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Frequency, Reasons for, and Perceptions of Lubricant Use among a Nationally Representative Sample of Self-Identified Gay and Bisexual Men in the United States Brian Dodge, PhD,* Vanessa Schick, PhD,† Debby Herbenick, PhD, MPH,* Michael Reece, PhD, MPH,* Stephanie A. Sanders, PhD,‡§ and J. Dennis Fortenberry, MD, MS¶ *Center for Sexual Health Promotion, Indiana University, Bloomington, IN, USA; †Division of Management, Policy and Community Health, University of Texas Health Science Center, Houston, TX, USA; ‡The Kinsey Institute for Research in Sex, Gender, and Reproduction, Indiana University, Bloomington, IN, USA; §Gender Studies, Indiana University, Bloomington, IN, USA; ¶Section of Adolescent Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA DOI: 10.1111/jsm.12640
ABSTRACT
Introduction. Few previous studies have examined lubricant use among gay and bisexual men outside the context of human immunodeficiency virus risk reduction associated with condom use during penile–anal intercourse and the potential use of lubricants to deliver rectal microbicides. The vast majority of studies examining lubricant use among gay and bisexual men have employed convenience sampling strategies for participant recruitment. Additionally, most studies have collapsed gay men and bisexual men into one category of “gay and bisexual men.” Aims. This study aimed to provide overall rates of lubricant use and related factors among a nationally representative sample of self-identified gay and bisexual men. Frequencies of lubricant use, reasons for using lubricant, and perceptions of lubricant use were examined separately for subsamples of both gay and bisexual men. Methods. Data were from the 2012 National Survey of Sexual Health and Behavior, which involved the administration of an online questionnaire to a nationally representative probability sample of women and men in the United States aged 18 and older, and we oversampled self-identified gay and bisexual men and women; the results from male participants are included in this article. Main Outcome Measures. Measure included demographic characteristics, recent and lifetime commercial lubricant use, lubricant use during specific sexual behaviors, frequency of lubricant use, and reasons for lubricant use during sexual activity. Results. Over 90% of both gay and bisexual male participants reported lifetime lubricant use. Use was most common during partnered sexual activities, particularly among men aged 25–29 years old. The most commonly reported reasons for lubricant use included to increase comfort during anal intercourse, curiosity, and to make sex more comfortable. Conclusions. Most gay and bisexual men in the United States have used lubricant to enhance a wide range of sexual activities, including but not limited to anal intercourse. Findings from this study will be of utility to clinicians and other health practitioners who seek to understand and promote sexual health among gay and bisexual men and other traditionally underserved public health populations. Dodge B, Schick V, Herbenick D, Reece M, Sanders SA, and Fortenberry JD. Frequency, reasons for, and perceptions of lubricant use among a nationally representative sample of self-identified gay and bisexual men in the United States. J Sex Med 2014;11:2396–2405. Key Words. Lubricant; Gay and Bisexual Men; Sexual Pleasure; Nationally Representative Sample
J Sex Med 2014;11:2396–2405
© 2014 International Society for Sexual Medicine
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Gay and Bisexual Men’s Lubricant Use Introduction
A
lthough an issue of public health significance, relatively little research has examined gay and bisexual men’s lubricant use during a range of partnered sexual activities. Interestingly, while previous research on lubricant use among heterosexual (male–female) sexual partners has acknowledged and explored relations between lubricant use and sexual pleasure and sexual enhancement [1–11], the small body of existing research on lubricant use among men with male sexual partners has focused almost exclusively on lubricant use in relation to sexual risk [1–6]. This is particularly the case in terms of the well-established sexual risk-reduction benefits of using appropriate lubricants, in addition to condoms, as a strategy to decrease human immunodeficiency virus (HIV) transmission during penile–anal intercourse [1–3]. Another line of research has explored the potential for lubricants to serve as a proxy for delivering rectal microbicide liquids or gels for HIV prevention purposes (pending the development of an effective preventative rectal microbicide) [4–6]. However, for the most part, researchers have not yet examined gay and bisexual men’s reasons for using, as well as perceptions of sexual experiences with, lubricants for a range of sexual interactions [8]. In addition to the relatively narrow focus on lubricant use as a risk-reduction strategy during penile–anal intercourse, the vast majority of sexual health research on gay and bisexual men, in general, has been based on non-probability convenience samples. While barriers associated with feasibility and cost have undoubtedly prohibited most researchers from obtaining probability samples of nonheterosexual men, recent technological innovations have facilitated the possibility of collecting data from samples of self-identified gay and bisexual men in the United States that are probabilistic and reflective of a national level population. Sampling is not an insignificant issue when it comes to the study of sexual minority individuals (including behaviorally homosexual and bisexual individuals, regardless of sexual self-identity or gender identity). Meyer and Wilson [12] concur: “(s)ampling has been the single most influential component of conducting research with lesbian, gay, and bisexual (LGB) populations. Poor sampling designs can result in biased results that will mislead other researchers, policymakers, and practitioners. Investigators wishing to study LGB populations must therefore devote significant energy and resources to choosing a sampling
approach and executing the sampling plan.” A large amount of previous research is based on convenience samples of “gay, lesbian, and bisexual” (GLB) individuals recruited from a narrow range of gay-identified venues, including gay bars, gay pride parades, gay community centers, sexual cruising areas, and other spaces that are reflective only of a larger group of individuals who are relatively connected to a larger “gay community” and, thus, likely to be present in these areas. Public health researchers and practitioners have cautioned that generalizing to all nonheterosexual individuals from previous samples of primarily white, well-educated, upper middle-class, selfidentified lesbians and gay men is dangerous as results may be simplistic, misleading, and not representative of the diversity of the general population. Collapsing bisexual and homosexual individuals under the common auspice of GLB has also proven to be problematic in previous research as bisexual individuals are unlikely to be captured in traditional “gay-identified” venues and may face stigma from both heterosexual and homosexual counterparts [13,14]. Aims
To fill existing gaps in both topic and sampling, this study aims to provide rates of lubricant use, as well as to explore factors related to lubricant use, among a probability sample of self-identified gay and bisexual men who participated in the 2012 National Survey of Sexual Health and Behavior (2012 NSSHB). Because of the well-documented limitations of previous studies that collapsed gay and bisexual men together into a single category, we also explore issues related to lubricant use separately for gay and bisexual men. Methods
This article presents data from the 2012 NSSHB, a population-based cross-sectional survey of adults in the United States. Data were collected during October to November 2012, via the KnowledgePanel of GfK Custom Research (GfK) (Menlo Park, CA, USA). Research panels accessed through GfK’s KnowledgePanel are based on a national probability sample established using both random digit dialing and an address-based sampling (ABS) frame [10,15–20]. ABS involves the probability sampling of a frame of residential addresses in the United States derived from the U.S. Postal Service’s Delivery Sequence File, a J Sex Med 2014;11:2396–2405
2398 system which contains detailed information on every mail deliverable address in the United States. Collectively, the sampling frame from which participants are recruited covers approximately 98% of all U.S. households. Randomly selected addresses are recruited to the research panel through a series of mailings and subsequently by telephone follow-ups to nonresponders when possible. To further correct sources of sampling and non-sampling error, study samples are corrected with a post-stratification adjustment using demographic distributions from the most recent data available from the Current Population Survey, the monthly population survey conducted by the U.S. Bureau of the Census considered to be the standard for measuring demographic and other trends in the United States. These adjustments result in a panel base weight that was employed in a probability proportional to size selection method for establishing the samples for this study. Once the sample frame was established, all individuals within that frame received a recruitment message from GfK that provided a brief description of the NSSHB and invited them to participate. In addition to a sample of 6,175 selfidentified heterosexual individuals, a total of 1,456 individuals who self-identified as GLB were oversampled from the GfK panels and invited to participate in the survey. Of these, 738 individuals provided informed consent and 96.5% (n = 712) of these participants completed the survey. This included 332 self-identified gay/homosexual men and 101 self-identified bisexual men. The survey was administered in either English or Spanish. All data were collected by GfK via the Internet. There were no incentives for participation in this study that will be provided by the researchers. Given that all individuals were part of an existing panel at Knowledge Networks, they were already receiving an established level of incentives. For some individuals, this includes that they are provided with free Internet access and hardware so that they can participate in such studies. Additionally, Knowledge Networks pays a small monthly incentive to their panel members to retain them; however, these incentives are not directly affiliated with this study. As the study was conducted via the Internet, participants provided consent by clicking a link and then proceeding to the survey. We utilized a routine informed consent statement in the study. All research protocols were approved by the Institutional Review Board of Indiana University— Bloomington. J Sex Med 2014;11:2396–2405
Dodge et al. Main Outcome Measures
Lubricant Use Participants were asked to provide details about the extent to which they had used a lubricant across varying points in their lifetime. Response options included that participants had used a lubricant within the 30 days prior to participating in the study, 90 days prior to the study, within the past 12 months, more than 1 year ago, or never. Participants were provided with a definition of lubricant that included: “any personal lubricant or vaginal moisturizer that you can purchase in a store marketed to enhance the sexual experience and/or increase lubrication.” Lubricant Use During Specific Sexual Behaviors and Other Product Use Participants were also asked (using the same response categories as above) to describe whether they had used a lubricant during specific sexual behaviors, including: while masturbating alone, during sexual play or foreplay with a partner, and during intercourse (vaginal and/or anal; if anal, insertive and/or receptive). Participants were also asked to respond similarly as to whether they had used a lubricant in conjunction with a condom, a vibrator, or a dildo. Reasons for Lubricant Use Men were asked to provide the main reasons for their initial use of a lubricant, with 18 response options including: “to make sex feel more wet” to “because my partner wanted to” and “to spice up my/our sex life,” among others. Perceptions of Lubricant Use Participants were asked to respond to the extent to which they agreed or disagreed with items related to their perceptions of the use of lubricant during sexual activities. These items ranged from those such as “lubricant use is embarrassing” to “lubricant makes sex feel better” to “lubricant is only for older people.” Response options included a fourpoint response scale ranging from strongly disagree to strongly agree. Data Analysis Prior to data analysis, post-stratification data weights based upon U.S. Census data were applied in order to reduce variance and minimize bias due to non-sampling error. This was part of a larger study on the sexual behavior of men and women in the United States. Therefore, the sample was con-
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Gay and Bisexual Men’s Lubricant Use Table 1 Participant sociodemographic distribution by lifetime lubricant use history using post-stratification weights (N = 433) Bisexual
Gay/homosexual No lubricant use
Characteristics Age 18–24 (Ref) 25–29 30–39 40–49 50–59 60+ Education Less than high school (Ref) High school or GED Some college or associates degree College degree or higher Race/ethnicity White, non-Hispanic (Ref) Black, non-Hispanic Other, non-Hispanic Hispanic More than two races, non-Hispanic Relationship status Single and not dating (Ref) Single and dating In a relationship but not living together Living with relationship partner Married and living together Married but not living together
% (n)
%
10.3 (11) 5.9 (7) 26.7 (29) 26.5 (29) 21.2 (23) 9.4 (10)
18.2 0.0 0.0 3.4 16.7 10.0
1.9 (2) 19.7 (22) 36.6 (40) 41.8 (46)
Lubricant use
No lubricant use
Lubricant use
% (n)
%
81.8 100.0 100.0 96.6 83.3 90.0
8.2 (29) 12.3 (43) 18.1 (63) 30.0 (105) 24.4 (85) 7.0 (25)
3.4 0.0 1.6 1.0 3.6 4.2
96.6 100.0 98.4 99.0 96.4 95.8
33.3 18.2 2.5 4.3
66.7 81.8 97.5 95.7
2.2 (8) 13.9 (49) 33.7 (117) 50.2 (175)
0.0 2.0 3.5 1.1
100.0 98.0 96.5 98.9
61.8 (68) 1.8 (2) 8.1 (9) 25.2 (28) 3.1 (3)
8.8 0.0 0.0 3.7 0.0
91.2 100.0 100.0 96.3 100.0
65.6 (229) 4.8 (17) 7.2 (25) 18.9 (66) 3.5 (12)
2.2 5.9 0.0 0.0 8.3
97.8 94.1 100.0 100.0 91.7
40.8 (45) 10.3 (11) 2.6 (3) 15.1 (17) 29.3 (32) 1.7 (2)
11.1 8.3 0.0 0.0 6.1 0.0
88.9 91.7 100.0 100.0 93.9 100.0
34.6 (121) 14.4 (50) 13.8 (48) 31.7 (111) 5.5 (19)
4.2 2.0 0.0 0.0 0.0
95.8 98.0 100.0 100.0 100.0
None of the sociodemographic characteristics were significant predictors of lubricant use at last event GED = General Educational Development
strained to only men who self-identified as gay/ homosexual or bisexual for the purpose of this article. Frequencies are used to present data on lubricant use rates, perceptions, and reasons for use. The relationship between lubricant use and sociodemographic characteristics was explored using a series of logistic regressions. Results
Demographic Characteristics Approximately three-quarters of the gay- and bisexual-identified men in the sample reported an age between 29 and 60 (Table 1). Similarly, close to 75% of both gay and bisexual men reported some college education. While most participants reported that they were white/non-Hispanic, a sizable minority of both gay and bisexual participants identified as Hispanic. Again, both bisexual and gay/homosexual men were similar in their relationship status with the highest percentage of participants reporting that they were “single and not dating” or “married and living together.” There were no significant differences between demographic characteristics and lubricant use
history for either gay/homosexual or bisexual men.
