Abstract
HIV/AIDS disproportionately impacts men who have sex with men (MSM) in the USA. Most existing literature on MSM with HIV focuses on transmission risk, but does not acknowledge health-promoting sexual behaviours men may undertake. This study examined sex toy use within this population to describe the extent to which using toys is incorporated into their sexual repertoires as a risk reduction practice. Data regarding sociodemographics, sexual/health-related behaviours and sex toy use were collected from 2275 MSM using an online survey. Most participants reported being sexually active (88.5%), and the majority (70.2%) of participants reported sex toy use within the previous year. Sex toy users were more likely to be white, in sexual relationships with others, and reported higher levels of sexual satisfaction. Given that sex toy use is common among this population, room for discussion exists about sex toys as tools to enhance pleasure and reduce HIV/sexually transmitted infection (STI) transmission.
INTRODUCTION
Due to advances in treatment, HIV has become a more manageable and chronic disease for those who are diagnosed and who have access to health care. Given extended life expectancies for individuals living with HIV, a body of literature has examined sociobehavioural outcomes and quality of life after an HIV diagnosis, such as mental health status 1–3 and fertility, contraception and reproductive choice. 4–6 Additionally, a significant amount of research has explored the sexual behaviours of people living with HIV and/or AIDS that may share associations with behaviours that are likely to increase the risk for HIV or other sexually transmitted infection (STI) transmission or other co-morbid infections. 5,7–10
Men who have sex with men (MSM) comprise the majority of the newly infected in the USA. 11 Accordingly, sexually active MSM living with HIV are among the most frequently studied, particularly in terms of the extent to which their sexual behaviours may pose the potential for HIV transmission. 12–20 A meta-analysis of unprotected anal intercourse among MSM living with HIV found that the majority of these men use protection (e.g. condoms) during sexual activity. 16 However, most studies have framed sexual behaviours by MSM living with HIV primarily for the potential they pose for disease transmission, and accounts of positive sexual health and the inclusion of pleasure among MSM living with HIV are limited. Given that receiving a diagnosis of HIV is not synonymous with future celibacy or lack of sexual desire, 16,20 information regarding the ways MSM living with HIV are still sexually vital and engage in pleasurable sexual relationships is an important component of understanding the sex lives of these men. The use of sex toys (e.g. vibrators and dildos) by MSM living with HIV may serve to bridge this gap, and offer a window into a means of promoting both pleasure and risk reduction among MSM living with HIV.
Sex toys and in particular, vibrators, have long been prescribed by providers in clinical settings for sexual health concerns, 21–28 and until recently, the majority of research on sex toys was conducted with women. 24 However, a new body of literature has emerged that explores the use of sex toys among men as health-promoting and pleasurable, and suggests that their use may positively influence sexual health. 26,28,29 In a nationally representative sample of adult men in the USA, Reece et al. 26 found that 44.8% of men reported having used a vibrating sex toy over the course of their lifetime, highlighting the extent to which the use of vibrators has become prevalent among the general population. A study specifically focusing on the sex toy use of gay and bisexual men in a nationwide sample found lifetime prevalence of vibrator use to be 49.6%, and lifetime use of at least one type of sex toy to be 78.5%. 29 This study found that the most commonly reported reasons for incorporating sex toys into solo and partnered activity were ‘for fun’ and ‘out of curiosity’, suggesting that men in large numbers are engaging in sexual activity using sex toys and attributing that use to the additional pleasure and enjoyment sex toys may offer. 29 These findings echo similar research on sex toy use among gay men in Australia, in which researchers assert that sexual pleasure and satisfaction are important constructs when examining the context of men's sexual patterns, not solely the investigation of behaviours that may confer risk of negative health outcomes. 30
In addition to the use of sex toys for purposes of enhancing the sexual experience, results from a recent USA-based study found that 39% of men in this sample reported sex toys as an alternative to anal intercourse, suggesting the possibility of sex toys being used as risk reduction techniques for protection against negative sexual health outcomes. 20 Furthermore, the largest USA study of sex toy use among gay and bisexual men to date, which included over 25,000 participants, found that seropositive men were significantly more likely to report using vibrators for safer sex purposes than their seronegative counterparts, highlighting that sex toys could be used as a strategy for HIV and other STI risk reduction. 28
The purpose of this study was to examine the prevalence and characteristics of sex toy use among MSM who are living with HIV, to describe the correlates of sex toy use with regard to demographics, sexual relationships and sexual behaviours of MSM, and to document the extent to which participants describe sex toy use as making contributions to the quality of their sexual experiences. We hypothesized that the use of sex toys may increase subjective sexual pleasure, and their use may have resulted in lower prevalence of STI infections. Additionally, we posited that the use of sex toys might have acted as a means of risk reduction, in that reported toy use may have been related to fewer instances of unprotected anal intercourse.
