Predictors of Unprotected Intercourse, Among Gay and Bisexual Youth: Knowledge, Beliefs, and Behavior

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Predictors

of

Unprotected

Intercourse

Among

Gay

and

Bisexual

Youth:

Knowledge,

Beliefs,

and

Behavior

Gary Remafedi, MD, MPH

ABSTRACT. Objective. To examine human

immuno-deficiency virus (HIV)-related knowledge, attitudes, and

behaviors and predictors of unprotected anal intercourse.

Design. Structured interviews and paper-and-pencil

instruments.

Setting. Community sites in Minnesota during 1989

to 1991.

Subjects. Two hundred thirty-nine gay and bisexual

male adolescent volunteers.

Outcome measures. AIDS knowledge and beliefs,

self-reported substance use, and sexual behavior.

Results. Subjects demonstrated accurate knowledge

and beliefs about HIV; but 63% were found to be at

“extreme risk” for prior HIV exposure, based on histories

of unprotected anal intercourse and/or intravenous drug

use. Thirty-four percent of subjects reported unprotected

anal sex with at least one of the last three partners in the

previous year. Perceived likelthood of HIV acquisition,

substance abuse, having a steady partner, noncommuni-cation with partners about risk reduction, and frequent

intercourse were found to be significantly associated

(P < .05) with unprotected anal sex in the previous year.

Conclusions. Programs for gay and bisexual youth

should focus on preventing unprotected anal intercourse. Other goals are to promote: communication with sexual partners, consistent condom use during oral and vaginal sex, low risk sexual practices, avoidance of substance use

in sexual situations, and developmentally appropriate HIV antibody counseling and testing services. Pediatrics

1994;94:163-168; human immunodeficiency virus,

homo-sexuality, prevention, sexual behavior.

ABBREVIATIONS. STh, sexually transmitted disease; HIV,

hu-man immunodeficiency virus.

High risk sex between men accounts for the largest

proportion of AIDS cases among adolescents (13 to

21 years of age). Sex between males has been

impli-cated in 70% of the cases that were unrelated to

blood products.’ In a national sample of sexually

transmitted disease (STD) clinics, human

immuno-deficiency virus (HIV) seroprevalence among 20- to

24-year-old male homosexual youths was found to

be 30.1 %, as compared to an overall rate of I .4%

among same-aged clients.2 HIV serosurveys of gay

and bisexual youth at a New York City runaway/

homeless shelter and a Maryland college found rates

Received for publication Sep 23, 1993; accepted Jan 7, 1994.

Reprint requests to (G.R.) Director, Youth and AIDS Project, University of Minnesota Hospital and Clinics, Box 721 UMHC, 420 Delaware Street SE, Minneapolis, MN 55455-0392.

PEDIATRICS (ISSN 0031 4005). Copyright l 1994 by the American Acad-emy of Pediatrics.

of infection to be, respectively, 26% (31 /121) and

4.2% (4/96).’

Existing data about HIV-related behaviors of gay

youth were mainly derived from mixed-age (adult

and adolescent) cohorts in the I980s. Among male

homosexual clinic patients screened for STD in 1983,

15 to 20 year olds had the highest age-specific rates of

rectal chlamydia and gonorrhea.5 High rates of

un-protected anal intercourse, anonymous sex, and

mul-tiple partners were noted in two small samples of

gay and bisexual teenagers6 and young adults.7

Var-ious studies of adult bi/homosexual men have found

that unsafe sex diminished with increasing age.8’3

Empirical data regarding current risk taking

be-havior among gay and bisexual adolescents are

lack-ing. Possible explanations for unsafe sex among gay

youth include unfamiliarity with HIV disease,8’9

per-ceptions of AIDS as a problem of older gay men,7

immature social skills,7 lack of supportive social

net-works,’#{176} substance abuse,” and self-compromising

behaviors arising from social stigma.’2 This study

examines current HIV-related knowledge, attitudes,

and behaviors and predictors of unprotected anal

intercourse among gay and bisexual youth.

