Exploring Gay and Bisexual Men's Explanations of 'Uncommon'

AIDS Behav (2016) 20:2266–2274 DOI 10.1007/s10461-016-1289-x

ORIGINAL PAPER

The Road Less Travelled: Exploring Gay and Bisexual Men’s Explanations of ‘Uncommon’ Routes of HIV Transmission

1,2 1,3 3 1 Denton Callander • Garrett Prestage • Jeanne Ellard • Kathy Trifﬁtt • 3 1 Graham Brown • Ian Down

Published online: 18 January 2016 Ó Springer Science+Business Media New York 2016

Abstract Although there are practices other than con- Introduction domless anal intercourse that may result in HIV transmission among gay and bisexual men, very little is known Research on HIV transmission among gay, bisexual and about these ‘uncommon’ transmission explanations. To other men who have sex with men has typically focused on address this topic, the free text survey responses from 465 condomless anal intercourse as the primary route of HIV positive gay men in Australia were thematically infection. Indeed, the quantification of HIV transmission analysed; 123 participants offered uncommon explanations risk places anal sex without a condom as significantly more for their seroconversion. Men described several sexual acts risky than any other route of sexual transmission, espe- they believed led to infection, categorised as adventurous cially for the receptive (i.e., ‘bottom’) partner [1]. In sex (e.g., fisting) and foreplay (e.g., oral sex). Participants Australia, one study found that over 70 % of gay and also identified mediating factors associated with their bisexual men attributed their seroconversion to condomless seroconversion, either internal (e.g., cum/pre-cum) or anal intercourse [2] and while it undoubtedly remains a key external (e.g., sores, illness) to sex. Finally, contextual area of focus for understanding sexual risk practices, there forces associated with infection were also explored, namely are also other less common transmission routes that bear physical spaces (e.g., sex on premises venues) or mental some consideration. This paper seeks to describe and states (e.g., depression). While some uncommon explana- unpack the diverse ways that gay and bisexual men explain tions are unlikely to have resulted in HIV transmission, their HIV infection via ‘uncommon’ transmission routes. these accounts reveal the diverse and intersecting ways that Routes of uncommon transmission have been previously men attempt to make sense of their seroconversion. explored by some research. In the early 2000s, a small study of 75 gay and bisexual men in Sydney identified oral Keywords HIV Á Seroconversion Á Gay men Á sex as a possible route of HIV transmission in five cases Uncommon transmission (7 %), particularly among men with genital piercings [3]. Transmission via oral sex was also explored in a larger study of gay and bisexual men in the UK, in which 3 % of respondents identified it as the route of their infection [4]. Although the complicated nature of self-reporting sexual & Denton Callander risk behaviour introduces some uncertainty about oral sex [email protected] and infection, a recent review of the virology of oral HIV transmission concluded that the virus can be transmitted 1 Kirby Institute for Infection and Immunity in Society, UNSW Australia, Level 6 Wallace Wurth Building, Sydney, orally, especially if mucosal membrane are enflamed or NSW 2052, Australia otherwise compromised [5]. One study in the USA, how- 2 Centre for Social Research in Health, UNSW Australia, ever, found that claims of seroconversion via oral sex were Sydney, NSW, Australia more common among gay and bisexual men of ethnic 3 Australian Research Centre in Sex, Health and Society, minority groups and those of lower socioeconomic status, UNSW Australia, Sydney, NSW, Australia which the author suggested was evidence of attempts to 123 AIDS Behav (2016) 20:2266–2274 2267 mitigate internal and/or external stigma among those most between December 2007 and December 2013, self-identi- exposed to various HIV and same-sex attraction stigmas fied as gay or bisexual, or reported past sex with another [6]. man. Beyond oral sex, uncommon routes of transmission have The survey instrument included a total of 197 multiple received little attention in the research literature. Of choice and open-ended (i.e., free text) items, which col- exception, the practices of partial anal penetration and of lected information on participant demographics, HIV rubbing one’s penis around or against the anus—known, diagnosis, HIV testing patterns, and sexual practices before respectively, as ‘dipping’ and ‘nudging’—have been dis- and after diagnosis. Participants were asked to identify one cussed in the context of risk practices. Although one study or more events that may have led to their infection. Those of sex on premises venues in Melbourne reported that unable to identify such an event were provided information around 20 % of men reported nudging and 5 % dipping, on activities representing high risk for infection, such as nothing is known how or if men with HIV associate these condomless anal intercourse or sharing injecting equip- practices with their seroconversion [7]. ment, and then asked again about a high risk event. Par- While the risks associated with HIV transmission via ticipants were asked to identify one event that they felt oral sex, dipping and other sexual practices are not entirely more likely resulted in their infection and then asked about clear, understanding how and if men explain their sero- what had occurred. conversion in these and other ‘uncommon’ terms is In addition to the survey’s multiple choice items per- important for developing a more complete picture of taining to risk and transmission, participants were also seroconversion generally. The current study aimed to invited to provide additional information on their experi- describe individuals’ beliefs about routes of sexual trans- ences through the free text item: ‘‘Are there any other mission other than condomless anal intercourse among gay things you feel contributed to you getting HIV that you and bisexual men in Australia. would like to tell us about?’’ Participants who could not identify any high risk event were also provided with an opportunity to describe how they believed they became Methods infected (‘‘Please explain in your own words what you think might have happened’’). Finally, participants were Recruitment and Survey asked at the end of the survey to provide final comments (‘‘Are there any other final comments you would like to Data were drawn from a survey of recent HIV serocon- provide?’’). All of these free-text questions were a non- verters in Australia known as the HIV Seroconversion compulsory; the responses were reviewed and analysed for Study. More details on the study have been published information about transmission other than condomless anal previously [8] with participants recruited in a number of intercourse. ways. Clinicians at general practice clinics and sexual health services referred some participants to the study, as Analysis did staff at state and territory-based HIV/AIDS organisations. In some cases, participants self-enrolled by finding We identified participants who entered explanatory or the study website or were linked to the study website via contextual free-text information about the reasons for their advertisements on websites maintained by local gay com- HIV infection other than by condomless anal intercourse. munity and/or HIV organisations. Printed promotional These responses were analysed using inductive (‘top material advertising the study website was also distributed down’) thematic analysis [9] to identify information rele- to sexual health clinics and community organisations vant to uncommon routes of transmission. Responses were across Australia. In an effort to achieve national recruit- read multiple times and organised into thematic categories, ment, clinics and organisations in every Australian juris- guided by our interest in uncommon explanations. Codes diction were involved. Recruitment was limited to were developed that sought to define the range of forces individuals aged 18 years at the time of participation and to men described relevant to explanations for their serocon- those living in Australia. In most cases participation was version. Responses were excluded from analysis if they restricted to people diagnosed with HIV in the 2 years referenced condomless anal intercourse only, were unre- prior, although that timeframe was relaxed to 5 years in lated to sex (e.g., needle sharing), or described experiences jurisdictions with few HIV diagnoses annually and where of rape. The coding framework along with textual exam- previous seroconversion research had not been conducted ples of each category was shared among all study investi- (i.e., Northern Territory, Australian Capital Territory, gators. The main interpretative differences were around South Australia, and Tasmania). The current analysis category names, with several amended to be more inclusive involved male participants who took part in the study of participant responses. The coding framework was also 123 2268 AIDS Behav (2016) 20:2266–2274 utilised by a second researcher to independently categorise associated with seroconversion. Beyond the acts them- a sub-set of 20 participant responses, an exercise that was selves, participants described a number of factors directly used to improve the explanation and definition for each and indirectly related to sex that they believed contributed category. to transmission, which we have called mediators. And finally, several men explored contextual forces relevant to Ethical Oversight their infection, which can be understood as the situation— spatial or mental—at the time of perceived seroconversion. All participants provided informed consent to participate in Figure 1 provides an overview of these thematic categories this study; no identifying details were collected. The HIV relevant to uncommon transmission. Seroconversion Study protocol was reviewed and approved by the Human Research Ethics Committees of La Trobe Sexual Practices University (Melbourne) and the University of New South Wales (Sydney). The first key theme developed from participant responses relates to the specific sexual acts associated with seroconversion. When asked to describe sexual experiences that Results may have contributed to their infection, participants offered a diverse list of sex and sex-related practices that Participants can be broadly categorised as either adventurous sex or foreplay. Table 1 provides an overview of frequencies A total of 506 gay and bisexual men participated in the relevant to sexual practices among our sample. seroconversion survey between the end of 2007 and end of 2013, of which 21 were excluded due to non-completion. A Adventurous Sex further 20 were excluded because they could not identify an event to which they attributed their HIV infection. The Many men described niche or esoteric sexual acts that they final sample comprised 465 men identified as gay or believed were relevant to their seroconversion, specifically: bisexual or reported previous sex with another man. Par- fisting, rough sex, and urination as a part of sex (‘water- ticipants ranged in age from 16 to 73 with a mean age of sports’). Overall, fisting was among the most commonly 34.5 (standard deviation = 9.5). The majority of partici- listed practice that men associated with their seroconver- pants were either full or part-time employed (73 %) and sion. In some cases men merely listed the act without had some form of university-level