“It's a Quick Way to Get What You Want”: A Formative Exploration of HIV Risk Among Urban Massachusetts Men Who Have Sex with Men Who Attend Sex Parties

Abstract

Community-based studies with men who have sex with men (MSM) suggest that between 8% and 25% of MSM have met recent male sexual partners at private sex parties. Little is known about HIV sexual risk behaviors of MSM who attend sex parties and whether risk reduction interventions can be delivered in this setting. In 2008, 40 MSM who reported attending and/or hosting sex parties in Massachusetts in the past 12 months completed a qualitative interview and quantitative assessment. Participants reported attending a mean number of 10 sex parties in Massachusetts in the past 12 months. A significant percentage (43%) reported also hosting sex parties. Participants had made sexual partner connections across multiple venues, including public cruising areas, bars/clubs, and the Internet. At the most recent sex party attended, the majority had used alcohol (58%) and/or drugs (50%), and one quarter (25%) put themselves at risk of acquiring or transmitting HIV or other sexually transmitted infections (STIs) by having unprotected anal sex with a mean number of three serodiscordant male sex partners. Although many participants perceived that communicating about sexual health in the sex party context would “ruin the mood,” the majority (80%) considered some form of HIV prevention at sex parties to be appropriate and necessary, as well as acceptable. Nonintrusive prevention and education activities were especially endorsed (i.e., condoms, lubricants, and coupons for free HIV/STI testing). The majority of participants (75%) expressed some interest in “safer sex” parties. MSM attending sex parties appear to be a subpopulation at high risk for HIV and STI acquisition and transmission. Risk reduction interventions responsive to the needs of MSM who attend sex parties are warranted.

Introduction

C ommunity-based studies with men who have sex with men (MSM) have found that between 8% and 25% of respondents report having met recent male sex partners at private sex parties.^1
–3 However, few studies to date have examined HIV sexual risk specifically in this context.^1,4,5 MSM who attend sex parties have been shown to engage in HIV risk behavior,¹ including concomitant substance use.^6,7 However, little is known about the contextual and psychosocial factors that may effect the sexual health of men who attend sex parties. Given that MSM comprised 53% of new HIV infections in the United States in 2007⁸ and represent a population disproportionately affected by incident sexually transmitted infections (STIs),^9
–11 additional research is warranted to identify potential risk and protective factors operative among MSM who attend sex parties to inform intervention development efforts.

Prior research has shown that the venue or context in which MSM have sex affects their HIV sexual risk behavior.^{1,4,5,12

–20} Several studies examining HIV sexual risk by venue have included private sex parties.^1,4,5 For example, Grov et al.¹ sampled 886 single or nonmonogamous mixed HIV serostatus MSM in New York City and Los Angeles, of whom 25% had met one or more sexual partners at private sex parties in the previous 3 months. In this study, MSM meeting partners at private sex parties were most likely to engage in unprotected anal intercourse (relative to MSM meeting partners at bathhouses, public cruising areas, or the gym), even after adjusting for relevant demographic and behavioral factors.¹

However, HIV risk behavior among MSM may not only differ by venue type (i.e., private sex parties versus public cruising areas), but within-venue differences may also exist (i.e., behavior may vary by type of private sex party attended). A study by Reisner et al. found that private safer sex parties may represent a strategy used by some MSM to reduce their HIV and STI risk.⁵ In this study, MSM recruited at private safer sex parties reported a higher mean number of anonymous partners, were more likely to report meeting sex partners via the Internet, and were more likely to report sex while drunk in the 12 months prior to study enrollment; however, they were less likely to report both unprotected insertive and receptive anal sex in the past year relative to men recruited from Gay Pride events and gay bars/clubs.⁵

In contrast, a study of 115 MSM in New York City examined sexual risk behavior at sex parties attended exclusively by HIV-positive MSM and found high rates of unprotected sex with multiple partners of the same serostatus, with 59% reporting unprotected receptive anal intercourse at a sex party (78% of these received ejaculate) and 72% engaging in unprotected insertive anal sex at a sex party (69% of these men gave ejaculate), suggesting high risk for STI transmission and acquisition in this context.⁴

Many questions about sexual behaviors of MSM who attend sex parties remain unanswered in the literature, including who hosts and attends sex parties, the reasons and motivations related to attending, and the individual behaviors and group norms operative that may contribute to HIV and STI risk in the sex party context. Further research is necessary to understand the prevalence and relative importance of different MSM sex parties, the contextual and other factors associated with HIV risk taking among MSM who attend sex parties, and the acceptability of HIV prevention interventions in this setting.

Methods

Design and setting

Between November and December 2008, 40 participants who reported attending and/or hosting sex parties completed a one-on-one, in-depth, semistructured qualitative interview and an interviewer-administered comprehensive quantitative assessment battery. All study activities took place at Fenway Health (FH), a freestanding health care and research facility specializing in HIV/AIDS care and serving the needs of the lesbian, gay, bisexual, and transgender community in the greater Boston area.^21,22 The FH Institutional Review Board approved the study, and each study participant completed an informed consent process.

Sample

Eligibility criteria

Prospective participants were screened by trained study staff on the telephone to determine eligibility. For the purposes of this study, a sex party was defined as a preplanned event (i.e., organized prior to the event taking place) with five or more men who intended to engage in sexual behavior with each other. Attendees were eligible if they (1) were age 18 years or older; (2) self-identified as a man; (3) reported sex (oral or anal) with another man in the past 12 months; (4) lived in Massachusetts; and (5) attended a sex party in the past 12 months in Massachusetts. Hosts were eligible if they were age 18 years of age or older and reported organizing/throwing/hosting at least three MSM sex parties with Massachusetts residents in attendance in the past 2 years.

Recruitment

A combination of venue-based recruitment strategies (including the use of the Internet) and snowball/chain referral sampling methods were employed to recruit participants. Venue-based recruitment strategies consisted of direct outreach and posting of study flyers at FH, local community-based organizations, Internet partner-meeting websites, bars/clubs, and community events. Snowball/chain referral sampling, in which enrolled participants referred potentially eligible peers, was also used. Qualitative interviews continued until redundancy in responses was achieved, as is typical in qualitative research.²³ Participants were remunerated $50 for their participation in the study after they underwent an informed consent process and completed the interview and survey assessment.

Data collection

Study participation lasted approximately 1.5 h in duration and interviews were conducted by one of two trained interviewers.

Qualitative interview

An initial focus group was conducted with 12 individuals who work at local community-based organizations and at Massachusetts Department of Public Health programs serving MSM in the Boston area to collect preliminary information about sex parties in Massachusetts. The qualitative interview guide was iteratively developed using focus group data, as well as by conducting a thorough literature review, presenting to members of FH's community advisory board (CAB), and gathering input from MSM health specialists at FH to ensure cultural relevance of study instruments.

The interview guide included the following topic areas:

Terminology: How would you define a sex party? What is a sex party and what is it not?

Motivations: When did you begin organizing/attending sex parties? What are some of your motivations and reasons for organizing/attending sex parties?