METHODS
Participant recruitment and data collection
Using a participatory framework, this study was conducted in collaboration with the public health advisers of a website that is one of the country's most frequented for men who are seeking social and sexual contacts with other men. In July 2009, an electronic recruitment message was sent to all individuals who had current accounts on this website. The recruitment message included a description of the study, a link to the study website and the incentives offered for participation. In alignment with the company's email procedures, the recruitment message was held in electronic mailboxes for seven days. If at the end of seven days the email remained unopened, it was removed automatically. A total of 127,489 men opened the recruitment message, and 34.1% of those men (n = 43,447) clicked through to the study information webpage. Potential participants were asked to review participant expectations and study procedures. Interested participants then proceeded to the study consent form. Those consenting to be a participant in the study were forwarded to the study questionnaire. Of those that read the consent form and participant expectations, 60.4% (n = 26,257) participated in the study.
Over the course of the study period, the first author changed affiliations. All study protocols were reviewed and approved by the Institutional Review Board at both of the academic institutions of the first author.
Measures
Participants completed items related to their demographic characteristics, the nature of their current sexual and romantic relationships, health screening behaviours and diagnoses, sexual behaviours, and current and past use of sex toys.
Demographic characteristics
Participants were asked to provide descriptions of their geographic location (USA state or District of Columbia), age, race/ethnicity, gender (male, female, transgender male-to-female, transgender female-to-male), sexual orientation, employment status and level of education completed.
Sexual and romantic relationships
Measures included those related to the participant's dating or relationship status (not currently dating anyone, currently dating more than one person, in a relationship with the same person for less than 3 months, 3–6 months, more than 6 months to 1 year, more than 1 year, more than 5 years). If a participant reported any option other than ‘not currently dating anyone’, they were asked to provide the gender of their current relationship partner (male, female, transgender male-to-female, transgender female-to-male, other). Participants were separately asked to report their sexual relationship status (currently not sexually active, having sexual relationships with more than one person, in a sexual relationship with only one person), as well as the gender(s) of their sexual partner(s) (only men, only women, both men and women).
Health status, screening and diagnoses
Physical and mental quality of life were assessed using the four-item Healthy Days Core Module from the CDC health-related quality-of-life measure (HRQOL-4), 31 an instrument frequently used for determining participants' perceptions of the degree to which their mental and physical health may have impacted them over the previous 30 days. 24,26 Participants were also asked to report whether they had had a physical exam by a medical provider during the previous year and whether they had performed a testicular self-exam (felt their testicles for lumps or other changes) within the past month. Sexual health status and screening were assessed by asking whether participants had been screened for STIs other than HIV in the past year, whether participants had been diagnosed with syphilis, gonorrhoea, chlamydia, human papillomavirus (HPV) and herpes within the past two years, whether participants had ever been tested for HIV and whether participants had ever received a diagnosis of HIV.