Lubricant Use History Table 2 provides an overview of lifetime and recent lubricant use. The vast majority (over 90%) of both gay/homosexual and bisexual participants reported using a lubricant at least once. The percentage of participants reporting lubricant use was also fairly consistent across age groups. When asked about lubricant use in various sexual contexts, the majority of participants indicated that they had used lubricant in the contexts provided in the survey. The most common time of use for both gay and bisexual participants was during partnered intercourse (bisexual = 83.7%, n = 92, gay/homosexual = 93.5%, n = 325) and the least was for use with a vibrator (bisexual = 54.8%, n = 57, gay/homosexual = 42.3%, n = 147). Overall, regardless of context, use was most commonly reported by participants aged 25–49 years old. Lubricant Use Frequency Participants who reported using a lubricant during sexual activity within the previous 90 days were J Sex Med 2014;11:2396–2405
Ever used Past 30 days Past 90 days Past 12 months (year) More than a year ago Used a lubricant Ever used during solo Past 30 days Past 90 days masturbation Past 12 months (year) More than a year ago Used a lubricant Ever used during partnered Past 30 days sexual play Past 90 days Past 12 months (year) More than a year ago Used a lubricant Ever used during partnered Past 30 days intercourse Past 90 days Past 12 months (year) More than a year ago Used a lubricant with Ever used a condom Past 30 days Past 90 days Past 12 months (year) More than a year ago Used a lubricant with Ever used a vibrator Past 30 days Past 90 days Past 12 months (year) More than a year ago Used a lubricant with Ever used a dildo Past 30 days Past 90 days Past 12 months (year) More than a year ago
Used a lubricant
92.9 (102) 37.6 (41) 7.4 (8) 9.5 (10) 38.4 (42) 71.4 (79) 34.1 (38) 4.3 (5) 6.6 (7) 26.4 (29) 81.2 (89) 14.8 (16) 6.6 (7) 9.1 (10) 50.7 (56) 83.7 (92) 17.1 (19) 3.7 (4) 15.2 (17) 47.8 (53) 73.2 (81) 14.0 (15) 2.8 (3) 8.9 (10) 47.5 (52) 54.8 (57) 5.7 (6) 4.9 (5) 6.4 (7) 37.8 (39) 67.0 (73) 12.9 (14) 12.3 (13) 4.9 (5) 36.9 (40)
Total sample % (n) 25–29
30–39
40–49
82.3 (9) 100.0 (7) 98.7 (29) 97.0 (28) 44.9 (5) 32.3 (2) 29.8 (9) 53.3 (16) 10.6 (1) 62.2 (4) 2.5 (1) 0.0 (0) 0.0 (0) 0.0 (0) 3.6 (1) 21.8 (6) 26.9 (3) 5.4 (1) 62.8 (18) 21.9 (6) 55.4 (6) 86.9 (6) 68.1 (20) 74.8 (22) 44.9 (5) 5.8 (0) 26.7 (8) 54.3 (16) 10.6 (1) 20.1 (1) 0.0 (0) 5.7 (2) 0.0 (0) 0.0 (0) 9.3 (3) 10.9 (3) 0.0 (0) 61.0 (4) 32.1 (9) 4.0 (1) 39.9 (5) 94.6 (6) 89.5 (26) 82.2 (24) 1.0 (0) 21.4 (1) 6.3 (2) 31.7 (9) 12.0 (1) 12.2 (1) 1.8 (1) 8.5 (2) 0.0 (0) 61.0 (4) 0.8 (0) 8.6 (3) 26.9 (3) 0.0 (0) 80.6 (24) 33.4 (10) 38.5 (4) 100.0 (7) 82.7 (24) 97.0 (28) 2.5 (0) 25.0 (2) 8.1 (2) 33.7 (10) 0.0 (0) 8.5 (1) 0.0 (0) 5.4 (2) 9.1 (1) 61.0 (4) 6.8 (2) 24.1 (7) 26.9 (3) 5.4 (0) 67.8 (20) 33.8 (10) 52.9 (6) 92.5 (6) 73.4 (22) 92.5 (27) 15.9 (2) 22.9 (2) 3.2 (1) 27.4 (8) 0.0 (0) 14.0 (1) 0.0 (0) 4.1 (1) 9.1 (1) 53.7 (4) 10.0 (3) 4.4 (1) 27.9 (3) 1.8 (1) 60.2 (18) 56.6 (16) 27.9 (3) 33.8 (2) 69.4 (20) 78.9 (18) 0.0 (0) 0.0 (0) 3.5 (1) 20.4 (5) 0.0 (0) 26.5 (2) 4.6 (1) 3.4 (1) 0.0 (0) 0.0 (0) 0.0 (0) 14.1 (3) 27.9 (3) 7.3 (0) 61.3 (18) 41.1 (9) 57.7 (7) 36.5 (2) 81.1 (24) 89.8 (26) 0.0 (0) 11.0 (1) 3.2 (1) 40.1 (12) 13.9 (2) 20.1 (1) 8.2 (2) 24.8 (7) 15.9 (2) 0.0 (0) 0.0 (0) 7.9 (2) 27.9 (3) 5.4 (1) 69.8 (21) 17.0 (5)
% (n)
18–24
Bisexual
84.8 (20) 28.9 (7) 1.1 (0) 8.3 (2) 46.5 (11) 71.7 (17) 24.5 (6) 2.6 (1) 3.9 (1) 40.8 (10) 84.1 (20) 9.2 (2) 6.9 (2) 5.9 (1) 62.2 (15) 81.8 (19) 12.1 (3) 6.9 (2) 2.6 (1) 60.2 (14) 63.2 (14) 10.4 (2) 2.8 (1) 1.9 (0) 48.1 (11) 43.9 (10) 1.0 (0) 3.0 (1) 8.7 (2) 31.3 (7) 39.6 (9) 2.9 (1) 4.1 (1) 2.7 (1) 30.0 (7)
50–59
Weighted lifetime and recency of lubricant use during various sexual contexts
Recency of lubricant use
Table 2
90.7 (9) 30.6 (3) 17.8 (2) 11.2 (1) 31.1 (3) 78.1 (8) 26.2 (3) 0.0 (0) 4.4 (0) 47.6 (5) 85.0 (9) 15.2 (2) 4.6 (0) 18.0 (2) 47.2 (5) 92.8 (10) 18.1 (2) 3.4 (0) 19.5 (2) 51.7 (5) 51.4 (5) 7.3 (1) 3.0 (0) 5.7 (1) 35.4 (4) 28.9 (3) 0.9 (0) 5.4 (1) 13.5 (1) 9.2 (1) 53.2 (5) 0.9 (0) 0.0 (0) 6.1 (1) 46.1 (4)
60+
97.9 (338) 57.1 (197) 10.7 (37) 13.1 (45) 17.1 (59) 82.3 (286) 41.7 (145) 10.5 (37) 13.7 (48) 16.3 (57) 87.7 (304) 34.5 (120) 11.0 (38) 14.2 (49) 28.0 (97) 93.5 (325) 44.7 (155) 9.9 (34) 14.6 (51) 24.3 (85) 86.4 (299) 20.0 (69) 10.7 (37) 16.2 (56) 39.4 (136) 42.3 (147) 10.2 (35) 6.4 (22) 5.5 (19) 20.2 (70) 65.7 (225) 10.9 (37) 12.5 (43) 14.9 (51) 27.5 (94)
% (n)
Total sample
97.5 (28) 30.7 (9) 10.8 (3) 50.2 (14) 5.8 (2) 60.5 (17) 18.0 (5) 13.5 (4) 14.3 (4) 14.6 (4) 65.9 (19) 20.8 (6) 11.6 (3) 27.1 (8) 6.4 (2) 74.4 (21) 30.2 (9) 14.3 (4) 24.3 (7) 5.7 (2) 86.3 (25) 20.0 (6) 11.4 (3) 46.3 (13) 8.7 (2) 14.5 (4) 0.7 (1) 3.5 (1) 9.5 (3) 0.7 (1) 38.5 (11) 8.1 (2) 0.0 (0) 23.8 (7) 6.6 (2)
% (n)
18–24
99.3 (42) 83.4 (36) 2.9 (1) 3.6 (2) 9.4 (4) 90.0 (39) 56.6 (24) 4.2 (2) 24.0 (10) 5.3 (2) 92.7 (40) 47.1 (20) 11.6 (5) 17.9 (8) 16.2 (7) 99.3 (42) 45.2 (19) 18.4 (8) 20.7 (9) 15.0 (6) 98.9 (42) 15.0 (6) 28.4 (12) 19.9 (9) 35.6 (15) 39.3 (17) 2.1 (1) 14.8 (6) 2.0 (1) 20.4 (9) 68.0 (28) 2.0 (1) 46.8 (19) 15.6 (6) 3.6 (1)
25–29
Gay/homosexual
99.1 (62) 78.3 (49) 0.9 (1) 7.5 (5) 12.5 (8) 93.0 (59) 51.1 (32) 19.2 (12) 16.6 (10) 6.0 (4) 97.5 (61) 43.2 (27) 15.3 (10) 17.0 (11) 22.0 (14) 99.1 (62) 57.5 (36) 11.6 (7) 16.1 (10) 13.9 (9) 91.9 (56) 23.8 (14) 6.3 (4) 21.9 (13) 39.9 (24) 69.2 (44) 31.9 (20) 5.7 (4) 8.6 (5) 23.0 (14) 82.0 (50) 12.5 (8) 9.5 (6) 31.4 (19) 28.6 (17)
30–39
98.6 (102) 51.2 (53) 16.3 (17) 10.6 (11) 20.5 (21) 82.1 (86) 44.7 (47) 12.8 (13) 8.0 (8) 16.5 (17) 89.9 (93) 41.6 (43) 9.4 (10) 8.1 (8) 30.9 (32) 96.4 (101) 51.5 (54) 5.4 (6) 12.1 (13) 27.5 (29) 89.1 (93) 24.8 (26) 6.8 (7) 11.6 (12) 45.9 (48) 41.2 (43) 6.5 (7) 6.5 (7) 4.4 (5) 23.8 (25) 61.6 (64) 12.8 (13) 9.7 (10) 5.7 (6) 33.4 (35)
40–49
96.2 (80) 46.9 (39) 16.2 (13) 13.8 (11) 19.4 (16) 80.7 (68) 33.4 (28) 4.7 (4) 14.2 (12) 28.4 (24) 84.3 (71) 19.1 (16) 11.1 (9) 13.1 (11) 41.0 (35) 89.3 (76) 32.8 (28) 9.7 (8) 12.8 (11) 34.1 (29) 74.1 (63) 12.5 (11) 11.6 (10) 9.7 (8) 40.2 (34) 38.0 (32) 6.2 (5) 3.9 (3) 5.9 (5) 22.0 (19) 69.8 (59) 7.3 (6) 8.0 (7) 14.3 (12) 40.2 (34)
50–59
95.5 (23) 46.9 (11) 6.8 (2) 8.6 (2) 33.2 (8) 73.5 (18) 35.6 (9) 6.2 (2) 10.6 (3) 21.1 (5) 81.8 (20) 30.3 (7) 4.5 (1) 15.0 (4) 32.1 (8) 93.3 (22) 39.8 (10) 5.1 (1) 5.9 (1) 42.5 (10) 82.2 (20) 25.1 (6) 3.7 (1) 3.0 (1) 50.4 (12) 29.9 (7) 8.8 (2) 4.6 (1) 2.9 (1) 13.6 (3) 57.2 (14) 28.5 (7) 4.6 (1) 3.6 (1) 20.5 (5)
