The Non-sexual Needs of Men that Motivate them to Engage in High-Risk Sexual Practices with Other Men

Abstract: Abstract: Currently there is a growing trend toward high-risk sexual practices with casual partners in the group of men who have sex with men (MSM) in many industrialized countries. This study offers some understanding of why a group of men had unprotected anal intercourse (UAI). A grounded approach was used to analyze 20 interviews with MSM from Barcelona between 18 and 40 years of age who had at least one episode of UAI in the past three months. The results reveal that many respondents had UAI practices with casual sexual partners because they were in search of experiences that were not directly tied to sexual relations: reaffirmation of a sense of personal worth and of their own physical attractiveness, offset shortcomings and feelings of emotional loneliness, the search for connection and intimacy, being in love, conversion of the risk into pleasure for the forbidden and a desire to rebel against established rules. In these cases, concerns about sexual and health care seemed to overwhelm and were not taken into account when having UAI. It is important that HIV prevention programs include in their messages the power of these motivations that lead to practices of UAI.

Key words: men who have sex with men (MSM); sexual risk behaviors; gay men; HIV; AIDS; qualitative research

Current conduct and epidemiological studies in the United States, Western Europe, Australia and Canada indicate that high-risk sexual practices are on the increase with casual and unknown partners among men who have sex with men (MSM) (DODDS, MERCEY, PARRY & JOHNSON, 2004; HALKITIS, PARSONS & WILTON, 2003; HAMERS & DOWNS, 2004; JAFFE, VALDISERRI & De COCK, 2007; PRESTAGE et al. 2005; STRATHDEE et al., 2000). Despite efforts to prevent and educate people about HIV and other sexually transmitted infections (STIs), an alarming tendency towards unprotected anal sex, the riskiest of sexual practices with regard to HIV transmission, has emerged among MSM (HALKITIS, PARSONS & WILTON, 2003). In Spain, a similar phenomenon is occurring (ROJAS, 2004; CENTRO NACIONAL DE EPIDEMIOLOGÍA, 2005). In the city of Barcelona there is a disturbing rise in high-risk sexual practices among MSM, not only among casual partners, but also among those in stable relationships (FOLCH, CASABONA, MUÑOZ & ZARAGOZA, 2005). There is also a rise in the number of men infected with HIV, where nearly one in every four homosexual men is HIV-positive (CENTRE D'ESTUDIS EPIDEMIOLÒGICS SOBRE LA SIDA DE CATALUNYA, 2006), and where prevalence rates of some STIs, such as syphilis, continue to climb (VALL MAYANS et al., 2006). [1]

The most common explanations for the current tendencies towards unprotected sex include difficulties with using a condom (for example loss of erection) (ADAM, HUSBANDS, MURRIA & MAXWELL, 2005), optimism with regard to HIV owing to advances in treatment (STEPHENSON et al., 2003; CREPAZ, HART & MARKS, 2004), fatigue regarding the prevention of AIDS (STOCKMAN et al., 2004), and the consumption of alcohol and recreational drugs (HIRSHFIELD, REMIEN, HUMBERSTONES, WALAVALKAR & CHIASSON, 2004; KOBLIN et al., 2006). However, the majority of studies of high-risk sexual behavior ignore the circumstances which could explain these episodes of unprotected sex among men who otherwise have the necessary knowledge, motivation, and ability to practice safer sex (DÍAZ, 1999). Some qualitative studies (ADAM et al., 2005; RIDGE, 2004) have already found a weak correlation between some official explanations and statements attributed to MSM who are involved in unprotected sexual practices. In general, the studies ignore individual circumstances which could explain these episodes (DIAZ, 1999). For example, anal sex and semen are described as risk elements for the transmission of HIV in epidemiological terms with very little exploration as to what anal sex means to MSM (SCHILDER et al., 2003). [2]

Some qualitative studies consider the importance of subjectivity when deciding to have unprotected sex. These assessments are built on beliefs, non-verbal messages or personal assumptions based on intuition, personal interpretations, confidence, emotional states, etc. (FERNÁNDEZ DÁVILA, 2007). This leads to the notion that high-risk sexual behavior is more than having sex without a condom and can have different meanings for those men who practice it (POPPEN, REISEN, ZEA, BIANCHI & ECHEVERRY, 2004). The meanings of high-risk sex are as varied as people are. So the crux of the matter is to understand the nature of the risk and whether this particular high-risk conduct can satisfy the inherent needs within it. Some authors (ADAM, SEARS & SCHELLENBERG, 2000; DIAZ, 1999; PERLOFF, 2001) have already pointed out that despite knowledge and information about HIV among MSM, high-risk sex is explained because it "satisfies" certain non-sexual or psychological needs (e.g. affection and social and emotional connections), which are also considered as irrational motives or decisions. Therefore it is necessary to explore this phenomenon and the associated processes of high-risk activities from a psycho-social perspective in order to have a clearer understanding of the meanings which MSM give to unprotected sexual practices (HALKITIS et al., 2003). [3]