Sex Party Scene: Can you describe the sex parties you host/attend? How many parties have you heard about/organized/attended in the past 12 months? How do you hear about them? Are there different kinds of sex parties (i.e., scenes, sexual subcultures, regularly occurring parties, etc.)?

HIV and STI risk: Are condoms and lube available at parties you host/attend? What kinds of sexual behaviors do men engage in and what HIV and STI risk behavior do you see happening? What kinds of substances do men use at sex parties? How, if at all, is information about HIV and STIs or safer sex communicated in the sex party context?

Participation: Do you participate in the parties you organize? As a host, do you have rules about behavior at parties you host (i.e., safer sex, substance use, etc.)? If so, do you (and how) enforce these rules? Do you have personal boundaries or limits about what you will or will not do at a sex party?

Prevention and education intervention activities: Would you be interested in expanding HIV prevention activities at the sex parties you host/attend? Why or why not? What types of activities would be helpful for you or for MSM who attend sex parties? What do you think might be some acceptable and feasible HIV prevention activities or intervention components in a sex party setting? What do you think some of the barriers to implementing these activities might be?

Recruitment: How would you recommend recruiting other men who host/attend sex parties for future studies?

Each interview was digitally recorded and then transcribed verbatim by a professional transcription company. Two study staff conducted the qualitative interviews. Interviewers were trained together and met regularly with the research team to discuss emerging themes and issues, as well as to minimize bias caused by differential interviewer methods.

Quantitative assessment

Demographics, sexual behavior, substance use, HIV status, STI history

Questions examining demographics (age, education, race/ethnicity, sexual orientation, “outness,” etc.), sexual behavior, and substance use during sex were adapted from the Centers for Disease Control and Prevention's National HIV Behavioral Surveillance Survey, MSM-2 cycle,²⁴ and from recent FH studies focusing on MSM HIV and STI risk.^25
–27 Questions assessed sexual behavior in the 12 months prior to study enrollment, including frequency of serodiscordant unprotected insertive and receptive anal sex, both in and outside sex party context. Men were also asked where else they met their sexual partners. Alcohol and drug use during sex in the prior 12 months was assessed. Participants were asked about their HIV testing history and about their HIV serostatus, and were asked whether they had ever been diagnosed with an STI. Participant knowledge and understanding of barebacking was also assessed using a series of questions used in previous research with MSM.³ Participants were asked whether or not they identify as a “barebacker.”

Characteristics of sex parties and HIV/STI risk in sex party environments

Using focus group information and input from community members, a series of questions were developed to gain a deeper understanding of MSM sex parties in Massachusetts. Questions included motivations and reasons for attending sex parties; the social, sexual, and community networks that function among MSM in this venue; where and how often sex parties occur; the number of men who attended; the types of sex parties (i.e., characterized by demographics, sexual subcultures, HIV serostatus, substance use, neighborhood, etc.); HIV and STI risk behaviors at sex parties; HIV disclosure and safer sex communication in this environment; and perceived feasibility and acceptability of expanding HIV prevention interventions in this setting.

Psychosocial factors

Given the documented role of psychosocial factors in sexual health, psychosocial indicators at time of study participation and self-reported history of psychosocial problems were captured.

Depression: Clinically significant depressive symptoms were assessed with the Center for Epidemiologic Studies Short Depression Scale (CES-D 10; Cronbach α = 0.86).^28,29 The 10-items were scored on a 4-point Likert scale from 0 to 3; items five and eight reverse coded (3 to 0). A score of 10 or greater was indicative of depressive symptoms and the internal consistency for the CES-D 10 in this sample was 0.60. Participants were also asked whether they had ever been given a diagnosis of clinical depression by a doctor, nurse, or other medical or mental health professional.

Anxiety: The Beck Anxiety Inventory (BAI) was used to assess physiologic and cognitive symptoms of anxiety (Cronbach α = 0.92).^30,31 The respondent is asked to rate how much he has been bothered by each of the 21 anxiety-related symptoms over the past week on a 4-point scale ranging from 0 to 3. Items were summed to obtain a total score ranging from 0 to 63, indicating the severity of anxiety. The BAI had an internal consistency of 0.92 in the current sample.

Problematic alcohol use and history of drug or alcohol abuse: The CAGE questionnaire, a clinical screening instrument for alcoholism (Cronbach α = 0.69), was used to assess problematic alcohol use where a score of three or more indicated probable alcohol dependence.^32
–34 The Chronbach α for the CAGE instrument in the current study was 0.80. Participants were also asked about their drug and/or alcohol abuse history, including whether or not they had ever been in treatment.

Trauma history: History of childhood sexual abuse was assessed using questions taken from the EXPLORE study.³⁵ Also included was a question to examine the prevalence of nonconsensual sex (e.g., rape) in adulthood.

Analytic approach

Qualitative data were analyzed using content analysis.³⁶ During the process of identifying and categorizing themes, developing theme-based codes, and coding the data, qualitative analysis continued until saturation.^37,38 Analyses concentrated on emerging themes that were relevant to HIV prevention interventions with MSM who host and/or attend sex parties.

Immediately following each interview, interviewers noted and identified the key points in interview data; analysis of transcripts concentrated on these identified key points and themes. Transcripts were reviewed for errors and omissions, including context and content accuracy, and cleaned to focus on the content of what was said. A codebook^39,40 was developed and NVivo® software (QSR International, Cambridge, MA)⁴¹ was used to aid with the coding, organization, and searching of narrative sections from each interview, as well as to facilitate the systematic comparison and analysis of themes across interviews. The coding scheme was independently applied to several transcripts by research staff. Percent coder agreement was checked to ensure acceptable reliability (>95%). Once reliability was established, the coding scheme was broadly applied to analyze all transcripts. Coded transcripts were regularly reviewed by members of the research team; ongoing discussion helped resolve any coding inconsistencies, further define coding categories, ensure consistency of code application and text segmentation, and asses interconnections between codes.

Survey data were used to provide a more comprehensive portrait of occurring themes, as well as to support qualitative results, and are integrated with the interview findings below. Descriptive analyses were conducted using SPSS® statistical software (SPSS Inc., Chicago, IL).⁴² To understand factors associated with HIV transmission risk behavior, mean group comparisons were made using t tests, comparing MSM who reported engaging in serodiscordant unprotected anal sex at the most recent sex party they attended versus those who did not report engaging in this behavior at the most recent sex party they attended.

Results

Demographic, behavioral, and psychosocial characteristics

Table 1 outlines the demographic, HIV risk, and psychosocial characteristics of the study sample. Participants (n = 40) ranged from 22 to 61 years old with a mean age of 41 (standard deviation [SD] = 10). Nearly half (47%) were nonwhite and 38% had a college degree or higher. Half of the sample reported being HIV-positive. Many were unemployed (30%) and/or disabled (30%). The majority (83%) of the sample identified as gay, and 20% were not “out” to friends, family and healthcare providers regarding their sexual behavior with other men.

Table 1.

