Do rural and non-rural single, young adults differ in their risk and protective HIV/STD behaviors?

Nov 27 2007

Single young adults living in rural areas are no more inclined to engage in safe sex behaviors than their non-rural peers, according to a new analysis by Indiana University sexual health experts of a nationally representative survey.

The singles' behaviors involving number of sexual partners, troubling frequency of unprotected sex and issues involving HIV testing put them equally at risk of acquiring and transmitting sexually transmitted diseases such as HIV.

"Rural living apparently isn't protective, despite the image that the rural environment is more conservative, with traditional values that result in people being less risky in their personal behavior," said William L. Yarber, senior director of the Rural Center for AIDS/STD Prevention at Indiana University Bloomington. "The study findings are contrary to beliefs that individuals, just because they live in a rural area, are shielded against many of the factors that contribute to HIV/STD transmission and acquisition."

The study, "Do rural and non-rural single, young adults differ in their risk and protective HIV/STD behaviors: Results from a national survey," will appear in the winter Health Education Monograph . Here are some of the findings of the analysis, which involved 1,500 men and 1,888 women between the ages of 18 and 29 who participated in the 2002 National Survey of Family Growth. Non-rural refers to anyone living in a county with more than 50,000 residents:

• Number of sexual partners: Non-rural and rural men reported an average of 8.8 and 7.2 female sex partners, respectively, in their lifetime and 1.7 and 1.4 on average in the previous 12 months. Non-rural and rural women reported an average of 5.9 and 5.6 male sex partners, respectively in their lifetimes, and an average of 1.5 and 1.6 male sex partners in the previous 12 months.
• Condom use and unprotected sex: Non-rural and rural men reported having sex without a condom an average of 4.9 and 6.2 times during the previous four weeks. Non-rural men (46 percent) and rural men (47 percent) were equally likely to report not using condoms the last time they had sex. Non-rural and rural women reported having sex without a condom an average of 6.8 and 6.5 times during the previous four weeks. Non-rural women (51 percent) and rural women (47 percent) were equally likely to report not using condoms the last time they had sex.
• STD and HIV testing and counseling: Non-rural women (59 percent) were more likely than rural women (50 percent) to receive an HIV test. There was no difference between non-rural men (44 percent) and rural men (44 percent). Non-rural men (69 percent) were more likely to discuss STDs after their last HIV test than rural men (37 percent), while no difference existed between the groups of women.
• Recommendation: The study recommends that AIDS prevention specialists continue their work in prevention, taking advantage of this "window of opportunity," to prevent incidence of HIV from escalating. "Rural residents may be quite hesitant to respond to a health issue that has yet to 'hit home' as a reality," the authors write. "Thus, intensified efforts to promote HIV/STD risk reduction in rural America are warranted. The efforts are warranted because rural outbreaks of HIV may be difficult to contain because of fewer resources in rural areas for controlling HIV compared to urban areas."

This study, funded by RCAP, is the first to compare the sexual risk-taking behaviors of single, young adults living in rural versus non-rural areas. While rates of STDs in rural areas are less than in urban areas, the study shows that the singles engage in similarly risky behaviors.

"In rural communities, if an STD begins spreading within a sexual network, the rate of STD can become pretty high," Yarber said. "Rural communities are probably less armed to deal with these issues because of lack of resources, more stigma and more denial related to the diseases."

Co-authors are Robin Milhausen, University of Guelph, Ontario; Bin Huang, University of Kentucky; and Richard Crosby, University of Kentucky.

SEXUALITY IS NOT BLACK-AND-WHITE ... NOR IS HIV/AIDS RISK

Greater support for bisexual men in general is vital to decreasing the secrecy involved in many bisexual men's sexual encounters, as well as its potential health risks.

"Bisexual men have long been the object of scorn from both heterosexual and homosexual individuals and communities," said Brian Dodge, associate director of the Center for Sexual Health Promotion at Indiana University Bloomington. "Until we begin to accept that individuals are not 'black-and-white' in terms of their sexual orientations and behaviors, the myths and stereotypes surrounding male bisexuality will continue to flourish."

Dodge and his research colleagues recommend that HIV prevention efforts should begin to broadly educate both women and men on HIV acquisition from male partners, any of whom could be bisexually active, rather than placing the burden of protection upon bisexual men alone. Dodge also says that evidence of bisexual men's female and gay male partners expressing intolerance toward bisexuality clearly warrants broader social and structural interventions with women and gay men, with the aim of increasing awareness and acceptance of bisexuality, if disclosure is to become an expectation among bisexual men.

"Prevention is still the best medicine we have for HIV and other sexually transmitted infections," Dodge said. "But as long as the Centers for Disease Control and Prevention and other public health entities continue to polarize HIV transmission in the mutually exclusive categories of 'men who have sex with men' (MSM) and 'heterosexual,' without specifically looking at the intersection of these groups, we will continue to live in the dark in terms of understanding the sexual behaviors and potential risks of bisexual men."

Background: Most male-focused HIV/AIDS research and interventions have concentrated on "gay men" or "MSM." Limited studies on bisexual men have highlighted unique HIV risk factors and prevention needs. Findings have shown that the specific factors involved in the sexual risk behaviors of bisexual men have been inadequately addressed in previous MSM-targeted interventions, most notably prevention skills with female partners. Recent research suggests that black bisexual men, in particular, are at relatively high risk for HIV transmission when compared to other risk groups. In the mass media, these so-called "men on the Down Low" have been the subject of intense public scrutiny and stigmatization. However, little to no scientific information is available with which to temper popular images and stereotypes of these men.

