Can you relate? A Qualitative examination of condom use in gay men's relationships.


See also: Can you (still) relate?
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Prepared for the AIDS Committee of Toronto
Allie Lehmann & Robb Travers
December 1993


Executive Summary:

1) A campaign addressing the illusion from safety from HIV infection within gay men’s relationships is needed.

2) Such a campaign must make safer sex normative at the outset of any relationship and state clearly the many issues involved in the decision to discontinue using condoms (i.e. HIV antibody status, testing, having sex outside of the relationships, etc.).

3) Such a campaign must target gay men in all types of relationships, depicting the wide diversity that exists.

4) Campaign materials must be available through broad distribution channels to effectively target diverse gay men in relationships.


Background and Purpose:

Several quantitative studies have shown that gay men in relationships are inconsistent in their use of condoms for anal sex (these studies are catalogued and available for perusal in the AIDS Committee of Toronto (ACT) Library). ACT has shown leadership in Canada in the development of HIV prevention materials targeted to gay men with such diverse publications as News for Gay Men and the Safer Sex Generation. In keeping with this educational mandate, ACT will be producing an HIV prevention campaign targeted to gay men in relationships for distribution in 1994.

The original objectives of this prevention education campaign are:
  • to target gay men in relationships with accurate and up-to-date information concerning the importance of consistency in condom use for anal sex.
  • to address the reasons that gay men in relationships give for inconsistent condom use.


    Research Objectives:

    The objectives of this research were:
  • to obtain insights into the particular reasons why some gay men in relationships are inconsistent in their use of condoms for anal sex.
  • to obtain information about the kinds of campaign concepts that gay men in relationships would consider appropriate.



    A Few Notes on Qualitative Methodology:

    As a research methodology, focus groups are a means of generating discussion and eliciting synergistic insights into particular questions. The purpose of a qualitative methodology such as focus groups is not to test predetermined hypotheses, but rather to elicit participants individual perspectives. Generalizing from a representative sample of gay men to gay men in general is not possible, nor is it necessary for the purpose of this research. Rather, the reader should assume that these results are illuminating and therefore directional.

    Method:


    Sample:

    A total of 26 gay men participated in focus groups held at a market research facility in Toronto on May 15, 1993. Participants were recruited through advertisements in the local gay newspaper, XTRA!, and through outreach to gay bars in Toronto. Participants were recruited according to the following criteria:
  • gay men in relationships, and,
  • not be employed, or volunteer (past or present) with HIV/AIDS organizations.


    Procedure:

    After introductions and orientation to the focus group procedure, participants were asked a series of questions concerning condom use in relationships by the two facilitators. Following this discussion, participants were told of the sponsoring agency, were thanked for their participation and were paid $30.00.


    Interpretative Analysis:


    1) A campaign addressing the illusion of safety from HIV infection within gay male relationships is needed.

    Relationships often provide an illusion of safety to those who are involved in them:

    “You feel comfortable enough in your relationship despite the fact that in the back of your mind you know that your partner has had other partners.”

    “I’ve often found a lot of people that say they are in relationships, where one person is running around and the other person doesn’t know.”

    “Really, I’ve never heard safe sex come up in a conversation - I don’t find that people are talking to one another about the use of condoms. It doesn’t come up in conversations.”

    “No, it’s strictly a personal matter”.


    Indeed, participants noted that because they were in relationships they would not read safer sex material that they perceived was geared to single men. Thus, a relationship campaign might say “in a relationship, consider yourself at risk” or “If you thought you were safe because you are in a relationship, think again”.

    Participants noted a gap in materials on safer sex for gay couples:

    “ I don’t find there’s any literature or conversations about couples using, or practising safer sex. The material we have is geared to the mainstream gay society - the single individuals.”

    “ There’s not a lot of focus on a couple or a relationship and the use of safe sex. I find there’s nothing geared towards that”.

    “ One couple I know who have been together for six months don’t practise safer sex (even though) they were both in high risk activities before that. They assume that because they don’t have HIV, they are fine”.

    2) Such a campaign must make safer sex normative at the outset of any relationship and state clearly the many issues involved in the decision to discontinue using condoms (i.e. HIV antibody status, testing, having sex outside of the relationships, etc.).

    “Many people are awkward if they are told to do something - they often do the opposite. However, if there is a trend, or if they think it is already in style to do something, they will change their behaviour to correspond with the trend. So, if you can portray something as the ‘in’ thing to do, that’s good.”


    Safer sex among all gay men, regardless of relationship status, must become normative. Some participants noted that they felt “ashamed’ if they did not have safer sex with their partners. As participants revealed:

    “ There’s a lot of shame if your not using condoms”.

