AIDS Behav (2013) 17:13701377

DOI 10.1007/s10461-012-0332-9

ORIGINAL PAPER

Versatility and HIV Vulnerability: Patterns of Insertive

and Receptive Anal Sex in a National Sample of Older Australian
Gay Men
Anthony Lyons Marian Pitts Jeffrey Grierson

Published online: 10 October 2012

Springer Science+Business Media New York 2012

Abstract According to mathematical modeling, HIV is

more likely to spread through a population of men who have
sex with men when high numbers practice versatile anal sex
roles, that is, engage in both insertive (IAI) and receptive anal
intercourse (RAI). Yet, actual patterns of versatility remain
largely unknown, particularly among older men who currently face growing rates of HIV. In this study, 1,135 Australian gay men aged 40 years and older completed a national
online survey of their sexual health and behavior over the
past 12 months. Of men who had anal intercourse, 62 %
engaged in both IAI and RAI. Factors associated with being
versatile included younger age (P = 0.01), higher income
(P = 0.009), and larger numbers of sexual partners (P =
0.003). Among men with multiple sexual partners, 20 %
were highly versatile, that is, reported similar numbers of IAI
and RAI partners. Having HIV (P = 0.003) and living in a
rural area (P = 0.04) were significantly associated with
being highly versatile. These data point to high rates of versatility among older Australian gay men, with implications
for mathematical predictions of change in HIV epidemics
and for the design of future HIV prevention strategies.
Keywords HIV
Anal sex

Men who have sex with men
Top
Bottom
Versatile

Introduction
In populations of men who have sex with men (MSM),
mathematical modeling of HIV epidemics suggests a
A. Lyons (&)
M. Pitts
J. Grierson
Australian Research Centre in Sex, Health and Society, La Trobe
University, 215 Franklin Street, Melbourne, VIC 3000, Australia
e-mail: a.lyons@latrobe.edu.au

123

strong link between HIV transmission and the proportion of

men who engage in both insertive (IAI) and receptive anal
intercourse (RAI) [14]. In other words, assuming condoms are not always used, those who engage in both anal
sex roles, referred to as versatile, are at heightened risk of
becoming infected with HIV through RAI and infecting
their partners through IAI. One model, based on data from
South America, predicts that a population with 100 %
versatile men would have double the HIV prevalence than
a population with 30 % versatile men [1]. Other models,
such as one based on data from the Netherlands, show
similarly high rates of HIV in populations with high proportions of versatile men [2].
Accurately predicting and controlling the scale of HIV
epidemics in MSM populations depends on information
about versatility, particularly given that many gay men and
other MSM do not always use condoms with casual sex
partners, despite years of safer sex campaigns [5, 6].
However, few studies have examined versatility among
MSM. Of those that have, many are from the 1980s and
1990s [2, 7] when sexual behavior patterns were likely to
have been different from those of today [8]. Several recent
studies were conducted in non-Western countries, including Peru [9, 10], Taiwan [11], and China [12]. Recent
studies in Western countries are rare. Two conducted in the
US involved convenience samples. One was conducted in
San Francisco and found 59 % from a sample of 199 White
Americans were versatile in a 6-month period, with
somewhat lower rates among other ethnic groups [13]. The
second was conducted in New York and found 46 % from a
sample of 84 were versatile [14]. Other studies have
examined anal sex role identities [1416], which generally
show around 4550 % of men label themselves as versatile, but anal sex role identity does not appear to be a strong
predictor of behavior [13].

