Condom use among East and Southeast Asian men attending a gay bathhouse in Toronto.
Subject: Condoms
Authors: Poon, Maurice Kwong-Lai
Wong, Josephine Pui-Hing
Sutdhibhasilp, Noulmook
Ho, Peter Trung-Thu
Wong, Bernard
Pub Date: 09/22/2011
Publication: Name: The Canadian Journal of Human Sexuality Publisher: SIECCAN, The Sex Information and Education Council of Canada Audience: Academic Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2011 SIECCAN, The Sex Information and Education Council of Canada ISSN: 1188-4517
Issue: Date: Fall, 2011 Source Volume: 20 Source Issue: 3
Product: Product Code: 3069770 Prophylactics & Diaphragms NAICS Code: 326299 All Other Rubber Product Manufacturing SIC Code: 3069 Fabricated rubber products, not elsewhere classified
Accession Number: 276516862
Full Text: Abstract: Prior research has shown that a large number of men who go to bathhouses engage in unprotected anal sex and have multiple sex partners. Relatively little is known about the behaviour and experiences of East and Southeast Asian men visiting bathhouses. The present study surveyed 101 men of East and Southeast Asian origin who attended a gay bathhouse in Toronto, Ontario, Canada. The objective was to document their HIV-testing history, likelihood of condom use during anal sex with casual partners and to identify their reasons for using or not using condoms. Participants' HIV-testing history indicated that 15.8% had never been tested and 23.5% were last tested 2-4 years ago or more. About one quarter of the 86 men who had casual sex in the six months prior to the survey said they did not always use a condom. Forty-three percent of the men who had not used condoms for anal intercourse on one or more occasions indicated that "Sex partner looked healthy; should be OK" and "Got carried away in the excitement of the moment" as reasons why a condom was not used. HIV prevention efforts for this population need to address issues regarding accessibility of HIV testing and the provision of accurate and culturally relevant information about the importance of condom use.

Introduction

Bathhouses are popular, commercial venues where men meet other men for sex (often anonymous and casual). The sexual nature of these venues has raised public health concerns regarding the spread of sexually transmitted infections (STI), including human immunodeficiency virus (HIV). For example, a study of 785 men who attended a gay bathhouse found that half had multiple anal sex partners and approximately one-third reported unprotected anal intercourse (Binson, Pollack, Blair & Woods, 2010). Other studies have reported similar findings of unprotected anal intercourse among bathhouse attendees ranging from 23% to over 30% in a prior three-month period (Reidy et al., 2009; Woods et al., 2007). There is little similar research information about the sexual behaviours of ethno-racial minority men who go to bathhouses in Canada. The present study sought to address this information gap.

Background

People of East and Southeast Asian origins make up more than 16% of the total population in Toronto and are the largest ethno-racial minorities in Canada (Statistics Canada, 2008). The limited data available indicate low rates of HIV testing and high rates of unprotected anal sex among East and Southeast Asian men who have sex with men (MSM) in Canada. For example, a recent study, conducted in Toronto and Ottawa, reported that South and Southeast Asian MSM had the lowest rate of HIV testing (78%) in comparison to other ethnic groups and an HIV prevalence of 11.5% (Myers et al., 2011). Earlier Canadian studies have documented even lower rates of HIV testing (65-69%) among East and Southeast Asian MSM (Bhat, Yee, & Koo, 1994; Poon, Ho, & Wong, 2001). Studies in Australia and the United States found similar rates of HIV testing among Asian MSM ranging from 62% to 81% (Boldero, Sanitioso, & Brain, 1999; Do, Hudes, Proctor, Han, & Choi, 2006; Do et al., 2005; Mayne, Weatherburn, Hickson, & Hartley, 1999; Multicultural HIV/AIDS Education and Support Service, 1996; San Francisco Department of Public Health cited in Choi, Salazar, Lew, & Coates, 1995; Shapiro & Vives, 1999).