60+
2400 Dodge et al.
J Sex Med 2014;11:2396–2405
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Gay and Bisexual Men’s Lubricant Use Table 3 Weighted frequency of lubricant used for participants who reported lubricant use in the following contexts within the past 90 days
Recency of lubricant use Used a lubricant
Used a lubricant during solo masturbation Used a lubricant during partnered sexual play Used a lubricant during partnered intercourse Used a lubricant with a condom
Used a lubricant with a vibrator
Used a lubricant with a dildo
Once or twice 3–5 times 6–10 times More than 10 times Once or twice 3–5 times 6–10 times More than 10 times Once or twice 3–5 times 6–10 times More than 10 times Once or twice 3–5 times 6–10 times More than 10 times Once or twice 3–5 times 6–10 times More than 10 times Once or twice 3–5 times 6–10 times More than 10 times Once or twice 3–5 times 6–10 times More than 10 times
Bisexual % (n)
Gay/ homosexual % (n)
20.13 (10) 27.11 (13) 8.37 (4) 44.39 (21) 12.21 (5) 21.56 (9) 8.27 (3) 57.96 (24) 23.78 (5) 10.63 (2) 10.80 (2) 54.80 (12) 18.57 (4) 11.74 (3) 16.59 (4) 53.10 (12) 20.72 (4) 24.54 (5) 5.35 (1) 49.40 (9) 38.95 (4) 31.69 (3) 15.00 (2) 14.36 (1) 39.81 (8) 34.05 (7) 22.59 (5) 3.56 (1)
18.97 (43) 13.23 (30) 12.58 (29) 55.22 (126) 26.61 (47) 12.45 (22) 14.62 (26) 46.33 (82) 20.56 (31) 19.47 (29) 13.37 (20) 46.60 (69) 20.93 (39) 18.09 (34) 20.64 (38) 40.34 (75) 29.08 (29) 23.71 (24) 20.94 (21) 26.27 (26) 37.13 (20) 53.71 (29) 2.16 (1) 7.00 (4) 44.95 (34) 29.88 (22) 8.64 (6) 16.54 (12)
asked how frequently they used lubricant within that context. Overall, the largest percentage of participants reported using lubricant more than 10 times within the past 90 days. The exception to this was toy use with the largest percentage of participants reporting using a lubricant with a vibrator and/or dildo once or twice over the previous 90 days (represented in Table 3). The other exception was lubricant use with condoms. Gay/ homosexual men were approximately evenly distributed in their reported frequency of lubricant use with condoms (once or twice, 3–5 times, 6–10 times, more than 10 times). Lubricant use was commonly used during solo masturbation for both bisexual and gay/homosexual men.
Reasons for Using Lubricants Participants were asked to endorse a variety of reasons for first starting to use lubricants (represented in Table 4). The most commonly endorsed response for both bisexual and gay/homosexual participants included “to comfortably have anal sex.” The next top three reasons were the same for bisexual and gay/homosexual participants. They
included “curiosity,” “to make sex more comfortable,” and “for fun.” Similar percentages of bisexual and gay/homosexually identified participants endorsed the remainder of the items with the exception of “to manage vaginal pain.” The reasons that participants indicated starting to use lubricant during sexual activities were similar for gay/homosexual and bisexual participants. The three most frequently endorsed reasons included a desire to reduce discomfort/pain, make sex more pleasurable, and because their partner recommended it. Few participants were recommended to use by a doctor/nurse or health educator.
Perceptions of Sexual Experience with Lubricants The majority of participants reported agreeing with the statements that lubricants enhanced their
Table 4 Lubricant users’ reasons for lubricant use by sexual orientation using post-stratification weights Gay/ Bisexual homosexual (n = 101) (n = 332) % (n) % (n)
Reason for use Reason for first starting use To comfortably have anal sex Curiosity To make sex more comfortable For fun To reduce the risk of tearing To make sex feel more wet To add pleasurable sensations to sex My partner wanted us to To enhance foreplay To manage vaginal pain To reduce the risk of condom breakage To spice up my/our sex life A friend said it was fun to use My (or my partner’s) body changed during pregnancy Other While postpartum/nursing Because of medication use/surgery Approaching menopause Reason for first starting use during sexual activities I wanted to reduce discomfort or pain during sex I wanted to make sex more pleasurable My partner suggested we use lubricant I noticed that lubricated condoms felt more comfortable A friend recommended lubricant Other I saw an advertisement for lubricant A doctor or nurse recommended lubricant A health educator or sex educator recommended lubricant A family member recommended lubricant
55.3 (57) 46.3 (47) 44.2 (45) 43.4 (44) 23.2 (24) 20.0 (20) 19.6 (20) 18.4 (19) 18.3 (19)
56.0 (189) 29.8 (101) 49.8 (168) 32.5 (110) 21.9 (74) 17.4 (59) 24.8 (84) 24.5 (83) 15.5 (52) 0.5 (2) 13.4 (14) 13.8 (47) 7.8 (8) 4.8 (16) 7.1 (7) 6.8 (23) 1.4 (1) 0.4 (2) 1.0 (1) 0.6 (1) 0.1 (0) 0.0 (0)
1.2 (4) 0.0 (0) 0.3 (1) 0.0 (0)
46.7 (48) 49.5 (167) 32.8 (34) 38.6 (131) 25.5 (26) 35.1 (118) 20.7 (21) 15.1 (51) 14.0 (14) 15.5 (52) 7.5 (8) 5.3 (18) 6.8 (7) 5.1 (17) 3.6 (4) 1.1 (4) 0.5 (1)
3.3 (11)
0.0 (0)
0.2 (1)
J Sex Med 2014;11:2396–2405
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Dodge et al.
Table 5
Perceptions of lubricant use by age using post-stratification weights Bisexual (n = 101)
Gay/homosexual (n = 332)
Using lubricant during sexual activities . . .
% disagree
% agree
Age by statement agreement† Odds ratio (95% CI)
Makes Makes Makes Is only Makes
33.3 34.5 25.8 97.2 10.4
66.7 65.5 74.2 2.8 89.6
1.03 (1.00–1.07) 1.02 (0.99–1.06) 1.03 (0.99–1.07) 1.25* (1.02–1.54) 0.97 (0.92–1.02)
it easier to feel aroused it easier to have an orgasm sex feel better for older people sex more comfortable
% disagree
% agree
Age by statement agreement† Odds ratio (95% CI)
21.7 26.8 11.8 93.7 5.9
78.3 73.2 88.2 6.3 94.1
0.98* (0.96–1.00) 0.98* (0.96–1.00) 1.02 (0.99–1.04) 0.95** (0.91–0.99) 1.01 (0.97–1.05)
*P ≤ 0.05, **P ≤ 0.01, ***P ≤ 0.005, ****P ≤ 0.001 †An odds ratio over 1.0 indicates increased agreement with the statement for every 1 year in age CI = confidence interval
sexual experiences (Table 5). The most highly endorsed item included using a lubricant during sexual activities “makes sex more comfortable” (bisexual 89.6%, gay/homosexual 94.1%). Overall, a higher percentage of gay/homosexual men tended to agree with the statements than bisexual participants. A small minority of the participants agreed with the statement that using lubricants during sexual activities “is only for older people” (bisexual 2.8%, gay/homosexual 6.3%). Age was a significant predictor of agreement with the statements using a lubricant during sexual activities makes it easier to “feel aroused” and “to have an orgasm” for gay/homosexual participants. Age was a significant predictor of the statement using lubricant during sexual activities “is only for older people” for all participants regardless of sexual orientation. However, younger gay/homosexual participants were less likely to endorse this statement (odds ratio [OR] = 0.95, P < 0.01), while older bisexual participants were more likely to indicate agreement (OR = 1.25, P < 0.05). Discussion
In a nationally representative probability sample of men aged 18 years and older in the United States—the 2012 NSSHB—it was found that the vast majority of self-identified gay and bisexual men have used lubricant, that lubricant use is prevalent across age cohorts, and that gay and bisexual men largely use lubricant during sexual activities for reasons related to increasing comfort and pleasure (including, but not limited to, during anal intercourse). These data underscore the widespread use of lubricants as sexual enhancement products among gay and bisexual men and their sexual partners. The frequent use of such products highlights the need for increased awareness of lubricant use as a common component of gay and J Sex Med 2014;11:2396–2405
bisexual men’s routine sexual behaviors, both in terms of understanding an individual’s sexual history in a clinical context and for educational interventions among public health practitioners. This study had both strengths and limitations. A significant strength is that sexual behavior and lubricant use were assessed in a subsample of a nationally representative probability sample of individuals aged 18 and older in the United States. Participants were able to complete the survey via the Internet, thus facilitating privacy, ease of access, and perhaps greater comfort responding to questions of a sensitive nature. Men were eligible to be part of the GfK’s KnowledgePanel—and thus part of the study—regardless of their financial or technological resources. That is, if they lacked Internet access or the hardware or software necessary to complete Internet-based surveys for the panel, they were provided with the needed resources as part of GfK membership. Participants were also already familiar with completing GfK surveys and thus did not require additional training regarding survey completion. The survey was also available in both English and Spanish languages. A limitation is that the sample was restricted to individuals who had a home address and who were community dwelling (e.g., not institutionalized, not homeless, etc.). This may have limited the sample, particularly for much older individuals, those experiencing health conditions that warrant inpatient care, and those who deal with issues related to housing instability. Some men may not have felt comfortable answering questions about their sexual or lubricant use behaviors or may not have understood the questions (and because the survey was administered online, they would not have been able to ask for clarification). Although we defined what we meant by a “lubricant” at various points throughout the survey, it is possible
Gay and Bisexual Men’s Lubricant Use that some participants had different definitions in mind. However, we expect that this number would be small enough so as not to have a significant influence on our findings. Although we were able to avoid using convenience sampling strategies for recruiting gay and bisexual men, participants in our study were classified as “gay” or “bisexual” based on their sexual self-identification, which may or may not accurately reflect their recent or routine sexual behaviors in terms of gender of their sexual partners. It may be that nongay-identified men who have sex with other men may use lubricants in different ways, and for different reasons, than their gay-identified counterparts. Our focus on sexual self-identity, rather than behavior, is a starting point for using probability sampling techniques for recruiting nonheterosexual populations. The data presented in this article provide a preliminary understanding of lubricant use behaviors among gay and bisexual men, but more refined data regarding the context of the specific sexual encounter are warranted. We have collected more specific data on gay and bisexual men’s lubricant use at the sexual event level to explore differences in, for example, experiences of pleasure and/or pain depending on whether the most recent sexual event involved insertive and/or receptive anal sex. We are currently analyzing these data to report in a separate article focused specifically on lubricant use at the event level. Lastly, in terms of sexual health implications, it is important to bear in mind that recent evidence has emerged, which suggests that some rectal lubricant products may be associated with increased rectal epithelial sloughing, higher in vitro HIV-1 replication, and higher odds of other sexually transmitted infection (STI) acquisition [21]. While we have emphasized lubricant use among gay and bisexual men in terms of sexual health and wellness, this evidence presents cause for concern as some lubricants may have compromising effects on rectal epithelial tissue. Further rigorous research and product development are recommended, particularly given the results finding such widespread use of lubricants among gay and bisexual men, including better testing of personal lubricant safety specifically in the context of ano-rectal sexual activity. It is noteworthy that among participants who reported using lubricant during the recent past (i.e., 90 days), the majority used lubricant at a relatively high frequency (more than 10 times) during this time frame. Among recent users, lubricant use was also frequent during partnered intercourse and also in tandem with condom use. This sug-