AIDS Behav (2013) 17:13701377

The most detailed investigation of versatility thus far is

a recent study involving a national sample of 854 Australian gay men [17]. Findings revealed high rates of versatility. In fact, 83 % reported engaging in both IAI and RAI
over a 12-month period. However, despite the strength of a
large national community-based sample, this study lacked
some important information. First, the numbers of older
gay men were relatively small, thus making it difficult to
draw conclusions about this group. Second, the epidemiology for versatility was not examined. In other words,
demographic and psychosocial factors for men who
engaged in versatile behavior were not reported. These are
all crucial details for informing mathematical modeling of
HIV epidemics and therefore predicting and understanding
the population-level spread of HIV.
It is particularly important to examine versatility among
older gay men. In Western countries, the prevalence of
HIV among older men is increasing rapidly. This is largely
due to the emergence of advanced HIV treatment that
enables those infected to live well into older age [1821].
In Australia, for example, the average age of HIV-positive
men is now 48 years [22]. While aging with HIV is a major
factor, a large proportion of new infections also occur
among this group. In the US, 41 % of new HIV diagnoses
from 2006 to 2009 were among people aged 40 years and
older [23] and in Australia, 38 % of new diagnoses in 2011
involved men aged 40 years and older [24]. With
increasing rates of HIV among the over-40s, information
about versatility in this group is vital for accurately predicting the future scale of the HIV epidemic, but very little
is known about versatility among older gay men, including
factors associated with men who engage in both IAI and
RAI. A complete picture of versatility also requires information not only about whether men engage in versatile
behavior, but also how versatile they are. Some men, for
example, may focus predominantly on one anal sex role
and only occasionally on the other. Others may regularly
switch between roles. The Australian study described
above [17] found over half of versatile men could be
classified as highly versatile, but whether this is the case
among older men requires further investigation.
The present paper addresses these gaps by reporting
findings from a large national community-based survey of
Australian gay men aged 40 years and older. There were
three main aims. The first was to report on rates of anal sex
role behavior, with a particular focus on those who engaged
exclusively in IAI, exclusively in RAI, or were versatile.
The second aim was to report sociodemographic factors for
engaging in versatile sexual behavior. The third aim was to
report on sociodemographic factors for men who were
highly versatile. Because the likelihood of HIV transmission increases when men regularly switch roles from one
partner to another, highly versatile men were regarded as

1371

those who reported similar numbers of IAI and RAI partners as opposed to men who engaged in one anal sex role
with most of their partners.

Methods
Participants
The survey was completed by 1,179 men from major cities,
regional towns, and rural areas in all states and territories in
Australia. Of these men, 44 reported a sexual identity other
than gay or homosexual and were excluded from analyses.
This left a sample of 1,135 gay-identified men aged
4081 years with a mean age of 49.3 years (SD = 7.4 years).
Survey
Data were from LifeTimes, a national survey of the health
and wellbeing of Australian gay men aged 40 years and
older. In the part of the survey reported in this paper, men
were first asked a series of sociodemographic questions.
These included age, highest educational attainment,
employment status (full-time, part-time, not working),
income, country of birth, residential location (major city,
regional town, rural area), and HIV status (positive, negative, not known). Men then provided information about sex
and relationships. They first indicated whether they were in
a regular ongoing relationship before answering questions
about their sexual history over the past 12 months. These
questions included the number of sexual partners they had,
whether they had engaged in anal intercourse, and the
number of partners with whom they had IAI and the
number of partners with whom they had RAI.
Data Collection
The survey was hosted online. Data collection took place
between November 2010 and April 2011. Advertisements
were posted on national-focused websites that attracted
large numbers of Australian gay men, such as those managed by HIV/AIDS organizations, and through targeted
advertising on Facebook. Advertising also occurred by way
of emails sent to two separate national databases of men
living with HIV. At the start of the survey, men were
informed that they would be participating anonymously
and that no identifying information would be collected.
They were required to indicate they had read this information before responding to the survey items. Completing
the survey took approximately 16 min on average. No
rewards or incentives were offered for participating. Ethical approval for the survey was granted by the La Trobe
University Human Ethics Committee.