Demographic, Sexual Behavior, and Psychosocial Characteristics of the Study Sample (n = 40)

	Total sample n = 40
	41 (10)
Age—Mean (SD)	n	%
Race/ethnicity ^a
White	21	53
Black/African American	14	35
Hispanic/Latino	4	10
American Indian/Alaskan Native	1	3
Asian/Native Hawaiian/Pacific Islander	1	3
Other	3	8
Education level
High school diploma/GED or less	12	30
Some college	13	33
College degree or more	15	37
Employment
Employed (FT or PT)	13	33
Unemployed	12	30
Disabled	12	30
Student	3	8
Income
11,999 or less	13	33
12K–23,999	13	33
24K–59,999	8	20
60K+	5	13
Unknown	1	3
Housing, health insurance, and access to health care
No health insurance	3	8
Difficulty getting health care past 12 mo	6	15
Sexual identity and disclosure of MSM behavior
Straight	2	5
Gay	33	83
Bisexual	5	13
Not out to family	5	13
Not out to health care provider	8	20
Not out to friends	8	20
HIV
HIV-infected	20	50
Not tested for HIV in the past 2 years	2	6
Never tested for HIV	1	3
STIs
STI history	21	53
Syphilis	11	28
Gonorrhea	15	38
Chlamydia	9	23
Herpes	6	15
Hepatitis A	7	18
Hepatitis B	3	8
Hepatitis C	3	8
Other (4 crabs, 2 anal warts)	6	15
Never tested for STIs	4	10
Reported gender of sex partner in past 12 mo
Men only	34	85
Both men and women	6	15
Mean number (SD) of sex partners and transmission risk episodes in past 12 mo
Number male sex partners oral or anal sex	47 (160)
Number anonymous male sex partners	40 (157)
Number serodiscordant unprotected insertive anal sex episodes	13 (49)
Number serodiscordant unprotected receptive anal sex episodes	7 (18)
Sexual risk behavior in past 12 mo
Serodiscordant unprotected insertive anal sex	18	45
Serodiscordant unprotected receptive anal sex	18	45
Sex work (i.e., sex with man for money, drugs, etc.)	16	40
Self-identify as a barebacker	10	25
Other sexual risk factors
“Very” or “Somewhat” difficult to use a condom	12	30
Circumcised	22	55
Where met male sex partners in past 12 mo
Internet	23	58
Use Internet 1×/week or more to meet sex partners	10	25
Bar/club	27	68
Public cruising	25	63
Adult bookstore	9	23
Bathhouse, sex resort	15	38
Private sex party	40	100
Circuit party or rave	4	10
Through friends	33	83
Social gathering	29	73
Other (on the street, T, library, museum)	7	18
Substance use during sex past 12 mo (at least monthly)
Sex while drunk “most” or “all” of the time	7	18
Crystal methamphetamine	10	25
Crack	13	33
Cocaine	15	38
Downer (valium, ativan, xanax)	3	8
Painkillers (oxycontin, percocet)	5	13
Hallucinogens	2	5
Ecstasy	4	10
GHB	6	15
Ketamine	2	5
Heroin	6	15
Marijuana	15	38
Poppers	17	43
Viagra, Cyalis, Levitra	11	28
IDU past 12 mo	7	18
Psychosocial issues
Current psychological distress
Alcohol abuse (CAGE score 3 or 4)	8	20
Depressive symptoms (CES-D score ≥16)	22	55
Anxiety symptoms (BAI score ≥16)	11	28
Past sexual experiences
Childhood sexual abuse	14	35
Forced sex (rape) as an adult (age 18+)	12	30
Psychosocial history
Diagnosis of clinical depression	20	50
Treatment for alcohol and/or drug abuse	24	60
Exposure to HIV prevention services in past 12 mo
Contact with outreach worker	30	75
Participated in 1 on 1 intervention	15	38
Participated in group intervention	17	43
“Very” or “somewhat” interested in future HIV prevention activities	34	85

Percentage exceeds 100% due to individuals being able to identify as more than one race/ethnicity.

SD, standard deviation; FT, full-time; PT, part-time; STIs, sexually transmitted infections; CES-D, Center for Epidemiologic Studies Short Depression Scale; BAI, Beck Anxiety Inventory; IDU, injection drug use.

Participants, all of who reported attending sex parties in the past 12 months, also had high rates of sexual partnering at other venues including bars/clubs (68%), public cruising areas (63%), and the Internet (58%). Overall, 25% reported using the Internet once per week or more frequently to meet male sexual partners in the past 12 months.

Complex presenting psychosocial factors appeared to be present for many participants, including clinically significant depressive symptoms (55%), anxiety symptoms (28%), and problematic alcohol use (20%). Lifetime psychosocial histories included alcohol and/or drug abuse (60%), history of childhood sexual abuse (35%), and forced sex (rape) as an adult (30%).

Attending sex parties in Massachusetts in the past twelve months

Types of sex parties attended in the prior year

Characteristics of sex parties attended in the past 12 months are presented in Table 2. In the past 12 months, participants reported attending a mean number of 10 (SD = 11) sex parties in Massachusetts, ranging from 1 to 50 parties. Parties ranged in size, with anywhere from 5 to 45 MSM attendees. Men reported attending sex parties that were seasonally or event-based (e.g., Gay Pride), weekly, or bimonthly weekend night gatherings. Participants had attended one or more sex parties in a private home (98%), hotel (45%), in the back room of a bar or club (20%), or other venue (18% including a guesthouse, health club, outdoors, and/or office).

Table 2.

Sex Parties Attended and Hosted in the Past 12 Months

	Total Sample n = 40
	10 (11)
Mean number (SD) sex parties attended	n	%
Sex party attendance past 12 mo
How heard about sex parties attended
Internet	17	43
Sex partner meeting websites	10	25
E-mail listserv	9	23
Through friends	31	78
Other (host)	5	13
Where attended sex parties
Home	39	98
Hotel	18	45
Back room of bar or club	8	20
Other (health club, outside, office building)	7	18
Geographic location of sex parties attended
Massachusetts	40	100
Rhode Island	7	18
Other New England (1 Vermont, 2 New Hampshire, 2 New York, 2 Pennsylvania)	7	18
Most recent sex party attended
Number of other male attendees
< 10 guys	22	55
11–15 guys	9	23
16+	9	23
Sexual risk behavior
SDUAS at most recent sex party	10	25
Condoms not readily available at sex party	7	18
Mean number (SD) sex partners and transmission risk episodes during most recent sex party
Number male sex partners	4 (3)
Number SDUAS episodes	1 (2)
Number SDOREJ episodes	2 (2)
Substance use
Alcohol or drugs just before or during party	23	58
Alcohol^a	17	43
Marijuana	9	23
Poppers	11	28
Crystal	6	15
Cocaine	10	25
Ecstasy	3	8
GHB	2	5
Ketamine	1	3
Viagra, Cyalis, Levitra	7	18
Heroin	2	5
Hosting sex parties in past 12 mo
Hosted sex party	17	43
How invited attendees
Internet	11	28
Sex partner meeting websites	9	23
E-mail listserv	5	13
Through friends	16	40
Other (flyers, word of mouth, grapevine, telephone)	8	20
Where hosted sex parties
Private home	16	40
Hotel	5	13
Back room of a bar or club	17	43
Geographic location of sex parties hosted
MA	17	43
Other New England (1 Rhode Island, 1 Connecticut)	2	5
Most recent sex party hosted
Number of male attendees
< 10 guys	14	35
11–15 guys	2	5
16+	1	3
Sexual risk and substance use
Made condoms readily available	13	33
Reported having hosted a private safer sex party	11	28
Alcohol use before or during	9	23
Drug use before or during	11	28
Marijuana	8	20
Poppers	11	28
Crystal meth	6	15
Cocaine	4	10
Ecstasy	3	8
GHB	3	8
Ketamine	2	5
Viagra, Cyalis, Levitra	7	18
Heroin	2	5

SD, standard deviation; SDUAS, serodiscordant unprotected and sex; SDORE, serodiscordant oral receptive sex with ejaculation.

