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AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
The sexual behaviour of young gay men in England and Wales a
b
b
b
P. M. Davies , P. Weatherburn , A. J. Hunt , F. C. I. Hickson , T. c
J. McManus & A. P. M. Coxon
a
a
Project SIGMA and Department of Sociology , University of Essex , Colchester b
South Bank Polytechnic , London
c
King's College Hospital , London, UK Published online: 25 Sep 2007.
To cite this article: P. M. Davies , P. Weatherburn , A. J. Hunt , F. C. I. Hickson , T. J. McManus & A. P. M. Coxon (1992) The sexual behaviour of young gay men in England and Wales, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 4:3, 259-272, DOI: 10.1080/09540129208253098 To link to this article: http://dx.doi.org/10.1080/09540129208253098
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
AIDS CARE, VOL. 4, NO.3,1992
259
The sexual behaviour of young gay men in England and Wales
Downloaded by [York University Libraries] at 05:41 14 November 2014
P. M. DAVIES',P. WEATHER BURN^, A. J. HUNT^, F. C. I. HICK SON^, T. J. MCMANUS3 & A. P. M. COXON' Project SIGMA and 'Department of Sociology, University of Essex, Colchester; 2South Bank Polytechnic, London and 3King's College Hospital, London, UK
Abstract Much research has concluded that young gay men are at disproportionately higher risk of HIV infection through unsafe sexual behaviour. This paper is the first report on this particular group in the UK. As part of a larger cohort study, 111 young ((21) gay and bisexual men were interviewed about their sexual behaviour, knowledge of AIDS and HIV; particularly safer sexual practices and other factors. Three per cent had not had sex and 13% had not had anal intercourse with a man at the time of interview. Forty-five per cent had sexual expm'ence with a woman and 34% had engaged in vaginal intercourse. The average age at first homosexual experience was just under 15 years and this is higher than other age groups in the cohort. Median number of male partners in the year before interview was 5, with 1 of whom anal intercourse occurred. Sexual repertoire was relatively resm'cted compared to older men. Condom use was slightly more consistent and levels of knowledge not significantly different. From these findings, the contention that young gay men are at higher risk of HIV infection through risky sexual behaviour is not supported.
Introduction There has been a great deal of research in the UK and elsewhere into the impact of HIVIAIDS on young people. The majority of research papers concentrate on beliefs about, and attitudes towards HIV/AIDS (e.g. Warwick et al., 1988a, b), and on knowledge of its modes of transmission and safer sexual practices (e.g. DiClemente et al., 1986, Kegeles et al., 1988; Crawford & Kippax, 1990). Where data on actual sexual practice are reported, it is assumed implictly to be heterosexual (Abrams et al., 1990; Sneddon & Kremer, 1988). The reader is left to ponder whether this invisibility of young lesbians and gay men is because they have chosen not to speak of their experiences; because authors have omitted to report it or, as we rather suspect, researchers have never thought to ask them. It is true that some papers on young people report data on 'sexual partners' (itself not an unambiguous notion-see Hunt & Davies, 1991) undifferentiated by gender, but the presumption in the consequent discussion remains that these are other-sex partners.
Address for correspondence: Michael Stephens, Project SIGMA, South Bank University, 103 Borough Road, London SE1 OAA, UK.
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260 P. M.DAVIES ETAL. Conversely, the difficulties of recruiting men under the current UK legal age of consent have also meant that this particular group remains largely invisible even in studies that look specifically into gay patterns of response to AIDS (see, for example, Fitzpatrick et al., 1990). The assumption that the romantic/sexual/relational experience of young lesbians and gay men is the same as that of the young heterosexual person or of older gay men is certainly not to be assumed without investigation. It is the aim of this paper to report some baseline data on the sexual practices of gay and bisexual men under the age of 21. A number of studies in the United States have reported data on ‘young gay men’ (e.g. Ramafedi, 1987; Kelly et al., 1990; Hays et al., 1990; Ekstrand & Coates, 1990), and concluded that this group is more likely to engage in ‘high HIV risk taking’ than older men. However, these findings are not replicated in studies by Soskolne et al. (1991) and Connell & Kippax (1 990). There are methodological reasons to suspect both the focus of interest on young people and the findings that emerge from this first set of studies. First, since the beginning of the epidemic, certain groups have been identified as problems, most notoriously the ‘risk groups’ of the early 1980s. It may mean that ‘young people’, or as they are often condescendingly termed, ‘adolescents’, are the latest group to suffer from this stigmatization. The focus of interest on the sexual risk-taking of young people derives in large measure from an ideological belief in the intrinsic irresponsibility of ‘adolescents’ (Warwick ?i Aggleton, 1990) and we should not be surprised to find researchers reporting risky behaviour. We suspect that within all social and demographic groups there will be behaviour that carries a risk from HIV and that the concern currently manifested over the behaviour of young people is generated and sustained by the ever increasing number of research studies focusing on them. Secondly, we are asked to believe that young people in general are more likely to engage in risky behaviour than other groups. It is far from clear what ‘other groups’ this comparison should be made with. Studies which concentrate exclusively on young people often make comparison with other studies with different sampling designs and research methodologies, most specifically and germanely, different ways of defining ‘safe’ and ‘unsafe’ sex and even the notion of ‘sexual partner’. With such methodological divergence, the comparability of studies in general and the conclusion that there is more ‘unsafe sex’ among young people in particular, must be examined critically and certainly not accepted as proven. Even those studies (like this one) which report data on a young sub-group of a larger study, will find it difficult to distinguish ‘more risky sex’ from ‘more sex’. Thirdly, and in continuation of the preceding point, it must be acknowledged to be difficult and dubious to compare findings from studies in different countries. It is at least possible that among the many factors now found to influence sexual behaviour and risktaking, cultural/national specificities might be significant. This is particularly true when the city under study is San Francisco (e.g. Ekstrand & Coates, 1990; Hays et al., 1990) whose particular role in the history of AIDS surely renders it unique and makes the generalisability of behavioural findings to other cities in the USA and other cities world-wide at least dubious. Fourthly, it is rare in any case for researchers to address the question of what is an ‘acceptable’ level of risk behaviour amongst a particular group, or to describe the imaginary ‘safe’ demographic group with which comparison is being made. For example, Hays et al. (1 990, p. 904) state that their research “found a high rate of HIV sexual risk taking among gay men aged 18-25”. Yet they do not report any comparisons with older men from the sample areas on which this assertion can be validated. Overall, in the literature pertaining to homosexual behaviour, the abiding impression is that researchers would like to see a return of rates such as those found in San Francisco in 1986 of 6Yo (Winkelstein et al., 1987). This
