Increasing Gender Awareness to Reduce Harm in Health Care.

In this guest editorial, the author first discusses how gender is a historical and biopsychosocial construct. This means that there are many aspects of gender besides identity, such as gender expressions, roles and experiences. They address how this issue highlights some of these aspects but that these are not exhaustive, given the topic. They highlight how being able to consider our own gender identities, roles, expressions and experiences is an essential starting point if we are to be competent health-care providers. Finally, they suggest that stories might be one way to learn about aspects of gender we may not be as familiar with, as they allow us to connect emotionally, not just cognitively, with these aspects.

Internet Pornography Use, Body Ideals, and Sexual Self-Esteem in Norwegian Gay and Bisexual Men.

The purpose of this study was to explore the relationship between perception of own appearance, Internet pornography consumption, preferences for pornographic actors' appearance, and sexual self-esteem in gay and bisexual men in Norway. An online survey of 477 gay and bisexual men showed that, despite the prevailing muscular and lean gay body ideal, many men with less ideal bodies also preferred to watch pornographic actors with body types similar to their own. Self-perceived attractiveness, having an ideal body type, and viewing Internet pornography in longer sessions each made a unique contribution to higher self-esteem as a sexual partner. Preferring to watch pornographic actors with ideal bodies was not related to sexual self-esteem. The findings underscore the importance for gay or bisexual men of both self-perceived attractiveness and being athletic or young and fit, for a positive self-evaluation of sexual performance and competence.

Non-monosexual Partnerships: Information, Motivation and Self-Efficacy among Methamphetamine-Using Men Who Have Sex with Men Who Also Have Sex with Women or Transgender Persons.

OBJECTIVES: Sex with more than one gender is associated with higher substance use, and sexual HIV risk. METHODS: We examined knowledge, motivation, and self-efficacy to engage in safer substance use and sexual behavior among methamphetamine-using U.S. men who have sex with more than one gender (N=343). RESULTS: Almost half(46.2%) of the men reported having sex with a man and a woman or transgender partner in the last 30 days. Compared to monosexual MSM, non-monosexual MSM reported greater condom use self-efficacy however, they reported more sexual partners who inject drugs. CONCLUSION: We observed distinct differences between men who do or do not have sex with more than one gender.

Acceptability of Sexually Explicit Images in HIV Prevention Messages Targeting Men Who Have Sex With Men.

Sexually explicit media (SEM) have been used in HIV-prevention advertisements to engage men who have sex with men (MSM) and to communicate content. These advertisements exist within larger discourses, including a dominant heteronormative culture and a growing homonormative culture. Cognizant of these hegemonic cultures, this analysis examined the acceptable level of sexual explicitness in prevention advertisements. Seventy-nine MSM participated in 13 online focus groups, which were part of a larger study of SEM. Three macro themes-audience, location, and community representation-emerged from the analysis, as did the influence of homonormativity on the acceptability of SEM in HIV-prevention messages.

Preferred aspects of sexually explicit media among men who have sex with men: where do condoms fit in?

Sexually explicit media (SEM) is viewed by many men who have sex with men (MSM) and is widely available via the Internet. Though research has investigated the link between SEM and sexual risk behaviour, little has been published about preferences for characteristics of SEM. In an Internet-based cross-sectional study, 1390 adult MSM completed an online survey about their preferences for nine characteristics of SEM and ranked them in order of importance. Respondents preferred free, Internet-based, anonymous SEM portraying behaviours they would do. Cost and looks were the most important characteristics of SEM to participants, while condom use and sexual behaviours themselves were least important. Results suggest that while participants may have preferences for specific behaviours and condom use, these are not the most salient characteristics of SEM to consumers when choosing.

An updated protocol to detect invalid entries in an online survey of men who have sex with men (MSM): how do valid and invalid submissions compare?

Researchers use protocols to screen for suspicious survey submissions in online studies. We evaluated how well a de-duplication and cross-validation process detected invalid entries. Data were from the Sexually Explicit Media Study, an Internet-based HIV prevention survey of men who have sex with men. Using our protocol, 146 (11.6 %) of 1254 entries were identified as invalid. Most indicated changes to the screening questionnaire to gain entry (n = 109, 74.7 %), matched other submissions' payment profiles (n = 56, 41.8 %), or featured an IP address that was recorded previously (n = 43, 29.5 %). We found few demographic or behavioral differences between valid and invalid samples, however. Invalid submissions had lower odds of reporting HIV testing in the past year (OR 0.63), and higher odds of requesting no payment compared to check payments (OR 2.75). Thus, rates of HIV testing would have been underestimated if invalid submissions had not been removed, and payment may not be the only incentive for invalid participation.