Subjects

MATERIALS AND METHODS

Eligible subjects were men between the ages of 13 and 21 years who were self-identified as gay or bisexual and/or who had sex with men. Subjects were recruited during 1989 to 1991 from ad-vertisements in gay publications and business venues, direct ap-peal at social groups and community events, and referrals from school and health professionals and previous participants.

Procedures

The instruments were administered at the subjects’ conve-nience in a private office setting. All subjects completed a struc-tured interview (conducted by a physician or social worker) and self-administered surveys, requiring 1.5 hours. Afterward, HIV risk reduction information, referral to other needed professional services, and a modest reimbursement for participation were pro-vided. Participation was voluntary and confidential, with the op-tion of anonymity. Parental consent for minors was not required. Subjects gave prior verbal and written consent to all procedures, as approved by the University Committee on the Use of Human Subjects.

Instrumentation

Paper-and-pencil instruments included: 30 true-false AIDS knowledge items by DiClemente et al’4; three questions about the

HIV antibody test; 16 items regarding beliefs about HIV

transmis-sion from the National Health Interview Survey’5; 21 questions about lifetime, annual, and quarterly substance use by Johnston et al’6; and Winters’ Personal Experience Screening Questionnaire (PESQ), which provided a substance abuse severity score from 38 true-false and ordinal-scale questions about drug purchase and at Viet Nam:AAP Sponsored on September 1, 2020

www.aappublications.org/news

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use, effects on relationships and finances, and physical and emo-tional symptoms of dependence.’7

The interview consisted of 184 multiple-choice, Likert-type, and

open-ended questions regarding: demographics’8; sexuality,

health and psychosocial status5”; personal HIV risk factors, prior HIV antibody testing, acquaintance with persons with HIV/ AIDS’9; and a sexual history.2’2’ The sexual history included ques-tions about first sexual experiences; sexual abuse/assault; lifetime, annual, and quarterly sexual behaviors; condom use; history of pregnancy or fatherhood; and a detailed account of sexual expe-riences with the last three sexual partners of the previous year. In a field trial with 60 male and female high school students, individual items were found to have high test-retest reliability (i.e., more than 90% of the sample gave consistent answers). Convergent validity was demonstrated by the correlation of self-reported, risky sexual behaviors with standard measures of im-pulsivity, self-efficacy in STD prevention, and AIDS knowledge (Remafedi G, Resnick M, Bearinger L., unpublished data).

Analyses

Subjects engaging in high or lower risk sex with

recent partners were compared, using chi-square and

t tests. Forward stepwise logistic regression analysis

was used to identify variables that were

indepen-dently predictive of high risk sex in the past year

while controlling for the effect of the other variables

in the model. All tests were performed with SPSS

software. The designated level of statistical

signifi-cance was <.05.

Sample Description

RESULTS

Subjects were 239 men between the ages of 13 and

21 years (median age 19.9 years) consecutively

en-rolled in 1989 to 1991 through direct appeal to social

groups (44%), advertisements (14%), referral from

school or health professionals (7%) and peers (6%), or

a combination of sources (29%).

The ethnic/racial composition of the sample was

79% Caucasian, 12% African American, 3% Asian

American, 2% Native American, 2% Hispanic, and

2% other. Almost half of subjects (48%) were raised

in metropolitan areas (with more than 100 000

per-sons); and the rest were from smaller cities (46%) or

rural areas (5%). Subjects’ median educational level

was 12th grade (range, grades 8 through 16).

Sixty-four percent were enrolled in school at the time of the

study; and 71 % were employed at least part-time,

with a median weekly salary of $150 (range: $5 to

$600).

Knowledge About HIV/AIDS

Newspapers and television were considered the

most important sources of information about AIDS

by 47% of subjects. Approximately half of subjects

(54%) reported some instruction about AIDS at

school; but school was ranked first in importance by

only 16% of the young men.

The mean score on DiClemente’s” AIDS

Knowl-edge Questionnaire was 91%. Seven percent of

sub-jects were unaware of the HIV antibody test; and

another 30% of the others incorrectly believed or

were unsure that this was a test for AIDS, as opposed

to HIV infection.