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SEXUAL BEHAVIOUR OF YOUNG GAY MEN
26 1
is simply unrealistic. We have commented elsewhere (Davies & Weatherburn, 1991) on the puritanical agenda which underpins much research in this area. We repeat here that the measurement of gross rates of particular behaviours, while of some epidemiological significance, does not reflect the subtle and often complex patterning of sexual activity that characterizes male-male sexual behaviour a decade into the pandemic. Fifthly, and in many ways most importantly, it should also be noted that the ceiling age in the definitions of ‘young’ ranges in these papers from 18 (DiClemente et al., 1986) to 25 (Hays et al., 1990) to 30 (Hays et al., 1991; Stall et al., 1991). Indeed, the paper by Wangel (1987) on ‘young people’ includes an age range from 15 to 71! It may be that these different boundaries reflect specific features of the research sites in question. Our choice of 21 as the upper age limit for our discussion of ‘young’ gay men is dictated by the particular legal situation current in the UK and it may be that in San Francisco the group under the age of 30 forms a distinct and homogenous social sub-group. We suspect, however, that many of these differences are due to the ease of sampling students in schools or colleges (e.g. Clift et al., 1990; Currie, 1990; DiClemente et al., 1986; Ford, 1988) or other adventitious features of the research process. Whatever the case, comparison remains a dubious and doubtful enterprise. Given the wide variations in method and approach in studies in this area, it is therefore important to treat with caution any conclusions which compare findings from different studies. In addition to the methodological problems associated with research on this group, the explanatory mechanisms which are invoked to explain research findings also betray an ideological basis in favour of pathologizing the young men involved. Hays et al. (1990, p. 901) identify four factors which they believe “may contribute to high HIV risk raking”. The authors state that the young men: may still be in a ‘coming out’ stage.. .[and] not fully identify themselves as ‘gay’ and therefore may not perceive themselves to be in a ‘risk group’ [sic] for AIDS. Due to their relative inexperience in personal and sexual relationships [they may be] less competent in negotiating low risk sexual interactions. Young people in general have heightened feelings of invulnerability, which may cause younger men to engage in more HIV risk behaviours than older men. Finally, since the bulk of AIDS cases among gay men are in the 30-40 age group, younger men may perceive AIDS to be a problem of older gay men. It should be noted that these are not findings. The research has not demonstrated that these are the relevant factors predicting differences of behaviour in this cohort. They are mere speculations about the possible factors. Yet the impression must remain with the reader that these have more than mere speculative force and add to the growing body of received though undemonstrated wisdom that young men are particularly vulnerable to risk taking. Moreover, it seems perverse to accuse young men of sexual inexperience when we are talking of a group with the mean age of 22.5, who have been sexually active since the age of 16.4 (Hays et al., 1990, p. 903), and since 64% had taken an HIV antibody test, the assertion that they do not see themselves as a ‘risk group’ seems dubious. There is a deal of anecdotal evidence to suggest that young men do indeed see older men as more at risk from HIV infection than they themselves are, but this is a matter of degree. There seems to be little difference between this blaming response by young gay men and the more general stigmatization of young gay men (and indeed young people generally) by many social and behavioural researchers working in the field of HIV/AIDS.
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The situation in the UK Young gay men in the UK find themselves in a particularly difficult position with respect both to the law, and access to health education. The Sexual Offences Act of 1967 stipulates 21 as the age of homosexual consent*. Men under that age, but particularly their sexual partners over that age, are at risk of prosecution for consensual sexual behaviour in private (Crane, 1980; Howard League, 1985; Tatchell, 1991). Statutory sector HIVIAIDS education initiatives targeted at young people usually assume that their audience is entirely heterosexual and that the needs of the homosexual minority will be met by initiatives emanating from within the voluntary sector (Homans & Aggleton, 1988; Weatherburn & Hunt, 1992). While it is certainly the case that the earliest and most effective health education initiatives have come from the gay community, they will have failed, and continue to fail, to reach those men who have not (yet) found their way into mainstream gay communities. It is unlikely that schools will provide the sort of information needed by young homosexual men, since they are required by the 1988 Education Act to deal with sex education within the context of the family, and emphasise love, marriage and procreation. Unlike other European countries (e.g. the Netherlands) there is little or no discussion of ‘healthy sexuality’. Section 28 of the 1988 Local Government Act further limits the possibility of positive discussion of homosexuality in schools and colleges. More importantly, in the UK voluntary agencies have rarely specifically targeted gay youth for HIV/AIDS health education initiatives (Weatherburn & Hunt, 1992). Young gay men in Great Britain remain, therefore, a group invisible in much research and ignored in much intervention work. In this paper, we present some baseline data on this group, using information gathered as part of Project SIGMA.
