3. Findings
The findings of the study are presented in three sections.
The first outlines the various factors which were found to contribute to the
likelihood of participants engaging in unsafer sexual practices. The second deals
with the kinds of risk reduction strategies participants employed in response
to the threat of HIV and STDs and the circumstances in which these strategies
were employed. The final section concerns participants’ perceptions HIV
vulnerability, their attitudes towards HIV testing, and their response to HIV
prevention messages.
3.1 Sexual Practices and Risk Factors
One of the limitations of the approach taken by many studies
on HIV related risk behavior as well as by many prevention programs is the rather
narrow view taken of the nature of risk and a failure to focus on the ‘meaning’
that is has for the individuals who engage in it. In this limited perspective,
risk is seen as primarily confined to the risk of HIV transmission, and the
motivation to engage in risk is seen to reside chiefly in the mind and decision
making processes of the individual. Furthermore, risk is generally regarded as
a universally negative phenomenon which, whenever possible, ought to be
decreased or eliminated.
Analysis of the segments from our diaries coded under the
categories ‘risk’ and ‘danger’, however, revealed a very different view of risk
and the way it is conceptualized and acted upon by MSM in real life situations.
Rather than a simple, unitary concept focusing on concerns about HIV/STD
transmission and mediated through the isolated decision making processes of the
individual, our diarists portrayed risk-taking as a complex, multifaceted and
socially constructed phenomenon associated with a wide range of possible negative
and positive consequences for the risk-taker.
When assessing the risk of a particular sexual practice,
participants rarely considered the risk of HIV transmission alone. Instead, the
threat of HIV was seen as only a part of a complex constellation of risks
associated with physical intimacy, these other risks often taking precedence
over the risk of HIV infection in the mind of the risk taker. Figure 1
illustrates the types and range of concerns participants associated with sexual
behavior. Along with the risk of HIV transmission, participants in sexual
encounters also considered the consequences various actions would have on
things like their present or future relationship with their partner, their
present or future degree of emotional or psychological well being, and their
social identity and ability to fulfill various socially and culturally
determined roles and obligations. The way the risk of HIV transmission was
assessed and acted upon was nearly always related to these other
considerations.
In longer-term or ‘romantic’ relationships, these concerns
focused primarily on whether or not participants would be able to maintain
their relationships and achieve the degree of intimacy and emotional or
physical satisfaction they desired. In such circumstances, the risk of
jeopardizing their relationship by, for example, creating the impression that
they did not love or trust their partner, not being able to sufficiently please
their partner, or not fulfilling the roles and obligations they perceived to be
required of them in the relationship, were often seen to outweigh the risk of
HIV. This perception was also fairly widespread among respondents to the
questionnaire, with nearly a third either agreeing or strongly agreeing with
the statement: ‘ Keeping my relationship is more important than worrying about
HIV’.
In more casual encounters, concerns focused more on whether
or not participants would be able to fulfill roles or portray identities which
they believed to be appropriate in certain social situations along with more
concrete risks related to things like disclosure or arrest. In these contexts,
such immediate concerns were often regarded with much more urgency than the
possible future consequences of HIV
infection. The excerpt below, for example, illustrates how, in public sex
situations, risk assessment might be considerably calculated, but might focus
on more ‘clear and present’ dangers than the risk of HIV transmission:
He (Mr. H) then walked into a
toilet cubicle. I sensed that he wanted me to come in and join him. My heart
was beating heavily and I was thinking of a lot of things. I knew it would be
very exciting if I followed, since I had never done this before. I realized
that it was early in the morning and that there shouldn't be many people using
the toilet. But I also said to myself what if I got caught? I could lose my job
and my family. But I wanted to join him badly. This time when I looked at the
toilet door, I didn't see his feet, I said to myself that other people could
hardly notice anything. So I went in. (Yo-yo 7, 15/25)
Furthermore, risk was rarely assessed by participants in the
same way with different partners in different situations, and its assessment
was rarely based on the kind of abstract logic which is often presented in
educational materials
about safer sex. On the contrary, risk assessment was highly
situational and context dependent, following less the ‘logic’ of epidemiology
or virology and more the internal logic of the relationship or the situation.
Finally, risk was not necessarily regarded by our
participants as a negative phenomenon which should be eliminated at all costs.
It was, in fact, almost always associated with benefits of some kind, including
the benefits of increasing the sense of trust or intimacy in a relationship, of
developing a stronger tongji identity,
of integrating more fully into the tongji ‘scene’, and of achieving
higher levels of psychological comfort or sexual satisfaction. Rather than an
aberration, risk was portrayed as an inevitable part of life, particularly for tongji,
something that they had to confront on an daily basis whether they engaged in
unsafer sexual practices or not.