Beliefs About HIV/AIDS

Subjects rated the likelihood of HIV acquisition

from 13 different behaviors on a 6-point scale,

rang-ing from “definitely not possible” to “100 percent

sure.” All sexual acts (ie, anal, vaginal, or oral) were

considered riskier when performed without

con-doms. Receptive acts (ie, oral or anal) were

consid-ered more dangerous than insertive ones. Finally,

male partners were viewed as riskier than female

partners for comparable sexual behaviors (eg, anal or

oral sex). Regardless of partner gender, unprotected

rectal sex was considered to be the riskiest behavior.

Eighty-three percent of subjects thought that HIV

acquisition by receiving oral sex was unlikely. Most

respondents (90%) said it was at least somewhat

likely that an acquaintance would contract HIV; and

44% believed the same for themselves.

Sexual Orientation

On a Kinsey scale, most clients described

them-selves as “100%” (56%) or “mostly homosexual”

(34%); and fewer chose the “bisexual” (9%) or “mostly

heterosexual” (1%) descriptors. When options were

limited to “heterosexual, homosexual, or bisexual,” 87%

(207/238) described themselves as homosexual; and 13%

(31/238), as bisexual.

First attractions toward persons of the same

gen-der typically were noted during early adolescence

(median age, 11 years). Self-identification as

homo-sexual (median age, 15 years) usually preceded

sex-ual experiences with males or females (median ages,

16 years). A median of 1 year elapsed before sexual

feelings were discussed with friends or parents. At

the time of participation in the study, more than one

third of clients had not discussed their orientation

with a parent.

Substance Abuse and Psychosocial Problems

Forty-four percent of users (99/224) had five or

more drinks in a row on at least one occasion in the

last 2 weeks. Marijuana was the most commonly

used illicit drug, tried by two thirds of the sample

(160/239). Twenty-three percent of subjects had used

cocaine at least once, one quarter of whom (14/54)

did so more than 40 times. Fewer had tried crack

(8%) or injectable drugs (5%).

Based on the PESQ, 20% of subjects scored in the

range of possible chemical dependency. Fifteen

per-cent of subjects had received substance abuse

treat-ment. Other common concerns were school problems

related to sexual orientation (140/238, 59%); history

of sexual abuse/assault (96/229, 42%); running away

from home (79/238, 33%); attempted suicide (70/

237, 30%); arrest for illegal activity (70/238, 29%);

and psychiatric hospitalizations (35/238, 15%), most

often for depression and/or attempted suicide.

HIV/STD Occurrence

Based on sexual and substance abuse histories,

subjects were assigned to a lifetime HIV risk

cate-gory. “Extreme Risk” was defined as any

unpro-tected anal intercourse with a male and/or

intrave-nous drug use. “Moderate risk” was defined as any

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TABLE 1. Prevalence of Sexual Behaviors with Male and Female Partners among 239 Subjects, with Median Annual Number of Partners

Lifetime Past Year Annual No. of

N (%F) N (%F)

Partners

Median Range

Male partners

Dating 187 (78) 172 (72) 3 1 to 50

Kissing 213 (89) 201 (84) 4 1 to 156

Deep kissing 21 1 (88) 200 (84) 4 1 to 156

Intimate touching 216 (90) 198 (83) 4 1 to 150

Receive oral sex 204 (85) 192 (80) 4 1 to 140

Give oral sex 204 (85) 190 (79) 3 1 to 150

Insertive anal sex 162 (68) 136 (57) 2 1 to 65

Receptive anal 161 (67) 132 (55) 1 1 to 140

sex

Accept money for 26 (11) 16 (7) 2 1 to 155

sex

Female partners

Dating 170 (71) 81 (34) 2 1 to 25

Kissing 174 (73) 84 (35) 2 1 to 50

Deep kissing 165 (69) 78 (33) 2 1 to 202

Intimate touching 142 (59) 65 (27) 1 1 to 50

Receive oral sex 84 (35) 35 (15) 1 1 to 20

Give oral sex 65 (27) 27 (11) 1 1 to 20

Vaginal sex 101 (42) 46 (19) 1 1 to 20

Insertive anal sex 13 (5) 4 (2) 1 1 to 7

Accept money for 2 (1) 2 (1) 1 1 .5 3 to 20

sex

unprotected vaginal or oral intercourse. “Low risk”

included the remaining subjects (ie, no unprotected

oral, vaginal, or anal sex and no intravenous drug

use). By this rating, 63% of the subjects were

consid-ered at extreme risk for prior exposure to HIV; 25%

at moderate risk; and 12% at low risk.

