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Sexual Behaviors and Situational Characteristics of Most Recent Male-Partnered Sexual Event among Gay and Bisexually Identied Men in the United States
jsm_2438 1..10

Joshua G. Rosenberger, PhD, MPH,* Michael Reece, PhD, MPH, Vanessa Schick, PhD, Debby Herbenick, PhD, David S. Novak, MSW, Barbara Van Der Pol, PhD, MPH, and J. Dennis Fortenberry, MD, MS
*Department of Global and Community Health, George Mason University, Fairfax, Virginia, VA, USA; Center for Sexual Health Promotion, Indiana University, Bloomington, IN, USA; Division of Adolescent Medicine, Indiana University, Indianapolis, IN, USA; OLB Research Institute, Online Buddies, Inc., Cambridge, MA, USA; Division of Epidemiology & Biostatistics, Indiana University, Bloomington, IN, USA DOI: 10.1111/j.1743-6109.2011.02438.x

ABSTRACT

Introduction. Recent nationally representative studies documenting event-level sexual behavior have included samples that are predominantly heterosexual, resulting in limited information on the sexual repertoire of gay and bisexually identied men. Aim. This study sought to document the sexual behaviors that gay and bisexually identied men report during their most recent male-partnered sexual event and to describe the situational characteristics and participants evaluation of these events. Methods. Via an internet-based survey, data were collected from 24,787 gay and bisexually identied men (ages 1887 years) from 50 US states and the District of Columbia. Main Outcome Measures. Measures included items related to sociodemographics, recent sexual behavior history, situational characteristics, orgasm, and ratings of arousal and pleasure. Results. Participants mean age was 39.2 years; ethnicities included white (84.6%), Latino (6.4%), and African American (3.6%); and most men (79.9%) identied as homosexual. The most commonly reported behavior was kissing a partner on the mouth (74.5%), followed by oral sex (72.7%), and partnered masturbation (68.4%). Anal intercourse occurred among less than half of participants (37.2%) and was most common among men ages 1824 (42.7%). Sex was most likely to occur in the participants home (46.8%), with less frequently reported locations including hotels (7.4%) and public spaces (3.1%). The number of behaviors engaged in during last sexual event varied with most (63.2%) including 59 different sexual behaviors. Conclusions. These data provide one of the rst examinations of sexual behaviors during the most recent malepartnered sexual event among gay and bisexually identied men in the United States. Findings from this study suggest that gay and bisexually identied men have a diverse sexual repertoire and that partnered sexual behaviors are not limited solely to acts of penile insertion. Rosenberger JG, Reece M, Schick V, Herbenick D, Novak DS, Van Der Pol B, and Fortenberry JD. Sexual behaviors and situational characteristics of most recent malepartnered sexual event among gay and bisexually identied men in the United States. J Sex Med **;**:****. Key Words. Sexual Event; Gay; Bisexual; Men; Sexual Behavior; MSM

Introduction

nderstanding the frequency and types of sexual behaviors has become increasingly important; in doing so, it provides data to help

promote positive sexual health among individuals. Several national studies have captured population level information about sexual behaviors including the National Health and Social Life Survey, the National Social Life, Health and Aging Project
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2011 International Society for Sexual Medicine

2 and, most recently, the National Survey of Sexual Health and Behavior (NSSHB) [113]. While these surveys have contributed detailed information about the sexual lives of adolescents and adults in the United States, a limitation of population data is an underrepresentation of sexual minorities, including gay and bisexually identied men. An additional limitation of research on gay and bisexual men is the almost exclusive focus on the human immunodeciency virus (HIV) epidemic as the rationale for research on mens sexual behaviors [14]. This emphasis has resulted in a body of literature about gay and bisexual men that is riskfocused, with limited understanding of the diversity and complexity of these mens sexual lives [1518]. Particularly missing from the literature has been research related to the composition of gay and bisexually identied mens sexual events, the context of the sexual event, and the association of certain behaviors with orgasm and mens ratings of pleasure and arousal. Furthermore, in order to provide clinicians and public health professionals with the necessary tools to promote sexuality in a positive and healthy manner, a more nuanced understanding of the biological, social, and psychological components of an individual sexual experience is needed.
Aims

Rosenberger et al. study were directed to the study questionnaire, completion of which took approximately 20 minutes. A total of 169,136 individuals opened the recruitment e-mail, and 55,452 (32.8%) of these men proceeded to the study web site. Of those viewing the study information and consent form, 32,831 individuals (59.2%) consented to and subsequently participated in the study. All study protocols were reviewed and approved by the Institutional Review Board at Indiana University.