This current study begins with the premise that interpretative and grounded theory approaches are the keys to developing concepts that will allow for a deeper and richer comprehension of the sexual behavior of the MSM population. Given that in Spain there is very little knowledge about the sexual behavior of MSM and concomitantly the prevention of HIV/AIDS, the goal of this study was to identify, describe, and analyze the motives (apart from the sexual ones) and their meanings, that make a group of MSM from the city of Barcelona practice high-risk sexual activities with casual partners. [4]

This study is an in-depth qualitative investigation of the complex motives which make a group of MSM participate in high-risk sexual practices. Social constructionism is the theoretical stance taken in this study. This perspective focuses on the ways individuals and groups create/construct the realities they perceive. The meanings of the phenomena of the social worlds are created by human social interaction. This implies looking at the ways in which phenomena are created socially, institutionalized, and converted into habits and traditions for human beings (GUBA & LINCOLN, 2005). This paradigm considers sexuality to be a social construction. A sex life is like a social life: an activity dependent upon social and cultural circumstances (GAGNON, 1990). The social construction of sexuality is more than a collection of ideas and discourses, it is a complex strategy of power made up of individuals, which shapes bodies, orders, and desires, and organizes all social relationships. Therefore, we conceive sexuality as a phenomenon which expresses a subjective, inter-subjective, and socio-cultural dimension (CÁCERES, 2002). [5]

The total number of participants was 48, but only 20 were selected for this study. Participants were MSM between the ages of 18 and 40 years, who during the three months prior to the study had had at least one experience of unprotected anal intercourse (UAI) which was not with a stable partner or within a current relationship. The 28 interviewees who were excluded did not fulfill these criteria. The time period of three months was chosen under the assumption that memory for events beyond three months could be faulty. [6]

The participants were contacted using a combination of intentional and accidental sampling (KERLINGER & LEE, 2002) and by the technique known as "snowballing." This combination of sampling methods was decided upon because groups like MSM are typically difficult to contact through other more common approaches.. [7]

These forms of selecting the sample have the advantage of being accessible and provide the opportunity to concentrate on men with characteristics of particular interest; e.g. men who partake in high-risk sexual conduct (ELFORD, BOLDING, DAVIS, SHERR & HART, 2004). To obtain a suitably diverse sample of MSM, samples from more than one source were included: (a) through third parties, using the "snowball" technique; (b) leaving notices in bars, sex shops, and gay discos, inviting people to participate; (c) asking for the help of gay associations (e.g. youth groups); (d) the creation of a profile on a gay contacts website. [8]

Although contacting participants via a third party turned out, at the start, to be a good way of getting interviewees, most of them claimed not to have had experience of UAI in the previous three months, leaving us doubting the sincerity of their responses. Looking for participants through adverts didn't work, nor did calling gay groups. Given the constant mention by many interviewees of looking for and meeting sexual partners on the Internet, it was decided to seek most participants through the web. [9]

All the participants mentioned having a profile to contact men and to chat on a very well known website for gays (http://www.gaydar.co.uk/). This site offers the opportunity to create a personal profile and to add photos. The page is very interactive and gives the user the chance to send instant online messages to another person who is connected at the same time. It also allows access to chat, where the rooms are divided, first by country and city, and then by subject (bears, leather, skinheads, etc.). Under these conditions we decided to register on the site and create a profile where only general information about the study was included, and with this profile we went into the chat room for Barcelona to contact participants. We did not mention that the investigation was about high-risk sexual activity so as not to influence or intimidate potentially interested participants. [10]

Regarding the characteristics of the participants, we found that the ages of participants ranged between 21 and 40 years. Most of them (65%) were Spanish, with the majority born in Barcelona. The rest were made up of foreigners (Europeans and mainly Latin Americans) living in Barcelona. Most of the participants (80%) were well educated. The sample consisted mostly (80%) of men identifying themselves as homosexual or gay, the rest defined as bisexual, and others preferring not to "label" themselves, describing themselves as "sexually diverse." Of the 20 interviewees, three were HIV-positive. [11]

We conducted in-depth semi-structured interviews (BERNARD, 1999; SCHENSUL, SCHENSUL & LeCOMPTE, 1999). Our use of interviews was based on the fact that they permit exploration of the meanings participants give to complex experience(s) that quantitative methods do not. Given that everyday communication is articulated on two levels, the subjective and the social (ABARCA, 2000),personal meanings are assimilated into the general discourse and are conveyed in specific conversation. [12]

