Young Gay & Bisexual Men and HIV: A qualitative study of safer sex knowledge and behaviour among young gay and bisexual men

John Maxwell
Gay Men's Health Promotion Coordinator
AIDS Committee of Toronto
May 1998

Thank You
A special thank you to ACT volunteer John Hart, for his invaluable help transcribing the focus group proceedings from audio tape.



Background and Purpose
A series of one-to-one interviews and one focus group discussion with young gay and bisexual male youth were conducted by the AIDS Committee of Toronto (ACT) in April 1998. The purpose of this research was to determine their knowledge of HIV/AIDS, HIV risk-taking behaviours, and HIV prevention strategies to reach these at-risk youth. The interviews and group discussion were also used to gage reactions to ACT's campaign for young gay and bisexual men (“Go Deeper into Safer Sex”) produced in the spring of 1995, with the aim of developing new educational materials and strategies.


Research Objectives
The objectives of this research were to:
    • determine the level of connection to the gay community/gay community organizations of gay and bisexual male youth in Toronto
    • determine the level of knowledge of HIV/AIDS of gay and bisexual male youth in Toronto
    • identify HIV risk-taking behaviours amongst this population
    • probe for possible reasons behind HIV risk-taking behaviours
    • identify HIV prevention strategies to reach these youth
    • obtain reactions to ACT's safer sex campaign for gay and bisexual male youth titled “Go Deeper into Safer Sex”.

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 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.


Executive Summary

1) Knowledge of HIV, comfort discussing and practising safer sex increases with the level of connection to the gay community and/or gay community organizations.

2) While most gay/bisexual male youth have an understanding of activities that pose a high risk for HIV infection, there is still some confusion surrounding low risk activities such as unprotected oral sex.

3) HIV risk taking among young gay/bisexual male youth is often associated with an inability to talk about and negotiate safer sex. There is also a belief that risk-taking is associated with lowered self-esteem.

4) Young gay/bisexual male youth desire educational materials that are contemporary in design, include photographs of diverse youth, and are delivered in a variety of ways.

5) Print-based materials should be augmented with peer-based outreach to venues where young gay/bisexual men socialize.


Method

Sample:
A total of nine gay and bisexual male youth participated in one-to-one interviews held at the ACT offices in April 1998. An additional nine youth participated in a focus group discussion held at the ACT offices (total sample N = 18).

Participants were recruited through an ad placed within the regular ACT full-page ad in XTRA! magazine. The ad stated: “Gay and Bisexual male youth under 25: ACT is interested in talking to you about safer sex and HIV. We are interested to know what we can do better to support you in having safer sex”. Payment for participation was $20.00. Potential participants were asked to contact John Maxwell at the AIDS Committee of Toronto where they were screened for suitability in this study. They were asked if they preferred to be in a group discussion or a one-to-one interview.

A total of 29 individuals responded to the ad over a two week period. Of these 29 individuals, ten were scheduled into the focus group discussion and a further ten into one-to-one interviews. The mean age for participants was 21.6 years, with the range from 18 - 25. The overwhelming majority of participants had English as their first language. Six participants were people of colour. Two participants identified as sex trade workers. One participant self-disclosed his HIV positive status.

The focus group and one-to-one interviews were facilitated by John Maxwell (Gay Men's Health Promotion Co-ordinator). Focus groups were audio taped and transcribed by an ACT volunteer.


Procedure:

After brief introductions and an outline of the purpose of these discussions, participants were asked (as an icebreaker exercise) to briefly tell their name and how long they have been ‘out’. There was much variance in the length of time that these men had been ‘out’ in the gay community; ranging from 0.5 years, to over seven. The mean length of time ‘out’ was 3.25 years.

Participants were then asked a series of questions that intended to gage their knowledge of HIV, HIV risk-taking behaviours and thoughts about HIV prevention strategies. As well, participants were asked to read through ACT’s 1995 educational campaign targeted to young gay and bisexual men, and comment on the content, design and imagery used. A copy of the Study Questionnaire Guide is attached (Please see Appendix A).