Main Outcome Measures To facilitate comparisons with recently obtained nationally representative data, many measures were consistent with those used in the NSSHB [5,11]. Participants completed information related to their sociodemographics and items associated with their most recent sexual event with a male partner including: sexual behaviors, condom use, event characteristics, and evaluation of sexual aspects of the event. Sociodemographics Measures included those related to a participants age, gender, sexual orientation, race/ethnicity, level of education completed, US state of residence, employment status, and religious practices. Sexual Behaviors During Most Recent Sexual Event Participants were provided with a list of 12 sexual behaviors and were asked to indicate which of these had occurred during their most recent sexual encounter with a male partner. These behaviors included: romantically held sexual partner (i.e., cuddled), kissed on mouth, solo masturbation, masturbation of partner, masturbation by partner, genitalgenital contact, gave oral sex, received oral sex, insertive anal intercourse (e.g., inserted their penis into their sexual partners anus), receptive anal intercourse (e.g., inserted their sexual partners penis into their anus), oralanal contact given, and oralanal contact received. Additionally, for each participant, a behavioral combination was created that provided description of the combinations of the specic sexual behaviors that occurred within the context of the reported event. Condom Use During Most Recent Sexual Event Condom use during mens most recent malepartnered sexual event was assessed by asking participants to indicate whether a condom was used at some point during the sexual act or a condom was not used at any time.

This study sought to document the sexual behaviors that gay and bisexually identied men report during their most recent sexual event with a male partner and to describe the situational characteristics and participants evaluation of that event.
Methods

Participant Recruitment and Data Collection This study was conducted via a participatory effort with one the worlds largest operators of Internet web sites for men who seek social or sexual interactions with other men. An electronic email recruitment message was sent (in October 2010) to registered users of two of the companys largest web sites, if the individual had indicated that their residence was within one of the 50 US states or the District of Columbia. The electronic message provided a brief description of the study and included a link to the study web site. At the study web site, individuals read a detailed description of the study and, if interested, proceeded to the study consent form. Those who consented to participate in the
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Gay and Bisexual Mens Sexual Behavior

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Results

Event Characteristics of Most Recent Sexual Event Recency of the last sexual event included six time options (past 7 days; past 30 days; past 90 days; more than 3, but less than 6 months; more than 6, but less than 12 months; and more than 1 year ago). The nature of the relationship status with the sexual partner was coded as follows: (i) boyfriend/ signicant other; (ii) casual/dating partner; (iii) friend; (iv) new acquaintance (someone I just met); (v) spouse/domestic partner; (vi) transactional (someone who paid me or gave me something for sex; someone who I paid or gave something to for sex). The location of the sexual encounter was categorized as: (i) participants home; (ii) sex partners home; (iii) a friends home; (iv) hotel/motel; (v) public (e.g., beach and park); (vi) car/truck/van; (vii) sex club/bathhouse; and (viii) other. Men were asked separately whether (yes, no, unsure) they or their sexual partner used any medications designed to help you attain or maintain an erection (such as Viagra, Cialis, and Levitra). Evaluation of the Sexual Aspects of the Event The sexual aspects of the event were assessed by asking separately how pleasurable the event was and how aroused the participant felt. Men who indicated having engaged in anal intercourse (insertive or receptive) during their most recent event were also separately asked whether they had experienced any penile pain or pain in the rectum or anus. Response options for all ve measures included: not at all, a little, moderately, quite a bit, and a lot. Lastly, participants were asked whether they had experienced an orgasm (yes, no, unsure) and perceptions of whether their partner had experienced an orgasm (yes, no, unsure). Analysis Men included in these analysis were those who: (i) self-identied as gay or bisexual, (ii) indicated their last sexual event was within the previous year, and (iii) reported their most recent sexual event was with another male. The nal sample included 24,787 men. All analyses were conducted using SPSS version 18.0 (SPSS Inc., Chicago, IL, USA). Descriptive analyses were conducted to present participant characteristics including demographics, sexual behaviors, and the context and evaluation of the sexual experience. Statistical techniques including t-test, regression, and chi-square were used where appropriate. Where appropriate, condence intervals were set at 99%, and to avoid type 1 errors, the acceptable P level was set at 0.01.