123

1372

Data Analysis
We first reported numbers and percentages of men who
engaged exclusively in either IAI, RAI, or both IAI and RAI
in the past 12 months. Two main analyses then followed.
For the first analysis, a multivariate logistic regression was
conducted to identify significant sociodemographic factors
for men engaging in both IAI and RAI, that is, were versatile in the past 12 months. For each sociodemographic
variable, odds ratios and 95 % confidence intervals were
reported. Wald tests were also conducted and reported for
each variable to determine its overall effect. The second
analysis examined the degree to which men had been versatile in the past 12 months. A versatility score was computed based on the ratio of IAI and RAI sexual partners.
This ratio was derived by comparing absolute numbers of
IAI and RAI partners that men reported having. Those with
versatility scores that indicated similar numbers of IAI and
RAI partners were regarded as highly versatile. A multivariate logistic regression was then conducted to identify
significant sociodemographic factors for having been highly
versatile. Odds ratios, 95 % confidence intervals, and Wald
tests were reported for each variable. For all analyses,
variables were treated as significant at P \ 0.05. Analyses
were conducted using Stata 11.1.

AIDS Behav (2013) 17:13701377

Table 1 Sociodemographic profile of the sample (N = 1,135)
No.

4044

354

31

4549

342

30

Age

5054

219

19

55?

220

19

Universitypostgraduate

201

18

Universityundergraduate

212

19

Non-university tertiary

332

29

Secondary or lower

Highest education

388

34

Employment
Full-time

711

63

Part-time

148

13

Not working

271

24

019,999

154

14

20,00049,999

262

24

50,00099,999

466

44

100,000?

186

17

Australia

861

79

Overseas

234

22

Major city

853

75

Regional town

187

17

91

Income

Country of birth

Residential location

Results
Sample Profile
Table 1 displays a sociodemographic profile of the sample.
All categories involved relatively large numbers of men,
including men aged 55 years or older. There were 189
HIV-positive men or 17 % of the sample. Two-thirds of
men reported having had anal intercourse in the past
12 months. Almost all (98 %) spoke English at home.
Anal Sex Roles in the Past 12 Months

Rural area
Relationship status
In a regular relationship

586

52

546

48

199

19

193

18

25

279

26

610

137

13

11?

264

25

Not in a regular relationship

Number of sexual partners

Had anal intercourse in past 12 months

Analyses of anal sex roles were restricted to the 739 (66 %)

men who reported having engaged in anal intercourse
during the past 12 months. Of these men, 46 did not provide complete information about their anal sex roles and
were therefore excluded from further analysis. Of the
remaining 693 men, 164 (24 %) engaged exclusively in
insertive anal intercourse, 99 (14 %) exclusively in
receptive anal intercourse, and 430 (62 %) in both insertive
and receptive anal intercourse. This latter group was
regarded as having been versatile with regard to their anal
sex roles during the past 12 months.
Table 2 displays numbers and percentages of men who
were versatile according to a range of sociodemographic

123

Yes

739

66

No

375

34

Positive

189

17

Negative

840

75

95

HIV status

Dont know

variables. A multivariate logistic regression was conducted

to identify significant sociodemographic differences in
versatility. According to Table 2, three significant factors
emerged. These were age (v23 = 11.10, P = 0.01), income
(v23 = 11.54, P = 0.009), and number of sexual partners in

AIDS Behav (2013) 17:13701377

Table 2 Numbers and
percentages of men who
reported engaging in both IAI
and RAI (versatile) in the past
12 months

1373

Number
versatile

Percent
versatile

OR (95 % CI)

4044a

166

71

4549

142

63

0.71 (0.461.08)

Age

5054

71

54

0.48 (0.300.78)

55?

51

50

0.48 (0.270.85)

Universitypostgraduate

78

61

0.67 (0.401.13)

Universityundergraduate

87

61

0.68 (0.411.13)

v2

11.10

0.01

3.07

0.38

2.35

0.31

11.54

0.009

1.53

0.22

5.94

0.05

0.84

0.36

13.67

0.003

0.58

0.75

Highest education

Non-university tertiary

124

60

0.80 (0.511.24)

Secondary or lowera

141

66

Employment
Full-timea

300

63

Part-time

47

63

1.56 (0.842.91)

Not working

81

59

1.41 (0.752.63)

41

57

0.49 (0.221.07)

