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Intensive sex partying: contextual aspects of 'sexual dysfunction'.

INTRODUCTION

In this paper we position patterns of sexual behaviour between HIV-positive and HIV-negative gay men, and understandings of reported sexual dysfunction, in relation to a particular sexual context: intensive sex partying. Our primary purpose here is to describe that context and the meaning of sexual desire and dysfunction within it

Most new HIV infections amongst gay men in Australia are associated with the practice of 'unsafe' anal sex [1]. This appears to be associated with specific contexts characterised by high levels of HIV and sexually transmissible infections (STI) [2-5]. In addition, recent seroconversions among gay men often involve receptive unprotected anal intercourse (UAI) with partners they knew to be HIV-positive at the time [1]. These infections occur even though, in Australia, rates of HIV testing among gay men remain high, and STI testing is increasing [6,7]. About 50% of gay men practice safe sex all of the time, including UAI in 'negotiated safety'--an agreement between two HIV-negative regular partners within an ongoing committed relationship to restrict UAI only to sex with each other [8]--while about 40% practice occasional unprotected anal intercourse with casual partners (UAIC) and about 10% do it more often [9-11]. The Ioccasionality' of much UAIC can be seen as a marker of a general commitment to a safe sex culture and of an awareness of the consequences of risk behaviour. Some UAIC involves men restricting occasions of UAIC to partners they believe to be of the same HIV serostatus as themselves [12]. This practice of serosorting relies on men having been tested for HIV, and testing regularly. It is sometimes accompanied by uneven levels of knowledge relating to the role of clinical markers such as the viral load of HIV-positive gay men in sexual risk-reduction practices [13,14].

The selected behavioural data reviewed here relate to the intersection between men who are sometimes known as 'sex pigs' (gay men who seek intensive, adventurous, sex experiences) and 'party boys' (gay men who frequently attend gay community party venues and events, often in the context of illicit drug use). We refer to this intersection between frequent partying, frequent sex, sequential or simultaneous multiple sex partners, drug use, adventurous sex, a broad sexual repertoire with sexual experimentation and UAIC as 'intensive sex partying'. It provides an analytic framework for analysing the behavioural and affective intensity characteristic of this context. The small subset of gay men who frequently engage in intensive sex partying seek to maximise their sexual pleasure, in physical and virtual spaces and in sexual networks that facilitate this. How gay men understand pleasure and their own sense of 'well-being' is socially constituted [15-17]. They have multiple behavioural motivations for participating [18,19].

The shared nature of these men's behavioural characteristics is considered in relation to studies of seroconversion [1,20,21], to the well practised use of sex venues [22,23], and to a body of research on adventurous sex [24-27]. We review reported findings from studies that include men we believe are engaged in intensive sex partying and consider the meaning of sexual desire and dysfunction in this context.

The behaviours of men engaging in intensive sex partying are associated with high levels of risk. There are strong associations between risk behaviour and some key indicators of what has been referred to elsewhere as sexual adventurism [10,28]. The initial configuration of adventurous sex included: multiple sex partners; use of amphetamine-type substances; use of sex parties and sex on premises venues; and, 'esoteric sex practices', such as sadomasochistic practices (S/M), brachioproctic practices ('fisting') and urolagnia ('watersports') [25]. A later modification argued that while sexual adventurism was designed to identify sociocultural and contextual predictors of HIV seroconversion it could be extended to refer to 'a set of sexual practices, to a sub-cultural network, and to a sexual context' [26]. This modification was itself subsequently adapted to include subcultural and individual aspects of adventurism within contextual analyses of risk amongst some gay men [27]. We locate adventurous sexual practices within these ongoing formulations and explore the contextual implications for the meaning of sexual dysfunction.

Much of the international research discusses these associations of risk and sexual adventurism in relation to 'barebacking' [29] or the use of methamphetamine or both [30,31]. Some of it includes the role of pleasure [30,32-34] and its implications for health promotion [35,36]. Our analysis indicates that understanding risk and adventurous sex requires not only accepting their association with high levels of pleasure, but also the likelihood that the self-conscious pursuit of pleasure may be primary in specific contexts.

HIV-positive gay men are less likely to engage in UAIC with men they do not necessarily know to also be HIV-positive [10,37,38] and their URIC with partners who are not known to be HIV-positive includes several risk reduction practices [39]. They are, however, more likely to be engaged in intensive sex partying than are men who have not tested HIV-positive. A comparison of findings from the large Australian cohort studies of HIV-negative gay men, Health in Men (HIM), with those from an equivalent study of HIV-positive gay men, Positive Health (pH), both in Sydney, shows that the HIV-positive men were likely to report a broader sexual repertoire in general [40,41]. (These two cohort studies are collaborative research projects between the National Centre in HIV Epidemiology and Clinical Research and the National Centre in HIV Social Research, at the University of New South Wales.) They were more likely to report engaging in most 'esoteric' practices: 28% of HIV-positive men and 11% of HIV-negative men reported insertive 'fisting'; 35% and 19%, respectively reported S/M practices. Also, they reported use of illicit drugs, including amphetamine-type substances, at higher rates [31,42]. Futures 5, a national survey of HIV-positive people, most of whom were gay men, found high rates of use of licit and illicit drugs: 22.9% reported recreational use of Viagra in the previous 12 months; 12% reported use of 'speed' (non-injected); over 17% reported use of methamphetamines; over 9% reported injecting speed; and over 7% used cocaine [37].