During the past five years, Dodge and colleagues at Columbia University and the University of Florida have conducted research in New York City focusing specifically on black and Latino bisexual men.

"Contrary to popular depictions, these men do not appear to live in a vacuum in terms of knowledge and awareness of the potential risks associated with their sexual behaviors. Rather, they exist within a society which is, on the whole, extremely ignorant and intolerant of their bisexual attractions, desires, and behaviors -- so secrecy and risk should really come as no surprise," Dodge said.

In their studies the research team found numerous unique risk and protective factors for bisexual men in comparison to other men. Here are some of the findings:

Condom use and sexual partner's gender. Among black bisexual men, nearly three-fifths of the research sample reported that they would use a condom during vaginal intercourse even if female partners were on the pill or other form of birth control, and most consistently used condoms with female partners -- primarily for pregnancy prevention purposes. However, nearly half of the participants also reported instances of not using condoms specifically with female partners, because they perceived those partners to be 'safer' in terms of HIV risk. This phenomenon is specific to bisexual men but has not yet been incorporated into HIV research and interventions.

Disclosure -- "coming up from the Down Low." The vast majority of these men reported it was easier to discuss their bisexuality with male sexual partners compared to female sexual partners. Additionally, disclosure of bisexuality was reportedly easier if the male partner also engaged in bisexual behavior and/or identified as bisexual. When asked why, most participants reported that male bisexuality was "bothersome" to women and gay men, and that disclosure could result in a variety of serious physical, emotional and social consequences (including violence, public humiliation and even death).

In contrast to media stereotypes. Most of these men did not wish to keep their wives and girlfriends completely ignorant of their bisexual behaviors. The majority of the men expressed that they would like to disclose to partners in serious and more long-term partnerships but, due to environmental constraints, simply could not. "Many of our participants lived in areas in which they could be seriously harmed if their bisexuality was publicly known," Dodge said. "In reality, these men have very logical reasons for why they do not typically disclose their bisexuality."

The Center for Sexual Health Promotion is part of the Department of Applied Health Science in IUB's School of Health, Physical Education and Recreation. In commemoration of World AIDS Day 2007, the center is sponsoring an address by internationally known sexual health researcher David Malebranche, M.D., of the Emory University School of Medicine and the President's Advisory Council on HIV/AIDS, on Thursday, Nov. 29. The address, "Black Bisexual Men and HIV: Time to Think Deeper," will be held at 7 p.m. in the Indiana Memorial Union's Dogwood Room. For more information, visit the center's Web site at http://www.sexualhealth.indiana.edu.

WHY MEN WEAR -- AND DON'T WEAR -- CONDOMS

An Indiana University study found that men who were highly motivated to wear condoms -- who thought they should for one reason or another -- were more likely to put the condom on before having sex with a woman. Men who had trouble with the fit and feel of their condoms or experienced an erection loss while wearing one were more likely to take the condoms off before finishing intercourse with a woman.

"The incomplete use of condoms is a big issue," said William L. Yarber, senior director of the Rural Center for AIDS/STD Prevention at Indiana University Bloomington. "It can lead to exposure to STIs (sexually transmitted infections) and unintended pregnancies. We need to inform people about the importance of using a condom for the entire sexual intercourse episode."

Background: More and more evidence is pointing to condom use as being the best method for reducing the risk of receiving or spreading sexually transmitted diseases, such as HIV, the virus that causes AIDS. Health care professionals know that condom use is effective but more research is needed to identify factors related to incorrect condom use. This study specifically looked at the factors involved in why male patients at an STD clinic would put on condoms after vaginal intercourse with a woman started and take the condoms off before sex ended. The results come from 278 male patients at an urban Midwestern STD clinic.

Findings: Nearly one in five men (18.7 percent) reported starting sex and putting the condom on later at least once during the past three times a condom was used. Of the 278 men in the study, 88 reported that their condom broke on one or more occasions; of the remaining 190 men, 23.7 percent reported they had removed the condom before sex ended during at least one of the past three times they used condoms.

Implications for preventive medical practice: Because motivation to wear condoms correctly was key to the correct use of them, it might be important in clinic-based education and counseling efforts to provide men with ample reason to wear them correctly. This could include talking with patients about pre-ejaculate and how small amounts of semen can be enough to cause pregnancy or transmit STDs; or talking about how their chances of acquiring an STD, such as HIV, from a female lover increase significantly if they begin sex before putting on a condom. Other targeted educational efforts could include talking with men about how erection loss is relatively common for most men and providing a wider range of condom sizes and brands.

The study, "Correlates of putting condoms on after sex has begun and of removing them before sex ends: A study of men attending an urban public STD clinic," was published in the American Journal of Men's Health , appearing online in May.

Co-authors are Richard A. Crosby, University of Kentucky; Stephanie A. Sanders, The Kinsey Institute for Research in Sex, Gender and Reproduction at Indiana University in Bloomington, Ind.; Cynthia A. Graham, Kinsey Institute and the Oxford Doctoral Course in Clinical Psychology, Oxford, U.K.; Janet Arno, M.D., Bellflower Clinic in Indianapolis; Robin Milhausen, University of Guelph, Guelph, Ontario; Lindsay Brown, Boston Medical Center, Boston; Martha Payne, Substance Abuse and Mental Health Services Administration, Indianapolis; and Alexis Rothring, San Carlos Park and Rescue District, Fort Myers, Fla; Rose M. Hartzell, Kimberly McBride and Laurie J. Legocki, Indiana University.