2403 gests that whether for purposes of sexual pleasure or sexual protection (or both), gay and bisexual men who utilize lubricants during sexual activity are likely to be adherent to using them as a routine part of their overall sexual repertoire. This finding may be of utility not only to clinicians and public health practitioners (who may promote lubricant use for routine use for gay and bisexual men who are seeking to decrease both sexual pleasure and potential sexual risk with potential partners), but also to corporate health care and other professionals who are seeking to promote lubricant use (who may utilize these findings as evidence that gay and bisexual men are likely a viable segment of the population to market to with sexual health enhancement products for both solo and partnered sexual activities). As sexual enhancement products become more widely available and marketed, research needs to be attentive to diverse forms of sexual expression and the increasing integration of such products into sexual activities for nonheterosexual individuals and partnerships. Gay and bisexual men reported a wide range of reasons for using lubricant use during sexual activity. The most commonly reported reason for using lubricant during partnered sexual activities included managing pain during anal intercourse with male partners and, with bisexual participants, also managing pain during vaginal intercourse with female sexual partners. These reasons are in line with those reported by heterosexual male and female counterparts in other samples. They also indicate that engaging in certain behaviors (e.g., anal intercourse) may introduce people to certain sexual enhancement products, such as lubricant, which is more commonly used as part of anal penetration compared with other sexual activities. Additionally, in terms of perceptions of lubricant use among gay and bisexual men, the majority of men who have used lubricants endorse that they do, indeed, decrease discomfort and increase sexual pleasure during partnered sexual activities. These findings are of great significance in terms of future public health efforts aiming to increase rates of lubricant use (in addition to condom use) among gay and bisexual men. For scientists engaged in work related to sexual health, this study provides the first comprehensive and nationally representative investigation of issues related to lubrication and lubricant use among gay and bisexual men. As a result, the findings will be valuable to those who need accurate prevalence rates on U.S. gay and bisexual men in these areas. Additionally, given that issues related to sexuality conJ Sex Med 2014;11:2396–2405
2404 tinue to present challenges to the well-being of individuals and that sexuality is a core component of our human existence, having data that help individuals in the general population to compare their sexual behaviors with others in a scientifically valid way can be normalizing and helpful. Traditional HIV prevention messages for gay and bisexual men have historically been framed in terms of a sexual risk-reduction perspective (i.e., promoting lubricant use to minimize potential tears in the ano-rectal region of the receptive sexual partner, thereby reducing likelihood that HIV may be transmitted from one partner to another). Given that most gay and bisexual men report using lubricant to facilitate comfort during sex, health promotion messages that are framed in terms of increasing sexual comfort and pleasure for both insertive and receptive sexual partners (along with explanations of how this will simultaneously help to reduce potential sexual risk) may be most effective in terms of their relevance and likelihood of use by gay and bisexual men. Public health’s traditional emphasis on sexual risk has often obfuscated the need to provide comprehensive information on the importance of sexual comfort, pleasure, and enhancement among gay and bisexual men (in addition to evidence-based recommendations for decreasing sexual risk behavior among men whose partners may be at risk for transmission of HIV and other STIs).
Conclusions
Our findings from the 2012 NSSHB demonstrate that majority of self-identified gay and bisexual men in the United States have used lubricant during sexual activity, that lubricant use is common across all age groups, and that, as with their subgroups of men and women, some of the most common reasons why gay and bisexual men report using lubricant relate to enhancing comfort and pleasure. While these men most commonly report using lubricant to facilitate comfort during anal intercourse, they also report using lubricant during a wide range of other solo and partnered sexual behaviors. Both public health practitioners and clinicians may use these data in their efforts to incorporate lubricant use into future sexual health promotion efforts, which may benefit from framing lubricant use among gay and bisexual men as useful for both decreasing potential sexual risk and also increasing sexual pleasure for these men and their sexual partners. J Sex Med 2014;11:2396–2405
Dodge et al. Acknowledgments
The authors are grateful to Church & Dwight Co., Inc. for a grant in support of this research. Corresponding Author: Debby Herbenick, PhD, MPH, Center for Sexual Health Promotion, Indiana University, SPH 116, Bloomington, Indiana 47405, USA. Tel: (1) 812-8557011; E-mail: [email protected] Conflict of Interest: Michael Reece is a member of the sexual health advisory council of Church & Dwight, Co., Inc., the maker of Trojan brand sexual health products. Statement of Authorship
Category 1 (a) Conception and Design Debby Herbenick; Brian Dodge; Vanessa Schick; Michael Reece; J. Dennis Fortenberry; Stephanie A. Sanders (b) Acquisition of Data Debby Herbenick; Brian Dodge; Vanessa Schick; Michael Reece; Stephanie A. Sanders; J. Dennis Fortenberry (c) Analysis and Interpretation of Data Vanessa Schick; Brian Dodge; Debby Herbenick
Category 2 (a) Drafting the Article Brian Dodge; Vanessa Schick; Debby Herbenick (b) Revising It for Intellectual Content Debby Herbenick; Brian Dodge; Vanessa Schick; Michael Reece; Stephanie A. Sanders; J. Dennis Fortenberry
Category 3 (a) Final Approval of the Completed Article Debby Herbenick; Brian Dodge; Vanessa Schick; Michael Reece; Stephanie A. Sanders; J. Dennis Fortenberry References 1 Martin DJ. Inappropriate lubricant use with condoms by homosexual men. Public Health Rep 1992;107:468–73. 2 Kiran D, Manjunath R, Aswin KK, Patil BK, Mahabalaraju DK. A study on risk factors associated with inconsistent condom and lubricant use among men who have sex with men in central Karnataka, India. Australas Med J 2011;4: 469–73. 3 Butler LM, Osmond DH, Jones AG, Martin JN. Use of saliva as a lubricant in anal sexual practices among homosexual men. J Acquir Immune Defic Syndr 2009;50:162–7. 4 Carballo-Diéguez A, Stein Z, Sáez H, Dolezal C, Nieves-Rosa L, Díaz F. Frequent use of lubricants for anal sex among men who have sex with men: The HIV prevention potential of a microbicidal gel. Am J Public Health 2000;90:1117–21. 5 Gross M, Buchbinder SP. Rectal microbicides for U.S. gay men. Sex Transm Dis 1998;25:296–302.
Gay and Bisexual Men’s Lubricant Use 6 Clark JL, Salvatierra HJ, Segura ER, Salazar X, Konda K, Galea J, Klausner JD, Coates TJ, Caceres CF. Frequency, patterns, and preferences of lubricant use during anal intercourse within male sexual partnerships in Lima, Peru: Implications for a rectal microbicide HIV prevention intervention. AIDS Care 2013;25:579–85. 7 Herbenick D, Reece M, Schick V, Sanders SA, Fortenberry JD. Women’s use and perceptions of commercial lubricants: Prevalence and characteristics in a nationally representative sample of American adults. J Sex Med 2014;11:642–52. 8 Reece M, Herbenick D, Schick V, Sanders SA, Fortenberry JD. Men’s use and perceptions of commercial lubricants: Prevalence and characteristics in a nationally representative sample of US adults. J Sex Med 2014;11:1125–35. 9 Reece M, Mark KP, Herbenick D, Jawed-Wessel S, Hensel D, Dodge B. An event-level analysis of adding exogenous lubricant to condoms in a sample of men who have vaginal sex with women. J Sex Med 2012;9:672–8. 10 Rosen RC, Bachmann GA, Reese JB, Gentner L, Leiblum S, Wajszczuk C, Wanser R. Female sexual well-being scale™ (FSWB Scale™): Development and Psychometric validation in sexually functional women. J Sex Med 2009;6:1297–305. 11 Hoffman S, Morrow K, Mantell J, Rosen R, Carballo-Diéguez A, Gai F. Covert use, vaginal lubrication, and sexual pleasure: A qualitative study of Urban U.S. women in a vaginal microbicide clinical trial. Arch Sex Behav 2010;39:748–60. 12 Meyer IH, Wilson PA. Sampling lesbian, gay, and bisexual populations. J Couns Psychol 2009;56:23–31. 13 Dodge B, Sandfort TGM. A review of mental health research on bisexual individuals when compared to homosexual and heterosexual individuals. In: Firestein BA, ed. Becoming visible: Counseling bisexuals across the lifespan. New York, NY: Columbia University Press; 2007:28–51.
2405 14 Dodge B, Schnarrs PW, Reece M, Goncalves G, Martinez O, Nix R, Malebranche D, Van Der Pol B, Murray M, Fortenberry JD. Community involvement among behaviourally bisexual men in the Midwestern USA: Experiences and perceptions across communities. Cult Health Sex 2012;14:1095–110. 15 Reece M, Herbenick D, Schick V, Sanders SA, Dodge B, Fortenberry JD. Sexual behaviors, relationships, and perceived health among adult men in the United States: Results from a national probability sample. J Sex Med 2010;7:291–304. 16 Sanders SA, Reece M, Herbenick D, Schick V, Dodge B, Fortenberry JD. Condom use during most recent vaginal intercourse event among a probability sample of adults in the United States. J Sex Med 2010;7:362–73. 17 Silver RC, Holman EA, McIntosh DN, Poulin M, Gil-Rivas V. Nationwide longitudinal study of psychological responses to September 11. JAMA 2002;288:1235–44. 18 Baker L, Wagner TH, Singer S, Bundorf MK. Use of the internet and e-mail for health care information: Results from a national survey. JAMA 2003;289:2400–6. 19 Heiss F, McFadden D, Winter J. Who failed to enroll in Medicare Part D, and why? Early results. Health Aff 2006;25:w344–54. 20 Herbenick D, Schick V, Reece M, Sanders SA, Smith N, Dodge B, Fortenberry JD. Characteristics of condom and lubricant use among a nationally representative probability sample of adults ages 18–59 in the United States. J Sex Med 2013;10:474–83. 21 Gorbach PM, Weiss RE, Fuchs E, Jeffries RA, Hezerah M, Brown S, Voskanian A, Robbie E, Anton P, Cranston RD. The slippery slope: Lubricant use and rectal sexually transmitted infections: A newly identified risk. Sex Transm Dis 2012; 39:59–64.