Interpretative Analysis:


Connection to the Gay Community:

All of the participants stated that they had some connection to the gay community and/or gay community organizations - not surprising, given that most participants found out about this study through the ad in XTRA! magazine, the local lesbian and gay community newspaper.

Several participants mentioned the “discomfort” they experienced when they first came into the Church/Wellesley gay community, but that this faded over time. Most mentioned that their primary connection to the community was through social venues - namely bars and/or dance clubs. For those who had been ‘out’ in the community for a relatively short period of time (three years or less), there generally was less acceptance of members of the community who “stood out” from the mainstream. As one participant noted in a one-to-one interview: “I'm not used to the whole gay ‘scene’ - you know, that stereotypical gay attitude you often find at Church and Wellesley”.

Several participants mentioned that they had attended gay peer groups - either those associated with a college/university, or groups such as Lesbian, Gay and Bisexual Youth Toronto, a peer-run group run out of the 519 Church Street Community Centre.

Many participants noted that it was often difficult to meet other gay/bisexual youth, as there seems to be a lack of places (outside of bars) for youth to socialize.

When asked about the differences between young gay/bisexual men who were just coming out now, and those who had been out for some time, many expressed a belief that there is more and more acceptance of homosexuality by the broader society today, than in the past. Many recounted stories of their own comings-out, and the positive support they received from friends, and in some cases, families. While this acceptance in broader society is encouraging, it is in no way a universal phenomena - several participants indicated that they either were not ‘out’ to their family, or else had very poor/non-existent relations with family. Many youth sought the support of social service organizations and or peer-led ‘coming out’ groups. Despite a belief that it was somewhat “easier” to ‘come out’ than in the past, many of the participants believed that it was still difficult to meet friends - particularly other younger gay/bisexual men - in the community.

Many of the study participants noted that as younger gay/bisexual men, they often felt that they were “preyed upon” by older or more sexually experienced gay men - even other more sexually experienced gay and bisexual youth. One participant lamented the lack of “mentoring” in the gay community:


"When I came out into the community (a few years ago) I felt that I needed to become totally immersed in the gay community. So, I left a lot of my straight friends behind. Unfortunately, rather than meeting other gay men who could help me manoeuvre my way in the community, I often met people who just wanted to take advantage of me, sexually."



Knowledge of HIV/AIDS:

Most participants believed that they had a high knowledge of HIV/AIDS and were aware of the activities that were highest risk for HIV infection - unprotected anal intercourse and sharing needles. While some of these young men stated that they had received AIDS education in high school, most believed that this “basic” AIDS education did not prepare them for “coming out into the gay community and being sexually active with other guys”. As one participant stated: “I thought I knew about safer sex; I had access to the information. But it's not until you begin having sex that you start to understand... you don't know how difficult it can be until you're in the situation.” For those youth who lived outside of the downtown core, it was very difficult to access information targeted to gay men.

Most of the men felt that their knowledge of HIV/AIDS increased as a result of their connection to the gay community: many participants mentioned discussions about safer sex in peer youth groups, conversations with gay friends, picking up AIDS information brochures in bars/baths and free condoms given out by outreach workers in gay community venues.

It should be noted that while participants generally believed they were knowledgeable about HIV/AIDS, several statements made in one-to-one interviews indicated misinformation with regards to the risks associated with unprotected oral sex and deep kissing.


Safer sex behaviour:

When asked about the things that influence safer sex behaviour, many participants noted the need for accurate information specifically targeted to gay and bisexual male youth. While most felt that there was a general awareness of HIV/AIDS, they were not prepared for the complexities of negotiating safety. As one young man stated “I didn't have (negotiating) skills when I first came out, but I was able to develop them over time. For me, I made a decision not to have anal sex when I came out, because I knew I didn't feel comfortable discussing condoms”.