    “ If you say you didn’t use a condom, the response is loaded with judgement”.


    One participant pointedly noted that partners need to establish condom use at the outset of a relationship in order to assist long-term consistency in their use:

    “ Condoms are like fish - nobody likes fish when you’re young, you like it when you’re older. But, if you’re not brought up on fish (or condoms) and the message isn’t hammered home, then it’s not a priority.”


    However, early condom use does not guarantee consistency. Participants in one of the focus groups referred to the inevitable, highly desirable ‘comfort zone’ that occurs at some point in the relationship:

    “ I think most couples hit a comfort zone at a certain point and don’t even consider the risk anymore... you feel comfortable enough in your relationship despite the fact that in the back of your mind you know that your partner has had other partners. You feel that enough time has elapsed...it’s safe.”


    It is imperative that a campaign targeted to gay men in relationships acknowledges this ‘comfort zone’ that many gay men reach within their relationships. The campaign, however, should point out to couples their need to assess their risk for HIV infection, their HIV status, HIV testing as well as sexual behaviour outside of their primary relationship.

    One participant questioned why the focus group facilitators were using the term “slippage” (relapse into unprotected anal sex) in our questioning:

    Facilitator: “The reality of the situation is that many gay men slip up when they are in relationships”.

    Participant: “I’m curious to know why you keep saying that they slip up, because it actually is quite a conscious decision. I don’t use condoms anymore in my relationship. We don't feel that we need to. I’ve explained the reasons behind our decision. I don’t think that I’ve ‘slipped’.”

    Another participant explained that both he and his partner made a conscious decision to discontinue condom use in their relationship, after they were in their relationship for some time:

    “ We went through almost a year using condoms. Then we both went to get tested (for HIV). The other think was that we talked a lot about our pasts and stuff like that. A lot of people don’t want to talk about their pasts, but I think it’s extremely important that the person you are going out with knows what you’ve done. This way, you get a better sense of whether your relationship is going to be monogamous or not.”


    Given similar kinds of comments from participants, it became clear that it was probably unrealistic to expect all gay men in relationships to consistently use condoms for anal sex; it should fundamentally be a choice that is made between couples. It is possible that some gay men (like the ones in the above examples) are capable of successfully negotiating safety with each other and can discontinue condom use within their relationships. This means, however, that both partners need to be accurately informed about HIV transmission and about HIV antibody testing. As well, couples need to be made aware of the myths concerning safety from HIV infection, and must be completely honest with each other about sexual behaviour outside of their primary relationship.


    Inaccurate knowledge Concerning the HIV Antibody test:

    Many participants indicated that both they and their partners had been tested for HIV. A few of the participants were in mixed sero-status relationships, but the majority of participants were in relationships where both partners were of the same antibody status. Many HIV positive participants who said that they were in a relationship with an HIV positive partner said that they continued to use condoms for anal sex out of concern of the possibility of reinfection with a different strain of HIV. Others chose to discontinue condom use within their relationships.

    Several participants possessed inaccurate knowledge about the efficacy of the HIV antibody test:

    “ I don’t think there’s any real way that you can be sure that an individual has a clean bill of health; that they don’t have HIV. There’s no real way of knowing that...it could take 10 years to surface and to be honest I don’t really think that the tests are accurate. Especially when you go to your doctor and he says ‘well you might test positive, but if you did that means that we have to test again, because we’re not sure if the first result was correct.” So what the hell would be the use of actually going in there for the first test if somebody’s going to say ‘yeah, you’ve (maybe) got it’.”

    “ More about the incubation period and how reliable is the test, and how long it takes to show up in the test. I think that might influence our degree of comfort in a relationship. Now, they say it could take up to 10 years to show up. Years ago they were saying like 4 years or 6 months or something. As this changes, our perception of the degree of safety that we have might be changing.”

    Even after many years of educational messages, accurate knowledge about the HIV antibody test has not filtered down to all gay men. This means that they may be making decisions (an behaving) based on inaccurate knowledge about HIV antibody testing. An important component of a relationships campaign must be the inclusion of up-to-date information and resources concerning HIV antibody testing. Alternatively, AIDS organizations such as ACT may with to revisit addressing the myths surrounding HIV antibody testing through a large scale campaign targeted to gay men.


    Trust:

    Participants indicated that the level of trust established between themselves and their partners influences their choices concerning condom use in their relationship:

    “ I think there are all sorts of different situations. And, I really think it depends on individuals. A lot of couples aren’t using condoms because they’ve both been tested and they’re confident that they can trust each other, so they don’t need to worry.”