Only one fourth of subjects (61 /237, 26%) had ever

been tested for an STD. Fifty-four subjects (23%)

reported 76 illnesses: 33 ectoparasitic infestations, 9

hepatitides (A, B, or unknown), 6 Chiamydia

tracho-matis infections, 6 other nonspecific urethritides, 5 N.

gonorrhoeae infections, 3 cases of venereal warts, 2

herpes progenitalis, I syphilis, and I I other

unspec-ified illnesses. Forty percent of subjects had

under-gone HIV antibody testing; four men (4%) reported

seropositive results, and three were unaware of their

results.

Sexual Behaviors: Annual Partner Recall

For a detailed description of sexual practices,

sub-jects were questioned about the last three partners of

the previous year. Twenty-one men (9%) reported no

sexual experiences in the prior year. The remaining

218 subjects described encounters with a total of 570

male (91 %) and female (9%) partners. The prevalence

of specific sexual behaviors and median annual

num-bers of partners are presented in Table I.

In more than a third of cases (223/570), couples

knew each other less than a week before having sex.

Afterward, 29% of couples who had vaginal or anal

intercourse (78/273) had no further relations. Couples

infrequently discussed HIV serostatus (105/570, 18%),

condom use (157/569, 28%), concern about AIDS (170/

569, 30%), or pregnancy prevention (17/53, 32%) before

sex.

The occurrence of common sexual practices

(de-fined as the percentage of partners with whom a

TAB

and port

LE

53 ed b

2. Occurrence of Sexual Behav female) Different Partners in the

y 218 Sexually Active Subjects

iors with 570 (517 male Previous Year, as

Re-Behavior N (%F)

Kissing 520 (91)

Deep kissing 503 (88)

Intimate touching 524 (92)

Receive oral sex 465 (82)

Give oral sex 445 (78)

Vaginal sex 47 (89)

Insertive anal sex 166 (29)

Receptive anal sex 186 (36)

particular behavior occurred) is presented in Tables 2

and 3. Insertive or receptive anal intercourse

oc-curred with 40% of partners (225/569); kissing,

touching, oral sex, and vaginal intercourse occurred

more than twice as often. Condoms were most

con-sistently used for anal sex (with 53% of partners) and

least consistently used for oral sex (6%). Of the total

sample, 89 subjects (37%) had anal intercourse with

any one of the last three partners of the previous

year. Only 8% (7/89) of these subjects used condoms

consistently with all of their latest partners.

Annual HIV Risk

In order to identify correlates of risky sexual

be-havior in the previous year, subjects who reported

unprotected anal intercourse with any of the last

three partners (ie, “high risk,” n = 82) were

com-pared with others who did not (ie, “lower risk,”

n = 156). Select analyses are presented in Table 4.

There were no significant demographic differences

between high and lower risk groups. High and lower

risk groups reported similar rates of sexual abuse/

assault, conduct problems (ie, history of running

away from home or arrest), and mental health

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TABLE 3. Occurrence of Sexual Behaviors With 570 Different

Partners in the Previous Year, as Reported by 218 Sexually Active

Subjects

N (%F) Condom Use (N (%F))

Never Sometimes Always

Any oral sex 479 (84) 419 (88) 30 (6) 30 (6)

Vaginal sex* 47 (89) 17 (41) 14 (34) 10 (25)

Any anal sex 225 (39) 68 (30) 38 (17) 119 (53)

*Condom use data not available for 6 cases.

concerns (ie, PESQ scores, attempted suicide and

mental health treatment), and HIV antibody testing.

Both high and lower risk groups had similar levels of

knowledge about HIV and realistic beliefs about the

risk of HIV transmission from unsafe sex.