Methods Project SIGMAt is a longitudinal study of a non-clinic based cohort of homosexually active men. Between 1987 and 1988, 930 respondents were recruited from 10 main sites across England and Wales. Full details of the sample, interview procedures and the range of data collected, including their reliability and validity, can be found elsewhere (Davies et al., 1990; Weatherburn et al., 1991). Interviews cover a wide range of issues ranging from sexual history and current behaviour, social attitudes and behaviour, health issues, knowledge of and attitudes towards HIV/AIDS and condom use. Respondents are asked, but not required to provide blood and/or saliva for testing for HIV antibodies (Hunt et al., 1990) but refusal to provide blood does not exclude respondents from the study. On recruitment 111 (1 1.9%) of the men in the study were under the age of 21. These young men were recruited by a variety of means including: (i) response to a postal questionnaire in the gay press; (ii) recruitment in gay pubs, clubs and social and political organisations; (iii) lesbian and gay youth groups and student gay societies; and (iv) contacts of the above. Approximately one third of respondents came from sources (i); (ii) and (iii); and (iv) respectively.
*Following the recommendation of the Wolfenden Report (1957, paras 65-71), in which the main justification is that 21 was then the age of contractual responsibility. This is now of course 18. The age of consent remains at 21. tzocio-sexual jnvestigations of s a y Men and AIDS.
SEXUAL BEHAVIOUR OF YOUNG GAY MEN
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Results
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The demographic characteristics of these respondents are summarized in Table 1. Excluding criteria upon which an age effect is to be expected (for example, marital status, employment status and educational qualifications) there are no differences between this age group and the older cohort members. The only notable exception is current gay relationship status. Recent data from the West Coast of the USA (Hays et al., 1990) has suggested that young gay men (in this case under 25) are more likely to have a boyfriend or male lover and this appears to be the case with this sample. Moreover, if they do have a relationship, it is significantly more likely to be closed (‘monogamous’). In short, significantly fewer of the under 21s reported open relationships than older cohort members (x’ =21.05, d.f.=2, p t0.001). Table 1. Demographic charactm‘stics (n= 111) Age in years Median Mean Range
19 18.9 15-20
Gay relationship status (%) Closed monogamous One regular-tothers No regular partner
33.3 12.6 54.1
Marital status (%) Single Married
99.1 0.9
Educational level (%a> ‘0’ levels or less ‘A’levels and equivalent Degree or more
55.9 43.2 0.9
Sexual feelings* (%) Exclusively homosexual Predominantly homosexual Othee
62.2 29.7 8.1
Ever HIV antibody tested (%) No Yes
64.0 36.0
*Rated using the 7-point scale of Kinsey (1948). tKinsey ratings 0, 1,2, 3, and 4.
First (homo)sexual experience
Despite the legal prohibition and the problems with the gay scene we have noted, this group of men is sexually active and they have started their sexual careers at a relatively early age. As we can see from Figure 1 more than 50% had their first homosexual experience by age 16, and over 90% by 18. One of the concerns of the Wolfenden Committee (Home Office, 1957), and one which tacitly informs much British policy in the area is the belief that young men can be ‘seduced’ into homosexual behaviours by predatory older men. This is not borne out by our data, even though most respondents (92.6%) reported their first sexual experience occurred
264 P. M. DAVIES ET AL. 100
80
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-s E, u
40
20
0 l
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~
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1
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Age
FIG.1. Age ofjirst sexual experience.