education (54 %). further explanation (e.g., ‘‘fisting’’), suggesting that some Racially, most men self-identified as White (88 %) or saw this practice itself as high risk for HIV transmission. Asian (6 %), while 28 % of participants were born outside The idea of fisting as inherently risky was reinforced by of Australia. Among men included in our sample, 34 % other participants who explored the implications of how completed the survey within three months of diagnosis, well one knew his partner (e.g., ‘‘being fisted by a man who while 33 % participated within 1 year. I had not met before’’) or the absence of protection (e.g., ‘‘I was fisted without gloves’’). Identifying ‘Uncommon’ Transmission Explanations Although some participant responses seemed to suggest fisting as an explanation for infection, the act itself is not a A total of 123 participants offered ‘uncommon’ explana- route of viral transmission. Some men did note that fisting tions for their seroconversion, many of which were sup- plementary to their experiences of condomless anal intercourse. Overall, 54 men offered solely uncommon explanations for their seroconversion. Men who offered Sexual pracces Mediang factors uncommon seroconversion explanations were demograph- Adventurous sex Internal mediators ically similar to the general study sample, ranging in age Fisting, rough sex, watersports Cum/pre-cum, tears/trauma Foreplay External mediators from 20 to 76 years (mean = 37.4, standard devia- Oral sex, fingering, dipping/nudging, Illness/infection, sores kissing, sex accessories tion = 9.1), with most reporting full or part-time employ- ment (71 %) and university-level education (55 %). Contextual forces Men’s uncommon seroconversion explanations have Spaal Mental been organised into three thematic categories: sexual Sex on premises, beats Trust, drugs/alcohol, depression practices, mediating factors, and contextual forces. Sexual practices are loosely defined as the physical acts or activ- Fig. 1 Thematic categories describing uncommon routes of HIV ities that characterised the sexual encounter participants transmission among gay and bisexual men 123 AIDS Behav (2016) 20:2266–2274 2269

Table 1 Uncommon sexual practices described as contributing fac- apply the same knowledge of safer anal sex to this sexual tors for seroconversion by gay and bisexual men act, namely that the unprotected exchange of fluids posed a Adventurous sex n Foreplay n risk for infection. As discussed relevant to fisting, it may be that without a clear understanding of what constitutes risk Fisting 14 Oral sex 30 for these more esoteric acts men fall back to a broader Rough sex 13 Fingering 7 application of more established safer sex guidelines rele- Watersports 2 Rimming 6 vant to the exchange of bodily fluids. Only two partici- Kissing 1 pants, however, actually raised the issue of watersports Dipping/nudging 6 relevant to seroconversion, suggesting that few gay and Sex accessories 10 bisexual men believe that urine carries the HIV virus.

Foreplay can damage the rectum and, therefore, increase the risk of Beyond the adventurous practices outlined here, many men transmission, but for others there was apparent conflation also referenced other more common sexual acts that they between the risks of anal sex and those associated with believed lead to seroconversion, namely oral sex, digital fisting. This inference is supported by the risk reduction anal penetration (‘fingering’), the use of sex accessories strategies referenced by some participants, namely partner (e.g., dildos, enemas), dipping/nudging, anilingus (‘rim- knowledge and using gloves as protection. Although fisting ming’), and kissing. has been previously identified as a marker for serocon- Overall, oral sex was the most commonly referenced version among gay and bisexual men [10], there is an uncommon sexual explanation for seroconversion. Similar important distinction to be drawn between the act itself and to descriptions of other sexual acts, some men related their what its presence may signal about sexual subcultures and experience very simply (e.g., ‘‘oral sex’’) while others other associated sexual practices. Nevertheless, some men provided more detail and, in doing so, offered clues for may have come to understand their seroconversion in these why they associated oral sex with seroconversion. For terms due to the broad categorisation of fisting as ‘high example, one participant wrote: ‘‘earlier that evening I risk’. received oral sex, the guy was a bit rough and I found Rough sex was a second type of adventurous sex ref- abrasions on my penis’’. Here we see the potential for erenced by participants. Similar to fisting, a few men listed overlap between acts, as this quotation describes not only rough sex without further explanation (e.g., ‘‘my partner & oral but also rough sex. Further, this participant also I had some kinky rough sex, I hadn’t tried before’’) but described ‘‘abrasions’’ to his penis as the result of rough participants mostly described how and why they thought (oral) sex, suggesting a possible route of infection. Indeed, rough sex was a possible explanation for their serocon- several participants explored multiple explanations for version. For example: their seroconversion, fostering non-exclusive themes and highlighting the challenge for some of trying to select a The sexual intercourse in question was what I would single reason for infection. describe as rough. I believe that I received a number Oral sex is somewhat unique among the other sex acts of injuries during which blood was drawn and bodily described by participants because it is one of the few that fluids were exchanged. Both of us were battered and has been explored in previous research as a route of bruised by morning. I had a number