Many stated that they thought that some young gay/bisexual men believed that you could “tell” if someone was "clean” (i.e. HIV negative). Although many men were able to admit that this wasn't a good risk reduction strategy, it would enter into their minds when meeting a new sexual partner:


"I know that this makes no sense, but sometimes you meet someone else who is young and you assume he's OK. I mean, you're more likely to look at an older man and think he's more (sexually) experienced, so he's more likely to be (HIV) positive. And yet, you could meet an 18 year old who has been having sex for five years, and he could be positive. There are a lot of assumptions based on age."


Being in a relationship was also believed to influence safer sex practises: namely, young gay/bisexual men were more likely to abandon condom use once they got into a relationship. For some, there was the pressure from a partner to discontinue condom use: “If you loved me, you'd trust me”. While some of the study participants spoke about the ability to negotiate safety within a relationship, they felt that this was a difficult process, especially for many younger men.

Since many young gay/bisexual men were putting themselves at risk for HIV, it was felt that it was important for organizations such as ACT to continue to make HIV prevention materials accessible: to provide accurate information, to distribute condoms and information in venues where young men socialize, and to ensure that HIV prevention messages are visible within the broader gay community.

Several participants noted the need for the gay press to increase its coverage of AIDS as it relates to younger gay/bisexual men. A few participants suggested training youth to act as peer educators in order to stimulate discussions about safer sex. One participant said that young gay/bisexual men should be given a course in “assertiveness training”.

Negotiating safer sex meant different things for different participants, but for most of these youth, negotiation often took the form of non-verbal gestures such as bringing out a condom during sex. As one participant stated “negotiating safer sex sounds more to me like convincing someone to have safer sex. Most people don't bring it up, it just happens.” One participant, who stated that he usually leaves discussions of condom use up to the other person stated: “ I don't want to be rejected, so I don't bring it up. I figure if the other guy is responsible, he'll bring it up.”

While a few participants felt that it was more difficult negotiating safer sex with someone who might become a “boyfriend” (versus someone who was just a casual, one night partner) most felt that this was not an issue to negotiation: safer sex either was negotiated (usually non-verbally and sometimes by the other partner) or unsafe sex occurred.

As one young man stated: “It's still hard for young guys to talk about safer sex, even though most of us have had some AIDS education in the past”. Many felt that it was somewhat easier to talk about sex, and safer sex, with friends (as opposed to sexual partners). One young man noted that culturally, it was very difficult for him to talk with his friends about sex and safer sex: “I can't talk with my Chinese gay male friends about sex or safer sex, as they might get the wrong idea and think that I am trying to pick them up.”


HIV Risk taking behaviour:

Most participants spoke of risks that young gay and bisexual men were taking: they either spoke of risks that they had taken, or, more likely, risks that their friends were taking. Most were able to recount stories where unprotected anal sex occurred. When asked why they thought their friends were taking risks, there was a variety of responses: “curious, wanting to try new things”, “he got really drunk”, “ he was in a relationship, so he stopped using condoms”. As one participant mused:


"Young guys seem to be coming out at a much younger age today. They're still growing up while they're coming out. I wonder how mature they are to handle all the intricacies of having sex. I mean, when you're young you are really daring, you want to take all kinds of risks. I sometimes wonder whether it's a good thing or not that guys are coming out into the community."


This comment was challenged by others in the group discussion, who felt that coming out at a younger age can be a liberating experience - provided that support services and appropriate HIV prevention education programmes are in place to ensure that young gay/bisexual men are adequately informed about HIV/AIDS.

Other participants spoke of a gay community that was “young-centric”. “If you are young and cute, everyone seems to want you. You go out to the clubs and it's so sexually charged. It's hard to resist getting caught up in the scene of drugs, alcohol and sex.”

Several participants believed that young gay/bisexual men were taking risks because of low self-esteem.


"They don't feel good about themselves. They feel like they have to fit in, they have to have lots of sex, and act a certain way. But, if they don't feel good about who they are, they are less likely to tell someone ‘no, I don't want to do that’. So, they end up having unsafe sex, because they are afraid of rejection."