with a male of the same age, or older. Nearly a half (39.4%) had their first experience with someone who was within a year of their own age; rising to 48.1% for within 2 years; 60.8% for 5 years; and 73.1% for 10 years. In all but two cases, this first experience was consensual and were usually reported to have occurred with friends (55.7%) or acquaintances (7.5%), or identifiable strangers (32%) such as someone they had just met in a park, pub or toilet. However, three of the first experiences were reported to have occurred with an authority figure and one each occurred with a brother and a cousin. While it is likely that these figures will underestimate the prevalence of non-consensual sex in childhood (see Hickson et al., 1992) the seduction thesis gains no support from this data. There is a widespread though largely unsubstantiated belief that the age at which people have their first sexual experience has decreased during this century (cf. Forman & Chilvers, 1989). Without contemporaneous evidence, such a statement is not easily proven, but if we take four decades in our cohort: those aged under 21, 21-29, 30-39, and those aged 40 or over, we may test the proposition. Since the older age groups contain men whose first homosexual experience is after the age of 21, and those in the under 21 age group are, with a few exceptions (n=3), sexually experienced we consider only those respondents whose reported age of first homosexual experience is under 2 1. Contrary to expectation, as Table 2 shows, the older the age group the younger the reported age at first (homo)sexual encounter (Frati,=5.029, d.f. =3, pt0.002). Thus, for those under 21 the mean age of first sexual experience with a male was 15. For those
SEXUAL BEHAVIOUR OF YOUNG GAY MEN
265
between 21 and 30, the man was 14.3; for those between 31 and 40, 14 and the over 40s report the youngest mean age, 13.4 years. The medians also reveal a similar trend. Table 2. Age ofjrst homosexual experience by age group
Age group
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Under 21s 21-29 30-39 40 f
Age of first homosexual experience Mean Median 15.00 14.31 13.96 13.42
15 14 14 14
Male sexual partners We move now to consider sexual behaviour from the specific point of view of HIV-risk. Project SIGMA makes the essential distinction between a sexual partner and a penetrative sexual partner or psp (Hunt et al., 1991; Hunt & Davies, 1991)-that is, a partner with whom anal intercourse occurs. Given the substantially greater probability of HIV infection as a result of engagement in anal intercourse (van Griensven et al., 1987; Hunt et al., 1990) than through other types of sex, the distinction between the gross number of partners and the number of psps is, we believe, crucial in understanding the response of homosexually active men to the threat of HIV infection, and the rate of spread of the epidemic. We typically find (Hunt et al., 1991) that, while numbers of partners are high, numbers of psps are low and this is the case with this group of young men. One hundred and eight (97.3%) of the 1 1 1 respondents reported at least one male sexual partner during their lifetimes, and 93 (83.3%) reported at least one male psp. In the year before interview, 107 (96.4%) reported a partner, and 85 (76.6%) a psp, and in the month preceding interview the figures are 83 (74.8%) and 52 (46.8%). Summary statistics for reported male partners and penetrative sexual partners (psps) are given in Table 3. Since all these distributions are highly skewed, towards the lower end, the median is the preferred measure of central tendency. Considering all the young men the median lifetime number of partners is 10, and 2 for psps. In the last year the median figures are 5 and 1 respectively, and in the last month there was a median number of 1 partner and no psps. Table 3. Summaly statistics of male sexual partners and penetrative sexual partners (PSPs) excluding far outliers Mean
Median
Male partners Whole life Last year Last month
15.5 6.6 1.3
10 5
Male PSPs Whole life Last year Last month
2.9 1.8 0.6
2 1
1
0
266
P. M. DAVIES ET AL.
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For all the time periods the proportion of psps to partners is low, that is, whilst the number of partners varies considerably, the proportion that are penetrative remains consistently low. As we have emphasized elsewhere there is no linear relationship between number of sexual partners and psps (Hunt et al., 1991), and thus it is essential to take account of numbers of psps-rather than partners-when making any assessment of the prevalence of unsafe sexual behaviour. Amongst these young men the mean lifetime proportion of sexual partners which were penetrative is 30.8% (median 22.7%); in the last year it is 37.4% (median 33.3%); and in the last month 52.1% (median 50.0%). Along with Jenkins et al. (1991) we believe that the number of psps is the most accurate indicator of risk behaviour. As it closely resembles that of older respondents, from this standpoint, the contention that gay young men are more at risk gains no support. Homosexual repertoire and current homosexual behaviour Table 4 outlines the proportion of the young men who have (a) ever engaged in each of 14 sexual practices (their cumulative sexual repertoire) with a male; (b) engaged in the acts with a male in the month preceding interview (their current behaviour); and (c) the ‘stapleness’ of each activity, defined as the number of those currently engaging expressed as a proportion of those who have ever done so. The lifetime sexual repertoire of a majority of these young men includes masturbation, fellatio, kissing, body-rubbing (frottage), anal fingering, massage, anal intercourse, anilingus and inter-crural intercourse. Only a minority reported ever having engaged in corporal punishment, ano-brachial insertion, lindinism, douching and coprophilia. Table 4. Percentage that have ever engaged in given sexual acts, percentage who had done so in the month preceding interview, and stapleness of these activities in sexual repertoire Sexual act Masturbation Fellatio Deep kissing Anal intercourse Receptive Insertive Body rubbing Anal fingering Massage Anilingus Inter-crural Int Corporal punishment Ano-brachial Ins Lindinism Douching Coprophilia
% Ever
% Current
% Staple
96 95 95 87 78 70 86 80 79
75 69 68 46 36 34 52 37 42 28 26 6 5 0 0 0
78 73 72 53 46 49 60 46 53 39 43 24 38 0 0 0
71
61 25 13 11
9 20
In the month preceding interview, this general pattern is repeated, although the absolute proportions involved are, of course, lower. There are only two, relatively minor, differences in the rank order of prevalence of the acts. The proportion of those currently engaging in acts which feature in their repertoire (the number currently engaging as a proportion of
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SEXUAL BEHAVIOUR OF YOUNG GAY MEN
267
those who have ever engaged) gives an indication of the relative popularity or frequency of the act in the repertoire. Among the nine majority acts, there are two distinct groups. Masturbation, fellatio and kissing are current activities for between 70% and 80% of those who have them in their repertoire and may, therefore, be regarded as staples of sexual activity. By contrast, anal intercourse, inter-crural intercourse and fingering currently feature for only between 39% and 53% and are, we conclude, relatively infrequent aspects of the sexual repertoire (body rubbing is interstitial at 61%). The proportion that currently engages in each of the sexual behaviours is statistically indistinguishable from the proportion of the older respondents (see Weatherburn, 1992). The younger men are, however, rather more likely to currently engage in receptive anal intercourse, where the difference approaches statistical significance (x’= 4.51 , d.f. = 1 , pt0.04). Whilst only 26.4% (n=216) of those over 21 engaged in receptive anal intercourse in the month preceding interview, 35.1% (n=39) of those under 21 did so. Multiple ANOVA shows however, that this difference can be accounted for by the higher rate of regular and monogamous partnerships (Table 1) among young gay men, (F=3.505,d.f.=5, p
AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
The sexual behaviour of young gay men in England and Wales a
b
b
b
P. M. Davies , P. Weatherburn , A. J. Hunt , F. C. I. Hickson , T. c
J. McManus & A. P. M. Coxon
a
a
Project SIGMA and Department of Sociology , University of Essex , Colchester b
South Bank Polytechnic , London
c
King's College Hospital , London, UK Published online: 25 Sep 2007.