Relatively more high risk persons recognized that

they were “very likely” or “100% sure” to become

infected (P = .02). High risk persons were more likely to

have had (P = .001) or currently have (P = .02) a steady

partner. They also reported more frequent insertive

(P < .0001) and receptive anal intercourse (P < .0001).

1-ligh risk subjects discussed fewer topics pertaining to

risk reduction with prospective partners (means 2.98 vs.

2.33, t value -2.47, df = 207, P = .014) and were more

likely to have used alcohol or drugs during sex (P = .005).

All seven items that univariate analyses found to

be significantly associated with high risk sex were

entered as independent variables in a forward

step-wise logistic regression analysis (Table 5). All seven

variables were available for 97% of cases. Perceived

personal risk of HIV infection, frequency of receptive

anal intercourse, and limited discussion of risk

re-duction topics with partners were found to be

inde-pendently associated with the dependent variable,

any unprotected anal sex with the last three partners

of the previous year. Considering oneself unlikely to

get HIV was associated with a greater than threefold

odds (odds ratio 3.14, 95% CI: 1.13 to 8.74) of

avoid-ing unprotected anal intercourse. With each

discus-sion of risk reduction, the odds of remaining safe

increased by a factor of 1 .14 (95% CI: I .01 to I .29).

Finally, when intercourse occurred often, the

likeli-hood of consistent condom use diminished

signifi-cantly (odds ratio .31, 95% CI: .16 to .59).

DISCUSSION

Unprotected anal intercourse and multiple

pant-ners are the strongest predictors of HIV infection

among adult gay men.4 Unprotected anal

inter-course transmits HIV more efficiently than other

sex-ual practices; and multiple partners increase the

like-lihood of exposure to the virus.

The cohort in this study reported high levels of

sexual activity. Only 9% of subjects abstained from

sex in the previous year. The median annual

num-bers of male partners for insentive oral and anal sex

were, respectively, 4 (range, I to 140) and 2 (range, I

to 65). In almost half of encounters, partners were not

well-acquainted before sex and often did not meet

again. Sexual anonymity may preclude easy

commu-nication about HIV risk reduction and notification of

an STD or HIV exposure when they are subsequently

diagnosed.

Despite their young ages, two thirds of the subjects

had engaged in behavior placing them at extreme

risk of prior HIV exposure. Based on reported

en-counters with the last three panthers alone, one third

of the sample had unprotected anal intercourse in the

last year. This figure probably underestimated the

true annual rate of unprotected anal intercourse,

since a number of subjects had intercourse with more

than three partners.

The generalizability of these findings to other

pop-ulations of bi/homosexual youth is difficult to

deter-mine. While this may be the largest study of sexual

risk behavior of gay and bisexual youth in published

research, the subjects were unselected volunteers.

Since many adolescents do not recognize their bi/

homosexuality until adulthood or hide their feelings

and experiences, identifying a probability sample of

TABLE 4. Comparison of High and Lo wer Risk Subjects (N = 238)

Variable N (%F) Chi Square

Value

df P

. . .

Lower Risk High Risk

Personal risk of HIV

Very likely 8 (5) 12(15) 5.28 1 .02

Unlikely 148 (95) 69 (85)

Current steady partner

Yes 42 (27) 35 (43) 5.40 1 .02

No 114 (73) 47 (57)

Ever steady partner

Yes 92 (59) 67 (82) 11.14 1 .001

No 63(41) 15(18)

Sexual behavior with last three partners:

Drug use during sex

Some 98 (63) 67 (82) 7.81 1 .005

None 57 (37) 15 (18)

Insertive anal sex

Never/seldom 125 (64) 41 (50) 21.7 1 <.0001

Often 31 (36) 41 (50)

Receptive anal sex

Never/seldom 126 (81) 40 (49) 24.6 1 <.0001

Often 30(19) 42 (51)

