Can you (still) relate? A qualitative examination of sexual health issues facing gay men in relationships

See also: Can you relate?


John Maxwell
Gay Men's Health Promotion Coordinator
September 1997



Background and Purpose:


Two focus groups were conducted in late August and early September 1997 with gay men in relationships for the purpose of identifying health concerns facing gay men in relationships, as well as evaluating the AIDS Committee of Toronto's educational brochure titled, "can you relate? Safer sex in gay relationships". This brochure was written and produced in 1993 and is currently out of print. It was hoped that these groups could be used to evaluate both the messages and the format of the brochure, as well as provide input into the development of replacement educational materials targeted to gay men in relationships.

Research Objectives:

The objectives of these focus groups were:
    • to identify some of the health issues facing gay men in relationships.
    • to discuss condom usage within relationships.
    • to obtain reactions to the “can you relate?” brochure in terms of language (vernacular), length, content and design.
    • to provide input into the development of new educational materials targeted to gay men in relationships.


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 pre-determined hypotheses, but rather to elicit the perspectives of individual participants. Generalizing from a "representative sample" of gay men to gay men in general is not possible; nor is it necessary for the purposes of this research. Rather, the reader should assume that these insights are illuminating and, therefore, directional.

Method
Sample:

A total of eighteen participants were recruited to participate in focus groups which were held on Thursday, August 28 and Wednesday, September 3 1997 at the AIDS Committee of Toronto.

A flyer, stating “Are you a gay man in a relationship?” was distributed via the ACT Information Board system in Toronto gay bars, bath houses and other community venues. An ad was also placed in XTRA! magazine. Payment for participation was $20.00. Potential participants were asked to contact John Maxwell at the AIDS Committee of Toronto and were screened out of attending the groups if they were not currently in a relationship. It was left up to the participants to define the term “relationship”. (Please see Appendix A, copy of ad/flyer).

In total, fourteen gay men participated in the focus groups: six in the first group and eight in the second. Of these, one man was Black, one man was south Asian and the others were Caucasian. One of the participants identified as a sex trade worker. Four of the participants self-disclosed as HIV positive.

The mean age of participants was 30, with a range from 19 - 46. The mean length of relationships was 3.4 years, with a range from 0.75 - 9 years.


Procedure:

After introductions and orientation to the focus group procedure, participants were told that the first part of the group would consist of a general discussion about issues facing gay men in relationships, to be followed by a pen-and-paper survey evaluation of educational materials produced for gay men in relationships. This written survey would then be followed by a group discussion. (Please see Appendix B, focus group outline as well as Appendix C, pen-and-paper survey evaluation).


Interpretative Analysis:


Issues facing gay men in relationships:

Participants were asked to talk about health concerns facing gay men in relationships. Not surprisingly, HIV was mentioned as the greatest concern for men in relationships, closely followed by infection with other sexually transmitted diseases (STDs).

As one participant stated, “Will I become (HIV) positive? You may know your own (sexual) behaviour, but you may not always know your partners’.” As several participants noted, trust in a relationship often leads to a discontinuation of condom usage for anal sex.

Several participants were quick to note the diversity of relationships that exist; not all are ‘monogamous’ in nature, many are based on agreed rules for sex outside of their primary relationship. The problem often arises when one is unsure as to whether or not their partner is adhering to these agreed upon rules. For this reason, some of the participants have decided to continue using condoms within their relationship, even though they are not having sex outside of their relationship.

For those participants who self-disclosed as HIV positive, condom usage varied. For those men who were in relationships with partners who were HIV negative, condom usage was important both to prevent HIV transmission to the HIV negative partner, and to protect the HIV positive partner from other sexually transmitted diseases. As one HIV positive participant stated:

“I'm in a monogamous relationship with someone who is HIV negative. We use condoms because of the possibility of HIV transmission and the fact that I don't want to pick anything up from him.”

For one HIV positive participant who was in a relationship with another HIV positive man, their decision to discontinue using condoms was not based on any discussion between the two, rather it was something that “just happened” after several months in their relationship. This participant was surprised to learn from other focus group members that re-infection with HIV can occur between two sero-positive partners.

For one participant who was in a relationship with a partner who was younger, and who recently came out into the gay community, he felt it was important not to “pressure” his partner to do things. He also had said to his partner that he could have sex with other men if he so desired, as long as they discussed this before. When his partner made it clear that he wanted a ‘monogamous’ relationship, they both agreed to get tested for HIV, to share their test results and to discontinue using condoms within their relationship.

While the above example points to the success that some men are able to have in negotiating safety with their partners, this is not a universal phenomenon. One partner noted that he had thought his relationship was monogamous, only to find out (from acquaintances) that his partner was seen frequenting a known public sex environment. Clearly, not all men are able to negotiate rules and boundaries regarding sex outside of their relationship.

When asked how people have negotiated safety in their relationships, there was great variance between participants. As one participants stated: “Do you start talking about this from day one? I mean, it isn't something you're likely to bring up on the first date.”
One man mentioned that he brought the subject in a “nonchalant” way while out at a club with his partner. “In this way, I was giving my partner permission to start talking about sex with other people. Is this something he might want? What do I think about this?”. Most agreed that it was important to be open and honest with your partner, and to be very clear about your needs within your relationship. The problem is, often this is a very difficult thing to do.

Several participants felt that there was not enough information (or support services) for gay men in relationships:

“It's as though everything is geared to single people in the gay community. There aren't places to meet other gay couples. XTRA! seems to be only for the bar crowd.”

Many men felt it would be useful if there was some kind of brochure that outlined the ‘steps’ that could be followed if a couple is considering bringing up the topic of sex outside of the relationship.