Participants reported most commonly hearing about sex parties through friends (78%), the Internet (43%), including sexual partner seeking websites (25%), e-mail listservs (23%), and other sources (13%).

Types of parties participants reported attending were identified based on the type of sexual activity, drugs of choice, specific demographic subpopulations of MSM, location and themes. Parties included: bareback parties, crystal methamphetamine-focused parties, fisting and sadomasochism (S&M) parties, “low-key, no pressure” parties, parties attended by mostly if not all men of color, age-specific parties, beach parties, and “safer” sex parties. One participant described differences he had observed by race/ethnicity, comparing parties frequented by white men and those attended by black men, describing his preference for sex parties attended exclusively by black and Latino men:

They're all African American and Latino. I haven't really been to any sex parties where there's a mixture of like white and Black and Latino and other groups. Or a mixture among age groups either. Not to seem racist or anything, but it's not a turn on for me. (Age 22, non-white, HIV-negative)

Other participants reported attending age-specific sex parties. For example, one participant described having been to parties over the years that were younger (MSM under 30) and older (MSM 30+):

The younger crowd, they tend to keep to themselves. A lot of people are not having sex that often, some just blow jobs, hand jobs, light kissing, and maybe some anal. Whereas in the older group, they get into sex a lot quicker, just a lot more group sex. I would say the older group is a little bit riskier because of that. (Age 31, white, HIV-negative)

Motivations and reasons for attending sex parties

Several interesting themes emerged concerning MSM motivations for going to sex parties.

Easy hook-ups and sexual encounters

Not surprisingly, the most commonly reported reason for attending sex parties was to have sex. The majority of participants (55%) mentioned the ease and convenience of meeting partners at sex parties as a reason for attending:

It's a quick way to get what you want. At sex parties, you don't have to do anything. You just show up and have a few shots of Bacardi Gold, and everybody's feeling nice and watching a movie, so you just sit there and let it happen. If you went to a bar or club you would have to work at it and make it happen. (Age 22, non-white, HIV-negative)

In addition to being a convenient and “efficient” way to hook up, participants reported attending sex parties because it was a pretense-free space (35%):

At sex parties it's more up front than other places. You know what you're there for. (Age 60, white, HIV-negative).

At other places, you've got to go do the protocol of asking your name, small conversations. At a sex party, you just get right to the point. (Age 49, non-white, HIV-positive)

Anonymity and discretion were thought to play an especially important role for MSM who were not “out”:

There are a lot of married guys at parties who are on the down-low doing their thing. I used to do it when I was married so I totally understand that. Sex parties are anonymous and easy. (Age 61, white, HIV-negative)

Other reasons for attending sex parties were a desire to have fun, to have variety and diversity in sexual experiences, to “expand horizons,” to “spice things up in my relationship,” to participate in specific sexual practices (i.e., water sports, S&M, fisting), and voyeurism (i.e., “I mostly just like to watch”). One participant explained:

The atmosphere is fun. It's exhilarating. It's a chance to escape into a different world, more so than a bath house, because a bath house has some rules. Whereas at a sex party, the sky's the limit. (Age 43, white, HIV-positive)

Socializing and community

Socializing (40%) was also endorsed as a popular motivator for sex party attendance:

I usually like to go to parties where in addition to having sex, there's space where you can just hang out and chat with people. A few years ago, I went to a couple of sex parties in hotel rooms in Boston and unfortunately, it was just a room and double bed and all you could do was have sex. I like sex parties in somebody's apartment or in a certain club that I go to which has a basement. There's space where you can just hang out and socialize with people, schmooze, and you don't even have to have sex if you're not in the mood. (Age 60, white, HIV-negative)

Feeling part of a community of gay men was especially described by older age participants who endorsed socializing as a primary motivator. A participant who lived outside of Boston described sex parties as a particularly important venue for him:

There's just no way to connect. You know? Like you live on the far south shore, it's either a trip to Boston, a trip to P-town, to the Dick Dock, or a trip to the bars in Providence. I mean, where else can you go? (Age 61, white, HIV-negative)

Several MSM acknowledged difficulty finding a relationship and reported that being around “a bunch of guys” at sex parties provided “comfort”:

Personally, I would much prefer to be in a relationship, but they are very difficult to come by. You know, gay men are not known for pairing off and staying in long term relationships. But there's a certain comfort and a certain sense of hope or a feeling of security knowing that once a month I can have a little casual party with a bunch of guys and I'll have some fun. It's something to look forward to. (Age 44, white, HIV-negative)

As one participant put it:

And you never know, you might just meet that Mr. Right at a party. (Age 57, white, HIV-positive)

Other reasons for attending parties included to get attention, to feel attractive and validated, and because of boredom and/or loneliness.

All my hang-ups and issues—you know, loneliness, insecurity, low self-esteem—all those things play a part. I've hosted sex parties and gone to sex parties for all those reasons. You know, I figure if I'm with a group and twenty guys have sex with me and find me hot then, you know, I must be hot. (Age 41, white, HIV-positive)

Drug and alcohol use

For some participants (38%), access to and use of drugs was the primary reason they reported attending sex parties. These participants mentioned crystal meth, crack, cocaine, marijuana, poppers, ecstasy, GHB, and heroin at parties:

Usually everyone's really drunk or high so getting to really know people isn't exactly the goal of the party. I mean, the goal of the party is to get high, get drunk, and get fucked. (Age 22, non-white, HIV-positive)

>“Party and play” (PNP) or “party favors” were phrases that came up often to describe using drugs and having sex in the sex party context by this subset of men:

“It's p and p, party and play, you know. The party is drugs and the play is having sex” (Age 43, non-white, HIV-positive).