Sample Characteristics Table 1 shows the characteristics of this sample (N = 24,787). The participants ranged in age from 18 to 87 (Mean = 39.20, SD = 12.57), the majority were white (84.6%, N = 20,894), self-identied as gay (85.9%, N = 21,288), and more than half of men had received a bachelors degree or higher (57.4%, N = 14,175). Characteristics of Most Recent Sexual Event The sexual behavior most commonly reported during mens most recent male-partnered sexual event was giving oral sex (75.0%, N = 18,590), followed by kissing their sexual partner on the mouth (74.8%, N = 18,541), and receiving oral sex (73.4%, N = 18,194) (Table 2). Sexual behaviors involving the anus were least common, with 35.5% and 33.8% of men reporting engaging in receptive or insertive anal intercourse, respectively. Receptive anal intercourse during mens most recent male-partnered sexual event was most common among men aged 1824 and was less common among men in older age cohorts, while the proportion of men reporting insertive anal intercourse at last event was largest among men aged 3039. In total, 32.9% of participants reported that a condom was used at some point during their most recent male-partnered sexual event, with almost half of participants (45.5%) who had engaged in anal intercourse indicating condom use. Most men (85.6%, N = 21,218) indicated that their most recent male-partnered sexual event occurred within the past 30 days, with the majority of these events occurring within the previous 7 days (59.5%, N = 14,748). The majority of participants described sexual encounters that took place either in their home (49.1%, N = 12,170) or their sexual partners home (28.6%, N = 7,089), while other locations included in a hotel/motel (7.2%, N = 1,785), public space (3.7%, N = 917), or car/truck/van (1.6%, N = 397). In total, nearly one-fth (18.8%, N = 4,660) of sexual events reported occurred in locations other than a house, and differences in sexual space were seen depending on age and sexual identity with younger men being signicantly more likely to have engaged in sexual activity in a car/truck/van (odds ratio [OR] = 0.95, condence interval [CI] = 0.93 0.96), and both men over 40 years of age (OR = 1.11, CI = 1.091.24) and those who selfidentied as bisexual (c2 = 13.86, P < 0.001) being
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Table 1 Participant characteristics for total sample (N = 24,787) and by sexual orientation
Total sample Sample characteristics Age 1824 2529 3039 4049 5059 60 Race/ethnicity White African American/black Hispanic/Latino Asian/Pacic Islander Other Education Bachelors degree or higher Some college High school graduate Less than high school Relationship status Single, not dating Single, dating more than one person In relationship, <3 months same person In relationship, 36 months same person In relationship, 612 months same person In relationship, 15 years same person In relationship, >5 years same person Geographic region of United States Northeast Midwest South West City size Large city Medium city Small city Small town, not near city Rural area Employment status Full time Part time Student No, looking for work No, not looking for work Religious service attendance More than once a week Once a week Once a month Special occasions or holidays Never Health status Excellent Very good Good Fair Poor % 15.4 13.1 21.3 27.8 17.0 5.5 84.6 3.6 6.4 2.4 2.9 57.4 32.5 9.4 0.7 54.6 7.3 3.7 1.8 2.3 9.4 20.9 25.1 24.4 30.3 20.2 30.4 28.4 24.8 11.0 5.3 69.7 9.3 7.4 7.6 5.9 2.5 10.1 6.0 26.5 55.0 26.6 45.1 23.8 4.0 0.5 N 3,813 3,238 5,277 6,888 4,218 1,353 20,894 886 1,589 599 729 14,175 7,995 2,267 122 13,488 1,800 913 451 574 2,311 5,160 6,057 5,902 7,312 4,875 7,539 7,032 6,149 2,733 1,307 17,112 2,291 1,822 1,869 1,447 602 2,456 1,452 6,468 13,412 6,596 11,185 5,890 993 112 Gay (N = 21,288) % 14.6 13.3 22.0 28.4 16.5 5.1 84.8 3.4 6.4 2.5 2.8 57.8 32.3 9.1 0.7 54.4 7.3 3.8 1.9 2.4 9.8 20.4 25.1 24.2 29.9 20.8 31.9 29.2 23.9 10.3 4.7 70.1 9.2 7.2 7.6 5.9 2.1 8.9 5.5 26.3 57.2 26.5 45.1 23.8 4.1 0.5 N 3,118 2,832 4,691 6,041 3,518 1,088 18,003 726 1,365 523 605 12,263 6,827 1,902 99 11,547 1,547 815 398 505 2,090 4,332 5,208 5,005 6,187 4,311 6,791 6,202 5,091 2,184 999 14,773 1,940 1,501 1,607 1,248 445 1,862 1,149 5,516 12,009 5,641 9,593 5,074 874 98

Rosenberger et al.

Bisexual (N = 3,499) % 19.9 11.6 16.7 24.2 20.0 7.6 82.6 4.6 6.4 2.2 3.5 55.0 33.6 10.7 0.9 56.0 7.3 2.8 1.5 2.0 6.4 23.9 24.7 26.1 32.8 16.4 21.4 23.8 30.3 15.7 8.8 67.4 10.1 9.2 7.5 5.7 4.6 17.4 8.9 27.9 41.2 27.3 45.5 23.3 3.4 0.4 N 695 406 586 847 700 265 2,891 160 224 76 124 1,912 1,168 365 23 1,941 253 98 53 69 221 828 849 897 1,125 564 748 830 1,058 549 308 2,339 351 321 262 199 157 594 303 952 1,403 955 1,592 816 119 14

signicantly more likely to have had a sexual encounter in a hotel/motel. The type of partner with whom participants described engaging in sexual activity during their last male-partnered sexual event varied, with similar proportions of men indicating their partner
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was a boyfriend/signicant other (18.0%, N = 4,462), casual/dating partner (19.0%, N = 4,710), or a friend (17.3%, N = 4,288). While older bisexually identied men were consistently more likely to describe their most recent malepartnered sexual event occurring with a new