The interview protocol covered seven areas of interest linked to sexuality, sexual practices and safe sex in general: sexual identity and sexuality, sexual practices with a stable partner, sexual practices with casual/unknown partners, history of STIs, use of condoms, information about HIV/AIDS, and HIV testing. [13]

The interview protocol was submitted for evaluation by expert judges, academics, and professionals from the human, social, and health sciences. Pilot interviews were conducted with three participants who had the desired characteristics for the sample of this study. This allowed for revision of and familiarization with the protocol. The pilot interviews were not included in the analysis. [14]

The researcher was responsible for the entire investigation. The recruitment of participants and the gathering of data lasted approximately three months and included, at the same time, the analysis of the collected data. This process was very interactive and useful for gaining quality and valuable information. The coding of the information, without ceasing to gather more, provided the opportunity to go back and complete information which might have been missing, thus making clear any ambiguities that may have been found in the data. This was done until reaching theoretical saturation¹⁾; that is, a sufficient amount of data was collected that addressed the issues being explored. [15]

The participants who found out about the study through advertisements left in the gay venues contacted the investigator directly by email; those who became aware of it via the Internet, contacted via the Chat. In other cases, the investigator telephoned potential participants referred by third parties. The majority of participants were found via the Internet. During initial contact, the participants were asked verbally for their consent and the reasons for the investigation were explained to them. The confidentiality and anonymity involved in their participation was stressed. Participation was voluntary, and no incentives were offered. Approximately 15% of the people initially interested declined to participate. [16]

After agreeing to participate a meeting was arranged. On the day of the interview, consent was confirmed again, this time in written form, and signed by both the investigator and the participant. The interviews were carried out either in a private office or in the homes of the participants who, due to time constraints and distance, could not come to the office; this was done with the stipulation that the home would be quiet and free of interruptions. The average duration of a single interview was approximately one hour. [17]

Once the interviews were transcribed the analysis began using grounded theory as a theoretical framework (GLASER & STRAUSS, 1967). Grounded Theory (meaning the generation of theory grounded in data) is an analytical theory applied to qualitative data within a constructionist framework (CHARMAZ, 2005). That is to say researchers avoid imposing an a priori theoretical framework on data, thus allowing theory to emerge from the analysis (AMEZCUA & GALVEZ, 2002; ULIN, ROBINSON, TOLLEY & McNEILL, 2002). However, we opted to use a modified approach to grounded theory proposed by STRAUSS and CORBIN (1990), which emphasizes meaning, action, and process and because it incorporates other relevant theories about the phenomenon into the grounded analysis. [18]

The first stage of analysis was to categorize the information using the qualitative analysis program Atlas.ti®. This software identified the themes that became the focus of further exploration. This was done by extracting all relevant material from every single interview and categorizing it in accordance with codes which summarized the information. The book of codes was constructed from the dimensions which appeared in the reading process of each interview; that is, open codification was used. The codes were then grouped into a thematic family matrix. The analysis process itself was carried out from these families of codes which guided the description of the results. [19]

The number of casual sexual partners in the last three months among those interviewed ranged from a minimum of 3 to a maximum of 150 men, although most had between 7 and 20 partners. The highest numbers of sexual partners belong to two of the HIV-positive interviewees. The majority of the interviewees mentioned having had between one and three experiences of UAI with sexual partners in the previous three months. As with the largest number of sexual partners, two of the three HIV-positive interviewees are those with the highest incidences of UAI. [20]

The places where sexual partners for casual meetings are usually sought are in general, bars, discos, sex shops, saunas, on the street and, more than any other, on the Internet.

"I meet (guys) in Salvation or Metro, two clubs ... that's where you make the first contact with people, sometimes you go home with guys, sometimes not ... these are the only ones there are, so if I want to meet guys I have to go there." (Interviewee [INT] 8 – 27 years old)

"Mostly by Internet. It's the easiest way to find sex these days, for me. Apart from the gay venues specifically for sex or in the street or somewhere like that. Above all, apart from being easy, it's comfortable." (INT9 – 32 years old) [21]

As UAI practices were investigated with casual partners, many interviewees had difficulty recognizing that they had had unprotected sex. We see this when some interviewees start by saying that they "always use a condom," but end up admitting having had some experience with UAI.

"Man, I've done it. What's more, it sounds like a contradiction, it sounds like a contradiction because I'll tell you something, I've done it on occasion ... It's one thing having done it, and another thing always doing it." (INT3 – 28 years old) [22]

The previous quote allows us to make the distinction between looking for or always having (intentionally) unprotected sex, and doing it occasionally. The former of the two distinctions is known as barebacking, the latter covers poor planning or a failure to take precautions in sexual matters (a "gaffe," a "lapse" or "slip-up"), which is more the rule than the exception in the experience of the majority of the interviewees. The occurrences of UAI are justified by varying motives. Below I shall describe the diverse motives related to non-sexual needs which led the interviewee to practice UAI with casual partners. [23]

The choosing of a sexual partner for a casual encounter will depend, for the most part, on many attributes which MSM find attractive. The most mentioned are: being masculine (not being feminine, not being "camp"), not being ugly, not being old, and not being fat, among others.