Sexual behaviours
Participants were asked to indicate the extent to which they had participated in the following sexual behaviours: masturbation, receptive anal intercourse, insertive anal intercourse, performing oral sex and receiving oral sex. For each, participants were asked to indicate whether they had participated in the behaviour within the past month, past three months, past year, more than a year ago or never. If a participant reported engaging in a specific sexual behaviour within the past year, they were subsequently asked how frequently they had engaged in each behaviour (a few times per year, about once a month, a few times per month, about once per week, two to three times per week, almost every day and more than once per day). Additionally, to assess condom use among those who reported having anal intercourse within the past year, participants were asked to report the number of times they used a condom during the past 10 times they engaged in insertive anal intercourse and receptive anal intercourse.
Use of sex toys
Participants were asked to report how frequently, if ever, they had used a range of sex toys. Sexual toy product options included a vibrating sex toy, a non-vibrating dildo, a non-vibrating butt plug, anal beads or balls and/or masturbation sleeves. As dildos and butt plugs are often identical both with regard to appearance and use, beyond initial reporting of lifetime and monthly use, dildos and butt plugs were collapsed into a single variable. Wording of this variable was changed to ‘dildo and/or butt plug.’
For each product, participants indicated whether they used the product in the past month, in the past three months, in the past year, more than a year ago or whether they had never used the product. Two composite product use scores were calculated by summing participants' responses as to whether or not they had used one of the specified products any time within the last year, as well as the past month and dichotomizing into toy users versus non-toy users. An explication of partnered versus solo toy use is included below.
Data analyses
The overall sample was narrowed to include (1) individuals who self-identified as male, (2) participants who indicated they had been tested for HIV more than a year ago and had been diagnosed with HIV and (3) men who either indicated that they had engaged in sexual activity with at least one male partner in the past year or identified as gay/bisexual. The final sample utilized for these analyses included 2275 men meeting these criteria. All analyses were conducted using PAWS version 17.0 (SPSS Inc, Chicago, IL, USA). Descriptive analyses were conducted to present participant characteristics including sociodemographics, health status, sexual behaviours and sex toy use behaviours. Differences in condom use behaviour were assessed using paired samples t-tests. A series of chi-square analyses were conducted to determine whether there were differences between those who used sex toys and those who did not.
RESULTS
Demographic characteristics
All 50 states and the District of Columbia were represented in the study sample. Participants ranged in age from 18 to 69 years (M = 43.4), with the highest proportion of men reporting ages between 35 and 54 years (71.2%, n = 1620). The majority of participants described their ethnicity as white (83.3%, n = 1894), followed by Hispanic/Latino (7.3%, n = 166), black, (4.4%, n = 101), other (3.4%, n = 77) and Asian/Pacific Islander (1.4%, n = 31). Predominantly, participants identified as homosexual (95.4%, n = 2170), while smaller proportions identified as bisexual (4.0%, n = 90), other (0.4%, n = 9) and unsure/questioning (0.2%, n = 5). Overall, the sample was well educated, with 34.9% (n = 795) reporting at least some college and an additional 52.0% (n = 1184) having received a bachelor's degree or higher. Although more than half were working full-time (62.3%, n = 1417), almost a quarter of participants reported currently being unemployed (24.7%, n = 562). A summary of participant characteristics is provided in Table 1.
Sociodemographic characteristics by lifetime history of sex toy use (n = 2275)
GED = General Educational Development tests
*P < 0.001
Sexual and romantic relationships
More than half of the participants (52.7%, n = 1199) reported that they were not currently dating anyone, 41.3% (n = 938) reported being in a dating/romantic relationship with another person and 5.8% (n = 132) were dating more than one person. In contrast to the numbers of men who reported they were not currently romantically dating anyone, 88.2% of the sample (n = 2007) reported currently being sexually active. Of those men who reported being sexually active, 83.8% (n = 1681) were sexually active with more than one person.
Sexual behaviours
A majority of participants (81.8%, n = 1860) reported having been the insertive partner in anal sex within the previous year; 85.4% (n = 1936) had been receptive in anal sex during the same time period. Regarding the proportion of the past 10 anal intercourse events that were condom protected, the mean number of protected sexual encounters was 5.68 (SD = 3.50) for receptive men and 5.85 (SD = 3.47) for insertive men [t(991) = −2.86, P < 0.005].