Table 2
Gay-identied men 1824 years (N = 3,118) % Endorsed Item 76.6 83.4 74.9 76.4 70.0 75.8 70.0 42.7 30.0 43.7 18.8 26.5 36.9 40.9 4.7 4.6 2.7 3.6 0.4 1.1 20.4 24.9 18.8 30.2 1.6 0.8 52.0 28.7 11.9 3.8 3.6 0.8 1.0 1.7 1.5 5.2 2.2 14.2 4.8 58.2 27.5 9.4 3.2 1.8 61.4 24.8 9.0 2.4 2.3 63.0 24.8 8.3 1.9 2.0 62.8 23.6 9.2 2.0 2.3 23.6 7.4 22.0 22.4 16.0 31.5 4.3 0.5 19.6 19.8 15.4 33.3 7.0 0.6 19.4 16.9 14.4 35.9 6.9 1.1 16.2 15.3 17.7 35.5 7.7 1.2 15.5 15.5 20.8 32.2 6.3 2.9 62.9 25.3 7.1 2.0 2.8 35.7 9.3 13.3 21.8 21.5 37.4 1.0 1.3 44.7 32.7 14.8 3.7 4.0 0.8 0.6 50.0 32.5 3.2 6.4 2.5 1.7 1.6 0.9 54.4 26.3 2.8 7.5 3.1 1.0 2.0 1.6 53.5 23.1 3.2 8.2 4.4 0.8 2.8 2.3 55.2 22.1 2.6 7.1 4.0 0.9 3.9 2.7 62.4 17.7 3.3 5.2 3.2 0.3 2.4 1.8 28.5 45.5 4.7 4.9 3.5 5.1 0.4 1.2 38.1 40.3 6.4 5.0 2.5 3.5 0.7 1.7 15.6 20.5 18.3 39.5 2.2 0.9 52.0 30.5 12.1 2.5 3.0 2.1 0.9 41.4 33.2 3.6 8.9 4.4 3.1 2.4 1.4 12.6 22.4 20.8 35.6 2.1 1.4 57.7 28.7 9.4 1.7 2.6 6.5 2.3 76.7 81.7 74.3 74.8 66.7 72.2 69.1 40.7 33.1 42.6 21.0 25.7 74.4 77.1 73.9 67.4 62.5 66.3 63.0 37.1 36.0 36.3 25.6 26.6 74.9 72.6 72.5 57.4 59.7 56.0 55.3 34.7 34.6 28.6 29.3 27.2 74.0 71.4 71.3 54.4 63.3 52.2 53.4 29.9 33.8 24.3 29.7 25.1 77.1 71.9 73.1 51.1 68.7 48.1 51.7 28.3 32.4 20.2 32.4 24.3 76.0 76.3 76.8 75.0 60.3 74.2 69.6 35.8 38.8 35.3 17.7 24.3 68.7 70.2 75.1 70.1 56.7 72.4 61.3 29.1 37.1 42.4 17.0 21.7 70.5 65.0 75.1 66.6 54.3 65.1 58.5 31.1 35.8 31.6 18.6 24.7 73.7 64.3 74.0 59.1 53.7 61.0 56.6 31.4 32.6 24.0 23.1 25.5 34.8 34.2 4.4 10.3 5.3 1.9 3.9 2.7 9.7 16.7 23.3 43.6 1.5 0.8 56.6 29.9 9.3 2.2 2.0 8.9 3.4 % Endorsed Item 75.1 60.7 73.0 53.3 55.0 52.1 54.0 29.4 30.1 21.4 26.3 27.0 30.9 35.5 5.3 11.5 6.2 1.9 2.9 3.0 6.0 16.0 25.2 43.2 1.1 1.3 57.7 26.6 7.9 3.9 4.0 22.1 4.8 2529 years (N = 2,832) 3039 years (N = 4,691) 4049 years (N = 6,041) 5059 years (N = 3,518) 60+ years (N = 1,088) 1824 years (N = 695) 2529 years (N = 406) Bisexual-identied men

Description of most recent male-partnered sexual event (within the past year), stratied by age (N = 24,787)

All participants

1860+ years (N = 24,787)

3039 years 4049 years 5059 years 60+ years (N = 586) (N = 847) (N = 700) (N = 265)

Gay and Bisexual Mens Sexual Behavior

Context of sexual event

75.0 74.8 73.4 63.7 62.8 62.4 60.3 35.5 33.8 32.6 25.4 26.1

78.1 60.8 75.1 49.1 61.9 49.8 54.0 29.1 24.9 16.2 28.3 27.6 34.4 32.1 5.7 12.2 5.3 1.5 3.4 4.2 5.3 14.0 32.1 34.0 1.5 3.0 60.8 24.2 9.1 3.4 2.6 32.5 5.5

49.1 28.6 3.5 7.2 3.7 1.6 2.4 1.9

18.0 19.0 17.3 34.5 5.3 1.0

Sexual acts during event Gave oral sex Kissed on mouth Received oral sex Masturbated partner Held partner romantically Masturbated by partner Genitalgenital contact Anal intercourse (receptive) Anal intercourse (insertive) Solo masturbation Oralanal contact (performed) Oralanal contact (received) Location Own home Partners home Friends home Hotel/motel Public (park, beach, etc.) Car/truck/van Sex club/bath house Other Partner type Boyfriend/signicant other Casual/dating partner Friend New acquaintance Spouse or domestic partner Transactional Recency of last sexual event Past 7 days Past 30 days Past 90 days 36 months 612 months Erectile medication Used medication Known partner use

59.5 26.1 9.4 2.5 2.5

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11.2 3.6

6 acquaintance, in total, 42.3% of all men indicated that their most recent male sexual partner was with a relationship partner. Overall, 11.2% of all men (N = 2,776) reported the use of erectile medications, while known partner erectile medication use was 3.6% (N = 917). Although the proportion of men reporting use of such medications was extremely low among gay identied men in the 18- to 24-year-old cohort (0.8%, N = 198), among gay identied men over the age 50, rates of use were substantially higher with nearly a quarter of men aged 5059 (23.6%, N = 5,850), and 35.7% (N = 8,849) of men 60 years of age and older reporting use.