of cuts and bites transmission. As discussed, evidence suggests that the HIV to the nipples, balls and undercarriage. virus can be transmitted orally [5] and it is, therefore, In this quotation, the participant identifies the specific possible that some men in our sample did become infected route of transmission facilitated by rough sex, namely cuts this way. Through our data it is difficult to know exactly and the exchange of fluids including blood. For most men, how men became infected but what is relevant here is that rough sex was not itself an explanation for seroconversion men appear to believe that oral sex carries at least some but a contributor to mediating factors that increased risk risk of infection, which aligns with the virology of HIV. (see Fig. 1). Digital anal penetration—‘fingering’—was described by And finally, a small number of participants described some men as a possible cause of transmission. Fingering watersports as a possible route of transmission. In some does not directly pose a risk for HIV infection but it is cases, men may have been genuinely uncertain if HIV worth noting that nearly all of the men who raised the issue could be transmitted via urine, as suggested by one par- of fingering also implicated semen (‘cum’) in their expe- ticipant who wrote: ‘‘we swallowed each other’s urine and rience, for example: ‘‘he fingered me using cum from his he urinated inside my arse’’. This participant appeared to penis as lube’’. In terms of transmission risk this act is akin 123 2270 AIDS Behav (2016) 20:2266–2274 to condomless anal intercourse, making it possible that Finally, one participant suggested that he became some participants became infected this way. infected with HIV as the result of: ‘‘prolonged (roughly Nine participants referenced sexual accessories as part 30 min) of passionate kissing’’. Interestingly, across all the of their seroconversion explanations, in particular sex toys, other questions, this participant offered no other explana- enemas, and penile piercings. Sharing equipment was the tion for his seroconversion. It is difficult to know if he primary concern among many participants, for example: actually believed that kissing was the cause of his infec- ‘‘we shared dildos/toys and didn’t wash them in between tion, but at the very least it suggests some disconnection each other’s use’’. Given that sex toys come in contact with between perception and reality. This example is unique but the rectal mucosal membrane, it is possible that when important because it highlights that some people do come shared without cleaning the virus could be transferred from to understand their seroconversion in truly ‘uncommon’, one person to another. In other cases, the concern was and in this case unlikely, terms. While it is possible that centred on tears caused by an accessory and the increased this explanation represents genuine misunderstanding transmission risk that posed. For example, one participant about how HIV can be transmitted, it is also possible that wrote: ‘‘I used an enema which sometimes leaves small kissing as an explanation is an attempt by this participant to scratch marks inside the ass that probably bled’’. If a sex manage internal or external stigma. Further, it may be that accessory compromised the integrity of the rectum, trans- this participant was trying to find a link with his serocon- mission risk would certainly have been increased. version to a particular person, time or experience. Such Some men entertained the possibility that they had explanations, however, are entirely speculative. become infected as the result of dipping or nudging, sexual Participants offered a wide array of sex practices to explain acts that involve partial insertive anal intercourse or rub- their seroconversion. While some of these may have resulted bing of the penis around the anus. The risk associated with in HIV transmission, others were far less likely routes for dipping was described by this participant: infection. Although part of our analysis has focussed on exploring the likelihood that transmission occurred as He had his dick near my arsehole and tried putting it described by participants, it is also important to consider the in bareback, but only got the shaft in before I stopped fine line between reality and perception. While it is difficult to him but I feel as though there may have been pre-cum know the conviction with which men maintained these present. explanations, the fact that these sexual practices were pre- This quotation nicely surmises dipping as a sexual sented as potential routes of transmission is significant in and practice while highlighting its similarities to fully expres- of itself, regardless of whether or not they resulted in sero- sed anal intercourse. The experiences of nudging described conversion. At times, men evoked prominent discourses of by our participants also seemed to play with the boundaries risk and risk reduction, and in many cases went beyond simply of what constitutes ‘anal intercourse’. Men may see dip- listing sex practices to explore what they believed to be the ping and nudging as sexual practices distinct from anal relevant mechanisms of transmission. As we explore in the intercourse even while they present some of the same risks next section, these mediators add an additional layer of insight and may have, for some, resulted in seroconversion. to men’s narratives of seroconversion. By contrast, it is unlikely that any participants became infected as the result of rimming. Only six participants Mediating Factors listed rimming relevant to their seroconversion and what is unique to descriptions of this sex practice is that it was The sexual practices that the gay and bisexual men in our always contained as part of a list of other sexual