In HIM, new HIV infections and STIs were often associated with a greater number of partners, sex with HIV-positive partners and some esoteric practices, such as fisting [3-5]. Also, those men who engaged in practices and behaviours associated with intensive partying were probably more likely to be HIV-positive: as well as being more sexually active and being more likely to engage in 'esoteric' sex practices, men who contracted syphilis were more likely to be HIV-positive [2]; men in the pH study reported high levels of all STIs [5]. Both HIV-negative and HIV-positive men who engaged in practices associated with intensive partying were also more likely to have HIV-positive partners: recent seroconverters often reported risky sex with partners they knew to be HIV-positive [1]; as did men who contracted other STIs [3,4]. A relatively small number of men probably accounts for a disproportionately large proportion of UAIC and this small number of men is likely to include a relatively large proportion of men engaged in intensive sex partying [10,28].

However, these practices and their effects on 'dysfunction' amongst gay men cannot be analysed adequately if they are understood only, or primarily, in relation to HIV or STI risk behaviours.

In the HIM study, many men reported some form of self defined sexual dysfunction and this was associated with indicators of intensive sex partying: having more casual sex partners, UAIC, sex with HIV-positive partners, esoteric sex practices and use of illicit drugs [43,44]. Cove and Petrak found relatively high levels of sexual dysfunction among HIV-positive men, and this was associated with risk-taking behaviour [45]. They also noted that while these men reported problems with sexual function, this did not necessarily reduce their likelihood of continuing to engage in the associated sexual practices.

It may be that for these men the nature of their sexual activity explains at least some of their reported sexual dysfunction: Being more sexually active, they may have been more likely to report occasions when they experienced some form of sexual problem. Also, highly sexually active men were more likely to use medications, and indeed any other methods, to improve their sexual performance and to enhance their experience of sexual encounters, regardless of any clinical diagnosis. The use of drugs to enhance sexual pleasure, including medications to enhance erection, was found to be associated with more frequent UAIC in the HIM cohort [28]. What is described as sexual dysfunction in the context of intensive sex partying may represent behaviours that concern the maximisation of pleasure over extended periods of intense sexual activity, or during encounters involving unusual, or 'esoteric' sexual practices. For these men, the sexual problem they experience may be an incapacity to maintain an erection for several hours while simultaneously using illicit drugs, or experiencing pain while a fist is inserted into the rectum.

This contextual understanding of sexual dysfunction is consistent with an emerging distinction between sexual dysfunction (as an assumed organic pathology) and more socially and circumstantially informed understandings of sexual difficulty [46]. The data we refer to here that relate to intensive sex partying make it likely that at least some sexual difficulties are transient. Ongoing analysis of the Sex in Australia survey data suggests difficulties are frequently contextualised as being of less importance over time by those reporting them [47]. Also Nobre and Pinto-Gouveia found that symptoms of sexual dysfunction were often related to individual beliefs about sexual function and performance, particularly more narrow gender-based beliefs [48]. Numerous studies have found that the experience of sexual problems is related at least as much to the quality of the affective relationship between partners as to physiological conditions [49].

Self-reported sexual dysfunction among these men is not, therefore, necessarily an indicator of pathology per se. It may equally be an indicator of their own levels of sexual activity and of an emphasis, by the men themselves, upon their own, and their partners' sexual pleasure, and, more broadly, of their active pursuit of that pleasure, often in the context of intensive sexual partying. That they report sexual 'problems' and relatively high use of medications and illicit drugs to enhance their sexual pleasure may suggest that they are seeking 'better' or more intense sexual experiences, and, in the pursuit of these, sometimes experience difficulties.

In HIM, younger and more sexually active HIV-negative men were also more likely to report difficulties during receptive anal intercourse [43,44] and reporting such difficulties was associated with UAIC. Usually the HIV-risk literature discusses dysfunction in relation to erections, and is less likely to report difficulties in receptive anal sex. This self-reported problem might be regarded as evidence of pathology, either as a clinical problem in its own right, or as evidence of a desire to engage in risk behaviour. Both are seen as requiring one or more interventions: prophylaxis, counselling or therapy. An alternative is to regard difficulties in receptive anal intercourse as an opportunity for sex-positive interventions. Workshops targeting young men to improve their experience of receptive anal intercourse, during which condom use and risk management are reinforced have since been developed by the AIDS Council of New South Wales. The median age of new HIV infection amongst gay men in Australia has been increasing in recent years and has now reached 37 years [50]. Interventions of this sort, targeting highly sexually active younger men may have some long-term impact on HIV infections among these men in future years by equipping them with the skills to engage in receptive anal intercourse more safely.