Safety and structure

One third of men (33%) mentioned sex parties as a “safe” environment. For some, this safety was physical:

It's safer in terms of not being mugged or being jumped or that kind of thing. You feel a little bit safer than being outside in some cruisy park or something like that. (Age 43, white, HIV-positive)

For one participant who was in recovery from alcohol and drugs, safety had to do with the structure of the environment:

For me it's a safe environment. It's like, I go to Alcoholics Anonymous and I go to Crystal Meth Anonymous. If you're there, it's structured and you know what you're there for. Sex parties are the same kind of thing—you know why you're there. That feels safer to me. (Age 40, white, HIV-positive)

>Other men talked about safety in terms of sexual health and HIV serostatus. Several HIV-positive participants attended sex parties to meet other men of the same HIV serostatus:

I thought it was kind of cool, because I could meet other HIV positive guys. And we're all in the same boat, you know. So I thought it'd be kind of cool to see what these HIV guys are doing at parties. (Age 57, white, HIV-positive)

Intimate space

Participants were also motivated to attend sex parties because they felt the space had greater intimacy (20%), particularly parties held in private houses or apartments:

It's more of a comfortable atmosphere, being in someone's home. It seems more intimate than being in a bathhouse or a cruising area or something like that. (Age 34, white, HIV-positive).

Accompanying this intimacy was eroticism associated with the space (25%), which was a motivator for attendance. The erotic nature was often linked to the freedom of being able to be completely naked/nude at sex parties. Nudity was noted as something that differentiated sex parties from other sex venues, where frequently sex occurred between men who were completely or partially clothed:

There's something really erotic about being in a room with lots of naked people having sex that you may or may not know. (Age 40, white, HIV-positive)

Hosting sex parties in Massachusetts in the past twelve months

Types of sex parties hosted in the past twelve months

In the past 12 months, 43% of the sample had hosted a mean of 17 (SD = 48) sex parties, ranging from 5 to 200 parties, in Massachusetts. Table 2 outlines the characteristics of sex parties hosted in the past 12 months. Hosts reported most commonly throwing parties in the back room of a bar or club, private homes, and hotels. Parties ranged in size from 5 to 35 MSM attendees. Hosts invited men through friends (94%) and used the Internet to publicize parties and recruit attendees (65%), including popular sexual partner meeting websites (53%), e-mail listservs (29%), and other means (47%) such as via flyers, the “grapevine” or word of mouth, or telephone. All men mentioned the existence of impromptu parties, but they distinguished their preplanned events from these spontaneous gatherings. Many hosts (71%) reported using a set prescreening criteria before disclosing the address or location of the party they hosted.

Motivations and reasons for hosting sex parties

The motivations and reasons MSM hosted sex parties were varied. All hosts mentioned sex being central (i.e., to facilitate casual encounters, to meet good-looking guys). Also mentioned were access to drugs, excitement, voyeurism, being in control, loneliness or boredom, and to make money. Similarly to attendees, some hosts (30%) talked about hosting sex parties as a “pretense-free” space, and described being motivated to throw sex parties because it was an environment unapologetic about drugs and sex. Other hosts (30%) mentioned that their parties provided a safe environment for MSM. MSM who reported hosting parties described in detail those aspects associated with the “safeness” of the space: sexual health (i.e., providing condoms and lube), physical protection (i.e., providing a violence-free space), discretion (i.e., having a private and confidential space), and a sense of community (i.e., a place for gay men to gather; come together and not be alone; “a service” to the community; a sense of identity and connection). The majority of hosts (70%) reported participating in the parties they hosted in the past 12 months. Among those who did not participate in parties they hosted, motivations and reasons for throwing parties included voyeurism and access to and use of drugs.

Most recent sex party hosted

Hosts reported having between 5 and 10 attendees at their most recent party they hosted in the past 12 months. Condoms were made “readily available” by 76% of hosts at the most recent party they threw:

When you come in I have the slings set up, the toys out, the dildos out, whatever, the lube, all types of condoms, all different sizes, all different kinds, and all different flavors. (Age 44, non-white, HIV-positive)

>When asked, the majority of hosts (65%) reported that the last party they threw was a “safer” sex party. However, only 6% reported actively enforcing a safer sex rule at this party; all others reported observing unsafe sexual behavior at their “safe” sex parties, including exchange of body fluids and unprotected anal sex. Several hosts also reported observing behaviors associated with HIV risk reduction among attendees at their parties, including engaging only in oral sex and only “topping” during anal sex as a perceived means to reduce their HIV risk.

HIV status disclosure and sexual risk behavior at sex parties

Communicating about HIV/STIs and HIV status disclosure

The majority of participants (75%) reported there was no discussion of condoms or HIV and STIs at the sex parties they attended in the prior 12 months: “It is pretty much an unspoken thing.” (Age 34, white, HIV-positive) Communicating about safer sex and/or HIV and STIs at a sex party was commonly perceived as something that would “ruin the mood” or, as one participant articulated, would be “a buzz kill” (Age 22, non-white, HIV-positive).

Several participants talked about how they simply assume that everyone is HIV-positive at the sex parties:

I always think that if you come to party time, most of the people are HIV positive anyways. So I think that they have it already. So I don't check it out, I don't say, “Hi, I'm HIV, how about you? Are you HIV, too?” I don't ask that question. But they can ask for condoms or not. It's up to them. (Age 43, non-white, HIV-positive)

It's like a 50/50 chance when you're going to a sex party. You're going to go to a party and you're going to smoke something, you're going to drink something, you're going to lose all inhibitions—and the last thing on your mind is to put on a condom, so there's always the 50/50. (Age 22, non-white, HIV-negative)

Many HIV-positive participants talked about feeling it was unnecessary to disclose HIV serostatus at sex parties because attendees should assume that it is a “high risk” environment:

I don't agree that you have to expose yourself [as HIV-positive]. I do agree if you want to be in a relationship with somebody, that's one thing. But if you have a sex party, you do not have to expose yourself because everyone who's there knows that they are at high risk when they walked through that door. (Age 44, non-white, HIV-positive)

Sexual risk at most recent sex party attended

At the most recent sex party they attended within the past 12 months, participants reported having oral or anal sex with a mean number of four (SD = 3) male sex partners. Although the majority (83%) of participants reported condoms were “readily available” at the most recent party they attended, 25% engaged in serodiscordant unprotected anal sex with a mean number of three (SD = 3) serodiscordant or unknown HIV status male sex partners:

I had sex without a rubber … at that last sex party. There wasn't any condoms left and I was in the mood so I was the top and I had sex and I didn't use a rubber. (Age 46, non-white, HIV-negative)

Of those participants who reported unprotected anal sex with a serodiscordant or HIV unknown status partner during their most recent sex party, 30% were HIV-positive and 50% self-identified as “barebackers.”

Participants who reported sexual risk behavior at the most recent sex party also reported elevated levels of HIV and STI sexual risk behavior over the past 12 months (Table 3). Participants who reported serodiscordant unprotected anal sex at the most recent sex party they attended were more likely to have engaged in serodiscordant unprotected insertive anal sex in the prior 12 months (odds ratio [OR] = 6.60; p < 0.05); but not serodiscordant unprotected receptive anal sex. They also reported having a significantly higher mean number of HIV risk transmission episodes (i.e., episodes of sex with a serodiscordant or unknown male sex partner) over the past 12 months, including serodiscordant unprotected insertive anal sex episodes (44 versus 3; t test statistic = 2.44; p = 0.0001) and serodiscordant unprotected receptive anal sex episodes (17 versus 4; t test statistic = 1.92; p = 0.007). Participants who engaged in serodiscordant unprotected anal sex at the most recent party they attended also reported a higher mean number of male sex partners (123 versus 21; t test statistic 1.84; p = 0.001) and anonymous male sex partners (115 versus15; t test statistic; p = 0.001) over the past 12 months.