    “ It also depends how much you trust your partner. Do you trust him not to fool around on you, or do you trust your partner to protect himself, and you, if he is fooling around?”

    “But, I mean, people have a right to feel safe. People have a right to trust people, and if they trust that person, it’s their choice. I might say you never can really know, or you can never really know what your partner is doing when you are at work... but I’m not going to tell someone they can’t trust their ‘better half’.”


    While it is important for gay men to feel that they can trust their partners, it is dangerous and naive for anyone to assume that trust alone can prevent HIV infection. This must be stressed in educational materials targeted to gay men in relationships.


    Love:

    Participants also indicated that love between themselves and their partners influenced their decisions to use condoms within their relationships:

    “ I tend to immediately fall in love with the person that I am having sex with, within the first three seconds. You don’t think about tomorrow, so it’s very easy to let your guard down.”

    “ If I love him and vice versa, you can be certain that he isn’t going to do anything that would put my life, or his, at risk for anything.”


    Like trust, it is naive and dangerous to believe that love alone is adequate protection from infection with HIV. However, it is a belief system that many gay men hold, and thus should be addressed in educational campaign materials.


    Monogamy:

    Many participants believed that monogamy can protect them from HIV infection:

    “ I think that it depends on the nature of the relationship. I mean, if it’s a monogamous relationship, then I think partners might feel compelled to no longer use condoms.”


    Gay men need more than simple assurances of monogamy to protect themselves from HIV infection; they need accurate information about HIV testing, about their HIV antibody status and strong communication skills that will allow frank, open discussions about their sexual relations with other men outside of their primary relationship.


    “I was the top”:

    One participant indicated that he assessed his risk for HIV being lower because he was the insertive partner (‘on top’):

    “ For me, I was on top, so to speak. I’ve rarely allowed him to have intercourse with me, and so I felt that I was being safe. I think I became infected (with HIV) because of that...you think that the penis can only push things forward, but things can also get in it as well. I guess I was aware of that possibility, but we never used condoms.”


    Although we did not probe to see if there was general agreement among focus group participants, this statement indicates that at least some gay men may still be under the impression that being on ‘top” (i.e. insertive partner in anal intercourse) will provide safety from HIV infection.


    ‘Condoms spoil the mood’ or ‘it was the heat of the moment’:

    As one participant stated: “ I think that when a lot of people start to feel comfortable with each other, and when they are in the ‘heat of the moment’, they just don’t want to be bothered with it (condom use).” Many empirical studies have shown that people often use this reason for not using condoms. HIV prevention campaigns must be consistent in addressing this issue.


    Cost and availability of condoms:

    Some participants indicated that condoms may not always be available, and that they are expensive. “They (condoms) are just not always convenient, if you know what I mean.” Or, as another man stated: “ The cost of condoms and lube...I don’t want to spend all of that money.”

    Educational campaigns should encourage gay men to have condoms on hand so that they are not seen s an inconvenience. Additionally, campaign (and other HIV prevention) materials should make gay men aware of the many places where condoms and lubricant are distributed free of charge.


    3) Such a campaign must target gay men in all types of relationships, depicting the wide diversity that exists:

    When it comes to role models for gay male relationships, there are very few, if any, that are visible. Gay men have had to develop relationship role models for themselves and, like heterosexual relationships, they are diverse. Respondents yearned for useful role models of men in relationships:

    “ I’d like to see a pamphlet that interviews men who’ve been in a relationship for a number of years, to see how they worked things out.”

    “ No one teaches you how to have a gay relationship in school. They teach you how to have a good husband-wife relationship.”


    It would be very advantageous for ACT to develop materials that show positive images of gay men, in a diverse range of relationships. because gay men have seen so little public representation of their relationships, it is likely that they would be quite apt to notice, and pick up and read, materials like these.


    4) Campaign materials must be available through broad distribution channels to effectively target diverse gay men in relationships.

    In one of the focus group discussions, only two of then ten participants lived in the Church/Wellesley gay ‘village”. None of the participants came to the groups as a result of being handed a flyer in a bar. Instead, all had responded to the advertisement in XTRA!. “ When you have a lover it’s not necessary to live in the ghetto”. As another participant stated: “Couples are hard to target. Originally as singles they may have gone to bars, but they drop out of those circuits.”

    Gay men in relationships may possibly frequent bars less than single gay men. Also, gay men in relationships may be more likely to move out of the Church/Wellesley area once they have coupled. Alternatively, it may be that gay male couples are less likely to move into the neighbourhood because they perceive it to be for singles. Whatever the reasons, it is still true that all of these men read XTRA!. Thus, this community newspaper should be utilized as a tool to raise awareness of ACT’s educational campaign for gay men in relationships.
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