20,00049,999

77

53

0.51 (0.310.83)

50,00099,999a

192

64

96

69

1.35 (0.842.17)

Australiaa

337

63

Overseas

75

55

0.77 (0.501.17)

332

61

0.89 (0.541.48)

Income
019,999

100,000?
Country of birth

Residential location
Major city

Of men who reported having

had anal sex in the past
12 months and who provided
information about anal sex roles
(N = 693)
Note Bold text indicates
variable is significantly
associated with versatility based
on a multivariate logistic
regression; IAI insertive anal
intercourse; RAI receptive anal
intercourse
a

Regional towna

57

61

Rural area
Relationship status

40

80

2.35 (0.975.67

In a regular relationshipa

249

64

Not in a regular relationship

181

60

0.84 (0.581.22)

82

61

0.65 (0.351.18)

Number of sexual partners

1
25

113

52

0.50 (0.290.86)

610a

74

68

11?

161

70

1.05 (0.611.81)

78

66

1.20 (0.741.94)

HIV status
Positive
Negativea
Dont know
Overall

317

61

32

64

1.01 (0.531.94)

430

62

Reference category

the past 12 months (v23 = 13.67, P = 0.003). In general,

men were more likely to have been versatile if they were
younger, had a higher income, or reported greater numbers of
sexual partners. Significant differences were found in the
odds ratios for versatility between men living in rural areas
and those living in a major city, but residential location as an
independent factor for versatility was only marginally significant (v22 = 5.94, P = 0.05). There were no significant

differences in the percentages of HIV-positive and HIVnegative men who were versatile during the past 12 months.
Degree of Versatility in the Past 12 Months
To examine the degree to which men were versatile, a
versatility score was computed to express the relative
proportions of IAI and RAI partners that men reported

123

1374

having in the past 12 months. Scores ranged between 0 and

1. For example, men who reported an equal number of IAI
and RAI partners scored 1, men who reported half as many
IAI partners as RAI partners or half as many RAI partners
as IAI partners scored 0.50, and men who reported
engaging in only one role scored 0. All analyses for degree
of versatility were restricted to men who reported having
had two or more sexual partners in the past 12 months
(N = 556). For these men, the distribution of scores was
highly skewed, with 72 % of men scoring 0.50 or below
and 28 % scoring above 0.50. We therefore divided the
sample into two categories: men who scored above 0.80
and men who scored 0.80 or below. Those who scored
above 0.80 were regarded as highly versatile.
Table 3 displays sociodemographic differences in the
numbers and percentages of men who were highly versatile
during the past 12 months. In all, 111 (20 %) were highly
versatile. A multivariate logistic regression was conducted
to identify significant sociodemographic differences in the
numbers of highly versatile men. Because the opportunity
to engage in both anal sex roles potentially increases with
greater numbers of sexual partners, it was important to
control for the overall number of sexual partners. Therefore, the number of sexual partners that men reported
having in the past 12 months was also entered into the
regression. HIV status (v22 = 11.81, P = 0.003), residential
location (v22 = 6.28, P = 0.04), and number of sexual
partners (v22 = 11.57, P = 0.003) were significant factors.
According to Table 3, HIV-positive men and men living in
rural areas were significantly more likely than other men to
have been highly versatile in the past 12 months. However,
men who reported having had more than ten sexual partners in the past 12 months were less likely to have been
highly versatile compared with those who reported fewer
partners.

Discussion
In this sample of Australian gay men aged 40 years and
over, almost two-thirds engaged in both IAI and RAI in a
12-month period. This compares with around four-fifths in
another Australian study of predominantly younger men
[17] and between 46 and 59 % in two studies in the US
[13, 14]. While rates appear higher in Australia than the
US, it remains unclear whether Australian gay men are
more versatile than those in other Western countries, particularly given that the US studies were conducted with
small convenience samples and no recent studies have been
conducted in Europe. Studies are clearly needed in these
countries. In the meantime, high rates of versatility in
Australia are likely to have important implications for the