Rosenberger et al. among those who were 60 years of age and older (72.9%, N = 18,070), and men were signicantly more likely to report orgasm if their sexual partner was a relationship partner (P < 0.001).

Evaluation of the Sexual Event Men were asked to evaluate several aspects of their sexual experience, and most reported their last male-partnered sexual event as relatively positive overall (Table 3). Ratings of arousal among participants was high with most (75.7%, N = 18,045) indicating that they were either extremely or quite a bit aroused at the time of the sexual encounter. Higher rates of arousal were seen among older cohorts of men, with both gay and bisexually identied men over the age of 60 indicating the highest rates of arousal, 80.8% (N = 20,028), and 84.0% (N = 20,821), respectively. Similar to arousal, the majority of men (72.5%, N = 17,323) reported the sexual event as extremely or quite a bit pleasurable, with gay identied men ages 1824 being most likely to report experiencing little or no pleasure during the event (11.9%, N = 2,950). Participants who reported engaging in either insertive or receptive anal intercourse during their last event were additionally asked whether they had experienced any penile and/or rectal/anal pain. Only 5.9% (N = 786) of men indicated any penile pain, of which 82.3% (N = 647) suggested only feeling a little pain. Occurrences of rectal/ anal pain were relatively minimal, with the large majority (85.8%, N = 10,138) of men indicating they experienced little or no pain. The proportion of men reporting anal/rectal pain was less common among older age cohorts and pain was signicantly more likely among men who self-identied as bisexual (P < 0.001). A considerable number of men (81.2%, N = 19,367) reported having an orgasm, and similar numbers reported they perceived their partner had an orgasm (83.5%, N = 19,910) during their last male-partnered sexual event. The lowest percentages of men reporting orgasm were
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Sexual Repertoire of Last Male-Partnered Sexual Event Mens sexual repertoires were diverse with gayidentied men reporting a total of 1,308 unique combinations of behaviors and bisexual-identied men reporting a total of 617 combinations of behaviors during their most recent male-partnered sexual event. As presented in Table 4, the number of behaviors engaged in varied, with most events (63.2%, N = 15,665) including between ve and nine different sexual behaviors. The most frequent behavioral combination (16.2%, N = 4,005) consisted of men: holding their partner romantically, kissing partner on mouth, solo masturbation, masturbating partner, masturbation by partner, and genitalgenital contact; followed by (13.4%, N = 3,329) men: holding their partner romantically, kissing partner on mouth, masturbating partner, masturbation by partner, genitalgenital contact, giving oral sex, and receiving oral sex.
Discussion

These data provide one of the rst examinations of the characteristics of a sexual event between men among a large sample of gay and bisexually identied men in the United States. Findings from this study demonstrate gay and bisexually identied men have a diverse sexual repertoire and that partnered sexual behaviors between men are not dominated by anal intercourse. While over a third of the sample did engage in either receptive (35.5%) and/or insertive anal intercourse (33.8%), when compared with other behaviors, anal intercourse was among the least common behavior that occurred during participants most recent sexual event with another male. For example, across all age groups and regardless of sexual orientation rates of giving and receiving oral sex were reported by 75.0% and 73.4% of participants, respectively. Furthermore, this study highlights that a sexual event is not solely limited to one individual behavior but rather includes a variety of different possible behavioral combinations, as has been previously documented in heterosexual populations [5]. Partner type during the most recent malepartnered sexual event varied, with many men indicating their sexual partner to be one with

Table 3
Bisexual-identied men 1824 years % endorsed item 39.0 30.3 21.8 7.8 1.1 30.6 34.3 23.2 9.6 2.3 0.1 0.1 0.9 5.2 93.7 1.8 5.2 14.0 45.2 33.8 80.5 17.0 2.5 82.8 12.3 4.9 85.2 11.7 3.1 84.8 12.5 2.7 84.3 13.2 2.5 83.6 15.0 1.3 83.6 15.5 0.9 81.3 17.9 0.8 78.4 21.0 0.6 81.8 15.8 2.4 1.4 4.3 11.0 39.3 44.0 0.9 3.8 9.2 32.8 53.3 0.8 2.6 7.8 29.4 59.3 0.8 2.2 5.9 30.7 60.4 1.2 0.9 5.1 30.3 62.6 72.9 25.8 1.3 80.5 17.2 2.3 0.1 0.1 0.7 5.2 94.0 0.1 0.2 0.5 4.5 94.7 0.1 0.2 0.7 4.2 94.8 0.1 0.3 0.6 4.3 94.7 0.0 0.0 0.8 4.4 94.8 0.5 0.3 1.3 5.9 92.0 2.7 9.1 18.6 38.6 31.0 81.9 15.6 2.5 82.3 11.3 6.4 0.0 0.0 1.0 6.7 92.3 2.7 8.6 8.6 35.1 44.9 82.6 15.2 2.1 82.0 11.9 6.1 31.2 35.0 24.0 8.0 1.8 32.4 36.0 20.6 6.9 1.1 41.8 33.2 18.5 5.6 0.8 45.2 31.8 16.2 6.2 0.6 47.1 35.5 13.0 3.8 0.6 32.9 34.9 20.7 9.3 2.1 33.8 35.9 20.1 9.2 1.1 37.9 34.6 19.6 6.9 1.1 0.0 0.3 1.6 8.2 89.9 1.5 2.2 13.4 33.8 49.1 85.3 13.4 1.2 83.4 12.3 4.2 38.2 32.6 21.8 6.5 0.9 41.7 32.4 19.5 5.9 0.5 45.4 33.0 16.8 4.4 0.4 48.1 30.8 16.3 4.5 0.4 47.6 33.2 14.5 4.3 0.4 40.6 32.2 18.6 7.5 1.1 43.0 31.7 18.7 5.0 1.6 41.1 34.4 17.3 6.7 0.5 51.6 28.4 15.8 3.3 0.9 47.4 29.7 17.4 4.8 0.7 0.0 0.5 1.0 5.0 93.6 0.8 2.8 8.8 35.9 51.7 84.0 15.6 0.4 83.0 14.0 3.0 49.9 30.3 13.2 6.5 0.1 44.9 31.1 15.9 7.7 0.4 0.0 0.0 1.9 5.9 92.3 0.4 3.2 7.6 30.2 58.6 80.0 19.1 0.9 81.0 15.6 3.4 2529 years 3039 years 4049 years 5059 years 60+ years 1824 years 2529 years 3039 years 4049 years 5059 years