activities. sample associated with seroconversion were only a part of For example, one participant provided a short list of how men came to explain their infection. As mentioned, practices of which rimming was a part: ‘‘suck, rim, toys, men also described a number of sexual and non-sexual gear’’. Succinctly and without detail this participant elements that were seen as integral to or, in some cases, responded to the question by, it seems, listing every prac- positioned as explanations for infection. Within the broader tice he associated with his seroconversion, from particular theme, the factors that men described can be organised into sex practices, to the use of sex toys and drugs (‘gear’). two sub-categories: internal mediators and external medi- While it is possible that he thought he became infected ators. Table 2 provides an overview of frequencies of through rimming, it is impossible to know solely from this reported mediating factors. response. Indeed, every man who discussed rimming did so without elaboration and it is very possible that they were Internal Mediators responding to the question by simply listing every sex act they could remember and not necessarily those that they Internal mediators describe the circumstances of trans- associated with seroconversion. mission risk that were part of or the direct result of the 123 AIDS Behav (2016) 20:2266–2274 2271

Table 2 Uncommon mediating factors described as contributing not have presented a risk of HIV transmission, the presence factors for seroconversion by gay and bisexual men of cum as a mediating factor changed the experience sig- Internal mediators n External mediators n nificantly, making it not only more likely that this participant became infected this way but also that it would be Tears 35 Illness/infection 24 remembered as such. Cum/pre-cum 21 Sores 21 Unlike tears, cum and pre-cum were sometimes listed independent of a sexual act, offered in and of themselves as explanations for seroconversion. One participant simply wrote, ‘‘precum’’ while another suggested that his sero- sexual experiences described by participants. We identified conversion may have resulted from a guy, ‘‘cumming on two specific internal mediators in participant responses: [him] and rubbing it into [his] skin’’. In previous work, tears and cum/pre-cum. Tears were most commonly asso- cum and the exchange of cum has been described as a ciated with the rectum but occasionally with the penis or powerfully erotic and abhorrent symbol among gay men, a nipples and were often linked to adventurous sex acts. In simultaneous reflection of deviance and intimacy [11]. describing his experiences with fisting one participant Indeed, ‘cum play’ has been identified as a relatively noted, ‘‘I was fisted and my arse bled’’. For this participant common practice among both HIV positive and negative the force of fisting resulted in a tear to the rectum and gay and bisexual men [12]. The fact that cum was some- subsequent bleeding. It is easy to imagine how the presence times positioned as a standalone explanation for serocon- of blood during sex would be a highly memorable expe- version among our sample highlights its powerful place in rience, particularly when reflecting on possible explana- the sexual discourses of gay and bisexual men, particularly tions for seroconversion. It is not surprising, then, that with respect of HIV. several men described experiences with blood as the result of a tear sustained during sex. External Mediators Tears during sex were not the exclusive purview of adventurous sex acts. Several men described instances of There were also factors that participants related to their oral sex that involved tears and blood, for example: seroconversion that were not part of, nor the result of, sex but had some relation to explanations of risk and infection, I received oral. He bit his tongue and I was fucking a specifically illnesses/infections and open sores. It was mouth full of blood in the dark in his bedroom. I was suggested by several participants that illnesses or infections unaware of what was happening until I looked down at the time of exposure compromised their immune system, when he spat on it. I saw something in his saliva in making it easier for seroconversion to occur. For example, the minimal light and then pushed him off and asked one participant wrote: ‘‘I had a throat infection and had him to turn the light on. gone out on a big night of drugs, so my immune system This quotation paints a vivid picture of what was clearly was down’’. Others identified specific infections, often a striking experience for this participant. Undoubtedly, the sexually transmissible infections, which they associated presence of blood during sex does increase the risk of HIV with seroconversion, for example: transmission substantially and this particular event could I believe I contracted HIV primarily because I par- have been the route by which this man became infected. took in high risk unprotected group sex. I believe I Central to this description is the trauma to his partner’s contracted HIV because the risk became even higher mouth, which served as a mediating factor for risk and when the STI gonorrhoea was present. became a key component of his uncommon explanation. The presence of cum or pre-cum was also an important It is true that some illnesses and infections may increase feature in several men’s explanations. It seems entirely the risk of seroconversion but not, as the first example reasonable that cum—the main vehicle for sexual HIV suggests, because of any compromise to the immune sys- transmission—would feature in how many men came to tem. Instead, illnesses like a common cold or infections understand their seroconversion. As discussed, the pres- like gonorrhoea may inflame