123

AIDS Behav (2013) 17:13701377

spread of HIV among Australian gay men, particularly

since condoms are often not used with casual sex partners
[6, 8]. While this is a concern for gay men of any age,
strategies for reducing infections should pay particular
attention to versatility among middle-aged and older gay
men due to a growing majority of HIV-positive men aged
over 40.
Several factors appear to be associated with versatility.
Younger men were more likely to have been versatile than
older men. It is possible that our findings reflect generational changes in sexual practices toward greater versatility, thus having important implications for the future spread
of HIV. Certainly, HIV diagnoses in many Western
countries have increased over the past decade [25, 26].
While multiple factors are likely to be involved [2729],
increased versatility may be one factor. Men on higher
incomes were also more likely to have been versatile,
perhaps reflecting differences in sexual practices according
to social class [30]. Previous studies have shown gay men
with working class backgrounds tend to feel less connected
to the gay community and have a range of different life
experiences, all of which may shape their sexual behavior
differently from other gay men [31, 32]. Finally, versatility
rates were highest among men who reported greater numbers of sexual partners in the past 12 months. While this
may reflect the fact that opportunities for switching roles
increase with a greater number of partners, it may also be
indicative of sexual adventurism [33, 34]. Sexual adventurism is often marked by having large numbers of sexual
partners [35, 36], and those who are adventurous may also
develop a diverse sexual repertoire that includes engaging
in both anal sex roles.
These findings provide important data for modeling the
scale of current and future HIV epidemics, but models also
require information about the degree of versatility. Of men
in our study who reported two or more sexual partners in
the past 12 months, more than a quarter were highly versatile. HIV-positive men were more likely to have been
highly versatile than HIV-negative men. Recent studies
have also found links between versatility and HIV [11, 12],
as well as other sexual health outcomes [10]. This may
again reflect a tendency toward greater sexual adventurism
among HIV-positive men [36]. For some men, having HIV
may also make it harder to appeal to more sexual partners,
perhaps resulting in some HIV-positive men needing to be
more flexible when negotiating anal sex roles. A smaller
pool of prospective sexual partners, and therefore a need
for greater flexibility, may also explain why men in rural
areas were more likely to have been highly versatile than
those in urban centers. Interestingly, although large numbers of men who reported more than ten sexual partners
were versatile, they were less likely to have been highly
versatile than other men. Although many may be sexually

AIDS Behav (2013) 17:13701377

Table 3 Numbers and
percentages of men who were
highly versatile in the past
12 months

1375

Number highly
versatile

Percent highly
versatile

OR (95 % CI)

Age
4044a

38

20

4549

38

21

1.03 (0.591.79)

5054

21

20

0.84 (0.431.62)

55?

14

17

0.78 (0.351.72)

Universitypostgraduate

17

17

0.74 (0.371.50)

Universityundergraduate

21

19

0.74 (0.371.47)

Highest education

Non-university tertiary

35

20

0.85 (0.471.52)

Secondary or lowera

38

22

Employment
Full-timea

77

20

Part-time

14

0.95 (0.392.35)

25

22

1.69 (0.743.87)

12

20

0.39 (0.131.14)

Not working
Income
019,999
20,00049,999

20

16

0.43 (0.210.88)

50,00099,999a

53

23

100,000?

20

17

0.80 (0.431.49)

Australiaa

83

19

Overseas

24

22

1.03 (0.581.84)

82

19

0.94 (0.481.88)

Country of birth

Residential location
Major city

Of men who reported having

had anal sex in the past
12 months and who provided
information about anal sex roles
and who reported having had
two or more sexual partners in
the past 12 months (N = 556)
Note Bold text indicates
variable is significantly
associated with having been
highly versatile based on a
multivariate logistic regression
a

Reference category

Regional towna

15

20

Rural area
Relationship status

14

36

2.69 (1.017.24)

In a regular relationshipa

58

21

Not in a regular relationship

53

19

0.95 (0.591.52)

53

24

0.89 (0.491.61)

Number of sexual partners

25
610a

28

26

11?