Table 3.

Mean (SD) Differences Observed by MSM Reporting Serodiscordant Unprotected Anal Sex (SDUAS) at the Most Recent Sex Party Attended vs. MSM not Reporting SDUAS at Most Recent Party Attended

	SDUAS at most recent sex party (n = 10)	No SDUAS at most recent sex party (n = 30)	t test statistic	p Value
How many male sex partners in past 12 months?	123 (308)	21 (29)	1.84	0.001
How many anonymous male sex partners in past 12 months?	115 (311)	15 (25)	1.80	0.001
How many episodes of serodiscordant unprotected insertive anal sex in past 12 months?	44 (95)	3 (6)	2.44	0.0001
How many episodes of serodiscordant unprotected receptive anal sex in past 12 months?	17 (31)	4 (10)	1.92	0.007
How many SDUAS partners at most recent sex party?	3 (3)	0 (0)	5.84	0.0001

SD, standard deviation; MSM, men who have sex with men.

Substance use contributing to HIV sexual risk at most recent party

The majority of participants (58%) used alcohol and/or drugs just before or during the most recent sex party they attended. Alcohol was commonly reported (43%) as an “icebreaker”:

Drinks generally help because it helps loosen up the mood and you're not so intense. Generally, that's the icebreaker. (Age 31, non-white, HIV-negative)

Also reported at the most recent party was use of cocaine (25%), poppers (called “rush” and “jungle juice”; 23%), marijuana (23%), Viagra, Cyalis, or Levitra (18%), crystal methamphetamine (15%), ecstasy (8%), GHB (5%), heroin (5%), and ketamine (3%). The highest levels of reported sexual risk behavior were observed among participants who reported drugs and/or alcohol use at the most recent party they attended:

Barebacking has never been a practice of mine before, but since I've been involved with sex parties and I got involved in using crystal, the condoms go away. There's no condoms usually. It's like using crystal completely puts down your inhibitions, and then immediately at parties everybody just barebacks. (Age 37, white, HIV-negative)

Several men noted the often spontaneous nature of group sex when using crystal meth, especially among HIV-positive MSM.

Substance use contributing to other types of risk

Substance use was perceived by some participants as contributing to other risks such as physical injury and sexual violence:

At the sex parties that I have attended where there was crystal involved there also was quite unsafe activity. I can't see anything more dangerous on so many different levels. Aside from disease, just injuring yourself is likely. Like there's a lot of parties where fisting goes on. When you get someone that's high on crystal and they don't know what they're doing it's dangerous, and you can't tell me that they really are giving consent. (Age 40, white, HIV-positive)

Another participant described dangers associated with GHB use and described an experience where he witnessed sexual violence which he attributed to excessive substance use at a sex party.

Group norms

Several participants described the sex party scene as “cliquey” and talked about group norms associated with the space. In particular, being good looking, having a good body, having a big penis, and doing drugs and/or bringing drugs were identified as contributing toward popularity in the sex party scene:

It's like a clique thing. If you're hot, well-built, they call you more to go to sex parties. If you're well-endowed, they will invite you more. And if you do drugs too, you're in. It's cliquey. (Age 43, non-white, HIV-positive)

Sex parties catering to men not in the “popular” scene were also reported by participants. For example, one host described how he throws parties and consciously tries to create an alternative space for gay men who may not fit these mainstream norms:

It's casual. It's not like everybody has to be naked, and everybody has to be hard, and everybody has to have a beautiful oiled down body and everything. You don't have to be the “uber bear” or the “uber muscle guy” and you don't have to be 10 inches and 12 inches [penis size] to come to my party. It's just like, the guy next door. It's not like the orchestrated, high-energy hotel sex parties that I see advertised a lot where you have to submit a facial shot, body shot, a cock shot, and then they give you secret codes. Those are for the Abercrombie & Fitch guys. These ones are for the rest of us. (Age 61, white, HIV-negative)

Group norms were also described as playing a central role in condom use in some sex party contexts:

You know, like minds attract. I'm sure that people go to sex parties where condoms are readily used. But I'm not in that kind of circle. (Age 40, white, HIV-positive)

Acceptability and perceived feasibility of HIV prevention at sex parties

The overwhelming majority (80%) of participants considered some form of HIV prevention at sex parties to be appropriate, necessary, and acceptable. With only two exceptions (the two participants self-identified as “barebackers”), participants highly endorsed “noninvasive” or “passive” intervention components, most commonly wanting condoms and lubricant out and readily accessible at sex parties. Of these participants, 80% also endorsed increasing HIV prevention at sex parties to promote education through other unobtrusive means such as pamphlets, flyers, and posters about HIV and STI symptoms, testing and treatment options.

Barriers to HIV prevention at sex parties

Several important barriers were identified to expanding HIV prevention services in the sex party context.

“A turn-off”

HIV prevention activities that were perceived to be active or “intrusive,” such as HIV and STI testing, one-on-one, or group-level interventions, were often perceived to be a “mood crusher,” “downer,” or “turn-off” in the context of a sex party:

Nobody wants to talk about HIV and all that at these parties. Everyone is just there to have a good time. (Age 46, non-white, HIV-negative)

Some (40%) men were open to HIV prevention activities at sex parties that might take a more active intervention approach, like having an outreach educator at a sex party to distribute information or make a presentation. Nearly one third (30%) of the sample responded that HIV and/or STI testing and counseling services at sex parties was an acceptable intervention. For those not wanting HIV or STI testing in the sex party environment, fear of learning one's status (50%) was a primary reason for not wanting this. Also mentioned were concerns about confidentiality and privacy. Although HIV and STI testing at sex parties was deemed inappropriate among a little more than half the sample, an equal amount of participants (53%) reported that distributing coupons at sex parties with information about free and anonymous testing would be acceptable.