When asked about the things that help young gay and bisexual men continue to practise safer sex, many participants noted the outreach that occurs in both bath houses, and bars. “I have a friend who goes to the baths, and he gets free condoms from the people who are there. He also can talk to people there about safer sex. This is a good idea.” Others spoke of the need for updated educational materials that look “cool” and are put in places where young people socialize.

One young man noted that some gay/bisexual youth today do not try and connect with the gay community. “Maybe they feel that because they are accepted by their straight friends, they don't have to connect with Church/Wellesley. So, they think that AIDS isn't a concern for them, even though they are having sex with other guys”. This participant felt that it was important to ensure that information for young gay/bisexual men was available beyond the gay community.


HIV Prevention Education Programming:

When asked about the kinds of educational campaign images that would be appealing to them as young gay/bisexual men, there was an overwhelming desire to see images of young “real” looking youth. There was a desire to see “real people in real situations”. Participants believed that campaign images should reflect the diversity within the community: both ethno-cultural diversity, as well as a diversity of dress styles:


"I want to see real looking people; people who are attractive, but not necessarily like the standard kind of model. I want to see all kinds of youth, in different kinds of clothes. Some images can be sexy, and others should be romantic and fun. I'd like to see photos of young people interacting with each other."


One participant said that he wouldn't like to see images of “buff, beefcake kinds of guys” in an HIV prevention campaign because “some people might think, ‘hey I don't look like this, so why would I want to pick up this information”.”

When asked about the kinds of HIV prevention materials that should be developed, the vast majority of participants felt that there needed to be a range of materials: brochures, postcards, print ads, small inserts that could be packaged with condoms, etc.

There were suggestions to broaden advertising to include newspapers such as Now and eye magazines - newspapers that have a broader distribution that XTRA! or fab which are primarily found in the gay community.

Several participants in one-to-one interviews commented on ACT condom packs that they had received from Outreach volunteers in bars. They liked the idea of creating condom packs that contained a youth-oriented insert, and delivered by peer outreach workers in a variety of venues: “you're more likely to take something from someone who is young like you” commented one participant.

One participant stated that ACT should insist better locations for its Information Boards in gay bars and bath houses:


"Sometimes they stick the board in really bad places. Either it's too dark, or it's in a place where there isn't much traffic. ACT should tell these places to put them in a better place, where more people can get the information."


In addition to traditional printed campaign materials, many participants believed that campaign materials should be augmented with a “personal touch”:


"It would be good to have young people giving out information and answering questions. I mean, sometimes you can read something and still have questions. Or, maybe you don't want to read a whole brochure. If there were events, even social events, where gay youth could get together. Something that was fun and interactive."


There were suggestions to have youth involved in developing the messages for outreach inserts, as well as handing them out.

Other suggestions for programming included public service announcements on radio and television (particularly Much Music), ads and billboards in the gay community, or murals throughout the city.

When asked where materials should be distributed, all agreed that they should target places where young gay/bisexual men socialize; bars and clubs (particularly Boots, Joy and other bars that have “gay nights”), coffee shops, peer-support groups, social service organizations, Health Clinics (including Hassle Free and Shout Clinics), campus lesbian and gay groups, washrooms in bars/schools (i.e. urinal advertising) and via the Internet. Several participants pointed to the need to have materials available “beyond Church Street”, as not everyone lives downtown or can come downtown.


Evaluation of “Go Deeper into Safer Sex” campaign:

Participants in both one-to-one interviews and the focus group were asked to look at the existing campaign targeted to young gay and bisexual men (Go Deeper into Safer Sex), which was produced in 1995 and will be replaced in 1998. Many of the participants stated that they had seen these campaign materials in the past.

An overwhelming majority of participants liked the campaign materials and the use of a variety of formats (posters, postcards and a booklet). The use of bright colours and “catchy” tag lines was appealing. Many of the participants liked the fact that the booklet was designed to fit inside a CD case; many were able to spot this even before the facilitator mentioned this to the group.

When it was explained that the campaign was launched at a special party where the booklets were slid into blank CD cases, filled with condoms and lube and given to youth at the event, people thought that idea was “excellent” and “amazing”. The link between music and youth was thought to be very good.