A study of East and Southeast Asian MSM in Toronto found that only 53% of respondents reported using condoms every time they engaged in sexual activity (Poon et al., 2001). Similarly, a Vancouver study found that 24% of East and Southeast Asian MSM had unprotected receptive anal sex to ejaculation with their primary sexual partners; many did not consider receptive anal sex without condoms (30%) and insertive anal sex without condoms (25%) to be high risk sexual activities (Bhat et al., 1994). U.S. studies have found comparable rates of unprotected anal intercourse among Asian and Pacific Islander MSM. For example, Raymond and McFarland (2009) reported that 18% of Asian and Pacific Islander MSM engaged in unprotected anal sex during the past six months (Raymond & McFarland, 2009). Some U.S. studies have documented even higher rates of unprotected anal intercourse among Asian and Pacific Islander MSM, ranging from 27% to 36% during the previous three months (Choi, Coates, Catania, Lew, & Chow, 1995; Choi, Han, Hudes, & Kegeles, 2002; Choi et al., 1996; Flores, Bakeman, Millett, Peterson, 2009; Lai, 1999).

The present study explored HIV-testing history, casual sex behaviour, condom use during anal intercourse, and reasons for using or not using condoms in a sample of men of East and Southeast Asian origins who visited a bathhouse in Toronto. The findings reported here are drawn from a larger study that also looked at sexual risk behaviours, identity, sense of belonging, and mental health in this population.

Methods

The present study was a community-based, collaborative project between a local university and an ethno-racial specific AIDS organization with over 15 years of experience serving the East and Southeast Asian communities in Toronto. The protocol was reviewed and approved by the institutional review board at McMaster University. Due to the sensitivity of the subject matter, an advisory group consisting of eight community members was formed to guide the study.

Questionnaire

The two-page questionnaire had 14 questions that provided demographic, behavioural, and attitudinal information. Ethno-cultural background was determined from the question, "Most people think of themselves as belonging to a particular ethnic or racial group. Are you (Check only one)". Response options were Chinese, Filipino, Vietnamese, Korean, Japanese, and Other (specify). Sexual self-identification was determined by one response to "Do you think of yourself as" with the options "heterosexual/straight", "homosexual/gay", "bisexual", or "other (specify)". Respondents also stated their age and checked their current marital or relationship status and their current living situation from a list of options. HIV-testing history was determined from the question, "Have you ever been tested for HIV/AIDS?" and by checking one response option to the questions, "When did you last have an HIV test?" and "Are you HIV positive? (yes, no, unknown)."

Sexual risk behaviours and perception were assessed using five questions from a larger questionnaire developed in reference to the prior work of Mao et al. (2003) and Smith, Chung, and Louey (undated). The behavioural questions asked "During the past 6 months, how many different people have you had casual sex with?" (response options were: to give a number, "don't know", or "refuse to answer"), "How often do you use a condom during anal sex with a casual partner?" (response options were "always", "often", "occasionally", "never"), and "Do you use a water-based lubricant (such as KY)?" (response options were: "yes"; "no", "didn't use lubricant"; "no, but did use other type of lubricant"). The two perception questions dealt specifically with reasons for using or not using condoms in which all response options that applied could be checked. The questions were: "If you sometimes, usually, or always use condoms for fucking, which of the following best describes why?" and "If there have been occasions when you have fucked WITHOUT a condom, which of the following best describes why?" (for response options see Table 4).

The questions were reviewed by the advisory group to ensure that they were relevant to the community, and that the language used was culturally appropriate. The survey was translated into Chinese (both simplified and traditional) and Vietnamese.

Recruitment

Respondents were recruited from February to May 2006 in a gay bathhouse popular with East and Southeast Asian men. To ensure that the study reached a diverse sample of respondents, recruitment was designed to cover various times and days (including evening, late night, and weekend). Each recruitment period spanned about three to four hours. The criterion for participation was that respondents were of East or Southeast Asian descent who visited gay bathhouses. To enhance recruitment effectiveness, six East and Southeast Asian peer research assistants were hired to help recruit and conduct the interviews. The research assistants were all former volunteers with the sponsor AIDS organization and were familiar with the local gay Asian community. They were selected based on their understanding of issues faced by East and Southeast Asian MSM and also their ability to speak, in addition to English, at least one Asian language fluently, including Cantonese, Korean, Mandarin, Tagalog, and Vietnamese. The peer research assistants were randomly assigned to scheduled recruitment and interview times.