"I wouldn't be with men who behave in a feminine way, with a feminine demeanor, for that I prefer a woman." (INT5 – 35 years old)

"With someone who doesn't turn me on or who is very effeminate or is in the least bit effeminate. That is a no-no, I can't do it ... I have nothing against them, but it doesn't excite me sexually." (INT9 – 32 years old)

"With an 18 year old kid, a 16 year old, a 20 year old, with a camp guy, with a fat old guy, with an obese guy, with a guy over 50, with a dirty guy. I mean come on, rather than that I have a wank and that's that." (INT14 – 38 years old – HIV+) [24]

These statements indicate the value of attraction among MSM and the relation to sexual risk. In trade-off situations, as described by ADAM et al. (2005), a social hierarchy can be seen which creates an economy of risk, where feelings of personal lack, a perception of one's own attractiveness and a desire not to ruin a sexual opportunity increase one’s vulnerability. Evidently, if an MSM in the sexual "market" does not conform to the "requirements" for the ideal man which others are looking for, if he is "camp," if he isn't good looking, if he doesn't have a good body or he is over 40, he is put in a vulnerable situation. In this respect, GUASCH (1995) says that the gay culture has created rules (e.g. the exaggerated emphasis on physical beauty associated with youth) which leads to exclusions and implies a symbolic violence towards those over 45. The majority of these men cannot get into the "scene" unless they use male prostitutes (ISP-COMUNIDAD DE MADRID, 2004) which puts them in a risky situation, given the characterization of sex workers in Spain being vulnerable to HIV infection (BELZA, 2005). [25]

Wanting to be with someone due to a strong physical attraction, because the person fits into the sexual prototype men are looking for, or fantasize about, is a motive for people to have UAI.

"When I did it once, it was with a French guy, the guy was really good, obviously, and I did it for a while with him without a condom [...] When I saw this French guy, he was great, he was hot, he was big, muscular and everything. I don't have much experience with muscular guys, but I found this muscular French guy, great arse, and it was like, get over here, straight back to mine, I'm only human." (INT3 – 28 years old)

"[It happens] when you are really turned on and on top of that you really like the guy, and he offers himself, you just want to penetrate him, even though it has never happened, apart from that one time. So yes, sometimes you get the urge and you say, let's go." (INT7 – 34 years old) [26]

The first quote above reveals that behind sexual interest in being with a muscular and attractive man, there is hidden type of non-sexual need which DÍAZ (1999) has described as the need to validate the meaning of your own physical attractiveness. WILTON, HALKITIS, ENGLISH and ROBERSON (2005) claim the same thing, finding that, for the men in their study, the sexual act serves as an affirmation of their physical attraction and sexual desirability. Also, these types of needs can be elevated to, according to DÍAZ (1999), socio-cultural factors, such as a certain obsession with one's masculinity, body, and physical beauty found in gay culture. [27]

The urgency of passion and the opportunity to connect with a particularly desirable partner, sometimes facilitated by drugs and alcohol, according to ADAM et al. (2005), can lead to some unprotected sexual encounters among MSM. Also, "heat of the moment" situations can be complicated when men who feel at some kind of disadvantage (whether it be age, race, or physical attraction) are scared of offending a desirable partner and they agree to sex so as not to lose an opportunity for sexual interaction which would increase their sense of personal value. [28]

Although it is mentioned that the search for casual sexual partners is motivated by sustaining quick sexual encounters, for many interviewees it was found that this search served to fill feelings of emptiness and loneliness.

"In periods when I need sex I don't feel very comfortable with this feeling, for the fact that it is a little like having to fill a void and often the sex I have during these periods is empty because it doesn't produce the pleasure which I was hoping for ... I suppose it kind of fills an existential void. An emptiness of ... not to find a meaning of life and all that, but to have an experience, which I wouldn't call mystical, but a very concrete and very strong experience, you know what I mean? One which shakes you up a bit, wakes you up, makes you react. Sometimes you are, like, sad about life perhaps, feeling very monotonous, a bit like that ... it makes you feel good, better... and as for during the sexual experience, sure you enjoy it and it's nice, but afterwards is when you feel empty, you get the bad vibe. But the truth is that the last time there wasn't that negative connotation ... it was more like mutually spreading affection rather than anything else." (INT1 – 28 years old) [29]