mucosal membrane and in ence of cum, and to a lesser extent pre-cum, often changed doing so increase the likelihood of viral transmission at an otherwise minimally risky practice into a possible exposure. In others, like syphilis, the presence of sores can explanation for seroconversion. Fingering is the perfect also provide the virus with easy access. It is difficult to say, example of this contention, highlighted by the stories however, if the illnesses or infections experienced by shared by several participants, for example: ‘‘after he came participants were at all related to their seroconversion. across my arse he wiped his fingers through the semen and Instead, men may be responding to the perception of vul- put his fingers in my arse’’. While the practice may itself nerability brought on by illnesses or infections that may not 123 2272 AIDS Behav (2016) 20:2266–2274 have in any way contributed to transmission. Further, ill- bathhouses. For example, in one evocative response a ness as an explanation for infection may have been con- participant wrote: flated with seroconversion symptoms experienced by some. I should never have gone to a sauna. I now know that Open sores, typically in the mouth or rectum, were also that is where a lot of HIV positive men go to have sex discussed as a mediating factor. Unlike illnesses or infec- and this is a huge concern and angers me that I went. tions, which as discussed were often described in terms of a compromised immune system, men perceived exposure to As in this example and responses from other men, be the risk posed by sores. For example, one participant descriptions of space were often coloured by assumptions wrote: ‘‘I had mouth ulcers at the time he ejaculated in my about the people thought to be present in such places and, it mouth’’. Here, the participant draws upon intersecting should be said, were often tinged with regret. Context in mediators (cum and sores) to explore transmission risk and these cases moves seroconversion beyond a solely bio- this experience could indeed have posed a risk for logical transaction to also consider its social and cultural seroconversion. components. The presence of context in these narratives For the most part, the mediating factors described by our reveals yet another way that men understood and made participants could have conceivably increased their risk of sense of their experiences. seroconversion and, in some cases, actually been the tip- In thinking about the meaning of context in the situa- ping point for viral infection. That many men drew upon tions described by our participants, it is useful to consider these factors to explain their experiences is itself somewhat models of behaviour from the field of social psychology. revealing. It not only highlights a depth of knowledge Context, it has been suggested, intersects with individual about the potential risks for transmission but speaks also to intention and habit to produce behavioural outcomes [13]. the multilayered approach many men took in explaining In theories of this vein, the actions of individuals are not their seroconversion. These examples of uncommon completely dependent or independent of the situation in explanation step beyond individual sexual acts to explore which they occur and are instead influenced by a number of other factors that may (or may not) have influenced the internal and external forces. Specific to sex, there have outcome of viral exposure. Thus, seroconversion for many been a number of attempts to explore the role of context in of these men was conceived not just as the result of distinct risk. In one study, for example, it was reported that men practices or experiences, but as a selection of intersecting who attend sex on premises venues were more likely to considerations. engage in condomless anal intercourse than those who did not [14]. That study, however, compared the men who Contextual Forces attended such venues with those who did not, and failed to focus on the practices enacted within such spaces. In Finally, a number of participants contemplated reasons for another study, survey results suggested that men were less their seroconversion that transcended a focus on the bio- likely to engage in condomless anal intercourse at a sex on logical mechanisms of transmission to factor in the context premises venue than they were in other locations [15]. within which they believe they became infected. This While it may not be appropriate to claim that sex on theme can be organised into two domains: spatial and premises venues and beats are spaces with ‘high risk’ for mental (Table 3). seroconversion, it appears that for some men these places did play important contextual roles in how they understood Spatial Forces their experiences. By seeking to understand not just behaviour but also the factors that motivated that beha- The physical spaces and places in which sex occurred were viour, participants once again demonstrated how multidi- referenced by several participants, namely sex in public mensional seroconversion explanations can become. By places (‘beats’) and sex on premises venues, such as drawing upon multiple forces—including the underlying influence of spatial context—men reveal the complexity of the events they believe led to and resulted in their sero- Table 3 Uncommon contextual forces described as contributing conversion, as well as need to acknowledge and unpack factors for seroconversion by gay and bisexual men that complexity. Spatial forces n Mental forces n

Sex on premises 4 Drugs/ 28 Mental Forces alcohol Beats 2 Trust 13 Similar to the spatial explanations that men offered for Depression 20 seroconversion, there were a host of mental contexts