Desire for drug use

Sixty percent of participants mentioned drug use as a barrier to HIV prevention at sex parties. Many HIV-positive MSM who reported using drugs described how sex parties offered them “an escape from reality” and communicating about HIV or STIs in a sex party setting was simply not of interest:

When I'm at a sex party, I don't want to think about reality. I want to get lost in the moment. I want to just be free and uninhibited and do what I want to do when I want to do it. And get really high and have lots of great sex. I don't want to think about all of the consequences that are associated with it. (Age 41, white, HIV-positive)

Among participants who reported drug use as central to their sex party experience, safer sex was associated with expectations of limited drug use and/or sobriety, especially when thinking about a safer sex party setting. For these men, lack of drug availability posed a major barrier to attending safer sex parties:

I've never been to a sex party where drugs have not been there. I mean, to me, they go hand-in-hand, at least in the circles that I've traveled in and the crowds that I've been in. I don't want to go to a sex party if there's not drugs or I can't use. (Age 46, white, HIV-positive)

However, a high percentage of men who mentioned substance use as a barrier to prevention efforts at sex parties also indicated drug use as being an important area to focus efforts on in an intervention. Moreover, participants often noted the spontaneous nature of group sex gatherings while using drugs, identifying sex parties that were not preplanned to be especially difficult venues at which to intervene:

When you start having sex and doing drugs, you're not thinking logically. So you might have ten people at your party, and then be like, “Oh, let's get on the Internet and get more people over.” And it's 2:00 in the morning at a hotel, you know? (Age 41, white, HIV-positive)

Space issues and confidentiality, privacy, and discretion

Space was often mentioned as a barrier to implementing HIV prevention activities at sex parties, in particular to incorporating more active intervention components such as HIV and STI testing. Confidentiality and privacy were seen as difficult to control in a sex party setting:

Usually at these parties, particularly the ones that are in homes, there might not be the space for it [HIV/STI testing]. Confidential space, especially, since a home is fairly open. Someone might not want to be seen getting a test. Whereas at a bathhouse, that's something that can be more easily done because there is maybe a little room off to the side where the nurse can close the door and have a one-on-one discussion with an individual. (Age 60, white, HIV-negative)

One participant who regularly hosts safer sex parties that include HIV and STI testing talked about the need to separate space between the sex party and the HIV prevention services offered:

Usually when I have a party where there's onsite testing, we have to have at least a two room suite in a hotel … We've also done it in somebody's home. You need to have at least three separate rooms: one for the party, one for a sitting area, and one for the nurses to have all their stuff and to do all of their testing, and they need to have their clinic area off to the side. (Age 44, white, HIV-negative)

Issues of confidentiality, privacy, and discretion were often mentioned as a barrier to HIV prevention activities in the sex party context:

Confidentiality would have to be a part of it. It would have to be. Like some of these guys are bankers and lawyers that run these parties. (Age 57, white, HIV-positive)

I know if I ever go to a party that somebody says, “All right, we'll have this dude here, he's giving [HIV/STI] tests. Did you want to take one?” I mean, I would, as long as it's confidential. (Age 22, non-white, HIV-negative)

Perceptions of risk

Many participants talked about their perceptions of sexual risk in different subpopulations of MSM in discussing interventions. For example, older MSM often felt younger MSM were riskier and needed the most intervention; however, younger MSM often perceived older MSM to demonstrate the highest HIV sexual risk behaviors. Similarly, many self-identified gay men mentioned that sex parties often attract men who are not “out” or who do not consider themselves gay, and perceived these men would benefit from learning more about HIV. Men who were not “out,” on the other hand, felt that self-identified gay men were most in need of HIV prevention activities. The only consistent pattern across participants was that the self-perception of being at “lower” risk compared to other peer groups (i.e., the perception of “others” being at higher risk) and this may represent a barrier to changing behavior among this subgroup of MSM.

Importance of engaging hosts and peers

Several participants discussed the important role of hosts in gaining access to sex parties for interventions. Hosts were ultimately thought to be the ones who not only decided who gets in and attends a party, but also what the rules and boundaries are in place at their particular sex party (i.e., what is “allowed” in the space). As one host put it, “They're at my party that I'm hosting. I'm paying for the hotel room, or I'm providing the venue. So then it's my rules … ” (Age 44, white, HIV-negative). Involving hosts and other peers in interventions was frequently mentioned as an important component of successful HIV prevention:

May be if it's coming from the host himself. But you know, anybody outside of that, I don't know if I would want to be there. (Age 43, white, HIV-positive)

I think it would be important to have somebody “doing it” [outreach and HIV prevention] that is “doing it” [participating in the party]. I mean, obviously it would have to be somebody who's into the scene, and seen as one of participants as opposed to somebody who's just there to lecture. I think if it was seen as just somebody who was just there to lecture, it would be a major turnoff for some. As opposed to if it was somebody who was going to play as well, or not even necessarily going to get involved, but just look like they are. (Age 61, white, HIV-negative)

One participant suggested the possibility of having fellow attendees trained to do sex party outreach, including giving out condoms, pamphlets, and resource information.

Acceptability of safer sex parties

Overall, 75% of the sample expressed interest in safer sex parties (i.e., parties with an agreement or guidelines to use condoms for anal sex at all times), although the level of interest and enthusiasm varied. Several participants were very enthusiastic about the idea of safer sex parties for MSM:

Absolutely! I feel like there are a lot of guys that are sort of interested in sex parties, and the idea sounds really hot to them, you know, it turns them on. But they choose not to go to them because they feel that it's unsafe. (Age 22, white, HIV-negative)

However, other participants who reported being open to safer sex parties were adamant about not having safer sex rules be “enforced.” For example, patrolling to make sure guys used condoms was considered “extreme” and “intrusive” by these participants who generally felt condom use was a personal choice and wanted to be left alone to decide for themselves. When discussing “condom checks” being conducted in a safer sex party setting, one participant said:

You know, honestly I couldn't even imagine going to a party and having that happen. (Age 40, white, HIV-positive)

Nonetheless, several of these same participants were open to the use of incentives in the context of HIV prevention interventions in a sex party setting, in particular to get guys to attend and try out safer sex parties. Suggestions included using gifts and incentives that would make the environment “enticing,” such as gift cards, hot men, go-go boys/dancers, and erotic massages.

Getting the word out about safer sex parties

Private safer sex parties were not well-known or advertised among many participants. Some participants had no idea how to go about locating a private safer sex party in Massachusetts, and several had no awareness of private safer sex parties prior to participating in the study:

I've never been to an all-condom sex party. A party that's just condoms only. I've never even heard of one. (Age 57, white, HIV-positive)

Participants were asked what they thought would be most effective in promoting HIV prevention at sex parties, including recruiting hosts and attendees into interventions. For nearly all participants, word of mouth was perceived vital to advertising and marketing, and using the social networks currently in place among sex party goers (i.e., listservs, groups) to communicate safer sex party alternatives was suggested.

Several participants also talked about the importance of making safer sex parties “sexy” and promoting the “safe sex” at the party. One host underscored the importance of advertising safer sex parties as a sexy space when recruiting men (i.e., there will be the “hottest guys,” “the best new pornos just released”, etc.):

You just have to sell me, you're trying to buy me, that's basically what you're doing. You're selling a product, it's the same way you're selling a product. How do I sell this product? I get somebody just to look at it. (Age 44, non-white, HIV-positive)

Community forums

When discussing possible strategies to get the word out about safer sex parties, many participants felt that promoting community forums or group-level interventions outside the sex party context would be well-received and effective. For example, forums on “How to host a safer sex party” or “How to maximize your health at a safer sex party” or “Everything you wanted to know about a safer sex party but were afraid to ask” were deemed acceptable and especially interesting for participants. Hosts, in particular, were interested in these forums as a way to get more information about legal issues and liability, including laws about parking cars in residential neighborhoods, noise level, sexual behavior, and drug use.