Questionnaire administration

The research assistants worked in teams of two--one served as the recruiter and the other as the interviewer. The recruiter approached potential participants individually, explained the goals and methodology of the study, and invited the man to participate in the study. To avoid duplication, each participant was asked, prior to the interview, whether he had previously completed the survey. Informed consent was obtained from each participant before the interview started and participation was entirely voluntary. To ensure that the survey was completed properly, each participant was interviewed by one of the peer research assistants. The interviews were conducted in a private office in the bathhouse. To make it easier for participants to follow the interview, they were provided with a copy of the survey and informed that the survey was available in Chinese and Vietnamese. Each interview lasted for approximately one hour. To ensure anonymity, each participant's survey was assigned a number. After the completion of the survey, each participant received a $20 honorarium.

Results

Demographic characteristics of respondents

Table 1 provides information on the demographic characteristics of the men participating in the study. Of the 101 participants, over half were Chinese, with the Filipino, Vietnamese, Korean and Japanese groups each representing less than 20% of the sample. Nearly all the men in the sample self-identified as gay or bisexual with none identifying as heterosexual. The participants ranged in age from 20 to 53 years with an average of age 33.7. Most participants (81.2%) were under the age of 39. Almost three quarters indicated that they were single, never married and more than half reported living alone. Three men (3%) participating in the study reported being HIV positive.

HIV-testing history

As indicated in Table 2, over 80% of the men participating in the study had ever been tested for HIV. Among men who had been tested for HIV, 58.9% reported that they had been tested in the previous 12 months. However, 23.5% reported that their last HIV test occurred two or more years ago.

Condom use during anal sex with casual partners

Of the 101 participants, five reported that they did not engage in anal sex and ten said that they only engaged in such behaviour with a regular partner, but not with a casual partner. Thus, there were 86 participants who indicated that they had anal intercourse with a casual partner in the previous six months (Table 3). Among these 86 participants, three quarters indicated that they had "always" used a condom during anal sex with casual partners in the past six months. Four of the 86 participants who always used a condom during anal sex with casual partners in the past six months, reported using non-water-based lubricant. In total, 25 of the 86 participants (29.1%) who engaged in anal sex with a casual partner in the past six months either did not always use a condom or did not use a condom with water-based lubricant. Among these 25 men, their number of casual partners in the past six months ranged from 1 to 120 (median=10) with an average of 23.4.

Reasons for using condoms during anal intercourse

Participants were asked to check all options from a list that best described why they did or did not use condoms during anal sex (we assume that for MSM fucking is synonymous with anal intercourse). It was understood that these questions applied to regular and/or casual partners. As indicated in Table 4, of the 91 men who checked one or more reasons why they used a condom for anal intercourse, all men indicated STI/HIV prevention as a reason. Almost three quarters checked Hygiene and just over two thirds indicated that the need to be careful with an unfamiliar sex partner was a reason they had used a condom. Just under a third indicated that a reason they had used a condom was because a partner had chosen to and 16 of these 91 men indicated a reason they had used condoms was that they had felt uneasy after being fucked without a condom and 15 cited being more cautious after becoming infected with an STI. Since only 4 of 96 checked "other reasons", it would appear that the list of options encompassed the participant's key reasons for condom use.

Reasons for not using condoms during anal intercourse

Forty-four (45.8%) of the 96 men who reported having anal sex checked reasons that best explained why they had not used condoms if there had been occasions where they had previously not used them for anal intercourse. As shown in Table 4, seven of the different reasons for not using a condom were cited by 20% of the men, suggesting that there are a wide variety of factors that explain unprotected anal intercourse in this population. Having a partner who appears to be healthy and getting carried away with the excitement of moment were each cited by over 40% suggesting that these are important obstacles to condom use for these men. Just over a third checked that a preference for bareback sex was a reason they had not used condoms.