123 AIDS Behav (2016) 20:2266–2274 2273 associated with seroconversion: drugs/alcohol, depression, however, trust was positioned in many responses as a failing and trust. The common thread between these three con- not only on the part of the participant (‘‘I was naı¨ve…’’) but textual descriptions was their perceived ability to affect also of the sexual partner(s) who betrayed that trust judgement and influence behaviours. For example: (‘‘…they wouldn’t put someone else at risk’’). That the gay and bisexual men in our sample considered I had a lacklustre attitude towards safe sex brought on the implications of context in their experiences of sero- by a couple of years of living with depression - turned conversion highlights its powerful role in, if not behaviours to anything that would make me feel better, which in themselves, then at least the perception of behavioural my case was smoking weed and having casual motivation in seeking to understand HIV infection. It is unprotected sex with different partners off the inter- conceivable that men sought to mitigate internal stigma by net, some of whom I knew were HIV ?, some were giving power to context but it is also possible that men undetectable, others I had no idea about. Smoking the were merely trying to convey the complexity of their story weed made me less worried before and after. and the circumstances that led to their seroconversion. In For this man, depression and the use of marijuana were either case, drawing upon context may have helped men seen as factors that he felt had contributed to having con- come to terms with their experiences and its place in men’s domless anal intercourse with casual partners. Here, con- stories highlights its role in how people come to understand text as an uncommon explanation is only part of the story, their own and other people’s behaviours. which centres on condomless anal intercourse as the route of transmission. Not only does this example highlight the (reflexive) relationship between depression and drugs/al- Conclusions cohol described by several men, but it touches upon why men felt they became infected this way, namely apathy and Gay and bisexual men recently diagnosed with HIV offered carelessness. diverse and often intersecting ‘uncommon’ explanations As another example, one participant wrote about his for their seroconversion. The explanations themselves drew experiences: ‘‘I had a lack of self-respect but most impor- upon behaviours, mediators and context—sometimes tantly the impact that crystal meth has on decision making’’. simultaneously—to describe routes of HIV infection that The idea that drugs, particularly crystal meth, impair ranged from the plausible to the highly unlikely. Collec- rationality and foster sexual risk taking has been explored in tively, participant responses suggest that for gay and much earlier research [16], and some work has sought to bisexual men the process of explaining their seroconver- unpack a similar relationship with depression [17]. Our sion is neither simple nor singular. Indeed, the fact that finding that some men drew upon these forces to describe men were willing to explore such diverse and complex their seroconversion speaks to the important role that they explanations for their infection suggests, as might be play in how some people believe they were infected, or at expected, that they had spent some time considering and least to their appeal as behavioural justifications. reflecting upon their experiences. Although this study And finally, trust as a mental force was described by sought to describe so-called uncommon routes of HIV many men as contextually significant to their seroconver- transmission, our analysis also hints at the internal nego- sion. Often expressed as love, men explained trust as a tiations that men undertake in finding a way to explain their rationale for condomless anal intercourse with both casual seroconversion to themselves and to others. and regular partners. Sometimes this trust was placed in Only a minority of men described their seroconversion in specific people, for example: solely uncommon terms, suggesting that even in the period shortly after diagnosis most gay and bisexual men can reflect We trusted each other but outside of when we had sex (and report) on their risk behaviours in ostensibly sensible I really don’t know a lot about his sex life and safe ways. It is possible, however, that some men did become sex habits (or lack thereof), and I guess he didn’t infected via the uncommon routes they described. As we know about mine either. have explored, a number of the sexual experiences outlined Other participants described trust more broadly as a by participants could have been routes of transmission or belief that people with HIV would disclose their status (e.g., increased the likelihood that transmission occurred. Ulti- ‘‘I was naı¨ve enough to really believe that if someone knew mately, the question of if transmission occurred as described they are positive they wouldn’t put someone else at risk’’). is somewhat less important than the question of why men In either instance, these men believed that trust influenced offered these more unusual explanations. In some cases, the their sex behaviours, and, in that sense, trust is similar to challenging experience of seroconversion may have depression or the use of drugs in how it was perceived to coloured men’s recollection and encouraged them to ignore affect sexual decision making. Unlike depression or drugs, routine or unremarkable transmission explanations in favour 123 2274 AIDS Behav (2016) 20:2266–2274 of those perceived as more poignant or unusual. And among Queensland, Western Australia, South Australia, Tasmania, Northern a minority of men, uncommon explanations for their sero- Territory, and the Australian Capital Territory. The authors acknowledge the contribution