J Sex Med 2014;11:2396–2405
Frequency, Reasons for, and Perceptions of Lubricant Use among a Nationally Representative Sample of Self-Identified Gay and Bisexual Men in the United States Brian Dodge, PhD,* Vanessa Schick, PhD,† Debby Herbenick, PhD, MPH,* Michael Reece, PhD, MPH,* Stephanie A. Sanders, PhD,‡§ and J. Dennis Fortenberry, MD, MS¶ *Center for Sexual Health Promotion, Indiana University, Bloomington, IN, USA; †Division of Management, Policy and Community Health, University of Texas Health Science Center, Houston, TX, USA; ‡The Kinsey Institute for Research in Sex, Gender, and Reproduction, Indiana University, Bloomington, IN, USA; §Gender Studies, Indiana University, Bloomington, IN, USA; ¶Section of Adolescent Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA DOI: 10.1111/jsm.12640
ABSTRACT
Introduction. Few previous studies have examined lubricant use among gay and bisexual men outside the context of human immunodeficiency virus risk reduction associated with condom use during penile–anal intercourse and the potential use of lubricants to deliver rectal microbicides. The vast majority of studies examining lubricant use among gay and bisexual men have employed convenience sampling strategies for participant recruitment. Additionally, most studies have collapsed gay men and bisexual men into one category of “gay and bisexual men.” Aims. This study aimed to provide overall rates of lubricant use and related factors among a nationally representative sample of self-identified gay and bisexual men. Frequencies of lubricant use, reasons for using lubricant, and perceptions of lubricant use were examined separately for subsamples of both gay and bisexual men. Methods. Data were from the 2012 National Survey of Sexual Health and Behavior, which involved the administration of an online questionnaire to a nationally representative probability sample of women and men in the United States aged 18 and older, and we oversampled self-identified gay and bisexual men and women; the results from male participants are included in this article. Main Outcome Measures. Measure included demographic characteristics, recent and lifetime commercial lubricant use, lubricant use during specific sexual behaviors, frequency of lubricant use, and reasons for lubricant use during sexual activity. Results. Over 90% of both gay and bisexual male participants reported lifetime lubricant use. Use was most common during partnered sexual activities, particularly among men aged 25–29 years old. The most commonly reported reasons for lubricant use included to increase comfort during anal intercourse, curiosity, and to make sex more comfortable. Conclusions. Most gay and bisexual men in the United States have used lubricant to enhance a wide range of sexual activities, including but not limited to anal intercourse. Findings from this study will be of utility to clinicians and other health practitioners who seek to understand and promote sexual health among gay and bisexual men and other traditionally underserved public health populations. Dodge B, Schick V, Herbenick D, Reece M, Sanders SA, and Fortenberry JD. Frequency, reasons for, and perceptions of lubricant use among a nationally representative sample of self-identified gay and bisexual men in the United States. J Sex Med 2014;11:2396–2405. Key Words. Lubricant; Gay and Bisexual Men; Sexual Pleasure; Nationally Representative Sample
J Sex Med 2014;11:2396–2405
© 2014 International Society for Sexual Medicine
2397
Gay and Bisexual Men’s Lubricant Use Introduction
A
lthough an issue of public health significance, relatively little research has examined gay and bisexual men’s lubricant use during a range of partnered sexual activities. Interestingly, while previous research on lubricant use among heterosexual (male–female) sexual partners has acknowledged and explored relations between lubricant use and sexual pleasure and sexual enhancement [1–11], the small body of existing research on lubricant use among men with male sexual partners has focused almost exclusively on lubricant use in relation to sexual risk [1–6]. This is particularly the case in terms of the well-established sexual risk-reduction benefits of using appropriate lubricants, in addition to condoms, as a strategy to decrease human immunodeficiency virus (HIV) transmission during penile–anal intercourse [1–3]. Another line of research has explored the potential for lubricants to serve as a proxy for delivering rectal microbicide liquids or gels for HIV prevention purposes (pending the development of an effective preventative rectal microbicide) [4–6]. However, for the most part, researchers have not yet examined gay and bisexual men’s reasons for using, as well as perceptions of sexual experiences with, lubricants for a range of sexual interactions [8]. In addition to the relatively narrow focus on lubricant use as a risk-reduction strategy during penile–anal intercourse, the vast majority of sexual health research on gay and bisexual men, in general, has been based on non-probability convenience samples. While barriers associated with feasibility and cost have undoubtedly prohibited most researchers from obtaining probability samples of nonheterosexual men, recent technological innovations have facilitated the possibility of collecting data from samples of self-identified gay and bisexual men in the United States that are probabilistic and reflective of a national level population. Sampling is not an insignificant issue when it comes to the study of sexual minority individuals (including behaviorally homosexual and bisexual individuals, regardless of sexual self-identity or gender identity). Meyer and Wilson [12] concur: “(s)ampling has been the single most influential component of conducting research with lesbian, gay, and bisexual (LGB) populations. Poor sampling designs can result in biased results that will mislead other researchers, policymakers, and practitioners. Investigators wishing to study LGB populations must therefore devote significant energy and resources to choosing a sampling
approach and executing the sampling plan.” A large amount of previous research is based on convenience samples of “gay, lesbian, and bisexual” (GLB) individuals recruited from a narrow range of gay-identified venues, including gay bars, gay pride parades, gay community centers, sexual cruising areas, and other spaces that are reflective only of a larger group of individuals who are relatively connected to a larger “gay community” and, thus, likely to be present in these areas. Public health researchers and practitioners have cautioned that generalizing to all nonheterosexual individuals from previous samples of primarily white, well-educated, upper middle-class, selfidentified lesbians and gay men is dangerous as results may be simplistic, misleading, and not representative of the diversity of the general population. Collapsing bisexual and homosexual individuals under the common auspice of GLB has also proven to be problematic in previous research as bisexual individuals are unlikely to be captured in traditional “gay-identified” venues and may face stigma from both heterosexual and homosexual counterparts [13,14]. Aims
To fill existing gaps in both topic and sampling, this study aims to provide rates of lubricant use, as well as to explore factors related to lubricant use, among a probability sample of self-identified gay and bisexual men who participated in the 2012 National Survey of Sexual Health and Behavior (2012 NSSHB). Because of the well-documented limitations of previous studies that collapsed gay and bisexual men together into a single category, we also explore issues related to lubricant use separately for gay and bisexual men. Methods
This article presents data from the 2012 NSSHB, a population-based cross-sectional survey of adults in the United States. Data were collected during October to November 2012, via the KnowledgePanel of GfK Custom Research (GfK) (Menlo Park, CA, USA). Research panels accessed through GfK’s KnowledgePanel are based on a national probability sample established using both random digit dialing and an address-based sampling (ABS) frame [10,15–20]. ABS involves the probability sampling of a frame of residential addresses in the United States derived from the U.S. Postal Service’s Delivery Sequence File, a J Sex Med 2014;11:2396–2405
2398 system which contains detailed information on every mail deliverable address in the United States. Collectively, the sampling frame from which participants are recruited covers approximately 98% of all U.S. households. Randomly selected addresses are recruited to the research panel through a series of mailings and subsequently by telephone follow-ups to nonresponders when possible. To further correct sources of sampling and non-sampling error, study samples are corrected with a post-stratification adjustment using demographic distributions from the most recent data available from the Current Population Survey, the monthly population survey conducted by the U.S. Bureau of the Census considered to be the standard for measuring demographic and other trends in the United States. These adjustments result in a panel base weight that was employed in a probability proportional to size selection method for establishing the samples for this study. Once the sample frame was established, all individuals within that frame received a recruitment message from GfK that provided a brief description of the NSSHB and invited them to participate. In addition to a sample of 6,175 selfidentified heterosexual individuals, a total of 1,456 individuals who self-identified as GLB were oversampled from the GfK panels and invited to participate in the survey. Of these, 738 individuals provided informed consent and 96.5% (n = 712) of these participants completed the survey. This included 332 self-identified gay/homosexual men and 101 self-identified bisexual men. The survey was administered in either English or Spanish. All data were collected by GfK via the Internet. There were no incentives for participation in this study that will be provided by the researchers. Given that all individuals were part of an existing panel at Knowledge Networks, they were already receiving an established level of incentives. For some individuals, this includes that they are provided with free Internet access and hardware so that they can participate in such studies. Additionally, Knowledge Networks pays a small monthly incentive to their panel members to retain them; however, these incentives are not directly affiliated with this study. As the study was conducted via the Internet, participants provided consent by clicking a link and then proceeding to the survey. We utilized a routine informed consent statement in the study. All research protocols were approved by the Institutional Review Board of Indiana University— Bloomington. J Sex Med 2014;11:2396–2405
Dodge et al. Main Outcome Measures
Lubricant Use Participants were asked to provide details about the extent to which they had used a lubricant across varying points in their lifetime. Response options included that participants had used a lubricant within the 30 days prior to participating in the study, 90 days prior to the study, within the past 12 months, more than 1 year ago, or never. Participants were provided with a definition of lubricant that included: “any personal lubricant or vaginal moisturizer that you can purchase in a store marketed to enhance the sexual experience and/or increase lubrication.” Lubricant Use During Specific Sexual Behaviors and Other Product Use Participants were also asked (using the same response categories as above) to describe whether they had used a lubricant during specific sexual behaviors, including: while masturbating alone, during sexual play or foreplay with a partner, and during intercourse (vaginal and/or anal; if anal, insertive and/or receptive). Participants were also asked to respond similarly as to whether they had used a lubricant in conjunction with a condom, a vibrator, or a dildo. Reasons for Lubricant Use Men were asked to provide the main reasons for their initial use of a lubricant, with 18 response options including: “to make sex feel more wet” to “because my partner wanted to” and “to spice up my/our sex life,” among others. Perceptions of Lubricant Use Participants were asked to respond to the extent to which they agreed or disagreed with items related to their perceptions of the use of lubricant during sexual activities. These items ranged from those such as “lubricant use is embarrassing” to “lubricant makes sex feel better” to “lubricant is only for older people.” Response options included a fourpoint response scale ranging from strongly disagree to strongly agree. Data Analysis Prior to data analysis, post-stratification data weights based upon U.S. Census data were applied in order to reduce variance and minimize bias due to non-sampling error. This was part of a larger study on the sexual behavior of men and women in the United States. Therefore, the sample was con-
2399
Gay and Bisexual Men’s Lubricant Use Table 1 Participant sociodemographic distribution by lifetime lubricant use history using post-stratification weights (N = 433) Bisexual
Gay/homosexual No lubricant use
Characteristics Age 18–24 (Ref) 25–29 30–39 40–49 50–59 60+ Education Less than high school (Ref) High school or GED Some college or associates degree College degree or higher Race/ethnicity White, non-Hispanic (Ref) Black, non-Hispanic Other, non-Hispanic Hispanic More than two races, non-Hispanic Relationship status Single and not dating (Ref) Single and dating In a relationship but not living together Living with relationship partner Married and living together Married but not living together
% (n)
%
10.3 (11) 5.9 (7) 26.7 (29) 26.5 (29) 21.2 (23) 9.4 (10)
18.2 0.0 0.0 3.4 16.7 10.0
1.9 (2) 19.7 (22) 36.6 (40) 41.8 (46)
Lubricant use
No lubricant use
Lubricant use
% (n)
%
81.8 100.0 100.0 96.6 83.3 90.0
8.2 (29) 12.3 (43) 18.1 (63) 30.0 (105) 24.4 (85) 7.0 (25)
3.4 0.0 1.6 1.0 3.6 4.2
96.6 100.0 98.4 99.0 96.4 95.8
33.3 18.2 2.5 4.3
66.7 81.8 97.5 95.7
2.2 (8) 13.9 (49) 33.7 (117) 50.2 (175)
0.0 2.0 3.5 1.1
100.0 98.0 96.5 98.9
61.8 (68) 1.8 (2) 8.1 (9) 25.2 (28) 3.1 (3)
8.8 0.0 0.0 3.7 0.0
91.2 100.0 100.0 96.3 100.0
65.6 (229) 4.8 (17) 7.2 (25) 18.9 (66) 3.5 (12)
2.2 5.9 0.0 0.0 8.3
97.8 94.1 100.0 100.0 91.7
40.8 (45) 10.3 (11) 2.6 (3) 15.1 (17) 29.3 (32) 1.7 (2)
11.1 8.3 0.0 0.0 6.1 0.0
88.9 91.7 100.0 100.0 93.9 100.0
34.6 (121) 14.4 (50) 13.8 (48) 31.7 (111) 5.5 (19)
4.2 2.0 0.0 0.0 0.0
95.8 98.0 100.0 100.0 100.0
None of the sociodemographic characteristics were significant predictors of lubricant use at last event GED = General Educational Development
strained to only men who self-identified as gay/ homosexual or bisexual for the purpose of this article. Frequencies are used to present data on lubricant use rates, perceptions, and reasons for use. The relationship between lubricant use and sociodemographic characteristics was explored using a series of logistic regressions. Results
Demographic Characteristics Approximately three-quarters of the gay- and bisexual-identified men in the sample reported an age between 29 and 60 (Table 1). Similarly, close to 75% of both gay and bisexual men reported some college education. While most participants reported that they were white/non-Hispanic, a sizable minority of both gay and bisexual participants identified as Hispanic. Again, both bisexual and gay/homosexual men were similar in their relationship status with the highest percentage of participants reporting that they were “single and not dating” or “married and living together.” There were no significant differences between demographic characteristics and lubricant use
history for either gay/homosexual or bisexual men.