In the context of discussing community forums, several participants mentioned that word choice is important and should be carefully monitored when delivering HIV information to sex party goers. In particular, many participants mentioned having negative reactions to words like “prevention,” “intervention,” and “rules” when talking about sexual health and sex parties. Finding alternative ways to talk about protecting one's sexual health were endorsed.

Discussion

The results of this study suggest that MSM sampled who reported attending sex parties are at high risk of HIV acquisition and transmission. At the most recent sex party they attended, participants had sex with a mean number of four male sex partners and one quarter of MSM put themselves at risk of acquiring or transmitting HIV or other STIs by having unprotected anal sex with more than one serodiscordant or HIV unknown status male sex partner. Compared to men who did not report sexual risk behavior at the most recent party attended, MSM reporting serodiscordant unprotected anal sex at the most recent party they attended reported a significantly higher mean number of HIV transmission risk episodes in the past 12 months. Moreover, and consistent with prior research documenting high rates of HIV risk behavior among some MSM who “saturate” sexualized venues in order to find sexual partners,⁴³ participants in this sample commonly reported sexual partner connections at other venues including bars/clubs (68%), public cruising areas (63%), and the Internet (58%). As indicated in prior research,^1,4,5 current findings suggest that HIV prevention interventions focused on the needs of MSM who attend sex parties are warranted to curb high rates of HIV and STI risk behavior among this subgroup, particularly given the frequency with which MSM sampled report meeting sexual partners across multiple venues.

Findings also suggest that sex parties represent social phenomena among MSM that are culturally specific and that have differing norms and attributes depending on the “scene,” location, and environmental context. Although sex-related motivations were the most common reasons reported for attending sex parties, other reasons not specifically sexual in nature were important factors for some MSM. Socializing and being part of a community, the perception of sex parties as a “safer” environment relative to other venues (i.e., public cruising areas or bathhouses), and the anonymity, privacy, and discretion sex parties offered were all mentioned as motivators. Interventions would benefit from considering and being sensitive to the diverse reasons why MSM attend sex parties when addressing HIV prevention in this context, including attention to age-specific factors which may affect younger and older MSM differently (i.e., body image, perceived standards of physical attraction, and sense of belonging).

Also important to consider in HIV prevention efforts are the sexual and behavioral patterns observed among this subset of high-risk men sampled. Many participants reported meeting sex partners across multiple venues. Given that men who take risks at sex parties likely take sexual risks in other contexts, the behavioral and sexual patterns emerging from these data suggest that some men may have a “risk-oriented” tenor to their lives in general, which is also consistent with the substance use/abuse patterns observed. Sex parties may represent a way of reaching high-risk MSM who frequent multiple venues and delivering prevention services.

The majority of men sampled reported using alcohol and drugs during the most recent sex party they attended. Given the documented role of substance use in facilitating sexual risk behavior among MSM across studies,^{26,44

–56} this high rate of substance use is a concern and necessitates intervention, particularly given the high proportion of MSM who reported a history of alcohol and/or drug abuse. Qualitative findings further underscored the central role that substance use plays and many MSM felt substance use was a motivation for attending sex parties as well as a barrier to engaging in HIV prevention activities in this context. Furthermore, the complex presenting psychosocial issues among many participants, including depression, anxiety, and past sexual violence and trauma warrant careful consideration as part of HIV prevention activities with this subgroup, since MSM with trauma histories may derive less benefit from traditional HIV prevention counseling and may require more intensive interventions that specifically address presenting mental health problems while integrating HIV prevention counseling.³⁵

Although many participants perceived that communicating about sexual health in the sex party context would “ruin the mood,” HIV prevention activities at sex parties was deemed to be desirable, acceptable and feasible by the majority of participants. Many participants expressed some interest in safer sex parties where there would be an agreement or guidelines to use condoms for anal sex at all times during the party. Although several important barriers were identified by participants when implementing HIV prevention activities at sex parties, including drug use, space constraints, and confidentiality and privacy issues, MSM offered suggestions as to how to overcome these barriers.

Components of interventions that were thought to help overcome barriers were (1) involving hosts and peers, (2) getting the word out into social networks about safer sex parties as a fun and viable option for MSM who enjoy sex parties as a venue, (3) incentivizing participants to attend safer sex parties as a method to start changing normative behaviors and beliefs that unsafe sex parties are the only option for hot sex, and (4) hosting community forums for MSM who attend and host sex parties to provide them with information about how to maximize their sexual health and the sexual health of their peers in a sex party context. Creating or supporting safer sex parties may represent an intervention strategy that offers an option for men who want the perceived social and sexual benefits of a sex party environment while supporting HIV risk reduction.

A few limitations are important to consider when interpreting these results. First, HIV serostatus was self-reported by participants and hence it is possible that more men were HIV-positive than what is reported. Second, our employment of non-probability sampling methods (i.e., venue-based recruitment and snowball sampling) means the possible introduction of sampling bias, a less representative sample of the population, and limited generalizability of results. Participants were recruited via Fenway Health, a community-based organization, which may have introduced bias in interviews (i.e., social desirability bias, participants were self-selected). Third, although qualitative interviews reached redundancy in responses, the participants interviewed in this study comprise only a specific subset of all MSM who attend sex parties. Finally, while MSM engaging in sexual risk behavior at parties also reported elevated sexual risk behaviors in the past year, it is unknown whether MSM who engage in risk behaviors are attracted to sex parties as a venue and/or whether the venue itself encourages HIV risk behavior. Additional research with larger samples is warranted to examine this question further.

To curb rising rates of HIV and STIs, effective, nuanced, and creative HIV prevention and education interventions are warranted to respond to the needs of at-risk MSM and should take into account the diverse venues where MSM engage in sexual activity. Designing HIV prevention and education interventions responsive to the needs of MSM who attend sex parties may represent an innovative approach to address transmission risk behaviors among this at-risk group. Given that results suggest sex parties represent a heterogeneous social phenomena, the acceptability and feasibility of specific HIV prevention efforts and activities will depend upon the sex party being targeted and the subculture that exists there (i.e., for men who attend a sex party for social reasons and where there is a separate space for socializing and having sex, such peer outreach delivered activities may represent a reasonable mode of HIV prevention delivery). Incorporating drug and alcohol abuse screening and/or treatment and triage to mental health services should be considered. Addressing perceived norms concerning condom and substance use, as well as body image and perceived attractiveness more broadly within the sex party context is also recommended.

Footnotes

Acknowledgments

We would like to thank Jarrod Rondeau and Brandon Perkovich, Epidemiology Research Interns at Fenway Health; Barry Callis and Michael Gaucher at the Massachusetts Department of Public Health, Office of HIV/AIDS; and our colleagues providing outreach and educational services to MSM in the Boston area who participated in the initial focus group to collect preliminary information about sex parties in Massachusetts.

This work was supported by the Massachusetts Department of Public Health, Office of HIV/AIDS.

Author Disclosure Statement

No competing financial interests exist.

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