The above statement gives reason to believe that feelings of isolation and loneliness among MSM puts them into a state of low self esteem and into taking risks in an attempt to connect through sex (ADAM et al., 2005; MORIN et al., 2003). This is consistent with the fairly widespread assumption that low self-esteem is an explanation for the transmission of HIV (CENTER FOR AIDS PREVENTION STUDIES, 2001). [30]

This shows that the feeling of loneliness comes from not having or looking for a stable partner for a long time, so feeling alone plays a very important role in finding casual sex partners. SEMPLE, PATTERSON and GRANT (2004) suggest that living and feeling alone is a potential platform for someone to involve themselves in UAI. This raises the question: Is anonymous sex a way of handling feelings of loneliness and boredom for those who live alone? This phenomenon needs to be investigated.

"Now that I'm single, loneliness is another factor and looking for a bit more affection maybe, or when you are single you act a bit more like a slut, right? And you start to discover things about yourself ... At this stage in my life it would be difficult for me [living without sex], difficult to be alone." (INT6 – 35 years old) [31]

For some interviewees it was found that these feelings of loneliness get worse when the search for casual sex partners turns into merely a "one night stand."

"Casual encounters are very cold, it starts off all very nice, you arrive, you talk, you have sex and then after it's all over it's like you turn the page, and you can never go back. It has made me think on several occasions, and what's more, on my profile (on the Internet), there have been eighteen thousand visits, sometimes I think and say to myself ‘for fuck's sake, eighteen thousand visits and still nothing', I have nobody in the sense that I'm still single but, well, that's how it is [...] What would I like to find? Someone I can share things with, someone I could ring and say "such and such happened today" or who rings me and says "hey, come and pick me up," things like that, a bit sad, right?." (INT12 – 21 years old) [32]

This last statement gives the impression of a depressed mood. This tells us that negative emotional states, particularly stress and depression, are associated with the vulnerability to have unprotected sex (DIAZ, 1999; KOBLIN et al., 2006). Looking for casual sex and having unprotected sex represents a way of coping, an escape, from this emotional discomfort (ADAM et al.. 2005; YEP, LOVAAS & PAGONIS, 2002); the same being true for HIV-positive MSM who feel this way because of their infection (BANCROFT, CARNES & JANSSEN, 2005). [33]

What is evident is that behind this search for casual sex partners, deep down what is sought is to satisfy needs for affection which disguise themselves as sexual desire. These non-sexual needs are satisfied indirectly through physical contact, the skin contact which sex provides, as an expression of affection at a more primal level.

"I notice that many people go [to the disco] in the same situation as me, looking primarily to enjoy themselves, have a good time and a lot of people also looking for enjoyment, which doesn't mean sex. But you are there, you meet a guy one night in the disco, you're dancing with him, you touch him, you kiss him, and that's where it ends, it doesn't mean that afterwards you are going to go to bed with him, but in some way you feel good about it, having had just the minimum physical human contact." (INT7 – 34 year old) [34]

These needs for affection are revealed at another level as well. For example, several interviewees mentioned that during a first contact some casual partners share personal and private information which would be considered inappropriate for a first sexual encounter. For them this reveals a lack of affection in the lives of many MSM.

"... you notice that there is excessive trust in telling you some things when you are with them, and that tells me that they have a certain lack of affection. [Such as] they explain very intimate things to you on the first night you meet them. They tell you that they visit a psychologist, etc, etc. Taking me as an example, I keep things to myself. If I have a problem, they will know about it after two [dates], or I don't know, when the time is right to explain it, I'll explain it, not during the intimacy of a first date, there's no need, as far as I'm concerned, no need to mention it." (INT8 – 27 years old) [35]

We are seeing that people go into sexual encounters looking for other experiences, not only sexual, such as interpersonal connection, social acceptance, or emotional liberation. In these cases, as DÍAZ (1999) suggests, where the need for connection, affirmation, or self valuation is so high and deeply felt, concerns about health and sexual safety can be overwhelming or an obstacle to fulfilling these types of non-sexual needs. [36]

Along the same lines, in many cases it is noted that behind this search for sex with casual partners lies the need to find somebody with whom one can later form something more stable. This can create a vicious cycle which makes many MSM go to gay venues, or go on the Internet, to look for a potential partner.