One of the strongest recurrent themes in diarists’ discussion
of tongji life in Hong Kong was the notion of ‘courage’ and the
important role that it played in both the ‘coming out’ process and in the
creation of opportunities for seeking out potential friends or sexual partners.
Narratives of early sexual experiences, of visiting tongji venues like
bars and saunas for the first time, of revealing one’s sexuality to friends or
family members, and of purchasing things like condoms and gay pornography
almost always included remarks about the fears or uncertainties associated with
these actions and the necessity of cultivating ‘courage’ in order to face up to
or conquer these fears. The diarists who did not access tongji venues
(or accessed them less frequently) and those who felt themselves less
integrated into the community often attributed this situation to a lack of
sufficient ‘courage’:
Though I knew a number of channels to find them (other tongji)
like going to bars, discos, saunas and organizations, I still didn't have the
courage to access these channels. (Jerry 2, 4/7)
‘Courage’ was also associated with engaging in public sex in
which the risk of being caught was high, and diarists sometimes expressed
admiration for those who were ‘daring’ enough to participate in these
activities:
I asked what would happen if I were
a cop. He said he was not afraid. (I get a feeling that gay people can be very
brave especially when they want to achieve something. Like what I did in the
past: mutual jerk off, caressing in the park). (Yo-yo 6, 23/28)
I thought the public toilet was not a good place since the police might catch us. They were really fearless! (Wai 1, 31/32)
‘Courage’ was not only associated with sex with strangers.
It was also seen to play an important
role in whether or not participants pursued long term relationships. Falling in
love, ‘chasing’ a potential lover, saying ‘I love you for the first time’ and
engaging in certain kinds of sexual behavior with a partner were all seen to
require ‘courage’:
He told me he didn’t have the courage
to chase me. I asked him what he meant by courage, and he said he didn’t have
the courage because I already had a boyfriend and some other expatriates
chasing me. (Peter 4. 52/54)
I dared not to run after him
further at the beginning because I was not brave and self-confident enough. (Ah
Lam 1, 160)
Any discussion of the factors contributing to HIV related risk behavior among MSM in Hong Kong, therefore must be seen in the context of the ‘meaning’ such risk behavior has for them in their lived experiences, and how this ‘meaning’ interacts with other ‘meanings’ of other risks which accompany homosexual behavior or identity in a society in which opportunities for meeting and developing relationships with other MSM are limited and social stigmatization of homosexuality remains high.
3.1.1 Factors and Conditions Associated with
Unsafer Sex
Analysis of the diaries, including both the 49 sexual
narratives isolated from them and diarists’ more general observations and
remarks about sex and HIV, generated a number of factors recurrently associated
with unsafer sexual activities. For the purpose of the discussion below, we
will define ‘unprotected sex’ as either anal sex or oral sex during which the
active partner does not wear a condom and ‘high risk ‘ sex as unprotected anal
intercourse, whether or not ejaculation occurs in the receptive partner’s anus,
or unprotected oral sex only in which ejaculation occurs in the mouth of the
receptive partner. The term ‘unsafer’ sex will be used to refer to the wide range
of sexual activities involving at least some risk of transmission.
It should be noted, however, that the actual degree of risk associated with any of the above practices
cannot be accurately assessed apart from the context of the particular sexual act.
Having unprotected anal intercourse in the context of a casual encounter in a
sauna, having it in the context of a long-term, monogamous relationship in
which partners are relatively sure about their stereo-status, or having it in
contexts in which one or both of the partners have little or no previous
history of risk behavior, situations all of which are reported in our data,
would all be classified as ‘high risk’ under the above set of definitions. The
degree of risk, however, among these three situations, however, obviously
varies greatly.
Figure 2: Incidents of Sexual Practices Reported in Sexual
Narratives
Figure 2 shows the number of times various practices were
reported by diarists
in their sexual stories. ‘Unprotected sex’ was reported 33
times, and 27 of those could be classified as ‘high risk’. Oral sex was the
most frequently reported activity, followed by masturbation and anal sex. While
masturbation was only reported in 25 stories, we can assume that it occurred
much more frequently but was not viewed by participants as sufficiently salient
to include in their narratives, particularly in episodes in which anal or oral
sex were portrayed as the main activity. Of the 27 reports of oral sex, only
two involved a condom and eight involved ejaculation into the mouth of the
receptive partner. Of the 19 reports of anal sex, 8 were unprotected and 2
involved ejaculation into the anus of the receptive partner. 33 of the sexual
stories involved sex with strangers, while 16 involved sex with partners
already known to the authors. One of the diarists did not report any sexual
activity, and one reported only masturbation and kissing. The diarist whose
submissions contained the greatest number of sexual narratives (12) (and who
reported the most unsafer sex) was the married man. The diarist who told the
second greatest number of sexual stories (9) was one of the two HIV+
participants.