Lubricant Use History Table 2 provides an overview of lifetime and recent lubricant use. The vast majority (over 90%) of both gay/homosexual and bisexual participants reported using a lubricant at least once. The percentage of participants reporting lubricant use was also fairly consistent across age groups. When asked about lubricant use in various sexual contexts, the majority of participants indicated that they had used lubricant in the contexts provided in the survey. The most common time of use for both gay and bisexual participants was during partnered intercourse (bisexual = 83.7%, n = 92, gay/homosexual = 93.5%, n = 325) and the least was for use with a vibrator (bisexual = 54.8%, n = 57, gay/homosexual = 42.3%, n = 147). Overall, regardless of context, use was most commonly reported by participants aged 25–49 years old. Lubricant Use Frequency Participants who reported using a lubricant during sexual activity within the previous 90 days were J Sex Med 2014;11:2396–2405
Ever used Past 30 days Past 90 days Past 12 months (year) More than a year ago Used a lubricant Ever used during solo Past 30 days Past 90 days masturbation Past 12 months (year) More than a year ago Used a lubricant Ever used during partnered Past 30 days sexual play Past 90 days Past 12 months (year) More than a year ago Used a lubricant Ever used during partnered Past 30 days intercourse Past 90 days Past 12 months (year) More than a year ago Used a lubricant with Ever used a condom Past 30 days Past 90 days Past 12 months (year) More than a year ago Used a lubricant with Ever used a vibrator Past 30 days Past 90 days Past 12 months (year) More than a year ago Used a lubricant with Ever used a dildo Past 30 days Past 90 days Past 12 months (year) More than a year ago
Used a lubricant
92.9 (102) 37.6 (41) 7.4 (8) 9.5 (10) 38.4 (42) 71.4 (79) 34.1 (38) 4.3 (5) 6.6 (7) 26.4 (29) 81.2 (89) 14.8 (16) 6.6 (7) 9.1 (10) 50.7 (56) 83.7 (92) 17.1 (19) 3.7 (4) 15.2 (17) 47.8 (53) 73.2 (81) 14.0 (15) 2.8 (3) 8.9 (10) 47.5 (52) 54.8 (57) 5.7 (6) 4.9 (5) 6.4 (7) 37.8 (39) 67.0 (73) 12.9 (14) 12.3 (13) 4.9 (5) 36.9 (40)
Total sample % (n) 25–29
30–39
40–49
82.3 (9) 100.0 (7) 98.7 (29) 97.0 (28) 44.9 (5) 32.3 (2) 29.8 (9) 53.3 (16) 10.6 (1) 62.2 (4) 2.5 (1) 0.0 (0) 0.0 (0) 0.0 (0) 3.6 (1) 21.8 (6) 26.9 (3) 5.4 (1) 62.8 (18) 21.9 (6) 55.4 (6) 86.9 (6) 68.1 (20) 74.8 (22) 44.9 (5) 5.8 (0) 26.7 (8) 54.3 (16) 10.6 (1) 20.1 (1) 0.0 (0) 5.7 (2) 0.0 (0) 0.0 (0) 9.3 (3) 10.9 (3) 0.0 (0) 61.0 (4) 32.1 (9) 4.0 (1) 39.9 (5) 94.6 (6) 89.5 (26) 82.2 (24) 1.0 (0) 21.4 (1) 6.3 (2) 31.7 (9) 12.0 (1) 12.2 (1) 1.8 (1) 8.5 (2) 0.0 (0) 61.0 (4) 0.8 (0) 8.6 (3) 26.9 (3) 0.0 (0) 80.6 (24) 33.4 (10) 38.5 (4) 100.0 (7) 82.7 (24) 97.0 (28) 2.5 (0) 25.0 (2) 8.1 (2) 33.7 (10) 0.0 (0) 8.5 (1) 0.0 (0) 5.4 (2) 9.1 (1) 61.0 (4) 6.8 (2) 24.1 (7) 26.9 (3) 5.4 (0) 67.8 (20) 33.8 (10) 52.9 (6) 92.5 (6) 73.4 (22) 92.5 (27) 15.9 (2) 22.9 (2) 3.2 (1) 27.4 (8) 0.0 (0) 14.0 (1) 0.0 (0) 4.1 (1) 9.1 (1) 53.7 (4) 10.0 (3) 4.4 (1) 27.9 (3) 1.8 (1) 60.2 (18) 56.6 (16) 27.9 (3) 33.8 (2) 69.4 (20) 78.9 (18) 0.0 (0) 0.0 (0) 3.5 (1) 20.4 (5) 0.0 (0) 26.5 (2) 4.6 (1) 3.4 (1) 0.0 (0) 0.0 (0) 0.0 (0) 14.1 (3) 27.9 (3) 7.3 (0) 61.3 (18) 41.1 (9) 57.7 (7) 36.5 (2) 81.1 (24) 89.8 (26) 0.0 (0) 11.0 (1) 3.2 (1) 40.1 (12) 13.9 (2) 20.1 (1) 8.2 (2) 24.8 (7) 15.9 (2) 0.0 (0) 0.0 (0) 7.9 (2) 27.9 (3) 5.4 (1) 69.8 (21) 17.0 (5)
% (n)
18–24
Bisexual
84.8 (20) 28.9 (7) 1.1 (0) 8.3 (2) 46.5 (11) 71.7 (17) 24.5 (6) 2.6 (1) 3.9 (1) 40.8 (10) 84.1 (20) 9.2 (2) 6.9 (2) 5.9 (1) 62.2 (15) 81.8 (19) 12.1 (3) 6.9 (2) 2.6 (1) 60.2 (14) 63.2 (14) 10.4 (2) 2.8 (1) 1.9 (0) 48.1 (11) 43.9 (10) 1.0 (0) 3.0 (1) 8.7 (2) 31.3 (7) 39.6 (9) 2.9 (1) 4.1 (1) 2.7 (1) 30.0 (7)
50–59
Weighted lifetime and recency of lubricant use during various sexual contexts
Recency of lubricant use
Table 2
90.7 (9) 30.6 (3) 17.8 (2) 11.2 (1) 31.1 (3) 78.1 (8) 26.2 (3) 0.0 (0) 4.4 (0) 47.6 (5) 85.0 (9) 15.2 (2) 4.6 (0) 18.0 (2) 47.2 (5) 92.8 (10) 18.1 (2) 3.4 (0) 19.5 (2) 51.7 (5) 51.4 (5) 7.3 (1) 3.0 (0) 5.7 (1) 35.4 (4) 28.9 (3) 0.9 (0) 5.4 (1) 13.5 (1) 9.2 (1) 53.2 (5) 0.9 (0) 0.0 (0) 6.1 (1) 46.1 (4)
60+
97.9 (338) 57.1 (197) 10.7 (37) 13.1 (45) 17.1 (59) 82.3 (286) 41.7 (145) 10.5 (37) 13.7 (48) 16.3 (57) 87.7 (304) 34.5 (120) 11.0 (38) 14.2 (49) 28.0 (97) 93.5 (325) 44.7 (155) 9.9 (34) 14.6 (51) 24.3 (85) 86.4 (299) 20.0 (69) 10.7 (37) 16.2 (56) 39.4 (136) 42.3 (147) 10.2 (35) 6.4 (22) 5.5 (19) 20.2 (70) 65.7 (225) 10.9 (37) 12.5 (43) 14.9 (51) 27.5 (94)
% (n)
Total sample
97.5 (28) 30.7 (9) 10.8 (3) 50.2 (14) 5.8 (2) 60.5 (17) 18.0 (5) 13.5 (4) 14.3 (4) 14.6 (4) 65.9 (19) 20.8 (6) 11.6 (3) 27.1 (8) 6.4 (2) 74.4 (21) 30.2 (9) 14.3 (4) 24.3 (7) 5.7 (2) 86.3 (25) 20.0 (6) 11.4 (3) 46.3 (13) 8.7 (2) 14.5 (4) 0.7 (1) 3.5 (1) 9.5 (3) 0.7 (1) 38.5 (11) 8.1 (2) 0.0 (0) 23.8 (7) 6.6 (2)
% (n)
18–24
99.3 (42) 83.4 (36) 2.9 (1) 3.6 (2) 9.4 (4) 90.0 (39) 56.6 (24) 4.2 (2) 24.0 (10) 5.3 (2) 92.7 (40) 47.1 (20) 11.6 (5) 17.9 (8) 16.2 (7) 99.3 (42) 45.2 (19) 18.4 (8) 20.7 (9) 15.0 (6) 98.9 (42) 15.0 (6) 28.4 (12) 19.9 (9) 35.6 (15) 39.3 (17) 2.1 (1) 14.8 (6) 2.0 (1) 20.4 (9) 68.0 (28) 2.0 (1) 46.8 (19) 15.6 (6) 3.6 (1)
25–29
Gay/homosexual
99.1 (62) 78.3 (49) 0.9 (1) 7.5 (5) 12.5 (8) 93.0 (59) 51.1 (32) 19.2 (12) 16.6 (10) 6.0 (4) 97.5 (61) 43.2 (27) 15.3 (10) 17.0 (11) 22.0 (14) 99.1 (62) 57.5 (36) 11.6 (7) 16.1 (10) 13.9 (9) 91.9 (56) 23.8 (14) 6.3 (4) 21.9 (13) 39.9 (24) 69.2 (44) 31.9 (20) 5.7 (4) 8.6 (5) 23.0 (14) 82.0 (50) 12.5 (8) 9.5 (6) 31.4 (19) 28.6 (17)
30–39
98.6 (102) 51.2 (53) 16.3 (17) 10.6 (11) 20.5 (21) 82.1 (86) 44.7 (47) 12.8 (13) 8.0 (8) 16.5 (17) 89.9 (93) 41.6 (43) 9.4 (10) 8.1 (8) 30.9 (32) 96.4 (101) 51.5 (54) 5.4 (6) 12.1 (13) 27.5 (29) 89.1 (93) 24.8 (26) 6.8 (7) 11.6 (12) 45.9 (48) 41.2 (43) 6.5 (7) 6.5 (7) 4.4 (5) 23.8 (25) 61.6 (64) 12.8 (13) 9.7 (10) 5.7 (6) 33.4 (35)
40–49
96.2 (80) 46.9 (39) 16.2 (13) 13.8 (11) 19.4 (16) 80.7 (68) 33.4 (28) 4.7 (4) 14.2 (12) 28.4 (24) 84.3 (71) 19.1 (16) 11.1 (9) 13.1 (11) 41.0 (35) 89.3 (76) 32.8 (28) 9.7 (8) 12.8 (11) 34.1 (29) 74.1 (63) 12.5 (11) 11.6 (10) 9.7 (8) 40.2 (34) 38.0 (32) 6.2 (5) 3.9 (3) 5.9 (5) 22.0 (19) 69.8 (59) 7.3 (6) 8.0 (7) 14.3 (12) 40.2 (34)
50–59
95.5 (23) 46.9 (11) 6.8 (2) 8.6 (2) 33.2 (8) 73.5 (18) 35.6 (9) 6.2 (2) 10.6 (3) 21.1 (5) 81.8 (20) 30.3 (7) 4.5 (1) 15.0 (4) 32.1 (8) 93.3 (22) 39.8 (10) 5.1 (1) 5.9 (1) 42.5 (10) 82.2 (20) 25.1 (6) 3.7 (1) 3.0 (1) 50.4 (12) 29.9 (7) 8.8 (2) 4.6 (1) 2.9 (1) 13.6 (3) 57.2 (14) 28.5 (7) 4.6 (1) 3.6 (1) 20.5 (5)