Condom use in relationships:

When participants were asked whether or not it is realistic to tell gay men in relationships that they must always use condoms, the majority of participants believed this was not realistic. As one man stated: “Both me and my partner made the decision to stop using condoms, even though we felt like we were breaking all the rules.”

Still, there were those participants who felt that it was important to continue using condoms within relationships: “What if one of you tested (HIV) positive? Think of the guilt you'd feel. You'd be worried every time you had sex about infecting your partner”.

Most participants felt that it was ultimately a choice that couples needed to make.

It is interesting to note the general lack of reluctance to admit to the discontinuation of condom use amongst the participants in these focus groups, versus those men who participated in similar focus groups in 1993. At that time, there was reluctance to admit that couples were abandoning condoms in their relationship. In fact, in those groups, it was one participant who challenged the focus group facilitators’ assertion that he and his partner had “slipped up” and stopped using condoms. The participant clarified that he and his partner had made a conscious decision to stop using condoms after a process of open communication, the establishment of rules for sex outside of their relationship and HIV testing.

Clearly, the concept of “negotiated safety” is better known today, perhaps as a result of articles last year in XTRA! magazine (and other forums) after the XI International AIDS Conference. These articles focused on an Australian campaign targeted to gay men in relationships, which was viewed as controversial as it was seen (by some) to be advocating for the discontinuation of condoms in gay relationships . Gay men in these focus groups were able to articulate the variety of ways in which they successfully (or unsuccessfully) maintain sexual safety within their relationships without a fear of being judged.


Information needs of gay men in relationships:

Participants believed that gay men in relationships needed information about safer sex that spoke to their unique realities. They also felt that it was important to have materials that showed the diversity of relationships that can exist; information that affirmed all types of relationships. Several participants believed it would be useful to have a guide for men that could be used to help them negotiate safety within their relationships: How to start talking about monogamy with a partner, how to go about developing “rules” for sex with other people. A few participants wondered whether ACT could be a place where gay men in relationships could go for counselling if they were starting to think about these things in their relationship.

One participant noted the emerging confusion over the new ‘drug cocktails’ that many people with HIV are now taking:

I hear from guys who find out that their viral load is undetectable, and think that they no longer have HIV. They believe that they can no longer infect people, and so don't think they need to use condoms.

He suggested that this confusion needs to be addressed in new safer sex materials, including materials targeted to gay couples.



Evaluation of “can you relate” brochure:


Participants were asked to read the “can you relate” brochure and then answer a series of pen-and-paper questions related to the brochure content and format. Participants were encouraged to provide written feedback on a variety of aspects of the brochure including it's format (size), length, design and overall impression of the material. A summary of several aspects of the brochure follows:

i) Format (size) of brochure: Using a Likert scale ranked from 1 (very good) to 5 (not good) the mean response was 3 (good).

ii) Length of brochure: Using a Likert scale ranked from 1 (too long) to 5 (too short) the mean response was 2.9 (just right).

iii) Design of brochure: Using a Likert scale ranked from 1 (very appealing) to 5 (unappealing) the mean response was 3.1 (good).

iv) Overall impression of brochure: Using a Likert scale ranked from 1 (very good) to 5 (not good) the mean response was 2.9 (good).

Several participants commented that they remembered seeing this brochure in the past. Most participants felt that the information included in the brochure was good: it affirmed all types of relationships and attempted to outline the (sometimes difficult) process that needs to occur if couples are considering no longer using condoms for anal sex in their primary relationship.

Many participants felt that one of the main messages of the brochure was the importance of maintaining open, honest communication with your partner. While the majority of participants felt that the brochure provided a balanced message with respect to condom use in relationships (by not passing judgment on couples should they decide to continue/discontinue using condoms in their relationship), one participant felt that the brochure (in stressing the long and difficult process involved in making the decision to discontinue condom usage) was giving a message that gay men in relationships should always use condoms. It is important to note that this individual was in the minority as most focus group participants felt that the brochure tried to deliver a balanced message.

Most participants felt that the length of the brochure was adequate, given the complexity of the brochure subject. One participant suggested adding other information that discussed the risks of other sexual activities (i.e. oral sex) , rather than solely concentrating on condom use for anal sex.

While the brochure's format was thought to be unique as compared to the standard brochure size, some of the participants felt that the relatively large format of the brochure might inhibit some people from taking the brochure away, as it does not easily fit into a pocket. Suggestions included not having as much photography, or reformatting the brochure to a longer and narrower design.

While the design of the brochure was considered good, many participants felt that more (and brighter) colours could have been used. The brochure was viewed by some as being “too serious” because of the dark colours. Participants liked the diversity of images used in photography and felt that this needed to be reflected in any new materials developed for gay men in relationships. Two participants felt that some of the photography could have been “more sexual” in nature; this might appeal to certain gay men.

Several participants suggested that the end of the brochure should contain information that would direct the reader to additional supports or more information (i.e. come to ACT to see a counsellor, call the Hotline).


Recommendations:


1) That safer sex information targeted to gay men in relationships is needed.

2) That such materials must affirm all types of gay relationships and reflect the cultural diversity within the gay community.

3) That materials should encourage the consistent use of condoms for anal sex at the outset of relationships and state clearly the many issues that are involved in the decision to discontinue condom use (HIV antibody status, HIV testing, agreement {from both partners} regarding sex outside of the relationship).

4) That information be made available to gay men in relationships in a variety of formats (brochures, posters, ads in XTRA!).

5) That the AIDS Committee of Toronto make it known that counselling services can be accessed by gay men in relationships who are considering the discontinuation of condoms within their primary relationships.

6) That other programmes and services be developed that would enable gay men to develop the needed communication skills and strategies in order to successfully negotiate safety within their relationships.

e-mail: Gay Men’s Community Development Coordinator