Health status, screening and diagnoses
When asked to describe their health status, 91.2% (n = 2074) described their health as ‘good’, ‘very good’ or ‘excellent.’ With regard to the previous 30 days, nearly all participants (90.7%, n = 1996) reported their physical health status as being ‘good’ or better for more than 23 of the previous 30 days, and most (76.3%, n = 1679) reported freedom from mental distress for more than 23 of the previous 30 days.
The vast majority reported having had a physical exam by a health-care provider in the previous year (91.5%, n = 2081), and just under half reported having conducted a testicular self-exam in the previous month (49.9%, n = 1135). Despite reporting having had an exam with a provider in the previous year, only about one-third (29.3%, n = 667) had been screened for STIs in that same period of time.
A majority of participants 63.1% (n = 1436) did not report any STI diagnosis (other than HIV) within the previous two years. A diagnosis of syphilis was reported by 16.2% (n = 368) of the total sample, gonorrhoea diagnoses were reported by 9.5% (n = 215), chlamydia by 8.0% (n = 181), herpes by 10.2% (n = 231) and HPV by 9.7% (n = 220).
Use of sex toys
Prevalence of use of at least one sex toy over the previous year was 70.2% (n = 1597), including dildos (49.4%, n = 1123), butt plugs (30.9%, n = 702), vibrators (28.3%, n = 644), masturbation sleeves (17.0%, n = 386) and anal beads or balls (15.6%, n = 356). The prevalence of toy use in the previous four weeks was 30.5% (n = 693). Of those men who reported use of at least one toy in the previous year, the mean number of types of toys used was 2.45; of men who reported using at least one toy during the previous four weeks, the mean number of types of toys used was 2.09.
Men who identified as white were more likely than men who identified as African-American/black, Hispanic/Latino or Asian/Pacific Islander to have used a toy within the past year (χ 2 [4, 2269] = 18.589, P = 0.001). Men who reported that they were not currently sexually active with another person were less likely than men in sexual relationships with only one person or men who were sexually active with more than one person to have used a sex toy in the previous year (χ 2 [2, 2267] = 39.83, P < 0.001). There were no significant differences in reported toy use by other demographic variables such as sexual orientation, age or education.
The most commonly reported sex toys included dildos/butt plugs (used by 82.5%, n = 1877) and vibrators (used by 51.3%, n = 1166), with most users reporting lifetime dildo/butt plug use during masturbation alone (90.2%, n = 1415), during sexual foreplay with a male partner (85.2%, n = 1331) and during sexual intercourse with a male partner (84.2%, n = 1321). Similar toy use patterns were found for vibrator users as described in Table 2. Those who reported masturbating alone with a vibrator or dildo/butt plug within the previous year were further asked to indicate the ways in which they had used the toy on their genitals and perianal area. Participants reported using vibrators and dildos/butt plugs in varying ways during masturbation with the highest proportion reporting that they had inserted the vibrator (38.8%, n = 883) or dildo/butt plug (58.3%, n = 1326) into their anus.
Timing of use of anal beads, vibrators and dildos/plugs during solo and partnered sexual behaviours (n = 2275)
As with the participants who reported masturbating with a vibrator or dildo/butt plug, participants who reported having used vibrators or dildos/butt plugs during partnered sexual interactions within the previous year reported having incorporated the vibrators or dildos/butt plugs into a range of activities (see Table 3). Partnered toy behaviours included vibrator insertion into one's own anus by a partner (49.1%, n = 316), dildo/butt plug insertion into a partner's anus (41.7% n = 601) and a partner rubbing a vibrator on a participant's anus (45.2%, n = 291).