60+
2400 Dodge et al.
J Sex Med 2014;11:2396–2405
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Gay and Bisexual Men’s Lubricant Use Table 3 Weighted frequency of lubricant used for participants who reported lubricant use in the following contexts within the past 90 days
Recency of lubricant use Used a lubricant
Used a lubricant during solo masturbation Used a lubricant during partnered sexual play Used a lubricant during partnered intercourse Used a lubricant with a condom
Used a lubricant with a vibrator
Used a lubricant with a dildo
Once or twice 3–5 times 6–10 times More than 10 times Once or twice 3–5 times 6–10 times More than 10 times Once or twice 3–5 times 6–10 times More than 10 times Once or twice 3–5 times 6–10 times More than 10 times Once or twice 3–5 times 6–10 times More than 10 times Once or twice 3–5 times 6–10 times More than 10 times Once or twice 3–5 times 6–10 times More than 10 times
Bisexual % (n)
Gay/ homosexual % (n)
20.13 (10) 27.11 (13) 8.37 (4) 44.39 (21) 12.21 (5) 21.56 (9) 8.27 (3) 57.96 (24) 23.78 (5) 10.63 (2) 10.80 (2) 54.80 (12) 18.57 (4) 11.74 (3) 16.59 (4) 53.10 (12) 20.72 (4) 24.54 (5) 5.35 (1) 49.40 (9) 38.95 (4) 31.69 (3) 15.00 (2) 14.36 (1) 39.81 (8) 34.05 (7) 22.59 (5) 3.56 (1)
18.97 (43) 13.23 (30) 12.58 (29) 55.22 (126) 26.61 (47) 12.45 (22) 14.62 (26) 46.33 (82) 20.56 (31) 19.47 (29) 13.37 (20) 46.60 (69) 20.93 (39) 18.09 (34) 20.64 (38) 40.34 (75) 29.08 (29) 23.71 (24) 20.94 (21) 26.27 (26) 37.13 (20) 53.71 (29) 2.16 (1) 7.00 (4) 44.95 (34) 29.88 (22) 8.64 (6) 16.54 (12)
asked how frequently they used lubricant within that context. Overall, the largest percentage of participants reported using lubricant more than 10 times within the past 90 days. The exception to this was toy use with the largest percentage of participants reporting using a lubricant with a vibrator and/or dildo once or twice over the previous 90 days (represented in Table 3). The other exception was lubricant use with condoms. Gay/ homosexual men were approximately evenly distributed in their reported frequency of lubricant use with condoms (once or twice, 3–5 times, 6–10 times, more than 10 times). Lubricant use was commonly used during solo masturbation for both bisexual and gay/homosexual men.
Reasons for Using Lubricants Participants were asked to endorse a variety of reasons for first starting to use lubricants (represented in Table 4). The most commonly endorsed response for both bisexual and gay/homosexual participants included “to comfortably have anal sex.” The next top three reasons were the same for bisexual and gay/homosexual participants. They
included “curiosity,” “to make sex more comfortable,” and “for fun.” Similar percentages of bisexual and gay/homosexually identified participants endorsed the remainder of the items with the exception of “to manage vaginal pain.” The reasons that participants indicated starting to use lubricant during sexual activities were similar for gay/homosexual and bisexual participants. The three most frequently endorsed reasons included a desire to reduce discomfort/pain, make sex more pleasurable, and because their partner recommended it. Few participants were recommended to use by a doctor/nurse or health educator.
Perceptions of Sexual Experience with Lubricants The majority of participants reported agreeing with the statements that lubricants enhanced their
Table 4 Lubricant users’ reasons for lubricant use by sexual orientation using post-stratification weights Gay/ Bisexual homosexual (n = 101) (n = 332) % (n) % (n)
Reason for use Reason for first starting use To comfortably have anal sex Curiosity To make sex more comfortable For fun To reduce the risk of tearing To make sex feel more wet To add pleasurable sensations to sex My partner wanted us to To enhance foreplay To manage vaginal pain To reduce the risk of condom breakage To spice up my/our sex life A friend said it was fun to use My (or my partner’s) body changed during pregnancy Other While postpartum/nursing Because of medication use/surgery Approaching menopause Reason for first starting use during sexual activities I wanted to reduce discomfort or pain during sex I wanted to make sex more pleasurable My partner suggested we use lubricant I noticed that lubricated condoms felt more comfortable A friend recommended lubricant Other I saw an advertisement for lubricant A doctor or nurse recommended lubricant A health educator or sex educator recommended lubricant A family member recommended lubricant
55.3 (57) 46.3 (47) 44.2 (45) 43.4 (44) 23.2 (24) 20.0 (20) 19.6 (20) 18.4 (19) 18.3 (19)
56.0 (189) 29.8 (101) 49.8 (168) 32.5 (110) 21.9 (74) 17.4 (59) 24.8 (84) 24.5 (83) 15.5 (52) 0.5 (2) 13.4 (14) 13.8 (47) 7.8 (8) 4.8 (16) 7.1 (7) 6.8 (23) 1.4 (1) 0.4 (2) 1.0 (1) 0.6 (1) 0.1 (0) 0.0 (0)
1.2 (4) 0.0 (0) 0.3 (1) 0.0 (0)
46.7 (48) 49.5 (167) 32.8 (34) 38.6 (131) 25.5 (26) 35.1 (118) 20.7 (21) 15.1 (51) 14.0 (14) 15.5 (52) 7.5 (8) 5.3 (18) 6.8 (7) 5.1 (17) 3.6 (4) 1.1 (4) 0.5 (1)
3.3 (11)
0.0 (0)
0.2 (1)
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Dodge et al.
Table 5
Perceptions of lubricant use by age using post-stratification weights Bisexual (n = 101)
Gay/homosexual (n = 332)
Using lubricant during sexual activities . . .
% disagree
% agree
Age by statement agreement† Odds ratio (95% CI)
Makes Makes Makes Is only Makes
33.3 34.5 25.8 97.2 10.4
66.7 65.5 74.2 2.8 89.6
1.03 (1.00–1.07) 1.02 (0.99–1.06) 1.03 (0.99–1.07) 1.25* (1.02–1.54) 0.97 (0.92–1.02)
it easier to feel aroused it easier to have an orgasm sex feel better for older people sex more comfortable
% disagree
% agree
Age by statement agreement† Odds ratio (95% CI)
21.7 26.8 11.8 93.7 5.9
78.3 73.2 88.2 6.3 94.1
0.98* (0.96–1.00) 0.98* (0.96–1.00) 1.02 (0.99–1.04) 0.95** (0.91–0.99) 1.01 (0.97–1.05)
*P ≤ 0.05, **P ≤ 0.01, ***P ≤ 0.005, ****P ≤ 0.001 †An odds ratio over 1.0 indicates increased agreement with the statement for every 1 year in age CI = confidence interval
sexual experiences (Table 5). The most highly endorsed item included using a lubricant during sexual activities “makes sex more comfortable” (bisexual 89.6%, gay/homosexual 94.1%). Overall, a higher percentage of gay/homosexual men tended to agree with the statements than bisexual participants. A small minority of the participants agreed with the statement that using lubricants during sexual activities “is only for older people” (bisexual 2.8%, gay/homosexual 6.3%). Age was a significant predictor of agreement with the statements using a lubricant during sexual activities makes it easier to “feel aroused” and “to have an orgasm” for gay/homosexual participants. Age was a significant predictor of the statement using lubricant during sexual activities “is only for older people” for all participants regardless of sexual orientation. However, younger gay/homosexual participants were less likely to endorse this statement (odds ratio [OR] = 0.95, P < 0.01), while older bisexual participants were more likely to indicate agreement (OR = 1.25, P < 0.05). Discussion
In a nationally representative probability sample of men aged 18 years and older in the United States—the 2012 NSSHB—it was found that the vast majority of self-identified gay and bisexual men have used lubricant, that lubricant use is prevalent across age cohorts, and that gay and bisexual men largely use lubricant during sexual activities for reasons related to increasing comfort and pleasure (including, but not limited to, during anal intercourse). These data underscore the widespread use of lubricants as sexual enhancement products among gay and bisexual men and their sexual partners. The frequent use of such products highlights the need for increased awareness of lubricant use as a common component of gay and J Sex Med 2014;11:2396–2405
bisexual men’s routine sexual behaviors, both in terms of understanding an individual’s sexual history in a clinical context and for educational interventions among public health practitioners. This study had both strengths and limitations. A significant strength is that sexual behavior and lubricant use were assessed in a subsample of a nationally representative probability sample of individuals aged 18 and older in the United States. Participants were able to complete the survey via the Internet, thus facilitating privacy, ease of access, and perhaps greater comfort responding to questions of a sensitive nature. Men were eligible to be part of the GfK’s KnowledgePanel—and thus part of the study—regardless of their financial or technological resources. That is, if they lacked Internet access or the hardware or software necessary to complete Internet-based surveys for the panel, they were provided with the needed resources as part of GfK membership. Participants were also already familiar with completing GfK surveys and thus did not require additional training regarding survey completion. The survey was also available in both English and Spanish languages. A limitation is that the sample was restricted to individuals who had a home address and who were community dwelling (e.g., not institutionalized, not homeless, etc.). This may have limited the sample, particularly for much older individuals, those experiencing health conditions that warrant inpatient care, and those who deal with issues related to housing instability. Some men may not have felt comfortable answering questions about their sexual or lubricant use behaviors or may not have understood the questions (and because the survey was administered online, they would not have been able to ask for clarification). Although we defined what we meant by a “lubricant” at various points throughout the survey, it is possible
Gay and Bisexual Men’s Lubricant Use that some participants had different definitions in mind. However, we expect that this number would be small enough so as not to have a significant influence on our findings. Although we were able to avoid using convenience sampling strategies for recruiting gay and bisexual men, participants in our study were classified as “gay” or “bisexual” based on their sexual self-identification, which may or may not accurately reflect their recent or routine sexual behaviors in terms of gender of their sexual partners. It may be that nongay-identified men who have sex with other men may use lubricants in different ways, and for different reasons, than their gay-identified counterparts. Our focus on sexual self-identity, rather than behavior, is a starting point for using probability sampling techniques for recruiting nonheterosexual populations. The data presented in this article provide a preliminary understanding of lubricant use behaviors among gay and bisexual men, but more refined data regarding the context of the specific sexual encounter are warranted. We have collected more specific data on gay and bisexual men’s lubricant use at the sexual event level to explore differences in, for example, experiences of pleasure and/or pain depending on whether the most recent sexual event involved insertive and/or receptive anal sex. We are currently analyzing these data to report in a separate article focused specifically on lubricant use at the event level. Lastly, in terms of sexual health implications, it is important to bear in mind that recent evidence has emerged, which suggests that some rectal lubricant products may be associated with increased rectal epithelial sloughing, higher in vitro HIV-1 replication, and higher odds of other sexually transmitted infection (STI) acquisition [21]. While we have emphasized lubricant use among gay and bisexual men in terms of sexual health and wellness, this evidence presents cause for concern as some lubricants may have compromising effects on rectal epithelial tissue. Further rigorous research and product development are recommended, particularly given the results finding such widespread use of lubricants among gay and bisexual men, including better testing of personal lubricant safety specifically in the context of ano-rectal sexual activity. It is noteworthy that among participants who reported using lubricant during the recent past (i.e., 90 days), the majority used lubricant at a relatively high frequency (more than 10 times) during this time frame. Among recent users, lubricant use was also frequent during partnered intercourse and also in tandem with condom use. This sug-