Discussion

The present study sought to document HIV-testing history, condom use during anal sex and reasons for using or not using condoms in a sample of East and South East Asian men surveyed in a bathhouse setting. The participants were mostly single, aged 20-39, homosexual/gay or bisexual. In these respects, they reflected the common social demographic of men who go to bathhouses, places that tend to attract younger, single men seeking anonymous sexual encounters with other men (Poon et al., 2001).

At the time of the study, about 3% of participants reported that they were HIV positive which seemed to be relatively low. However, a sizeable percentage had never been tested for HIV or had last been tested two to four years or more ago. This is particularly concerning because about a quarter of participants did not always use a condom during anal sex with casual partners in the past six months and many had multiple sexual partners in that period. These men are at high risk for HIV infection and many are unaware of their current HIV status. Our findings reinforce the need to educate men visiting bathhouses of the importance of more frequent HIV testing. Development of culturally-appropriate strategies (such as linguistically specific HIV-testing information and counseling, and accessible HIV testing) is needed to encourage bathhouse patrons of East and Southeast Asian descent to be regularly tested for HIV. Past research has shown that many bathhouse patrons of East and Southeast Asian descent, who had never had an HIV test, would have done so had it been offered in bathhouses (Poon et al., 2001).

Consistent with previous research (Poon, Ho, Wong, Wong, & Lee, 2005; Singer et al., 1996), the present study suggests that some of the East and Southeast Asian MSM in this sample held misconceptions about HIV transmission and sexual risk behaviour. For example, a large percentage of the respondents who acknowledged having had unprotected anal sex with a casual partner chose "If sex partner looked healthy, should be ok" as one of their reasons for not using condoms. HIV prevention education still needs to emphasize that HIV status cannot be determined by a partner's appearance. As in other studies (Adam, Husbands, Murray, & Maxwell, 2005; Adam, Sears, & Schellenberg, 2000), these men chose not one but, rather, a combination of reasons for engaging in unprotected anal sex. It is thus important to develop holistic and culturally relevant strategies that address other risk-related issues such as substance use and social isolation (Poon & Ho, 2002; Poon et al., 2001, 2005).

The findings of this study have implications for the formulation of public health interventions targeting HIV risk reduction among East and Southeast Asian MSM visiting bathhouses. Interventions can reinforce men's existing perceptions as to why they should use condoms. For example, all the men in this study who used condoms for anal intercourse did so, at least partially, to prevent STI/HIV infection. While this may seem like an obvious finding, it suggests that prevention messages that clearly and explicitly link condom use to HIV prevention will resonate with men visiting bathhouses. In addition, the reasons the men in this study gave for not using condoms provide clear direction for the content of HIV prevention interventions targeting East and Southeast Asian MSM. In particular, interventions need to stress that appearance does not indicate the HIV status of a partner. Sexual risk reduction interventions may also need to stress skills development that will help men to pause to put on a condom when they are in a high state of arousal. It may also be helpful for interventions to encourage men who prefer barebacking to reassess the HIV risk of not using a condom.

Limitations of the study

Our study sample of East and South East Asian men was drawn from a single bathhouse in one Canadian city. Although we were able to recruit 101 participants, the sample size is still relatively small. These factors may limit the generalizabilty of our findings for these populations. Furthermore, sex is a sensitive subject in many Asian cultures (Poon & Ho, 2002; Poon et al., 2005), and our participants may thus have been hesitant about fully disclosing their sexual behaviours for fear of being judged. Our findings nevertheless showed that many of the participants had multiple sexual partners and had engaged in unprotected anal sex with at least one casual partner in the past six months. These men were clearly vulnerable to HIV infection and it is a limitation of the study that we did not ask questions regarding the number of casual partners with whom these men engaged in unprotected anal sex. Further study is needed to determine the extent of HIV transmission in this population.

Acknowledgements: This project was funded by the Community-Linked Evaluation AIDS Resource Unit at McMaster University. The authors would also like to thank Gina Browne, Rose Sokolowski, and Maria Wong for their assistance in conducting this project.