Typologies of sexually explicit media use among MSM: An application of latent class analysis.

The viewing of sexually explicit media (SEM) is widespread, especially among men, and research linking SEM viewing and sexual behavior has shown a variety of results, some positive (e.g., sexuality education) and some negative (e.g., poorer body image). These results might be due to limitations in measuring SEM consumption, particularly around typology. The goal of the current study was to examine potential patterns of SEM viewing activities. Using data from an online survey of men who have sex with men (MSM), we conducted latent class analyses of 15 SEM activities. Results suggested a three-class solution. The most prevalent class included over 60% of men and was characterized by viewing primarily safer-sex or conventional behaviors. The second class included 32% of men and had a similar albeit amplified pattern of viewing. The final class included just 7% of men and was marked by high levels of viewing of all activities, including fetish and kink. Compared to the conventional or safer-sex class, the other classes had lower internalized homonegativity, lower condom use self-efficacy, and higher SEM consumption or dose. Implications for HIV prevention, sexuality research and the SEM industry are discussed.

Examining the relationship between use of sexually explicit media and sexual risk behavior in a sample of men who have sex with men in Norway.

The purpose of this study was to investigate consumption patterns of gay-oriented sexually explicit media (SEM) among men who have sex with men (MSM) in Norway, with a particular emphasis on a possible relationship between gay SEM consumption and HIV risk behavior. Participants included 529 MSM living in Norway recruited online to complete a SEM consumption and sexual risk survey. Of the 507 participants who responded to the all items measuring exposure to SEM, 19% reported unprotected anal intercourse with a casual partner (UAI) in last 90 days, and 14% reported having had sero-discordant UAI. Among those with UAI experience, 23% reported receptive anal intercourse (R-UAI) and 37% reported insertive anal intercourse (I-UAI). SEM consumption was found to be significantly associated with sexual risk behaviors. Participants with increased consumption of bareback SEM reported higher odds of UAI and I-UAI after adjusting for other factors using multivariable statistics. MSM who started using SEM at a later age reported lower odds of UAI and I-UAI than MSM who started earlier. Future research should aim at understanding how MSM develop and maintain SEM preferences and the relationship between developmental and maintenance factors and HIV sexual risk behavior.

The relationship between use of sexually explicit media and sexual risk behavior in men who have sex with men: exploring the mediating effects of sexual self-esteem and condom use self-efficacy.

This study tests the following three hypotheses: 1) there is a direct association between consumption of sexually explicit media (SEM) depicting non-condom use and STI-related sexual risk behavior among men who have sex with men (MSM), 2) The association between SEM consumption and STI-related sexual risk behavior is mediated by men's sexual self-esteem, and 3) the relationship between SEM consumption and sexual risk behavior is mediated by condom use self-efficacy. A cross-sectional, Internet-based survey on exposure to SEM and sexual behavior of 1,391 MSM in the USA was conducted in 2011. The results confirmed hypothesis 1 and 3 while hypothesis 2 was rejected. Accordingly, a significant association between the use of SEM picturing condom use and STI related sexual risk behavior among MSM was found. Likewise, we found that the association between the use of SEM and sexual risk behavior was mediated by condom use self-efficacy in an indirect path. However, SEM did not influence sexual risk behavior via sexual self-esteem. To promote STI prevention, the actors in SEM may be used as role models in managing condom use in sexual contexts.

Recommendations for internet-based qualitative health research with hard-to-reach populations.

Researchers new to online qualitative health research frequently have questions about how to transfer knowledge of offline data collection to an online environment. In this article, we present best-practice guidelines derived from the literature and our experience to help researchers determine if an online qualitative study design is appropriate for their research project and, if so, when to begin data collection with a hard-to-reach population. Researchers should reflect on administrative, population, and data collection considerations when deciding between online and offline data collection. Decisions must be made regarding whether to conduct interviews or focus groups, to collect data using asynchronous or synchronous methods, and to use only text or to incorporate visual media. Researchers should also reflect on human subjects, recruitment, research instrumentation, additional data collection, and public relations considerations when writing protocols to guide the research team's response to various situations. Our recommendations direct researchers' reflection on these considerations.

A comparison of mental health, substance use, and sexual risk behaviors between rural and non-rural transgender persons.