"You always hope for something more, but it's more difficult. I hope to find someone with whom I can repeat this moment many times and really be able to have a lasting relationship with." (INT9 – 32 years old)

"I would prefer a partner more than going out and fucking around with the whole world but, of course, when the issue comes up, one goes and the other stays [...]. On the subject of meeting people, I always feel like I'd like to get married, hahaha, be in a relationship, so I go out and say to myself ‘let's see if my boyfriend is out tonight, or maybe he has stayed at home' ... I would like it [to be in a relationship], but it's not something you can choose ... But I think that the more people I meet, the more chance I have of meeting the person who could be the one for me." (INT19 – 35 years old) [37]

The above statements reveal that a relationship with a partner, for many MSM, seems to be something remarkable in their personal narrative on the value of life and the future (ADAM et al., 2005). But if they always complain about what is difficult, such as maintaining lasting relationships, then discouragement and despair will creep in, with the consequent risks of what these types of feelings may result in. [38]

We have seen that the role of psychological and emotional elements can affect the decision-making process with regard to sexual care. People use sex and physical contact to express emotions and send messages. According to YEP et al. (2002), specific acts, such as UAI, are linked to specific emotions and it would be difficult to express these emotions in any other way. [39]

In other cases, searching for sexual partners on the Internet can suggest a momentary search for company, more than sex, to erase feelings of loneliness. Sometimes, people who feel this way hope to find a relationship which goes further than a simple "one night stand." If the encounter was good and a good time was had, many will hope to repeat the experience. However, they do not confess their true intentions to find a stable partner because they know that they would not be well received and, consequently, rejected.

"If I'm in chat and I put that I am looking for my knight in shining armor, they tell me to fuck off, haha. So it's best to say I'm looking for sex and then see what happens. I know that normally guys use the Internet to find sex, first you get them into bed, and then you find out their name. What I ask for and what I offer is sex, then if I like the person, maybe something else will happen, whether it be friendship or even better a stable relationship, but as the situation is, the only way is to go for sex first and see what happens." (INT19 – 35 years old) [40]

According to a number of interviewees, there is another psychological component in which the use of a condom detracts from the possibility of being in "unity" with the other person. In this sense, it could be interpreted that UAI seeks to strengthen the intimate link which has been created at that moment with the other person in terms of physical pleasure and emotional bonding. Feeling emotionally closer, or the desire to reach intimacy with a sexual partner, have been frequently mentioned by some MSM who practice UAI (SCHILDER et al., 2003; WOLITSKI, 2005).

"It is also a factor psychologically, that is completely ... you feel completely united one hundred per cent with the person. Because the other way there's a condom in the way. [United in the sense that] the other person is inside you, that is to say ... you are completely united ... you form a part of him. This is the closest you can possibly be to a person, in the physical sense. It's just that you are inside ... the other person has you, and you have him." (INT2 – 31 years old)

"Skin feels skin, or you feel the person, it feels as though you're not inside a ... that is to say, there is no material separating one skin from the other and therefore you feel more the [anal] duct ... Well, I feel more for the person, I get that feeling." (INT16 – 37 years old) [41]

In some cases, this "connection" which people are seeking stems from lack of, or need for, affection as previously noted. .

"When I have had sexual relations without a condom it has been because I have felt very connected to that person ... connected in the sense of affection, a lot of affection." (INT4 – 27 years old)

"At the start I was scared, afterwards completely the opposite, a very strong connection with the other person ... Confidence in the person, or the thought that that person is close to you, for example." (INT6 – 35 years old) [42]

Some interviewees said that having been in love with someone, but not in a stable relationship with that person, had been a significant cause of deciding to have UAI as proof of their love.

"In my case I was in love, so maybe at that moment no, I didn't see the danger involved in using or not using a condom." (INT4 – 27 years old) [43]

Anticipating that a relationship will develop or identifying a new partner as a "potential boyfriend" is sufficient motivation for some men not to use a condom as a sign of the seriousness of the relationship (ADAM et al., 2005). Unprotected sex is seen as a show of love and intimacy, so this type of practice is being used to mark the transition to a more serious relationship and to symbolize love (CROSSLEY, 2004). [44]

SHERNOFF (2005a) and YEP et al. (2002) have shown that being in love, wanting to deepen intimate relationships, and show confidence in a partner are factors which drive sexual risk. In this way, sex and love become linked in a complicated way, and rather than risk losing this love, according to PERLOFF (2001) and SHERNOFF (2005b), they prefer to have unprotected sex. For people incapable of differentiating between passion and love, unprotected sex is often an attempt to cling to love, or at least the potential for love. For this reason, in relationships between an HIV-positive man and an HIV-negative man, it is the non-infected partner who pushes to increase the level of sexual risk taking (MURPHY, ELLARD & NEWMAN, 2003). [45]

Also, having ended a relationship with a partner on good terms and keeping in contact with the ex-partner means they could continue to see each other and, occasionally, have UAI due to the love and confidence that once existed between them.