30

13

0.39 (0.200.73)

HIV status
Positive

28

26

Negativea

79

19

10

0.36 (0.101.27)

111

20

Dont know
Overall

adventurous, little difficulty attracting sexual partners may

allow those with a preference for a particular anal sex role
to engage in that role more often.
Until recently, researchers have largely focused on
reporting rates of IAI and RAI separately. However, given
the extent of versatility found in this and other studies, and
its potential implications for HIV transmission, versatile
sexual practices deserve closer investigation [37].
Although a number of factors have likely resulted in HIV

v2

0.72

0.87

1.03

0.79

1.82

0.40

5.94

0.11

0.01

0.91

6.28

0.04

0.05

0.82

11.57

0.003

11.81

0.003

2.26 (1.293.97)

spreading more widely in gay and other MSM populations

compared with the general population, such as numbers of
casual sex partners, versatility may be an additional factor.
In other words, the potential for gay men to switch between
insertive and receptive roles provides a clear path for HIV
transmission, which is less so for heterosexual men and
women. With the HIV epidemic showing little sign of
slowing, it will be important to monitor rates of versatility.
Without detailed knowledge of the epidemiology of

123

1376

versatility, it is not possible to accurately predict the scale

of HIV epidemics in the gay population or to fully assess
the likely impact of safer sex or other campaigns aimed at
reducing infections.
There were some limitations to this study that ought to
be considered and addressed in future research. First, this
study was cross-sectional, therefore making it impossible
to assess directions of causality between sociodemographic
factors and versatility. For example, we cannot confirm
whether lower rates of versatility with greater age are due
to an aging effect or reflect generational changes in sexual
behavior. To shed light on this issue, it is recommended
that cohort studies be conducted that follow patterns in anal
sex roles over a number of years.
Second, men were regarded as highly versatile depending on a particular ratio of IAI to RAI sexual partners.
Variations in the definition of a high degree of versatility
may lead to different findings. We used a relatively strict
criterion of 0.80, which closely approximates similar
numbers of IAI and RAI partners. However, some
researchers may wish to apply an even stricter criterion or a
less strict one. Future studies that employ different criteria
will need to highlight this fact to enable an appropriate
comparison of findings.
Third, this study involved self-reported data. Some degree
of recall error may have occurred when men reported the
numbers of partners with whom they had IAI or RAI, especially for those men who had large numbers of sexual partners. That said, a large majority of men reported fewer than
ten partners, so the likelihood of recall errors would have
been low. There is also no reason to suspect that errors in
recall would not be randomly distributed across the sample
or be biased toward high or low levels of versatility.
Finally, because this study involved a self-selected
online sample, we cannot claim it to be representative of all
middle-aged and older Australian gay men, particularly the
oldest men, who are less likely to have Internet access.
However, it is worth noting that almost all Australians do
in fact have Internet access, including a large majority of
those aged 60 years and over [38]. Moreover, the sample
profile for this study was highly diverse. None of the
sociodemographic categories was under-represented and
the sample profile was similar to that of other studies of
Australian gay men in which data were collected using
multiple methods [22, 27, 39, 40]. We are therefore confident that findings in this study closely approximate the
population, particularly with a large national sample.
In conclusion, this study revealed high rates of anal sex
role versatility among a large middle-aged and older
sample of Australian gay men. With a growing majority of
HIV-positive men now aged 40 years and over, high rates
of versatility among these men have potential implications
for further HIV transmission. Findings from this study

123

AIDS Behav (2013) 17:13701377

could be of interest to anyone concerned with reducing

HIV transmission in gay and other MSM populations, from
health service providers seeking to educate clients about
risky sexual behavior to policymakers seeking to monitor
and control current and future HIV epidemics. The findings
are of particular importance to researchers concerned with
advancing mathematical models of HIV epidemics, which
are becoming increasingly central to resource-planning and
other decision-making by governments and other health
authorities. To establish detailed understanding of the
dynamics of the HIV epidemic, particular attention needs
to be given to factors associated with greater versatility,
such as men who are HIV-positive, who live in rural areas,
or have higher incomes.
Acknowledgments This project received funding support from the
Australian Department of Health and Ageing.