2403 gests that whether for purposes of sexual pleasure or sexual protection (or both), gay and bisexual men who utilize lubricants during sexual activity are likely to be adherent to using them as a routine part of their overall sexual repertoire. This finding may be of utility not only to clinicians and public health practitioners (who may promote lubricant use for routine use for gay and bisexual men who are seeking to decrease both sexual pleasure and potential sexual risk with potential partners), but also to corporate health care and other professionals who are seeking to promote lubricant use (who may utilize these findings as evidence that gay and bisexual men are likely a viable segment of the population to market to with sexual health enhancement products for both solo and partnered sexual activities). As sexual enhancement products become more widely available and marketed, research needs to be attentive to diverse forms of sexual expression and the increasing integration of such products into sexual activities for nonheterosexual individuals and partnerships. Gay and bisexual men reported a wide range of reasons for using lubricant use during sexual activity. The most commonly reported reason for using lubricant during partnered sexual activities included managing pain during anal intercourse with male partners and, with bisexual participants, also managing pain during vaginal intercourse with female sexual partners. These reasons are in line with those reported by heterosexual male and female counterparts in other samples. They also indicate that engaging in certain behaviors (e.g., anal intercourse) may introduce people to certain sexual enhancement products, such as lubricant, which is more commonly used as part of anal penetration compared with other sexual activities. Additionally, in terms of perceptions of lubricant use among gay and bisexual men, the majority of men who have used lubricants endorse that they do, indeed, decrease discomfort and increase sexual pleasure during partnered sexual activities. These findings are of great significance in terms of future public health efforts aiming to increase rates of lubricant use (in addition to condom use) among gay and bisexual men. For scientists engaged in work related to sexual health, this study provides the first comprehensive and nationally representative investigation of issues related to lubrication and lubricant use among gay and bisexual men. As a result, the findings will be valuable to those who need accurate prevalence rates on U.S. gay and bisexual men in these areas. Additionally, given that issues related to sexuality conJ Sex Med 2014;11:2396–2405
2404 tinue to present challenges to the well-being of individuals and that sexuality is a core component of our human existence, having data that help individuals in the general population to compare their sexual behaviors with others in a scientifically valid way can be normalizing and helpful. Traditional HIV prevention messages for gay and bisexual men have historically been framed in terms of a sexual risk-reduction perspective (i.e., promoting lubricant use to minimize potential tears in the ano-rectal region of the receptive sexual partner, thereby reducing likelihood that HIV may be transmitted from one partner to another). Given that most gay and bisexual men report using lubricant to facilitate comfort during sex, health promotion messages that are framed in terms of increasing sexual comfort and pleasure for both insertive and receptive sexual partners (along with explanations of how this will simultaneously help to reduce potential sexual risk) may be most effective in terms of their relevance and likelihood of use by gay and bisexual men. Public health’s traditional emphasis on sexual risk has often obfuscated the need to provide comprehensive information on the importance of sexual comfort, pleasure, and enhancement among gay and bisexual men (in addition to evidence-based recommendations for decreasing sexual risk behavior among men whose partners may be at risk for transmission of HIV and other STIs).
Conclusions
Our findings from the 2012 NSSHB demonstrate that majority of self-identified gay and bisexual men in the United States have used lubricant during sexual activity, that lubricant use is common across all age groups, and that, as with their subgroups of men and women, some of the most common reasons why gay and bisexual men report using lubricant relate to enhancing comfort and pleasure. While these men most commonly report using lubricant to facilitate comfort during anal intercourse, they also report using lubricant during a wide range of other solo and partnered sexual behaviors. Both public health practitioners and clinicians may use these data in their efforts to incorporate lubricant use into future sexual health promotion efforts, which may benefit from framing lubricant use among gay and bisexual men as useful for both decreasing potential sexual risk and also increasing sexual pleasure for these men and their sexual partners. J Sex Med 2014;11:2396–2405
Dodge et al. Acknowledgments
The authors are grateful to Church & Dwight Co., Inc. for a grant in support of this research. Corresponding Author: Debby Herbenick, PhD, MPH, Center for Sexual Health Promotion, Indiana University, SPH 116, Bloomington, Indiana 47405, USA. Tel: (1) 812-8557011; E-mail: [email protected] Conflict of Interest: Michael Reece is a member of the sexual health advisory council of Church & Dwight, Co., Inc., the maker of Trojan brand sexual health products. Statement of Authorship
Category 1 (a) Conception and Design Debby Herbenick; Brian Dodge; Vanessa Schick; Michael Reece; J. Dennis Fortenberry; Stephanie A. Sanders (b) Acquisition of Data Debby Herbenick; Brian Dodge; Vanessa Schick; Michael Reece; Stephanie A. Sanders; J. Dennis Fortenberry (c) Analysis and Interpretation of Data Vanessa Schick; Brian Dodge; Debby Herbenick
Category 2 (a) Drafting the Article Brian Dodge; Vanessa Schick; Debby Herbenick (b) Revising It for Intellectual Content Debby Herbenick; Brian Dodge; Vanessa Schick; Michael Reece; Stephanie A. Sanders; J. Dennis Fortenberry
Category 3 (a) Final Approval of the Completed Article Debby Herbenick; Brian Dodge; Vanessa Schick; Michael Reece; Stephanie A. Sanders; J. Dennis Fortenberry References 1 Martin DJ. Inappropriate lubricant use with condoms by homosexual men. Public Health Rep 1992;107:468–73. 2 Kiran D, Manjunath R, Aswin KK, Patil BK, Mahabalaraju DK. A study on risk factors associated with inconsistent condom and lubricant use among men who have sex with men in central Karnataka, India. Australas Med J 2011;4: 469–73. 3 Butler LM, Osmond DH, Jones AG, Martin JN. Use of saliva as a lubricant in anal sexual practices among homosexual men. J Acquir Immune Defic Syndr 2009;50:162–7. 4 Carballo-Diéguez A, Stein Z, Sáez H, Dolezal C, Nieves-Rosa L, Díaz F. Frequent use of lubricants for anal sex among men who have sex with men: The HIV prevention potential of a microbicidal gel. Am J Public Health 2000;90:1117–21. 5 Gross M, Buchbinder SP. Rectal microbicides for U.S. gay men. Sex Transm Dis 1998;25:296–302.
Gay and Bisexual Men’s Lubricant Use 6 Clark JL, Salvatierra HJ, Segura ER, Salazar X, Konda K, Galea J, Klausner JD, Coates TJ, Caceres CF. Frequency, patterns, and preferences of lubricant use during anal intercourse within male sexual partnerships in Lima, Peru: Implications for a rectal microbicide HIV prevention intervention. AIDS Care 2013;25:579–85. 7 Herbenick D, Reece M, Schick V, Sanders SA, Fortenberry JD. Women’s use and perceptions of commercial lubricants: Prevalence and characteristics in a nationally representative sample of American adults. J Sex Med 2014;11:642–52. 8 Reece M, Herbenick D, Schick V, Sanders SA, Fortenberry JD. Men’s use and perceptions of commercial lubricants: Prevalence and characteristics in a nationally representative sample of US adults. J Sex Med 2014;11:1125–35. 9 Reece M, Mark KP, Herbenick D, Jawed-Wessel S, Hensel D, Dodge B. An event-level analysis of adding exogenous lubricant to condoms in a sample of men who have vaginal sex with women. J Sex Med 2012;9:672–8. 10 Rosen RC, Bachmann GA, Reese JB, Gentner L, Leiblum S, Wajszczuk C, Wanser R. Female sexual well-being scale™ (FSWB Scale™): Development and Psychometric validation in sexually functional women. J Sex Med 2009;6:1297–305. 11 Hoffman S, Morrow K, Mantell J, Rosen R, Carballo-Diéguez A, Gai F. Covert use, vaginal lubrication, and sexual pleasure: A qualitative study of Urban U.S. women in a vaginal microbicide clinical trial. Arch Sex Behav 2010;39:748–60. 12 Meyer IH, Wilson PA. Sampling lesbian, gay, and bisexual populations. J Couns Psychol 2009;56:23–31. 13 Dodge B, Sandfort TGM. A review of mental health research on bisexual individuals when compared to homosexual and heterosexual individuals. In: Firestein BA, ed. Becoming visible: Counseling bisexuals across the lifespan. New York, NY: Columbia University Press; 2007:28–51.
2405 14 Dodge B, Schnarrs PW, Reece M, Goncalves G, Martinez O, Nix R, Malebranche D, Van Der Pol B, Murray M, Fortenberry JD. Community involvement among behaviourally bisexual men in the Midwestern USA: Experiences and perceptions across communities. Cult Health Sex 2012;14:1095–110. 15 Reece M, Herbenick D, Schick V, Sanders SA, Dodge B, Fortenberry JD. Sexual behaviors, relationships, and perceived health among adult men in the United States: Results from a national probability sample. J Sex Med 2010;7:291–304. 16 Sanders SA, Reece M, Herbenick D, Schick V, Dodge B, Fortenberry JD. Condom use during most recent vaginal intercourse event among a probability sample of adults in the United States. J Sex Med 2010;7:362–73. 17 Silver RC, Holman EA, McIntosh DN, Poulin M, Gil-Rivas V. Nationwide longitudinal study of psychological responses to September 11. JAMA 2002;288:1235–44. 18 Baker L, Wagner TH, Singer S, Bundorf MK. Use of the internet and e-mail for health care information: Results from a national survey. JAMA 2003;289:2400–6. 19 Heiss F, McFadden D, Winter J. Who failed to enroll in Medicare Part D, and why? Early results. Health Aff 2006;25:w344–54. 20 Herbenick D, Schick V, Reece M, Sanders SA, Smith N, Dodge B, Fortenberry JD. Characteristics of condom and lubricant use among a nationally representative probability sample of adults ages 18–59 in the United States. J Sex Med 2013;10:474–83. 21 Gorbach PM, Weiss RE, Fuchs E, Jeffries RA, Hezerah M, Brown S, Voskanian A, Robbie E, Anton P, Cranston RD. The slippery slope: Lubricant use and rectal sexually transmitted infections: A newly identified risk. Sex Transm Dis 2012; 39:59–64.
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