The aim of this study was to compare the mental health, substance use, and sexual risk behaviors of rural and non-rural transgender persons. Online banner advertisements were used to recruit 1,229 self-identified rural and non-rural transgender adults (18+ years) residing in the United States. Primary findings include significant differences in mental health between rural and non-rural transmen; relatively low levels of binge drinking across groups, although high levels of marijuana use; and high levels of unprotected sex among transwomen. The results confirm that mental and physical health services for transgender persons residing in rural areas are urgently needed.

Normal, Problematic and Compulsive Consumption of Sexually Explicit Media: Clinical Findings using the Compulsive Pornography Consumption (CPC) Scale among Men who have Sex with Men.

To assess problematic sexually explicit media (SEM) consumption, and to identify clinically meaningful cut-off points, we examined clinical correlates using the new Compulsive Pornography Consumption (CPC) scale among 1165 participating MSM. Building on scale practices in measuring compulsive sexual behavior, two cut-off points were identified. While most (76-80%) MSM do not report compulsive symptoms, about 16-20% report levels of problematic SEM consumption, including 7% with extreme scores consistent with DSM criteria for compulsive disorders. Demographic, sexual, and HIV risk differences were identified between the three groups. Researchers and clinicians are encouraged to consider using the CPC scale for comprehensive assessment of compulsive sexual behavior.

Acceptability of HIV-prevention messages in sexually explicit media viewed by men who have sex with men.

To inform HIV/STI prevention messaging, the authors used cross-sectional data from 1,231 men who have sex with men (MSM) to examine the acceptability of strategies for delivering prevention messages in sexually explicit media (SEM). The majority of participants (83%) found it acceptable to include prevention messages in SEM. A latent profile analysis identified three classifications of men with similar views on the acceptability of strategies. Compared to men endorsing some strategies (54%), men endorsing all strategies (29%) were younger (PORadj = 0.56 [0.39, 0.79]) and preferred viewing SEM in which the actors used condoms for anal sex (PORadj = 1.53 [1.05, 2.23]). Men endorsing no strategies (17%) were of similar age to men endorsing some, but were more likely to prefer viewing SEM in which the actors did not use condoms (PORadj = 2.44 [1.43, 4.16]) and to report engaging in insertive unprotected anal sex within the past 3 months (PORadj = 2.03 [1.11, 3.70]). Opportunities exist to use SEM for HIV/STI prevention.

The effects of gay sexually explicit media on the HIV risk behavior of men who have sex with men.

This study sought to study consumption patterns of gay-oriented sexually explicit media (SEM) by men who have sex with men (MSM); and to investigate a hypothesized relationship between gay SEM consumption and HIV risk behavior. Participants were 1,391 MSM living in the US, recruited online to complete a SEM consumption and sexual risk survey. Almost all (98.5 %) reported some gay SEM exposure over the last 90 days. While 41 % reported a preference to watch actors perform anal sex without condoms (termed "bareback SEM"), 17 % preferred to actors perform anal sex with condoms (termed "safer sex SEM") and 42 % reported no preference. Overall SEM consumption was not associated with HIV risk; however participants who watched more bareback SEM reported significantly greater odds of engaging in risk behavior. The results suggest that a preference for bareback SEM is associated with engaging in risk behavior. More research to understand how MSM develop and maintain preferences in viewing SEM, and to identify new ways to use SEM in HIV prevention, is recommended.

Open, closed, or in between: relationship configuration and condom use among men who use the internet to seek sex with men.

Nearly 70 % of HIV+ men who have sex with men (MSM) are estimated to have contracted HIV from a main partner. We examine whether condom use varies by relationship configuration, including open relationships with and without cheating. 656 MSM in committed relationships were recruited through a sexually explicit social networking website. Of the 55 % of MSM who had anal sex with a non-main partner in the past 90 days, two-thirds did not use a condom. Adjusting for covariates, MSM in relationships characterized as open with cheating versus monogamous were more likely to have unprotected anal sex with both main and non-main partners. MSM who perceived that their partner played around or cheated were more likely to have unprotected anal sex with a non-main partner. Prevention messages should attempt to reduce cheating and increase personal responsibility for protecting partners from HIV. Messages should be tailored to reflect open and monogamous relationships.

The SEM Risk Behavior (SRB) Model: A New Conceptual Model of how Pornography Influences the Sexual Intentions and HIV Risk Behavior of MSM.