References
1. Goodreau SM, Goicochea LP, Sanchez J. Sexual role and transmission of HIV Type 1 among men who have sex with men in
Peru. J Infect Dis. 2005;191(Suppl 1):S14758.
2. Van Druten H, Van Griensven F, Hendriks J. Homosexual role
separation: implications for the analyzing and modeling of the
spread of HIV. J Sex Res. 1992;29(4):47799.
3. Wiley A, Herschkorn SJ. Homosexual role separation and AIDS
epidemics: insights from elementary models. J Sex Res. 1989;
26(4):43449.
4. Goodreau SM, Golden MR. Biological and demographic causes
of high HIV and sexually transmitted disease prevalence in men
who have sex with men. Sex Transm Infect. 2007;83(6):45862.
5. Rosenberger JG, Reece M, Schick V, et al. Condom use during
most recent anal intercourse event among a US sample of men
who have sex with men. J Sex Med. in press.
6. Zablotska IB, Grulich AE, De Wit J, Prestage G. Casual sexual
encounters among gay men: familiarity, trust and unprotected
anal intercourse. AIDS Behav. 2011;15(3):60712.
7. Coxon AP, Coxon NH, Weatherburn P, et al. Sex role separation
in sexual diaries of homosexual men. AIDS. 1993;7(6):87782.
8. Prestage G, Mao L, Fogarty A, et al. How has the sexual
behaviour of gay men changed since the onset of AIDS:
19862003. Aust N Z J Public Health. 2005;29(6):5305.
9. Goodreau SM, Peinado J, Goicochea P, et al. Role versatility
among men who have sex with men in urban Peru. J Sex Res.
2007;44(3):2339.
10. Lama JR, Agurto HS, Guanira JV, et al. Hepatitis B infection and
association with other sexually transmitted infections among men
who have sex with men in Peru. Am J Trop Med Hyg. 2010;
83(1):194200.
11. Chen Y-J, Lin Y-T, Chen M, et al. Risk Factors for HIV-1
seroconversion among Taiwanese men visiting gay saunas who
have sex with men. BMC Infect Dis. 2011;11:334.
12. He Q, Wang Y, Lin P, et al. High prevalence of risk behaviour
concurrent with links to other high-risk populations: a potentially
explosive HIV epidemic among men who have sex with men in
Guangzhou, China. Sex Transm Infect. 2009;85(5):38390.
13. Wei C, Raymond HF. Preference for and maintenance of anal sex
roles among men who have sex with men: sociodemographic and
behavioral correlates. Arch Sex Behav. 2011;40(4):82934.

