'False beliefs' about HIV driving gay men's risk behaviour

15 April 2003

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"False beliefs" about the risk of contracting or passing on HIV are the main reason why gay men have unprotected anal sex, according to a small study conducted in east London and published in the April 2003 edition of the journal Sexually Transmitted Infections. (See editorial comment on the findings below).

The study also found that low-mood, anxiety, depression and a history of non-consensual sex were not associated with sexual risk taking.

Investigators at a gay men’s sexual health clinic in east London recruited 123 gay men to a study to see if they could identify any social or psychological factors which were predictive of gay men having unprotected sex.

Glossary

depression

A mental health problem causing long-lasting low mood that interferes with everyday life.

risky behaviour

In HIV, refers to any behaviour or action that increases an individual’s probability of acquiring or transmitting HIV, such as having unprotected sex, having multiple partners or sharing drug injection equipment.

anxiety

A feeling of unease, such as worry or fear, which can be mild or severe. Anxiety disorders are conditions in which anxiety dominates a person’s life or is experienced in particular situations.

insertive

Insertive anal intercourse refers to the act of penetration during anal intercourse. The insertive partner is the ‘top’.

receptive

Receptive anal intercourse refers to the act of being penetrated during anal intercourse. The receptive partner is the ‘bottom’.

Study participants were asked to complete a questionnaire which enquired about demographics, HIV status, sexual history and sexual risk taking, non-consensual sex, psychological distress, self esteem and self justification of sexual risk.

Over 70% of the men were white, with an average age of 32. Most identified as being in higher social classes, even though the clinic was situated in a socially deprived area of London.

Men reported an average of 43 sexual partners a year, however men who had a history of non-consensual sex had significantly fewer partners a year, at 19. Men with a history of non-consensual sex were slightly more likely to report unprotected sex in the last year (40.6% versus 36.7%), but the difference was not significant.

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Depression was identified as a possible predictor for unprotected sex, with 13.6% of depressed men reporting anal sex without condoms against 2.7% with no evidence of depression. However, the methodology used in the study could not show a definitive link. The investigators note that “it may be the case that unsafe sex is an antecedent for low mood prompted, for example, by self reflection following risk behaviour.” No link was found between either low self-esteem, or anxiety, and sexual risk taking.

However, the investigators did find that men who agreed or strongly agreed with statements reflecting erroneous assumptions about HIV transmission were more likely to have unprotected sex. These included: “If I’m active..my chances of getting HIV are low.” and "This guy and I have been faithful to each other for a long time and neither of us has the symptoms of AIDS."

Several limitations are noted with the study, including its small size and over-representation of men from higher social classes.

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The investigators suggest that reductions in risk behaviour could be achieved by psychological interventions targeted at people who justify their sexual risk behaviour with false beliefs.

Editorial comment

Over the past decade several theories have been adopted, and sometimes dismissed, as the reason why large numbers of gay men have unprotected anal sex, despite ongoing, targeted sexual health education campaigns. Low self-esteem was the favourite for much of the early 1990s, and depression and social exclusion have been cited more recently. This study explored some of these theories, particularly related to the work of the Australian researcher Ron Gold, who has argued that cognitions about sexual risk-taking, once recognised, could be changed.

However the study failed to enquire about pleasure and satisfaction as a reason for anal sex without condoms (a more recent, and perhaps obvious theory) and focused on mental illness and abuse and in doing so continued to pathologise sexual behaviour which, although it may carry health risks, is arguably driven by factors associated with pleasure and the quality of physical intimacy rather than mental ill health. Recent research into gay men’s sexual behaviour can be viewed on the Sigma Research website.

It is also notable that one of the “erroneous cognitions” identified by the investigators as driving unprotected sex – being active carries less of an HIV risk – recently featured in HIV harm minimisation campaigns targeted at gay men by both the Terrence Higgins Trust and GMFA. This belief was identified as one of ten statements that needed to be addressed with accurate information in order to allow gay men to make their own decisions about sexual practices. The campaign noted that insertive anal intercourse is associated with a significantly lower risk of HIV infection than receptive anal intercourse but did not prescribe taking the active role in unprotected anal intercourse as a risk reduction activity.