of study participants. The authors conversion may have been an attempt to mitigate perceived declare that they have no conflict of interest. stigma, been caught up in misunderstandings about viro- logical risk, or were hampered by some other challenge to recall fostered by the stress of being diagnosed with HIV. References Whatever the reason, such explanations underscore that experience does not always fit neatly within clinical and 1. Vargehese B, Maher JE, Peterman TA, Branson BM, Stekette epidemiological categories. RW. Reducing the risk of sexual HIV transmission: quantifying the per-act risk for HIV on the basis of choice of partner, sex act, The inferences drawn through this analysis must be and condom use. Sex Transm Dis. 2002;29(1):38–43. considered in light of the study’s limitations. First, the use 2. Jin F, Prestage GP, Ellard J, Kippax SC, Kaldor JM, Grulich AE. of self-reported data means that our analysis of uncommon How homosexual men believe they became infected with HIV: transmission is limited to individual perception and not the the role of risk-reduction behaviors. J Acquir Immune Defic Syndr. 2007;46(2):245–7. reality of how transmission occurred. It is rarely possible, 3. Richters J, Grulich A, Ellard J, Hendry O, Kippax S. HIV trans- however to identify a route of HIV transmission with cer- mission among gay men through oral sex and other uncommon tainty, which is why clinicians and scientists rely on self- routes: case series of HIV seroconverters, Sydney. AIDS. reports of behaviour from those who seroconvert. While 2003;17(15):2269–71. 4. Gilbart V, Evans B, Dougan S. HIV transmission among men behaviours that adhere to expectations largely go unchal- who have sex with men through oral sex. Sex Transm Infect. lenged, uncommon explanations like those presented here 2004;80(4):324. may face incredulity or suspicion. Ultimately, perception is 5. Wood LF, Chahroudi A, Chen H-L, Jaspan HB, Sodora DL. The the reality of these men and it should, therefore, not be oral mucosa immune environment and oral transmission of HIV/ SIV. Immunol Rev. 2013;254(1):34–53. discarded because it challenges convention. Second, the 6. Moskowitz DA. Claiming HIV infection from improbable modes survey items used to collect information on uncommon as a possible coping strategy. J Appl Soc Psychol. transmission may have impacted upon who provided these 2010;40(2):311–24. details. The structure of these items as non-compulsory and 7. Hoff CC, Faigeles B, Wolitski RJ, Purcell DW, Gomez C, Par- sons JT. Sexual risk of HIV transmission is missed by traditional open-ended may have discouraged some people from methods of data collection. AIDS. 2004;18(2):340–2. answering, even if they maintained additional information 8. Down I, Ellard J, Triffitt K, Brown G, Prestage, G. Factors about their seroconversion not otherwise captured by the associated with recent previous HIV testing among a sample of survey. And finally, the static nature of survey data chal- recently HIV-diagnosed gay men in Australia: a cross-sectional study. Sex Transm Infect. 2014;online:1–5. lenges the depth to which participant responses should be 9. Braun V, Clarke V. Using thematic analysis in psychology. Qual analysed. Without the ability to explore or unpack respon- Res Psychol. 2006;3(2):77–101. ses in any detail beyond what was provided by participants, 10. Kippax S, Campbell D, Van de Ven P, Crawford J, Prestage G, our analysis may have misconstrued meaning in some cases. Knox S, et al. Cultures of sexual adventurism as markers of HIV seroconversion: a case control study in a cohort of Sydney gay This study reveals how complex and challenging sense- men. AIDS Care. 1998;10(6):677–88. making can be for gay and bisexual men in the wake of an 11. Mowlabocus S, Harbottle J, Witzel C. Porn laid bare: gay men, HIV diagnosis. Uncommon explanations for sexual trans- pornography and bareback sex. Sexualities. 2013;16(5–6):523–47. mission among gay and bisexual men provide insight into 12. Prestage G, Hurley M, Brown G. ‘‘Cum play’’ among gay men. Arch Sex Behav. 2013;42:1347–56. this process by highlighting the diverse range of behaviours 13. Triandis HC. Interpersonal Behavior. Monterey: Brooks/Cole and forces that men consider in explaining their infection. Publishing Company; 1977. They also reveal the diversity that can exist within catch-all 14. Binson D, Woods WJ, Pollack L, Paul J, Stall R, Catania JA. categories like ‘other’ or ‘unknown’. As HIV prevention Differential HIV risk in bathhouses and public cruising areas. Am J Public Health. 2001;91(9):1482–6. efforts expand to encompass pre-exposure prophylaxis and 15. Phang CW, Hocking J, Fairley CK, Bradshaw C, Hayes P, Chen treatment-as-prevention, the complexity of seroconversion MY. More than just anal sex: the potential for sexually trans- explanations other than condomless anal intercourse will mitted infection transmission among men visiting sex-on-pre- undoubtedly grow and may even become more common- mises venues. Sex Transm Infect. 2008;84(3):217–9. 16. Mimiaga MJ, Fair AD, Mayer KH, Koenen K, Gortmaker S, Tetu place. Thus, the results of this study may help HIV test AM, et al. Experiences and sexual behaviors of HIV-infected facilitators and those who provide post-diagnosis coun- MSM who acquired HIV in the context of crystal metham- selling to understand the complexity of sense-making for phetamine use. AIDS Educ Prev. 2008;20(1):30–41. many gay and bisexual men and support them through the 17. Houston E, Sandfort T, Dolezal C, Carballo-Die´guez A. Depressive symptoms among MSM who engage in bareback sex: process. does mood matter? AIDS Behav. 2012;16(8):2209–15.

Acknowledgments The HIV Seroconversion Study receives funding from the health departments of New South Wales, Victoria,

123