To cite this article: P. M. Davies , P. Weatherburn , A. J. Hunt , F. C. I. Hickson , T. J. McManus & A. P. M. Coxon (1992) The sexual behaviour of young gay men in England and Wales, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 4:3, 259-272, DOI: 10.1080/09540129208253098 To link to this article: http://dx.doi.org/10.1080/09540129208253098
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
AIDS CARE, VOL. 4, NO.3,1992
259
The sexual behaviour of young gay men in England and Wales
Downloaded by [York University Libraries] at 05:41 14 November 2014
P. M. DAVIES',P. WEATHER BURN^, A. J. HUNT^, F. C. I. HICK SON^, T. J. MCMANUS3 & A. P. M. COXON' Project SIGMA and 'Department of Sociology, University of Essex, Colchester; 2South Bank Polytechnic, London and 3King's College Hospital, London, UK
Abstract Much research has concluded that young gay men are at disproportionately higher risk of HIV infection through unsafe sexual behaviour. This paper is the first report on this particular group in the UK. As part of a larger cohort study, 111 young ((21) gay and bisexual men were interviewed about their sexual behaviour, knowledge of AIDS and HIV; particularly safer sexual practices and other factors. Three per cent had not had sex and 13% had not had anal intercourse with a man at the time of interview. Forty-five per cent had sexual expm'ence with a woman and 34% had engaged in vaginal intercourse. The average age at first homosexual experience was just under 15 years and this is higher than other age groups in the cohort. Median number of male partners in the year before interview was 5, with 1 of whom anal intercourse occurred. Sexual repertoire was relatively resm'cted compared to older men. Condom use was slightly more consistent and levels of knowledge not significantly different. From these findings, the contention that young gay men are at higher risk of HIV infection through risky sexual behaviour is not supported.
Introduction There has been a great deal of research in the UK and elsewhere into the impact of HIVIAIDS on young people. The majority of research papers concentrate on beliefs about, and attitudes towards HIV/AIDS (e.g. Warwick et al., 1988a, b), and on knowledge of its modes of transmission and safer sexual practices (e.g. DiClemente et al., 1986, Kegeles et al., 1988; Crawford & Kippax, 1990). Where data on actual sexual practice are reported, it is assumed implictly to be heterosexual (Abrams et al., 1990; Sneddon & Kremer, 1988). The reader is left to ponder whether this invisibility of young lesbians and gay men is because they have chosen not to speak of their experiences; because authors have omitted to report it or, as we rather suspect, researchers have never thought to ask them. It is true that some papers on young people report data on 'sexual partners' (itself not an unambiguous notion-see Hunt & Davies, 1991) undifferentiated by gender, but the presumption in the consequent discussion remains that these are other-sex partners.
Address for correspondence: Michael Stephens, Project SIGMA, South Bank University, 103 Borough Road, London SE1 OAA, UK.
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260 P. M.DAVIES ETAL. Conversely, the difficulties of recruiting men under the current UK legal age of consent have also meant that this particular group remains largely invisible even in studies that look specifically into gay patterns of response to AIDS (see, for example, Fitzpatrick et al., 1990). The assumption that the romantic/sexual/relational experience of young lesbians and gay men is the same as that of the young heterosexual person or of older gay men is certainly not to be assumed without investigation. It is the aim of this paper to report some baseline data on the sexual practices of gay and bisexual men under the age of 21. A number of studies in the United States have reported data on ‘young gay men’ (e.g. Ramafedi, 1987; Kelly et al., 1990; Hays et al., 1990; Ekstrand & Coates, 1990), and concluded that this group is more likely to engage in ‘high HIV risk taking’ than older men. However, these findings are not replicated in studies by Soskolne et al. (1991) and Connell & Kippax (1 990). There are methodological reasons to suspect both the focus of interest on young people and the findings that emerge from this first set of studies. First, since the beginning of the epidemic, certain groups have been identified as problems, most notoriously the ‘risk groups’ of the early 1980s. It may mean that ‘young people’, or as they are often condescendingly termed, ‘adolescents’, are the latest group to suffer from this stigmatization. The focus of interest on the sexual risk-taking of young people derives in large measure from an ideological belief in the intrinsic irresponsibility of ‘adolescents’ (Warwick ?i Aggleton, 1990) and we should not be surprised to find researchers reporting risky behaviour. We suspect that within all social and demographic groups there will be behaviour that carries a risk from HIV and that the concern currently manifested over the behaviour of young people is generated and sustained by the ever increasing number of research studies focusing on them. Secondly, we are asked to believe that young people in general are more likely to engage in risky behaviour than other groups. It is far from clear what ‘other groups’ this comparison should be made with. Studies which concentrate exclusively on young people often make comparison with other studies with different sampling designs and research methodologies, most specifically and germanely, different ways of defining ‘safe’ and ‘unsafe’ sex and even the notion of ‘sexual partner’. With such methodological divergence, the comparability of studies in general and the conclusion that there is more ‘unsafe sex’ among young people in particular, must be examined critically and certainly not accepted as proven. Even those studies (like this one) which report data on a young sub-group of a larger study, will find it difficult to distinguish ‘more risky sex’ from ‘more sex’. Thirdly, and in continuation of the preceding point, it must be acknowledged to be difficult and dubious to compare findings from studies in different countries. It is at least possible that among the many factors now found to influence sexual behaviour and risktaking, cultural/national specificities might be significant. This is particularly true when the city under study is San Francisco (e.g. Ekstrand & Coates, 1990; Hays et al., 1990) whose particular role in the history of AIDS surely renders it unique and makes the generalisability of behavioural findings to other cities in the USA and other cities world-wide at least dubious. Fourthly, it is rare in any case for researchers to address the question of what is an ‘acceptable’ level of risk behaviour amongst a particular group, or to describe the imaginary ‘safe’ demographic group with which comparison is being made. For example, Hays et al. (1 990, p. 904) state that their research “found a high rate of HIV sexual risk taking among gay men aged 18-25”. Yet they do not report any comparisons with older men from the sample areas on which this assertion can be validated. Overall, in the literature pertaining to homosexual behaviour, the abiding impression is that researchers would like to see a return of rates such as those found in San Francisco in 1986 of 6Yo (Winkelstein et al., 1987). This