"One of my sexual partners has been an ex, my last ex, because I have certain problems with ex-boyfriends in that every so often I fall in the memory trap and... Let's see, I have had two partners in my life who I've been with for longer than the others, not an especially long time, but with both of them I have done it [had UAI]." (ENT1 – 28 years old)

"For those that I have confidence in, because I have confidence I know that, at the start, it's not one hundred per cent, but fairly safe. Because my ex -boyfriend, I know him, I know he's healthy like me, we both had the test, and it turned out ok ... in the case of my ex boyfriend I don't even think about it because I know he's someone I can fuck without a condom." (INT18 – 30 years old) [46]

For some MSM, having had UAI is linked to the search for other types of experimentation with sensations, apart from physical pleasure. This search can be related to experimenting with the feeling produced when you put yourself in a risky situation and feel the excitement of having done something prohibited with an "accomplice." In this way, risk is eroticized and becomes an element of feeling pleasure.

"Apart from the fact that a condom takes away pleasure, that's obvious right? Apart from that, doing it without a condom is like a ... an added plus ... the fact that you are doing something that carries danger, doing it with someone you don't know at all, all this turns you on … it makes it attractive the fact that it's without a condom ... it turns me on that I don't know the guy at all ... even in the dark, without really knowing what I'm doing sexually ... doing it without a condom, but without finishing off." (INT10 – 28 years old)

"At that moment it was like, I don't know, I had the feeling we were doing something prohibited, like really prohibited. For everything else it was fine, you are liberated, I have no problems, it's like something tremendously prohibited. Like transgression, prohibited, the turn-on, the pleasure, like something not allowed, I'm doing something I shouldn't." (INT13 – 38 years old) [47]

The pleasure of the prohibited, associated with a desire to rebel against the established norms (e.g. doing something taboo), is one of the reasons why MSM practice UAI (CROSSLEY, 2004; WOLITSKI, 2005). Unprotected sex, an explicitly against-the-rules behavior, serves as an escape from the tension produced from having to live according to rules (PERLOFF, 2001). For this reason, we start to understand sex without a condom among gay men as a symbolic act of rebellion and transgression which they are not necessarily conscious of.

"I have this thing that makes me sometimes rebel against the world and it could, on the one hand, seem like a self-destructive attitude, but on the other hand, could be seen as rebelling against myself and what is happening ... it seems pretty stupid justifying it like that. Well, that's how I see it sometimes [...]. Right, AIDS and everything like it is a very strong reality, but there's a point of … I don't know, rebellion, which is also a bit of a stupid term for it, but to take it on in a confrontational way, no? Attacking, doing ... well, putting your health at risk." (INT15 – 37 years old) [48]

When this happens, there are clearly two desires which enter into conflict; on the one hand, an irrational impulse stemming from pleasure, and on the other hand, moral conscience.

"You feel like, you are doing something you shouldn't, but at the same time enjoying it. Of course, the bad conscience, good conscience issue is there." (INT3 – 28 years old) [49]

A different point of view, considered by BILLIG (as cited in CROSSLEY, 2004), offers the explanation that the prohibited becomes a desire. According to BILLIG, desires are formed through processes of social interaction. Desire is formed within a particular society through implicit socialization practices. Through these practices the youngest members of a society, from day one, are taught what is permissible and what is not with regard to what you say and do and, later on, what you think. It is via these processes of creating social rules, and the production of capable individuals, motivated to adhere to the norms,, that the possibility of "prohibited desire" increases. Social rules do not exist to cancel out "innate temptations." In place of this, they create their own restrictions, their own temptations. What is prohibited becomes an object of desire and pleasure. Prohibitions create their own desires. [50]

The phenomenon of barebacking, intentional UAI, is an example of this motive. Out of all the interviewees, three could expressly fit into the category "barebackers"; of these three two were HIV-positive. The explanations which some interviewees gave for the emergence of barebacking is that it is the best expression of the eroticization of the risk, of enjoying something extremely prohibited. This argument, barebacking as a superior experience of transgression to the erotic, has been found in many studies on the causes of its emergence. (CARBALLO-DIÉGUEZ & BAUERMEISTER, 2004; RACE, 2003; WOLITSKI, VALDISERRI, DENNING & LEVINE, 2001).

"I think it is a practice like any other, in which the person doing it feels [a] certain incentive or pleasure, risk. It's not the same as having sex in a public place, the risk is distinct, that is to say, the risk that somebody sees you or catches you or that you are accused of a public scandal or something like that, it's not the same." (ENT17 – 40 years old – HIV+)

"I think that these people who get turned on by fucking without a condom ... more than anything it's for the turn-on of the prohibited, something they shouldn't be doing." (INT19 – 35 years old) [51]

More intellectual arguments, like those of an interviewee who mentioned Freud and his theory of impulses, say that barebacking is the eroticization of a risk directly associated with self-destruction, with death; which, subconsciously, makes many people practice it. Deeper investigations into this argument need to be carried out.