Event experience stratied by age and sexual orientation

Gay-identied men

All respondents

60+ years

Event experience

% (N)

Gay and Bisexual Mens Sexual Behavior

43.7 32.0 18.2 5.5 0.6

(10,419) (7,626) (4,353) (1,319) (148)

51.2 32.8 10.9 4.7 0.4 50.4 33.6 10.5 4.3 1.2 0.0 1.0 1.0 10.5 87.6 2.2 1.1 2.2 39.8 54.8 74.6 23.8 1.6 78.5 18.0 3.5

38.6 33.9 19.4 6.8 1.2

(9,218) (8,105) (4,643) (1,629) (281)

0.1 0.2 0.7 4.8 94.1

(13) (26) (100) (647) (12,597)

1.2 3.6 9.5 34.5 51.3

(136) (426) (1,118) (4,078) (6,060)

Arousal Extremely Quite a bit Moderately A little Not at all Pleasure Extremely Quite a bit Moderately A little Not at all Penile pain* Extremely Quite a bit Moderately A little Not at all Rectal/anal pain* Extremely Quite a bit Moderately A little Not at all Participant orgasm Orgasm No orgasm Unsure Partner orgasm Orgasm No orgasm Unsure

81.2 (19,367) 17.6 (4,201) 1.2 (277)

83.5 (19,910) 13.4 (3,193) 3.1 (749)

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*Penile and rectal/anal pain items only apply to men who indicated having engaged in anal intercourse during their most recent sexual event.

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Table 4 Combinations of behaviors engaged in during the most recent male-partnered sexual event
Total sample (N = 23,836) Sexual behaviors Number of sexual behaviors reported 1 2 3 4 5 6 7 8 9 10 11 12 Most frequent behavioral combinations at last event Held romantically; kissed on mouth; solo masturbation; masturbated partner; masturbated by partner; genitalgenital contact Held romantically; kissed on mouth; masturbated partner; masturbated by partner; genital-genital contact; gave oral sex; received oral sex Kissed on mouth; solo masturbation; masturbated partner; masturbated by partner; genitalgenital contact; gave oral sex; received oral sex Held romantically; kissed on mouth; masturbated partner; masturbated by partner; gave oral sex; received oral sex Held romantically; kissed on mouth; genitalgenital contact; gave oral sex; received oral sex; receptive anal sex Held romantically; kissed on mouth; solo masturbation; masturbated partner; masturbated by partner; received oral sex; gave oral sex Gave oral sex Held romantically; kissed on mouth; masturbated partner; masturbated by partner; genitalgenital contact; received oral sex Kissed on mouth; masturbated partner; masturbated by partner; genitalgenital contact; received oral sex; gave oral sex; receptive anal sex Received oral sex % 4.1 4.8 6.0 8.3 10.6 12.3 15.1 15.1 11.1 7.1 3.6 1.8 16.2 13.4 2.3 2.3 1.8 1.5 1.4 1.3 1.2 1.2 N 984 1,155 1,430 1,977 2,522 2,936 3,592 3,600 2,651 1,690 864 435 4,005 3,329 568 563 455 364 335 320 300 301

Rosenberger et al.