Dildo or plug and vibrator behaviours with male partners within the past year
Participants were also asked to report the reason why they used a vibrator or dildo/butt plug during their most recent use. The most frequently reported reasons for recently using vibrating sex toys were: ‘for fun’ (18.2%, n = 415), ‘to spice up my sex life’ (8.3%, n = 188), ‘my partner wanted to’ (6.3%, n = 143) and ‘curiosity’ (4.7%, n = 106). Similarly, dildo and butt plug users reported using these toys most recently ‘for fun’ (29.1%, n = 661), ‘to spice up my sex life’ (15.2%, n = 346), ‘my sexual partner wanted to’ (11.3%, n = 258) and ‘curiosity’ (7.5%, n = 170). Only 0.7 (n = 17) of vibrator users and 1.9% (n = 44) of dildo/butt plug users reported that they had used toys most recently for the purposes of ‘safer sex.’
Sex toys and health
History of STI diagnoses was not significantly different between toy users and non-toy users; 35.3% (n = 541) of toy users had received an STI diagnosis within the previous two years and 32.6% (n = 214) of non-users had received an STI diagnosis within the previous two years.
Men who reported having used at least one sex toy during the previous year were equally likely to have reported undergoing a physical exam with a medical provider in the previous year as those men who had not used any toy (91.9% of toy users and 90.4% of non-toy users, respectively). There were no significant differences between toy users and non-toy users over the previous four weeks with regard to general health status (χ 2 [5, 2275] = 1.27, P > 0.05). Regarding sexual satisfaction, men who reported having used at least one toy over the previous four weeks were significantly more likely to report being moderately or very satisfied with their sex lives than men who had not used a toy in the previous month (χ 2 [4, 1934] = 18.89, P = 0.001).
There were no significant differences between previous four weeks toy users and non-toy users in the mean number of condom-protected events of the last 10 events. For men who reported having used toys within the previous four weeks, the mean number of receptive condom-protected sexual encounters was 5.45 (SD = 3.58), and for non-toy users it was 5.79 (SD = 3.58) (t [1023] =1.42, P = 0.151). For men who reported having used toys within the previous four weeks, the mean number of insertive condom-protected sexual encounters was 5.70 (SD = 3.57), and for non-toy users it was 5.91 (SD = 3.44) (t [989] =0.89, P = 0.374).
DISCUSSION
In spite of relatively low numbers of participants reporting that they were in a dating relationship (47.2%, n = 1070), most men reported that they were sexually active with at least one partner (88.5%, n = 2007). This indicates that, similar to other findings, MSM continue to be sexually active following an HIV diagnosis. 32–34
More than two-thirds of participants (70.2%) reported using at least one sex toy in the previous year and one-third (30.5%) had used at least one toy during the previous four weeks. Men who reported not being currently sexually active were more likely to use toys in their solo sexual behaviour, which may offer further insight into solo sexual experiences by these men; even if they did not report having a current sexual partner, men were using toys for sexual enjoyment purposes. Given that sex toy use among MSM living with HIV is only currently being enumerated, medical and social service providers may use this information to guide the questions they ask of their clients, with the goal of achieving a more complete understanding of these men's sex lives and sexual activities.
There were significant differences between those who reported having used a toy in the previous year and those who had not, with regard to their reported sexual relationship status, as well as ethnicity. Toy users were more likely to be white, and were currently engaged in sexual relationships. Many participants reported that their partner wanting to use a toy was the primary reason they had most recently used one during a sexual encounter; therefore, further research could explore the mechanisms by which men introduce sex toys to their sexual partners, and the impact of partner type and length of relationship on the introduction and use of sex toys among MSM.