AIDS Behav (2013) 17:13701377

14. Wegesin DJ, Meyer-Bahlburg HF. Top/bottom self-label, anal
sex practices, HIV risk and gender role identity in gay men in
New York City. J Psychol Hum Sex. 2000;12(3):4362.
15. Moskowitz DA, Rieger G, Roloff ME. Tops, bottoms and versatiles. Sex Relation Ther. 2008;23(3):191202.
16. Hart TA, Wolitski RJ, Purcell DW, Gomez C, Halkitis P. Seropositive urban mens study team. Sexual behavior among HIVpositive men who have sex with men: whats in a label? J Sex
Res. 2003;40(2):17988.
17. Lyons A, Pitts M, Smith G, et al. Versatility and HIV vulnerability: investigating the proportion of Australian gay men having
both insertive and receptive anal intercourse. J Sex Med.
2011;8(8):216471.
18. Lyons A, Pitts M, Grierson JW, Thorpe R, Power J. Ageing with
HIV: health and psychosocial well-being of older gay men. AIDS
Care. 2010;22(10):123644.
19. Bhavan KP, Kampalath VN, Overton ET. The aging of the HIV
epidemic. Curr HIV/AIDS Rep. 2008;5(3):1508.
20. Grierson J, Pitts M, Thorpe R. State of the (positive) nation:
findings from the fourth national Australian HIV futures survey.
Int J STD AIDS. 2007;18(9):6225.
21. Pitts M, Grierson J, Misson S. Growing older with HIV: a study
of health, social and economic circumstances for people living
with HIV in Australia over the age of 50 years. AIDS Patient
Care STDS. 2005;19(7):4605.
22. Grierson J, Power J, Pitts M, et al. HIV futures six: making
positive lives count. Australia: Melbourne; 2009.
23. Centers for Disease Control and Prevention. HIV Surveillance
Report 2009; vol. 21. 2011. http://www.cdc.gov/hiv/topics/
surveillance/resources/reports/. Accessed 15 mar 2012.
24. The Kirby Institute. HIV, Viral hepatitis and sexually transmitted
infections in Australia annual surveillance Report 2011. Sydney:
Kirby Institute; 2011.
25. Sullivan PS, Hamouda O, Delpech V, et al. Reemergence of the
HIV epidemic among men who have sex with men in North
America, Western Europe, and Australia, 19962005. Ann Epidemiol. 2009;19(6):42331.
26. Grulich AE, Kaldor JM. Trends in HIV incidence in homosexual
men in developed countries. Sex Health. 2008;5(2):1138.
27. Lyons A, Pitts M, Grierson JW, Smith A, McNally S, Couch M.
Age at first anal sex and HIV/STI vulnerability among gay men in
Australia. Sex Transm Infect. 2012;88(4):25257.

1377
28. Prestage G, Jin F, Zablotska I, et al. Trends in agreements
between regular partners among gay men in Sydney, Melbourne
and Brisbane, Australia. AIDS Behav. 2008;12(3):51320.
29. Prestage G, Mao L, Kippax S, et al. Use of viral load to negotiate
condom use among gay men in Sydney, Australia. AIDS Behav.
2009;13(4):64551.
30. Carrier JM. De Los Otros: intimacy and homosexuality among
Mexican men. New York: Columbia University Press; 1995.
31. Dowsett G, Davis M, Connell R. Working class homosexuality
and HIV/AIDS prevention: some recent research from Sydney,
Australia. Psychol Health. 1992;6(4):31324.
32. Hope VD, MacArthur C. Safer sex and social class: findings from
a study of men using the gay scene in the West Midlands region
of the United Kingdom. AIDS Care. 1998;10(1):818.
33. Hurley M, Prestage G. Intensive sex partying amongst gay men in
Sydney. Cult Health Sex. 2009;11(6):597610.
34. Prestage G, Down I, Grulich A, Zablotska I. Sex partying among
gay men in Sydney, Melbourne and Brisbane, Australia. AIDS
Behav. 2011;15(2):298304.
35. Halkitis PN, Parsons JT. Intentional unsafe sex (barebacking)
among HIV-positive gay men who seek sexual partners on the
internet. AIDS Care. 2003;15(3):36778.
36. Kippax S, Campbell D, Van de Ven P, et al. Cultures of sexual
adventurism as markers of HIV seroconversion: a case control
study in a cohort of Sydney gay men. AIDS Care. 1998;10(6):
67788.
37. Moskowitz DA, Hart TA. The influence of physical body traits
and masculinity on anal sex roles in gay and bisexual men. Arch
Sex Behav. 2011;40(4):83541.
38. ABS. Household use of information technology, Australia,
200809. Canberra, Australia: Australian Bureau of Statistics;
2010.
39. Frankland A, Zablotska I, Prestage G, et al. Gay community
periodic survey: Melbourne 2008. Sydney, Australia: University
of New South Wales; 2008.
40. Lyons A, Pitts M, Grierson JW, Smith A, McNally S, Couch M.
Sexual behavior and HIV testing among bisexual men: A
nationwide comparison of Australian bisexual-identifying and
gay-identifying men. AIDS Behav. 2012;16(7):193443.

123

Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.