Gay (N = 20,498) % 4.0 4.7 5.9 8.2 10.4 12.4 15.1 15.4 11.2 7.2 3.7 1.9 16.7 13.3 2.3 2.3 1.8 1.5 1.3 1.3 1.2 1.2 N 821 958 1,206 1,678 2,132 2,537 3,093 3,157 2,297 1,475 751 393 3,559 2,835 493 492 378 327 275 274 254 251

Bisexual (N = 3,338) % 4.9 5.9 6.7 9.0 11.7 12.0 14.9 13.3 10.6 6.4 3.4 1.3 12.7 14.1 2.1 2.0 2.2 1.1 1.7 1.3 1.3 1.4 N 163 197 224 299 390 399 499 443 354 215 113 42 446 494 75 71 77 37 60 46 46 50

whom they were not in a relationship. Of particular interest was that men who self-identied as bisexual were less likely to have reported engaging in their most recent sexual encounter with a relationship partner, particularly among bisexual men in age cohorts 5060 and 60 years of age and older. This nding could potentially be linked to high levels of stigma documented by men who are bisexual and engage in behavior with other men [19,20], or perhaps could be a function of bisexual men being more likely to have been in a relationship with a female partner at the time of the study, resulting in male-partnered events that exist outside of the primary relationship. Our nding that the location of a given sexual event differed depending on age suggests perhaps that some sexual space could also be a function of utility. For example, older men may be more likely to not share a living space and have the nancial resources to purchase a hotel room, while younger men may be more limited economically, resulting in the utilization of private spaces for which they do have access such as vehicles.
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Men in this study indicated relatively high rates of erectile medication use, with men 50 years of age and older being most likely to have reported such use. While the overall percentage of use was much higher, the increased use with age is a nding consistent among heterosexual men as described in other studies [5] and suggests that the use of erectile medications within this population may be normative. While participants reported lower rates of perceived partner use of erectile function medications, this can be most likely attributed to the fact that many participants were unsure/unaware of whether their sexual partner had taken such enhancers, resulting in underreporting of actual use by mens most recent male sexual partner. Evaluations of the most recent sexual event with a male partner were mostly positive among participants, yet several key points emerged. Ratings of both pleasure and arousal were higher among older men. While higher ratings of arousal are most likely explained by the greater prevalence of erectile medication use among older men,

Gay and Bisexual Mens Sexual Behavior increased pleasure may extend beyond physiologic effects associated with erectile medication and be suggestive of a developmental component of sexuality that results in being able to achieve increased gratication from sexual experiences over time. This same nding is supported by reports of anal pain being less common with older age, perhaps suggesting the learned ability of men to engage in anal intercourse after developing a familiarity of practices associated with the behavior (e.g., proper lubrication). Alternatively, it may be that men who consistently experience pain during anal intercourse cease engaging in this behavior over time [21]. Furthermore, it may also be the case that as men age their individual repertoire becomes more varied, demonstrating an increased willingness to engage in behaviors that they have come to knowingly associate with increased pleasure. Overall, this study provides medical and public health providers with an understanding of the range of behaviors that gay and bisexually identied men engage in during a specic sexual event with a male partner. Much of the public health and medical literature, particularly that which has been predominantly risk focused, has stressed the importance of disease prevention during anal intercourse. These data provide our elds with a more diverse perspective on gay and bisexual mens sexual behavior that suggests our research and interventions may need to be more inclusive of the range of behaviors performed during a sexual event and not only focus on the need for avoiding disease transmission during anal intercourse. Additionally, understanding the roles of pleasure, pain, orgasm, and the situational characteristics of a sexual event may inform our research and intervention efforts in ways that lead to a more sensitive and holistic understanding of the manner in which men construct their sexual lives. In doing so, these data may be helpful to informing the development and delivery of more efcacious clinical and educational campaigns to improve gay and bisexual mens sexual health. Additionally, while a single sexual encounter does not fully contextualize mens behavior more generally, an event-specic assessment of mens sexual behaviors provides a rich opportunity for understanding other important health-related issues such as condom use. To that end, our omission of detailed data related to condom use in this article was intentional. Given the disproportionate rates of HIV transmission and the burden of the HIV epidemic among gay and bisexually identied men, the nature of the measures obtained in this study warrant a separate

9 comprehensive analyses that offer a more complete understanding of the manner in which these event-level characteristics are related to condom use across the range of sexual behaviors reported by these men [22]. These data should be considered in terms of limits inherent in the study design. The sample was not representative of the general population, and participants were recruited through a web site that might appeal to people who are more sexually conscious; however, challenges exist with establishing truly nationally representative samples of gay and bisexual men. While the size of our sample provided a large number of participants of varying race and ethnicity, the majority of men in this study were white. Because the sample was entirely Internetbased, we acknowledge the potential for our data to not be generalizable to all gay or bisexual men in the United States; however, this same limitation provides a strength in that previous studies have demonstrated that online data collection has the potential to limit social desirability bias and result in more accurate and honest responses from study participants [23,24]. Furthermore, recent nationally representative sexual behavior data documented similar proportions of oral and anal sex behaviors among gay and bisexually identied men during their most recent male-partnered sexual event compared with men in this sample [25]. NSSHB rates of sexual behavior during gay and bisexual mens most recent male-partnered sexual event included: receptive anal intercourse (31.8%), insertive anal intercourse (19.8%), giving oral sex (77.6%), and receiving oral sex (65.9%), while rates for men in this study were 35.5%, 33.8%, 75.0%, and 73.4%, respectively.
Conclusions