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is simply unrealistic. We have commented elsewhere (Davies & Weatherburn, 1991) on the puritanical agenda which underpins much research in this area. We repeat here that the measurement of gross rates of particular behaviours, while of some epidemiological significance, does not reflect the subtle and often complex patterning of sexual activity that characterizes male-male sexual behaviour a decade into the pandemic. Fifthly, and in many ways most importantly, it should also be noted that the ceiling age in the definitions of ‘young’ ranges in these papers from 18 (DiClemente et al., 1986) to 25 (Hays et al., 1990) to 30 (Hays et al., 1991; Stall et al., 1991). Indeed, the paper by Wangel (1987) on ‘young people’ includes an age range from 15 to 71! It may be that these different boundaries reflect specific features of the research sites in question. Our choice of 21 as the upper age limit for our discussion of ‘young’ gay men is dictated by the particular legal situation current in the UK and it may be that in San Francisco the group under the age of 30 forms a distinct and homogenous social sub-group. We suspect, however, that many of these differences are due to the ease of sampling students in schools or colleges (e.g. Clift et al., 1990; Currie, 1990; DiClemente et al., 1986; Ford, 1988) or other adventitious features of the research process. Whatever the case, comparison remains a dubious and doubtful enterprise. Given the wide variations in method and approach in studies in this area, it is therefore important to treat with caution any conclusions which compare findings from different studies. In addition to the methodological problems associated with research on this group, the explanatory mechanisms which are invoked to explain research findings also betray an ideological basis in favour of pathologizing the young men involved. Hays et al. (1990, p. 901) identify four factors which they believe “may contribute to high HIV risk raking”. The authors state that the young men: may still be in a ‘coming out’ stage.. .[and] not fully identify themselves as ‘gay’ and therefore may not perceive themselves to be in a ‘risk group’ [sic] for AIDS. Due to their relative inexperience in personal and sexual relationships [they may be] less competent in negotiating low risk sexual interactions. Young people in general have heightened feelings of invulnerability, which may cause younger men to engage in more HIV risk behaviours than older men. Finally, since the bulk of AIDS cases among gay men are in the 30-40 age group, younger men may perceive AIDS to be a problem of older gay men. It should be noted that these are not findings. The research has not demonstrated that these are the relevant factors predicting differences of behaviour in this cohort. They are mere speculations about the possible factors. Yet the impression must remain with the reader that these have more than mere speculative force and add to the growing body of received though undemonstrated wisdom that young men are particularly vulnerable to risk taking. Moreover, it seems perverse to accuse young men of sexual inexperience when we are talking of a group with the mean age of 22.5, who have been sexually active since the age of 16.4 (Hays et al., 1990, p. 903), and since 64% had taken an HIV antibody test, the assertion that they do not see themselves as a ‘risk group’ seems dubious. There is a deal of anecdotal evidence to suggest that young men do indeed see older men as more at risk from HIV infection than they themselves are, but this is a matter of degree. There seems to be little difference between this blaming response by young gay men and the more general stigmatization of young gay men (and indeed young people generally) by many social and behavioural researchers working in the field of HIV/AIDS.
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The situation in the UK Young gay men in the UK find themselves in a particularly difficult position with respect both to the law, and access to health education. The Sexual Offences Act of 1967 stipulates 21 as the age of homosexual consent*. Men under that age, but particularly their sexual partners over that age, are at risk of prosecution for consensual sexual behaviour in private (Crane, 1980; Howard League, 1985; Tatchell, 1991). Statutory sector HIVIAIDS education initiatives targeted at young people usually assume that their audience is entirely heterosexual and that the needs of the homosexual minority will be met by initiatives emanating from within the voluntary sector (Homans & Aggleton, 1988; Weatherburn & Hunt, 1992). While it is certainly the case that the earliest and most effective health education initiatives have come from the gay community, they will have failed, and continue to fail, to reach those men who have not (yet) found their way into mainstream gay communities. It is unlikely that schools will provide the sort of information needed by young homosexual men, since they are required by the 1988 Education Act to deal with sex education within the context of the family, and emphasise love, marriage and procreation. Unlike other European countries (e.g. the Netherlands) there is little or no discussion of ‘healthy sexuality’. Section 28 of the 1988 Local Government Act further limits the possibility of positive discussion of homosexuality in schools and colleges. More importantly, in the UK voluntary agencies have rarely specifically targeted gay youth for HIV/AIDS health education initiatives (Weatherburn & Hunt, 1992). Young gay men in Great Britain remain, therefore, a group invisible in much research and ignored in much intervention work. In this paper, we present some baseline data on this group, using information gathered as part of Project SIGMA.