"It is a risk which is provoking pleasure, pleasure provokes death. Freud would applaud. I can look at it in that way ... for me pleasure is the cause of death, through pleasure you are going to die. Even clearer, in my opinion ...." (INT11 – 28 years old) [52]

This study offers an understanding of some of the motives for some MSM to indulge in high-risk sexual practices which many investigators do not consider while attempting to explain this behavior. This level of understanding is critical to the success of individual or community interventions seeking to reduce the risk of HIV infection among MSM. [53]

The reasons for having UAI are embedded in the ecology of personal, interpersonal, and social circumstances, which create contexts or situations that increase the probability of transmitting HIV. Some of these reasons, emotional states or needs for affection (e.g. the presence of strong feelings of loneliness and feelings of alienation with respect to "gay culture") are present in many MSM who look for sexual partners and practice UAI. These non-sexual needs experienced by our interviewees are social and cultural in their origin. Culture moulds these self-perceptions and gives meaning to sexual encounters and practices. As MANZELLI and PECHENY (2002) state, they are needs which stem from current and past social conditions through which people's subjectivity is formed, and which should guide their sexual and affectionate relationships. The contexts of risk described in this study, although experienced subjectively as psychological states, motivations, or feelings; are more a reflection of life oppressors in MSM. These needs are related to socio-cultural factors found in gay culture. They could be the obsession with beauty and youth, which brings about the high frequency of recreational sex, they discourage emotional affiliations, and produce difficulty in integrating love and sex, intimacy and sexual passion, into stable relationships. Organizations and groups of MSM themselves should create and encourage other alternative social spaces which facilitate meeting men in environments that are not necessarily sexual. The ability of MSM to form and develop both sexual and romantic relationships with other men should be strengthened but without implying the potential risk of transmitting HIV. [54]

Although sex-related prevention programs often convey universal messages ("always use a condom"), such easy and simple messages cannot cover the emotional complexities that influence sexual practices among MSM. Prevention programs should include and emphasize the irrational thinking and need for affection that interfere in decision-making and sexual risk taking, to redirect their messages. We believe that if these elements are not included in the design of these prevention programs aimed at MSM, they are condemned to failure. [55]

Given the existence of a subgroup of MSM who have difficulty maintaining safer sexual conduct (e.g. consistently adopting the use of a condom during anal penetration), we believe that innovative conceptions of risk and the prevention of risk are needed and that the individual support and/ or advice given on safe sex should include information on risk reduction strategies in their services (e.g. ejaculating outside the anus, internal and external cleaning after sex, assuming the active role during sex, reducing numbers of sexual partners, etc.) as ways of minimizing risk of HIV infection. [56]

The increasing practice of barebacking should be a concern for public health organizations. This implies a better understanding that there is a new sexual culture (the sex without a condom culture). Thus it is necessary to better understand the reasons why people practice UAI despite knowing the risks. To ban it or condemn it would be the least effective strategy. [57]

The successful way in which the Internet was used to recruit participants with the desired profile leads to two ideas for future studies: an exploration of how the Internet is used by MSM to look for and meet sexual partners who practice UAI; the potential of the Internet as a tool to gather information in qualitative studies concerning difficult to reach communities. [58]

More investigations on the contexts, situations, and circumstances which underpin real attempts, motivation, and abilities of MSM to protect themselves from HIV should continue to be carried out. [59]

This study was carried out with the support of the Programa Alβan, scholarship program of the European Union for Latin American, Scholarship Nº: E04D033387PE.

Special thanks to Kati ZARAGOZA, Stop AIDS manager, for encouraging the author to complete part of the implementation of this study, and to Tony KEIRLE, for his time in reviewing and correcting the English version of this article.

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Percy FERNÁNDEZ-DÁVILA is a psychologist. He studied for his PhD in Psychological Research at Ramón Llull University in Barcelona, Spain, focusing his studies on applied qualitative research He has participated in research on issues such as sexuality, masculinity and sexual diversity, and HIV/STI prevention activities for the Cayetano Heredia University and the NGO Redess Jóvenes, in Lima, Peru. Currently he works at Stop Sida NGO, in Barcelona.

Ramón Llull University & Stop Sida
Calle Muntaner 121, entslo. 1º, 08036
Barcelona
Spain

Fernández-Dávila, Percy (2009). The Non-sexual Needs of Men that Motivate them to Engage in High-Risk Sexual Practices with Other Men [59 paragraphs]. Forum Qualitative Sozialforschung / Forum: Qualitative Social Research, 10(2), Art. 21, http://nbn-resolving.de/urn:nbn:de:0114-fqs0902219.

Forum Qualitative Sozialforschung / Forum: Qualitative Social Research (FQS)

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