Participants felt that the information in the booklet was thorough and they liked the list of referral numbers on its back. The fact that the postcards stood on their own and reinforced the campaign messages, was felt to be positive.

Criticisms of the campaign included the imagery used; it was felt that some of the models looked “older than 25”. Even though they were all under 25 years old, it was noted that any new materials that are developed should include young looking models. Other suggestions included having photos on the front cover (so that youth would know that the brochure is targeted to them) and/or some text that states clearly that this campaign is for young gay and bisexual gay men.


Other Comments:

Many of the study participants were both aware and appreciative of the outreach initiatives undertaken by the Gay Men's Health Promotion programme at ACT in bars and bath houses, but did not feel that ACT was an agency that they could come to for more information and/or support. ACT is primarily perceived as an organization for (older) people with HIV. It is vital that ACT endeavour to change this perception within the community. To that end, it would be advantageous for ACT to continue to pursue partnership strategies with social service agencies that currently serve young gay/bisexual male youth in Toronto.


Programming Recommendations:
1) The Gay Men's Health Promotion Team, working in partnership with other staff, teams, and external agencies, should develop a new HIV prevention education campaign targeted to young gay/bisexual male youth.

2) The AIDS Committee of Toronto should continue to develop partnerships with Toronto-based gay youth serving agencies, with the goal of providing joint programming targeted to gay/bisexual male youth, so as to ensure that young gay/bisexual male youth have access to HIV information, support and referrals.

3) The Gay Men's Health Promotion Team should explore the feasibility of developing a peer-youth volunteer outreach programme, to assist in the dissemination of campaign materials.

4) The Gay Men's Health Promotion Team should work with ACT’s Development Team to explore the feasibility of developing washroom advertising in venues frequented by gay/bisexual male youth.


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Appendix A:
Focus group Questions: Young gay and bisexual men

Welcome, introductions and climate setting:

- moderators name, no right or wrong answer, confidentiality, payment at end (must sign for payment, but can use a false name)

- give your name, age and how long you have been ‘out’.


1) How connected are you to the Gay community?

-probe: gay/bi, drug, bar scene, bath house scene, community groups, school lesbigay groups etc.


2) What's different for those guys that are newly out and those of you who have been out for some time?

- probe for : connection to community, awareness of safer sex, more vulnerable to sexual coercion.


3) Where do you get your information about HIV/AIDS?
-probe for brochures, school, friends etc.


4) What kinds of things influence you to practise/not to practise safer sex?

- probe use of condoms every time: how often, which situations
- what stops you from practising safer sex? (negotiating skills, influence of alcohol & drugs)
- what makes it easier to practise?


5) What does 'talking about sex" (negotiating) mean to you?

a) who does the talking: who initiates discussions about safer sex?
b) is talking about sex different with respect to "casual" sexual partners vs. “boyfriends”
c) what do you say/ how do you say it?
d) do you try and assess whose "clean"
e) when do you talk about sex?
f) is it easy or hard to talk about sex?


6) What risks do you think your friends are taking? What risks are you taking?

-probe for things that cause them to take risks : having sex with other young guys, influence of drugs/alcohol.


7) What have you seen and/or heard that helps people practise safer sex?
- what would motivate you?
- how would you "sell" safer sex to your friends


8) What images of gay/bisexual men appeal to you and your friends?
- probe for images they may have seen in past campaigns or media


9) What kind of campaign materials do you prefer?

- probe for: posters, postcards, pamphlets, booklets, comic books, condom packets any others.


10) Where should HIV/AIDS education materials be distributed, in order to reach younger gay/bisexual men?


11) Take about 5 minutes and look at old ACT campaign (Go Deeper into safer sex - brochure and 4 postcards and 3 posters)

- what do you think about the campaign images? messages? design?
- would you pick up this material ?
- what do you think are the main message(s) of the campaign?


12) Any other thoughts, comments, concerns?


Thank you and payment.

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