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TABLE 5. Summary Tabl (N = 233)

e: Logistic Regres sion Analysis of U nprotected Anal Sex in the Past Year

Variable Odds Ratio 95% CI Regression

Coefficient

SE P

Constant -.01 1.05 .99

Personal risk 3.14 (1.13 to 8.74) 1.15 .051 .02

Receptive anal sex .31 (.16 to .59) -1.17 .13 .0003

Discussion with partners 1.14 (1.01 to 1.29) .13 .06 .04

gay and bisexual youth has been theoretically and

technically difficult. In order to represent the

diver-sity of young men who have sex with men, subjects

were recruited from various sources; and their

socio-demographic characteristics closely resembled

an-other cohort of self-identified homosexual youth in a

representative sample of secondary students in the

same

State?-The study illustrated that risky sexual behavior

was not associated with sociodemographic

charac-tenistics, reported psychosocial problems, or HIV

an-tibody testing. Subjects often engaged in high risk

sex, despite good knowledge about HIV,

acquain-tance with infected persons, and awareness of

sus-ceptibiity. For some youth, non-use of condoms was

a calculated risk measured by relationship status.

Persons in steady relationships were more likely

than others to have unprotected intercourse. Similar

studies of homosexual adults’9’2628 and adolescent

and adult women attending family planning clinics29

have noted that condoms were less frequently used

in primary relationships than with casual partners.

High risk subjects correctly recognized they were

more likely than others to become infected, but were

not deterred from dangerous behavior. Inconsistent

use of condoms was associated with frequent anal

intercourse, noncommunication with partners about

risk reduction, and substance use in sexual

situa-tions. Similar “clusters” of risky behaviors have been

observed in other cohorts of homosexual men,’3’27’28”#{176}

junior high school students,3’ and female adolescent

clinic attendees.32

IMPLICATIONS

Consistent use of condoms during intercourse and

avoidance of risky behaviors are common themes in

HIV prevention programs for youth. These generic

guidelines should be tailored to different

subpopu-lations in order to be maximally effective. For young

men who have sex with men, consistent use of

con-doms during anal intercourse needs emphasis.

Pro-moting alternatives to intercourse may be another

promising approach to HIV prevention for gay and

bisexual youth.

As suggested by the logistic regression analysis,

HIV risk reduction requires self-assuredness and

communication with partners. Assertive

communi-cation with partners about HIV prevention is often

difficult for adolescents who are exploring same-sex

relationships without the benefit of prior learning

and example. Moreover, some gay and bisexual youth

have

complex

psychosocial

problems

and deeply

en-grained patterns of risky behavior which impede risk

reduction. Whenever possible, HIV prevention programs

should be paired with opportunities for friendship and

positive

role models,

as are offered

by support groups for

gay and lesbian youth.”2 Also, more intensive mental

health and social services may be a useful adjunct to I-HV

prevention programs.

Finally, gay and bisexual youth should have access

to age-appropriate HIV antibody counseling and

testing services. In the interest of HIV prevention

and services for infected youth, testing sites should

attend to adolescents’ developmental level, fund of

knowledge, confidentiality, informed consent,

finan-cial concerns, transportation, continuity of care, and

emotional and social supports.

ACKNOWLEDGMENTS

We acknowledge the expert technical assistance of Charles Tamble, William Foster, Russ Nordmeyer, and Xiaohe Liu.

This work was supported in part by the Minnesota Department of Health Project MNDOH/12500-29679-01 and by Projects BRH/ P05053 and MCJ000985-1 I I from the Maternal and Child Health

Program, Health Resources and Services Administration, Depart-ment of Health and Human Services.

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THE “POST-INCEST

SYNDROME”

HYSTERIA

[Read] the evidence that helped convict a man in Miami of child

molestation-and you will feel a wave of nausea at what adults are capable of inflicting on

children. Read only one false-accusation case, and you will feel misery and anger

at what bureaucrats are capable of inflicting on parents. To further confuse the

issue, the reality of the victimization of children is being obscured by a chorus of

adults clamoring that they were victims too-if not as children, then as infants; if

not in this life, then in a previous one. The evidence that abuse is more common

than we knew is being trivialized by unvalidated claims made by pop-psychology

writers that abuse is nearly universal, and that if you can’t actually remember the

abuse, that’s all the more evidence that it happened to you.

Tavris C. Beware the incest-survivor machine. The New York Times Book Review. January 3, 1993.

Submitted by Student

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1994;94;163

Pediatrics

Gary Remafedi

Beliefs, and Behavior