While the effects of sexually explicit media (SEM) on heterosexuals' sexual intentions and behaviors have been studied, little is known about the consumption and possible influence of SEM among men who have sex with men (MSM). Importantly, conceptual models of how Internet-based SEM influences behavior are lacking. Seventy-nine MSM participated in online focus groups about their SEM viewing preferences and sexual behavior. Twenty-three participants reported recent exposure to a new behavior via SEM. Whether participants modified their sexual intentions and/or engaged in the new behavior depended on three factors: arousal when imagining the behavior, pleasure when attempting the behavior, and trust between sex partners. Based on MSM's experience, we advance a model of how viewing a new sexual behavior in SEM influences sexual intentions and behaviors. The model includes five paths. Three paths result in the maintenance of sexual intentions and behaviors. One path results in a modification of sexual intentions while maintaining previous sexual behaviors, and one path results in a modification of both sexual intentions and behaviors. With this model, researchers have a framework to test associations between SEM consumption and sexual intentions and behavior, and public health programs have a framework to conceptualize SEM-based HIV/STI prevention programs.

Discussions of viral load in negotiating sexual episodes with primary and casual partners among men who have sex with men.

Recent studies suggest that people living with HIV with lower viral load are at reduced risk for transmitting HIV to their sexual partners. As information about the association between viral load and risk for HIV transmission disseminates throughout high-risk communities, viral load discussions may be used more often as a risk reduction strategy. The overall purpose of this study was to determine the frequency of viral load discussions and unprotected anal intercourse (UAI) in primary and casual sexual partnerships among men who have sex with men (MSM). An online survey was completed by 326 MSM (82% Caucasian, 62% college educated, 7% HIV-positive or thought they were HIV positive) in January 2011. Results showed that viral load discussions occurred in 93% of primary partnerships in which at least one partner was HIV-positive; UAI was reported with 46% of all primary partners and 25% of serodiscordant primary partners with whom viral load was discussed. Viral load discussions occurred in 53% of the three recent sexual episodes with casual sex partners with whom participants had either sex with once or had sex with multiple times in the past three months. UAI was more common in sexual encounters with casual sex partners when viral load was not discussed than when viral load was discussed (75% v. 56% of encounters). The finding that casual sexual episodes that did not include viral load discussions had a higher percentage of UAI than those that did include viral load discussions suggests either that men who do not discuss viral load may be higher risk-takers than men who do, or that the former are less adept at negotiating safer sex with casual sex partners than men who do discuss viral load. More research is needed to understand the role of viral load discussions in negotiating sexual activities among MSM.

A commentary on the role of sexually explicit media (SEM) in the transmission and prevention of HIV among men who have sex with men (MSM).

Although research has been conducted over the last half century to test the hypothesis that pornography, or sexually explicit media (SEM), influences behavior, information regarding usage and its effect on men who have sex with men (MSM) is limited. It is important for researchers studying online risk factors for HIV to consider the relationship between SEM consumption and risky sexual behavior, particularly given the exponential increase in SEM exposure as a result of the near-compulsory use of the Internet. In this commentary, we review findings regarding this relationship from studies of international and heterosexual populations. We then suggest future directions for research regarding MSM in the United States and practical applications of such research if the results from other populations extend to them. Research suggests there might be ways to use SEM to create innovative approaches to online HIV prevention, particularly among such at-risk populations as youth and MSM of lower socio-economic statuses.

A review of the content and format of transgender-related webpages.

Transgender persons represent a highly diverse group of individuals who have been historically underserved, despite being disproportionately at risk for HIV (human immunodeficiency virus) and other health conditions. Despite the need for more research on transgender health issues, no review of online transgender-related resources has been conducted. The purpose of this study was to broadly characterize (1) the types of transgender-related webpages that appear as a result of keyword searches, and (2) the extent to which webpages differ in content and format depending on whether the intended audience for the webpage was transgender individuals, health professionals, or the general population. An online search using 28 keywords yielded 204 eligible webpages, of which 58% targeted transgendered individuals, 23% targeted health professionals, and 39% targeted the general public. The highest percentage of webpages appeared to be operated and/or created by transgender individuals or groups (46%), followed by for-profit businesses (17%). The majority of mental health (80%), HIV-related (89%), and primary care (100%) webpages targeted health professionals. Although various features are available that may increase user interest in and perceived credibility of a webpage, the results show that many of these features were underutilized. There appears to be significant opportunity to develop web resources that directly target unique subgroups within the transgender community to improve their health outcomes, increase the visibility of features that increase user interest and perceived credibility of webpages, and possibly train transgender individuals to seek relevant online information.