Methods Project SIGMAt is a longitudinal study of a non-clinic based cohort of homosexually active men. Between 1987 and 1988, 930 respondents were recruited from 10 main sites across England and Wales. Full details of the sample, interview procedures and the range of data collected, including their reliability and validity, can be found elsewhere (Davies et al., 1990; Weatherburn et al., 1991). Interviews cover a wide range of issues ranging from sexual history and current behaviour, social attitudes and behaviour, health issues, knowledge of and attitudes towards HIV/AIDS and condom use. Respondents are asked, but not required to provide blood and/or saliva for testing for HIV antibodies (Hunt et al., 1990) but refusal to provide blood does not exclude respondents from the study. On recruitment 111 (1 1.9%) of the men in the study were under the age of 21. These young men were recruited by a variety of means including: (i) response to a postal questionnaire in the gay press; (ii) recruitment in gay pubs, clubs and social and political organisations; (iii) lesbian and gay youth groups and student gay societies; and (iv) contacts of the above. Approximately one third of respondents came from sources (i); (ii) and (iii); and (iv) respectively.
*Following the recommendation of the Wolfenden Report (1957, paras 65-71), in which the main justification is that 21 was then the age of contractual responsibility. This is now of course 18. The age of consent remains at 21. tzocio-sexual jnvestigations of s a y Men and AIDS.
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Results
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The demographic characteristics of these respondents are summarized in Table 1. Excluding criteria upon which an age effect is to be expected (for example, marital status, employment status and educational qualifications) there are no differences between this age group and the older cohort members. The only notable exception is current gay relationship status. Recent data from the West Coast of the USA (Hays et al., 1990) has suggested that young gay men (in this case under 25) are more likely to have a boyfriend or male lover and this appears to be the case with this sample. Moreover, if they do have a relationship, it is significantly more likely to be closed (‘monogamous’). In short, significantly fewer of the under 21s reported open relationships than older cohort members (x’ =21.05, d.f.=2, p t0.001). Table 1. Demographic charactm‘stics (n= 111) Age in years Median Mean Range
19 18.9 15-20
Gay relationship status (%) Closed monogamous One regular-tothers No regular partner
33.3 12.6 54.1
Marital status (%) Single Married
99.1 0.9
Educational level (%a> ‘0’ levels or less ‘A’levels and equivalent Degree or more
55.9 43.2 0.9
Sexual feelings* (%) Exclusively homosexual Predominantly homosexual Othee
62.2 29.7 8.1
Ever HIV antibody tested (%) No Yes
64.0 36.0
*Rated using the 7-point scale of Kinsey (1948). tKinsey ratings 0, 1,2, 3, and 4.
First (homo)sexual experience
Despite the legal prohibition and the problems with the gay scene we have noted, this group of men is sexually active and they have started their sexual careers at a relatively early age. As we can see from Figure 1 more than 50% had their first homosexual experience by age 16, and over 90% by 18. One of the concerns of the Wolfenden Committee (Home Office, 1957), and one which tacitly informs much British policy in the area is the belief that young men can be ‘seduced’ into homosexual behaviours by predatory older men. This is not borne out by our data, even though most respondents (92.6%) reported their first sexual experience occurred
264 P. M. DAVIES ET AL. 100
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FIG.1. Age ofjirst sexual experience.