When asked about what led them recently to the use of a sex toy, participants reported that they believed that sex toys would be fun and that they were curious about them, indicating that this sample of MSM living with HIV are actively engaged in pursuing sexual pleasure and a vital sex life. Also, this may be an indication of the positive attitudes MSM may have towards sex toy use, an arena that could be further investigated. Positive attitudes towards sex toy use could be useful in promoting toys as a means of safer sex between serodiscordant men and their partners. Men in this sample uniformly responded that safer sex was not a primary reason for initially using a toy; however, given that the use of toys such as dildos, butt plugs and vibrators, especially when used with condoms, may allow for increasing sexual pleasure without the exchange of bodily fluids, public health practitioners may want to discuss sex toy use as having the additional benefit of also allowing for safer sexual interactions. Therefore, though sex toy use seems to be common among HIV-positive MSM in this sample as a means of increasing subjective sexual satisfaction, they are not yet being realized for their capacity to reduce STI and HIV transmission risk. Given indications that MSM may be experiencing ‘burnout’ with regard to public health messaging about the importance of condoms, 35,36 a conversational switch to the discussion of sex toys may be welcomed by this population.
Our hypotheses regarding the utility of sex toys as a means of sexual health improvement were borne out only in part. Rates of unprotected insertive and receptive anal intercourse encounters did not differ between previous month toy users and non-toy users. This finding aligns with having few participants report their toy use was a means of engaging in safer sex. One limitation of these findings is that we are not able to tie condom use events to particular partners or sexual encounters, which might offer additional information as to motivations for condom use based on partner type, seroconcordancy/discordancy, choices of sexual behaviours or communication and negotiation prior to sexual activity. It is important to continue to promote condom use as a primary means of preventing the further transmission of HIV, especially given that participants report inconsistent condom use. However, further research that measures event-level sexual behaviours could bring to light contextual factors influencing sexual behaviours, such as already knowing a partner's serostatus or engaging in seroconcordant behaviours.
Rates of condom use during anal sex varied for this group. However, it should be noted that men in this sample were reporting higher rates of condom use when they were the insertive partner in anal intercourse than when they were the receptive partner. The significant difference in condom use for these behaviours may be an indication of strategic positioning on the part of participants. Multiple other studies of MSM have found that strategic positioning is often employed by serodiscordant sexual partners, where the HIV-positive individual is the receptive partner in anal intercourse, as a perceived means of reducing HIV risk. 37–40 For example, they may be conscious of the risks of further transmitting HIV if they are the insertive partner, but may be less concerned about the risks of being a receptive partner, when they already have an HIV diagnosis.
While this study represents an exploration of health behaviours and sex toy use among a large sample of MSM living with HIV from all states in the USA, it remains limited by the extent to which the sample is one of convenience, as challenges remain with establishing true nationally representative samples of MSM for research. Further, because this sample was entirely Internet-based and utilized only members of a single Internet-based site, the data may not be generalizable to all MSM in the USA. However, this method of recruitment was purposive and closely resembles national representations of MSM in the USA. Additionally, previous research has demonstrated that data collected through Internet surveys can be generalized to the population. 41,42
Future research among MSM living with HIV should explore whether direct promotion of sex toys might be useful as an educational tool for healthy sexuality, specifically for reducing the chance of transmitting HIV infection while not decreasing pleasure or satisfaction. This study found that, when comparing toy users with non-toy users, STI rates were not significantly different, indicating that toy use was probably not a factor in higher STI prevalence. Building on this finding, the discussion of sex toys by public health practitioners, including using condoms with them as well as proper hygiene before and after use, may be a way of promoting safer sexual health behaviours between serodiscordant men without characterizing sexual activity as innately dangerous. In addition, sex toys used with condoms could be recommended as a means of maintaining and enhancing sexual pleasure while reducing the risk of bacterial and viral STIs, which can affect those with compromised immune systems more seriously.
CONCLUSIONS
Overall, results of this study indicate that MSM living with HIV continue to have robust and diverse sexual experiences. Sex toy use was common among these men, generally thought of as fun, and a means of satisfying sexual curiosity. Given this, there is ample room for practitioners to promote the healthy use of sex toy products among this group of men, with the goal of encouraging enjoyable sex lives while also reducing HIV and STI transmission possibilities. Further research should examine the contextual factors leading to toy use or non-toy use between men in sexual encounters, and whether discussion and promotion of sex toys as a means of safer sex could impact the incidence of negative sexual health outcomes among MSM living with HIV.