Findings from this study provide one of the rst contemporary large scale assessments of recent sexual behaviors of gay and bisexually identied men in the United States, demonstrating that individual sexual encounters are complex and include a variety of sexual behaviors. Documenting the unique characteristics associated with a specic sexual event will provide a useful framework for improving the sexual health of gay and bisexual men.
Corresponding Author: Joshua G. Rosenberger, PhD, MPH, Department of Global and Community Health, George Mason University, 4400 University Drive, MSN 5B7, Fairfax, VA 22030, USA. Tel: 703-993-3546; Fax: 703-993-1908; E-mail: jrosen10@gmu.edu J Sex Med **;**:****

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Conict of Interest: None.
Statement of Authorship

Rosenberger et al.
9 Reece M, Herbenick D, Schick V, Sanders SA, Dodge B, Fortenberry JD. Condom use rates in a national probability sample of males and females ages 14 to 94 in the United States. J Sex Med 2010;7(5 suppl):26676. 10 Fortenberry JD, Schick V, Herbenick D, Sanders SA, Dodge B, Reece M. Sexual behaviors and condom use at last vaginal intercourse: A national sample of adolescents ages 14 to 17 years. J Sex Med 2010;7(5 suppl):30514. 11 Sanders SA, Reece M, Herbenick D, Schick V, Dodge B, Fortenberry JD. Condom use during most recent vaginal intercourse event among a probability sample of adults in the United States. J Sex Med 2010;7(5 suppl):36273. 12 Dodge B, Reece M, Herbenick D, Schick V, Sanders SA, Fortenberry JD. Sexual health among US Black and Hispanic men and women: A nationally representative study. J Sex Med 2010;7(5 suppl):33045. 13 Reece M, Herbenick D, Schick V, Sanders SA, Dodge B, Fortenberry JD. Background and considerations on the National Survey of Sexual Health and Behavior (NSSHB) from the investigators. J Sex Med 2010;7(5 suppl):2436. 14 Centers for Disease Control and Prevention. HIV/AIDS surveillance report, 2006 (Vol. 18). Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2006. Available at: http://www.cdc. gov/hiv/topics/surveillance/resources/reports/ (accessed April 21, 2011). 15 Reece M, Dodge B. A study in sexual health applying the principles of community-based participatory research. Arch Sex Behav 2004;33:23547. 16 Connell RW, Kippax S. Sexuality in the AIDS crisis: Patterns of sexual practice and pleasure in a sample of Australia gay and bisexual men. J Sex Res 1990;21:16798. 17 Kalichman SC, Weinhardt LW, DiFonzo K, Austin J, Luke W. Sensation seeking and alcohol use as markers of sexual transmission risk behavior in HIV-positive men. Ann Behav Med 2002;24:22935. 18 Winkelstein W, Lyman DM, Padian N, Grant R, Samuel M, Wiley JA, Anderson RE, Lang W, Riggs J, Levy JA. Sexual practices and risk of infection by the human immunodeciency virus. JAMA 1987;7:32132. 19 Herek GM. Hate crimes and stigma-related experiences among sexual minority adults in the United States: Prevalence estimates from a national probability sample. J Interpers Violence 2009;24:5474. 20 Dodge B, Jeffries WL, Sandfort TGM. Beyond the down low: Sexual risk, protection and disclosure among at-risk Black men who have sex with men and women (MSMW). Arch Sex Behav 2008;37:68396. 21 Rosser S, Short BJ, Thurmes PJ, Coleman E. Anodyspareunia, the unacknowledged sexual dysfunction: A validation study of painful receptive anal intercourse and its psychosexual concomitants in homosexual men. J Sex Marital Ther 1998;24:28192. 22 Rosenberger JG, Reece M, Schick V, Herbenick D, Novak DS, Van Der Pol B, Fortenberry JD. Condom use during most recent anal intercourse event among a US sample of men who have sex with men. Under Review, 2011. 23 Metzger DS, Koblin B, Turner C. Randomized controlled trial of audio computer assisted self interviewing utility and acceptability. Am J Epidemiol 2000;152:99106. 24 Ellen JM, Gurvey JE, Pasch L, Tschann J, Nanda JP, Catania J. A randomized comparison of A-CASI and phone interview to assess STD/HIV-related risk behaviors in teens. J Adolesc Health 2002;31:2630. 25 Reece M, Herbenick D, Schick V, Sanders S, Dodge B, Fortenberry JD. 2011. Unpublished raw data from the National Survey of Sexual Health and Behavior (NSSHB).

Category 1
(a) Conception and Design Joshua G. Rosenberger; J. Dennis Fortenberry; Debby Herbenick; Barbara Van Der Pol; David S. Novak; Michael Reece (b) Acquisition of Data Joshua G. Rosenberger; David S. Novak; Michael Reece (c) Analysis and Interpretation of Data Joshua G. Rosenberger; Vanessa Schick

Category 2
(a) Drafting the Article Joshua G. Rosenberger (b) Revising It for Intellectual Content J. Dennis Fortenberry; Barbara Van Der Pol; Debby Herbenick; Vanessa Schick; David S. Novak; Michael Reece

Category 3
(a) Final Approval of the Completed Article Joshua G. Rosenberger; J. Dennis Fortenberry; Debby Herbenick; Barbara Van Der Pol; Vanessa Schick; David S. Novak; Michael Reece
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