with a male of the same age, or older. Nearly a half (39.4%) had their first experience with someone who was within a year of their own age; rising to 48.1% for within 2 years; 60.8% for 5 years; and 73.1% for 10 years. In all but two cases, this first experience was consensual and were usually reported to have occurred with friends (55.7%) or acquaintances (7.5%), or identifiable strangers (32%) such as someone they had just met in a park, pub or toilet. However, three of the first experiences were reported to have occurred with an authority figure and one each occurred with a brother and a cousin. While it is likely that these figures will underestimate the prevalence of non-consensual sex in childhood (see Hickson et al., 1992) the seduction thesis gains no support from this data. There is a widespread though largely unsubstantiated belief that the age at which people have their first sexual experience has decreased during this century (cf. Forman & Chilvers, 1989). Without contemporaneous evidence, such a statement is not easily proven, but if we take four decades in our cohort: those aged under 21, 21-29, 30-39, and those aged 40 or over, we may test the proposition. Since the older age groups contain men whose first homosexual experience is after the age of 21, and those in the under 21 age group are, with a few exceptions (n=3), sexually experienced we consider only those respondents whose reported age of first homosexual experience is under 2 1. Contrary to expectation, as Table 2 shows, the older the age group the younger the reported age at first (homo)sexual encounter (Frati,=5.029, d.f. =3, pt0.002). Thus, for those under 21 the mean age of first sexual experience with a male was 15. For those
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265
between 21 and 30, the man was 14.3; for those between 31 and 40, 14 and the over 40s report the youngest mean age, 13.4 years. The medians also reveal a similar trend. Table 2. Age ofjrst homosexual experience by age group
Age group
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Under 21s 21-29 30-39 40 f
Age of first homosexual experience Mean Median 15.00 14.31 13.96 13.42
15 14 14 14
Male sexual partners We move now to consider sexual behaviour from the specific point of view of HIV-risk. Project SIGMA makes the essential distinction between a sexual partner and a penetrative sexual partner or psp (Hunt et al., 1991; Hunt & Davies, 1991)-that is, a partner with whom anal intercourse occurs. Given the substantially greater probability of HIV infection as a result of engagement in anal intercourse (van Griensven et al., 1987; Hunt et al., 1990) than through other types of sex, the distinction between the gross number of partners and the number of psps is, we believe, crucial in understanding the response of homosexually active men to the threat of HIV infection, and the rate of spread of the epidemic. We typically find (Hunt et al., 1991) that, while numbers of partners are high, numbers of psps are low and this is the case with this group of young men. One hundred and eight (97.3%) of the 1 1 1 respondents reported at least one male sexual partner during their lifetimes, and 93 (83.3%) reported at least one male psp. In the year before interview, 107 (96.4%) reported a partner, and 85 (76.6%) a psp, and in the month preceding interview the figures are 83 (74.8%) and 52 (46.8%). Summary statistics for reported male partners and penetrative sexual partners (psps) are given in Table 3. Since all these distributions are highly skewed, towards the lower end, the median is the preferred measure of central tendency. Considering all the young men the median lifetime number of partners is 10, and 2 for psps. In the last year the median figures are 5 and 1 respectively, and in the last month there was a median number of 1 partner and no psps. Table 3. Summaly statistics of male sexual partners and penetrative sexual partners (PSPs) excluding far outliers Mean
Median
Male partners Whole life Last year Last month
15.5 6.6 1.3
10 5
Male PSPs Whole life Last year Last month
2.9 1.8 0.6
2 1
1
0
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For all the time periods the proportion of psps to partners is low, that is, whilst the number of partners varies considerably, the proportion that are penetrative remains consistently low. As we have emphasized elsewhere there is no linear relationship between number of sexual partners and psps (Hunt et al., 1991), and thus it is essential to take account of numbers of psps-rather than partners-when making any assessment of the prevalence of unsafe sexual behaviour. Amongst these young men the mean lifetime proportion of sexual partners which were penetrative is 30.8% (median 22.7%); in the last year it is 37.4% (median 33.3%); and in the last month 52.1% (median 50.0%). Along with Jenkins et al. (1991) we believe that the number of psps is the most accurate indicator of risk behaviour. As it closely resembles that of older respondents, from this standpoint, the contention that gay young men are more at risk gains no support. Homosexual repertoire and current homosexual behaviour Table 4 outlines the proportion of the young men who have (a) ever engaged in each of 14 sexual practices (their cumulative sexual repertoire) with a male; (b) engaged in the acts with a male in the month preceding interview (their current behaviour); and (c) the ‘stapleness’ of each activity, defined as the number of those currently engaging expressed as a proportion of those who have ever done so. The lifetime sexual repertoire of a majority of these young men includes masturbation, fellatio, kissing, body-rubbing (frottage), anal fingering, massage, anal intercourse, anilingus and inter-crural intercourse. Only a minority reported ever having engaged in corporal punishment, ano-brachial insertion, lindinism, douching and coprophilia. Table 4. Percentage that have ever engaged in given sexual acts, percentage who had done so in the month preceding interview, and stapleness of these activities in sexual repertoire Sexual act Masturbation Fellatio Deep kissing Anal intercourse Receptive Insertive Body rubbing Anal fingering Massage Anilingus Inter-crural Int Corporal punishment Ano-brachial Ins Lindinism Douching Coprophilia
% Ever
% Current
% Staple
96 95 95 87 78 70 86 80 79
75 69 68 46 36 34 52 37 42 28 26 6 5 0 0 0
78 73 72 53 46 49 60 46 53 39 43 24 38 0 0 0
71
61 25 13 11
9 20
In the month preceding interview, this general pattern is repeated, although the absolute proportions involved are, of course, lower. There are only two, relatively minor, differences in the rank order of prevalence of the acts. The proportion of those currently engaging in acts which feature in their repertoire (the number currently engaging as a proportion of
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those who have ever engaged) gives an indication of the relative popularity or frequency of the act in the repertoire. Among the nine majority acts, there are two distinct groups. Masturbation, fellatio and kissing are current activities for between 70% and 80% of those who have them in their repertoire and may, therefore, be regarded as staples of sexual activity. By contrast, anal intercourse, inter-crural intercourse and fingering currently feature for only between 39% and 53% and are, we conclude, relatively infrequent aspects of the sexual repertoire (body rubbing is interstitial at 61%). The proportion that currently engages in each of the sexual behaviours is statistically indistinguishable from the proportion of the older respondents (see Weatherburn, 1992). The younger men are, however, rather more likely to currently engage in receptive anal intercourse, where the difference approaches statistical significance (x’= 4.51 , d.f. = 1 , pt0.04). Whilst only 26.4% (n=216) of those over 21 engaged in receptive anal intercourse in the month preceding interview, 35.1% (n=39) of those under 21 did so. Multiple ANOVA shows however, that this difference can be accounted for by the higher rate of regular and monogamous partnerships (Table 1) among young gay men, (F=3.505,d.f.=5, p