It should be remembered that these sexual narratives do not
represent the full extent of sexual activity reported by the participants, but
only those activities which were incorporated into a recognizable narrative
structure (and so do not include, for instance, unelaborated statements such as
‘I got fucked in the sauna twice last month’). Furthermore, the number of
sexual stories a diarist told is no definite indication of the extent of his sexual activity, more accurately
measuring, perhaps, the extent of his willingness or desire to tell stories
about it.
The factors diarists mentioned when discussing their unsafer
sexual behavior or describing the conditions in which it occurred were multiple
and varied. They can be divided into three types: 1) Relational Factors--those
having to do with diarists’ relationship with the person with whom they were
engaging in sexual behavior; 2) Psychological/Individual Factors--those related
to the individual’s psychological or emotional state at the time of the sexual
episode or the individual’s past experiences; and 3) Social/Contextual
Factors--those related to the physical and social context of the sexual
episode, where it occurred, the kinds of social norms and routines associated
with the particular situation, as well as issues pertaining to the broader
social context like perceptions of the tongji community, social
stereotypes, and discrimination or fear of discrimination. The factors mentioned most by the diarists
were included on the questionnaire within a set of items asking respondents to
rate the degree to which they felt each of these factors might contribute to
their engaging in unsafer sex. Figure 3 shows the results from these
items.
Figure 3: Factors contributing to
unsafer sex (Questionnaire responses; mean based on 5-point Likert scale)
It is important to note, however, that in the majority of
sexual narratives isolated from the diaries more than one factor was mentioned.
Most narratives of unsafer sex involved a complex combination of factors
interacting with one another, and sometimes it was difficult to identify any
single ‘main’ factor contributing to the unsafer sex. The following episode
illustrates this complex mixture of risk factors:
Mr. A and I got very horny in the middle of the night…We caressed, sucked. I fucked him from behind and felt particularly high. It lasted longer and felt better without a condom. Mr. A kept spitting on my penis and on his arse as lubricant. I felt extremely comfortable. When I felt I was about to come, I felt so high that I didn’t care and shot in his arse. Mr. A accepted it. He then "shitted" out my cum and took a shower. He said it could lower the risk of getting AIDS but the best of course was not to ejaculate inside. I said to myself that he was my first gay lover and I was sure that I was OK and therefore I needed not to worry. (Yo-yo 2, 25/35)
On the one hand, what seems to be driving the unsafer sex on
the surface of the narrative are psychological and emotional factors,
‘horniness’, ‘feeling so high that I didn’t care’. On the other hand, there is
an underlying course of negotiation running through the story, with Mr. A
responding to the author’s advances by ‘spitting on (the author’s) penis and
his arse’ and ‘accepting’ the author’s semen, signaling to the author both Mr.
A’s desires and the extent of Mr. A’s compliance and pleasure. Despite the
author’s claims of clouded judgment, throughout the episode an awareness that
what they are doing is risky is maintained, and, as a result of this awareness,
a risk reduction strategy is applied, albeit rather late and of questionable
efficacy. Relational factors also contribute to the assessment of risk, with
the narrator considering his own sexual history and his relationship with Mr.
A, although the logic of his reasoning seems to ignore the risk Mr. A’s sexual
history may pose to him. One of the most interesting things about this episode
is that, contrary to our expectations about unsafer sexual encounters, this one
involves an explicit discussion of HIV risk between the participants, although
it occurs after the fact, and even an instance of what might be regarded as
‘peer education’, with Mr. A advising the narrator to adopt a more effective
risk reduction strategy in the future (withdrawal). Ironically, this first
unsafer experience led this diarist to adopt measures to reduce the risk of HIV
transmission in his subsequent sexual activity, though perhaps not to the
degree that would satisfy most AIDS educators:
I realize that the chance to get AIDS is higher if we allow people to come inside, therefore whenever I get fucked now I ask people not to come inside. (Yo-yo 4, 32/34)
Engaging in unsafer sex most often involves the interaction
of relational factors, individual cognitive and emotional factors, situational
factors and social and cultural factors converging in one particular moment of
time. Each sexual episode involves a new and unique constellation of factors.
Avoiding unsafer sex, therefore, is not simply a matter of making a decision
once and for all time only to engage in safer sex; it is a decision made anew
in each sexual encounter in response to that encounter’s own particular
combination of factors (Dowsett 1993, Davies and Project SIGMA 1992, Gold et al. 1991, Turner 1997, Zeller 1993).
Furthermore, because sexual encounters are inevitably interactive, participants
are influenced by different factors to different degrees with different sexual
partners and in different situations with the same partner (de Zwart et al.1998).
Individual and Emotional
Factors
