5.56
c2 24.53**
107.41**
factor associates Internet use to seek sex and risk behaviours, like a sensation-seeking personality. It should be noted that in terms of behaviour variables, no differences were found between participants who used the Internet for sex-seeking and those who did not in the frequency of meeting sexual partners in other venues. Yet, with the convenience of Internet sex-seeking and high frequency of this sex-seeking tool, even those who do not engage in such risk behaviours are exposed, during their online sex seeking, to sexual encounters that puts them at risk for sexually transmissible infections, including HIV. Previous research explained seeking sex online among YGBM in terms of the characteristics of same-sex identity formation and social stressors that put YGBM in the vulnerable mental situation of concealing their sexual identity and looking for anonymous places to meet other MSM.31 However, the findings of the present study offer a different explanation; namely, that YGBM who engage in seeking sex online are no different from those who do not, in terms of mental health and personal acceptance of their sexual identity, while, in contrast, they do report higher levels of outness, friends’ support and connectedness to the LGBT community. These findings suggest that seeking sex online behaviour might be influenced by other reasons rather than by societal stressors related to sexual orientation identity formation. In addition, although lower levels of mental health were found to predict risky sexual behaviour among YGBM, which is in keeping with the social stress hypothesis,7 high levels of outness, connectedness to the LGB community and friends’ support were associated with increased incidence of sexual risk behaviour. Qualitative research conducted among gay men suggested that using the Internet for sex-seeking allows participants to express their desires, manage their identity, facilitates HIV status disclosure and allows sexual exploration.30 In addition, with the convenience of using the Internet for sex-seeking, the popularity of geo-social networks (e.g. Grindr) among GBM33 and the motivation of facilitating social connections through the Internet, may explain the findings that high levels of outness, friends’
134.50**
support and connectedness to the LGBT community were predictors of Internet sex-seeking. It should be noted that our findings demonstrated that seeking sex online was strongly associated with risky sexual behaviour, even after discounting personal variables, social characteristics and mental health status. This suggests that although there are potential positive social aspects of electronic networks between YGBM, the Internet also exposes participants to risky sexual behaviours. Young GBM are an under-studied population at risk for HIV. This study shows that adolescents (aged below 18 years) were less likely to use the Internet for sex-seeking, while being a young adult (18–30 years) was correlated with increased risky sexually behaviour. It is probable that young adults enjoy better access to gay community venues, and are thus exposed more to the gay lifestyle and are able to adopt risky sexual behaviour and other risk behaviours.9 Although young adults in the survey were found to engage in seeking sex online more often than their adolescent counterparts, it should be noted that one-fifth of the adolescent respondents reported this practice. Although the legal age restriction of 18 years is required to register and use sex-seeking websites in Israel, our findings suggest that adolescents can find a way to get around legal restrictions and parental control. The increased incidence of HIV infection among YGBM, both in Western countries and in Israel,13,17 coupled with the average age of 16 years for ‘coming out’ to friends and families, makes the fact that online sex seeking, practised by GBM as young as 12 years old, a risky behaviour and a target for intervention at younger ages. Being in a steady same-sex relationship was found to be a protective factor for both seeking sex online and sexual risk behaviour.16 Our study shows that YGBM in steady relationships tend not to engage in seeking sex online, which is not surprising, but it does run counter to the common assumption30 or prejudice that GBM are constantly looking for sexual relations irrespective of their personal relationship status.32 These findings underline the importance of social support and legalisation for same-sex relationships as a
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protective factor for sexually transmissible infections, including HIV.34 The present study had several limitations. First, it was based on a convenience sample, which may not be representative of all YGBM in Israel. However, this is an acceptable method in sensitive data collection, especially among youth.19 Second, the cross-sectional design limits the conclusions that may be drawn regarding causality. Nonetheless, studies of adult MSM have also found that MSM who meet their partners online are at high sexual risk. Third, all the findings are based on self-reporting, which is susceptible to reporting bias, especially concerning sensitive and intimate aspects such as sexual practices and substance use. To minimise this bias, in light of other studies that showed that Internet-based samples among MSM reduce reporting bias and increase validity,19 participants were asked to complete the data anonymously and only with regard to the previous 6 months. Conclusion Young GBM who used the Internet to seek sex were more likely to report sexual risk behaviour and substances use than those who found their sexual partners via other venues. It may be that online sex-seekers are influenced by the gay sub-culture lifestyle and peer group relationships, rather than by social stressor variables related to sexual orientation formation processes, such as concealment of sexual orientation and self-acceptance or mental health condition. With the increasing adoption of new technologies by YGBM, electronic networks can be used as a valuable tool to convey safe-sex messages and to perform online studies. Conflicts of interest The authors are not aware of any conflict of interest, real or perceived, with regard to this article. Acknowledgements The authors would like to thank Uri Shefer, Oren Pizmoni-Levy, Nadav Antebi, Yaron Gal and Ori Kapara for their assistance in forming the study concept and in developing the questionnaire. This study was partially supported by the Israeli Gay Youth Organisation.
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