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Maurice Kwong-Lai Poon (1,3), Josephine Pui-Hing Wong (2,3), Noulmook Sutdhibhasilp (3), Peter Trung-Thu Ho (3,4), and Bernard Wong (5)

(1) School of Social Work, York University, Toronto, ON

(2) Daphne Cockwell School of Nursing, Ryerson University, Toronto, ON

(3) Asian Community AIDS Services, Toronto, ON

(4) Regent Park Community Health Centre, Toronto, ON

(5) Department of Mathematics, University of Toronto, ON

Correspondence concerning this article should be addressed to Maurice Kwong-Lai Poon, School of Social Work, York University, 4700 Keele Street, Toronto, ON M3J 1P3. E-mail: mklpoon@yorku.ca
Table 1 Demographic characteristics of survey
participants (n=101)

Ethnicity
  Chinese                      57 (56.4%)
  Filipino                     17 (16.8%)
  Vietnamese                   12 (11.9%)
  Korean                        5 (5%)
  Japanese                      4 (4%)
  Other (Thai, Indonesian)      6 (5.9%)

Sexual identity
  Heterosexual/straight         0
  Homosexual/gay               77 (76.2%)
  Bisexual                     20 (19.8%)
  Other                         4 (4%)

Age
  20-29                        33 (32.7%)
  30-39                        49 (48.5%)
  40-49                        15 (14.9%)
  50 and up                     3 (3%)
  Not stated                    1 (1%)

Marital Status
  Married                       5 (5%)
  Live with partner            11 (10.9%)
  Divorced/separated/widowed   11 (10.9%)
  Single/never been married    74 (73.3%)

Living arrangement
  Living alone                 55 (54.5%)
  Spouse/partner               13 (12.9%)
  Friend/ room-mate            13 (12.9%)
  Family/relative              19 (18.8%)
  Other                         1 (1%)

Table 2 HIV testing of survey participants

HIV testing (n=101)

  Ever tested             85 (84.2%)
  Never tested            16 (15.8%)

Last HIV test (n=85)

  0-6 months ago          27 (31.8%)
  7-12 months ago         23 (27.1%)
  1-2 years ago           15 (17.6%)
  2-4 years ago           13 (15.3%)
  More than 4 years ago    7 (8.2%)

Table 3 Condom use with casual partners in the past
six months (n=86)

Condom use
  Always         65 (75.6%)
  Often          13 (15.1%)
  Occasionally    4 (4.7%)
  Never           4 (4.7%)

Table 4 Reasons for using and not using condom in anal intercourse

Reasons for using a condom (n=91) *

  Prevention of STIs and HIV/AIDS                          91 (100%)
  Hygiene                                                  66 (72.5%)
  Unfamiliar sex partner, would rather be careful          62 (68.1%)
  Partner chooses to use condoms                           28 (30.8%)
  Prevent from feeling uneasy after being fucked without   16 (17.6%)
    a condom
  Previously infected with STIs, now becoming more         15 (16.5%)
    cautious
  To delay ejaculation                                      4 (4.4%)
  Other reasons                                             4 (4.4%)

Reasons for not using a condom (n=44) **

  If sex partner looked healthy, should be ok              19 (43.2%)
  Got carried away in the excitement of the moment         19 (43.2%)
  Prefer bareback                                          16 (36.4%)
  Under the influence of drugs                             11 (22.7%)
  No point in worrying since already having chosen to go   11 (22.7%)
    out and play
  No condom available                                       9 (20.5%)
  Partner refused                                           9 (20.5%)
  Uncomfortable to suggest it                               6 (13.6%)
  Felt bored or depressed                                   4  (9.1%)
  Other reasons                                             7 (15.9%)

* Respondents were asked to check all that apply. Of the 96
participants who had ever engaged in anal intercourse, 91
replied to the question about their reasons for using a condom.
Percentages are based on these 91 men.

** Respondents were asked to check all that apply. Of the 96
participants who had ever engaged in anal intercourse, 44
replied to the question about their reasons for not having used a
condom at some time.
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