Intensive sex partying is not problematic in itself. Much of the sex that occurs is safe. This safety takes various forms: HIV seroconcordancy, use of condoms, non-anal sex. It becomes problematic in relation to the likelihood of disease transmission, infection or the presence of other health issues. In the absence of these it simply involves the pursuit of pleasure. While for health professionals, disease transmission is an unavoidable consideration, for the men themselves this may not always be their first priority. It would appear that, for many, the cultural space of intensive sex partying involves the active construction of sexual pleasure and social participation. It may also include distraction and dissociation from the mundane. Distraction is actively sought and knowingly choreographed [22,23]. It involves the intentional pursuit, and creation, of experience as extraordinary. It is an extraordinary space in that the players, in interaction, maximise the potential for intense moments of corporeal immersion. Increased sensation and affect are delicately balanced with more regulatory versions of care of the self and others. This is the case for both HIV-positive and HIV-negative men, although the mix of matters requiring regulatory diligence has different components for each. Safe sex is still a consideration, but it is more likely to break down in intensive sex partying. HIV-negative players, in particular, may become distracted from viral self-care. This is especially so when they break their own rules and choose to 'bottom' in UAIC, as is commonly reported among recent seroconverters [1].

Smith et al. characterise contexts of adventurous sex in terms of ongoing tensions between disinhibition and self regulation [27]. We have found this to be a particularly suggestive characterisation and have shifted the application of this tension to the context of 'intensive sex partying'. However, we renamed 'disinhibition' as 'the maximising of pleasure' in order to highlight the positive sense of productivity involved for participants and we further distinguished between structural aspects of the tension and its presence in sexual practices.

In terms of sexual practice, 'intensive sex partying' includes a desire for, and practices likely to lead to, the maximisation of pleasure, as well as practices of self-care. In practice, the techniques involved in both are often coincident. Contextually, however, they can polarise. Time in the sense of duration is a key factor here [24]. The polarisation has to do with: (1) maintaining the quality of sexual interaction over time, especially, but not only, under the influence of alcohol or drugs, or a mix of the two; and (2) the desire to 'top' or 'bottom' in anal intercourse and the associated bodily requirements of each position. It affects (3) the risk of HIV transmission by positive men; (4) the risk of HN infection for HIV-negative men; and (5) the risk of STI transmission.

The tension in practice between a desire for the extraordinary and the management of practical details requires active choreographing if the maximising of pleasure is to be achieved. This is as much about location or event selection, self-presentation, partner selection (having multiple partners is not necessarily an indiscriminate selection process) drug administration rituals and procedures and dose management, as it is about chosen sexual roles. Indeed those roles may, and do, vary over time within the same and between different encounters. The tension is also sometimes intensified by, amongst these other things: drug taking for sexual purposes [28,30]; the management of the drug using; and, at least with methamphetamines, any difficulties associated with that management [34]. It is the ongoing nature of the tension in practice that we emphasise here though, not the drug use per se. This tension holds for non drug users in the same space, although the maximisation of pleasure may involve different procedures. The tension is ongoing both within a single extended period of sex partying as well as in the frequent repetition of such periods. For some, managing, if not exploiting, the tension may be a deliberate strategy in the production of peak experience.

In terms of HIV-negative men and the risk of HIV infection, and HIV-positive men and the risk of transmission, intensive sex partying as a cultural space is structured by a potential polarisation between pleasure maximisation and self-care. Because the tension is situationally normalised and becomes habitual, ongoing risk management strategies can tend to minimise or underestimate the likelihood over time of the tension being resolved by reversion to one of the poles--the maximisation of pleasure. Given the likelihood of high HIV and STI prevalence in this space, this structural tension and its practical resolution are major contributory factors in risk exposure. It is difficult to believe that successful risk management is possible for most men over time in this context.

'Sero-sorting', 'strategic positioning' and other risk minimisation strategies require detailed knowledge about HIV transmission, mutual and accurate disclosure of HIV serostatus, and complex negotiations and trust. The HIV prevention problem in the context of intensive partying is that even those HIV-negative men involved who are highly informed do not keep to their own risk-reduction rules and as a result they seroconvert.

Among the men who seroconvert the main reason cited for their seroconversion is that they engaged in receptive UAI, usually with a casual partner, and often with a partner they knew to be HIV-positive at the time [1], all of which is a clear departure from the risk-minimisation strategies that are usually observed. Most seroconversions in this context involve participants becoming anally receptive. For some HIV-negative men, sexual dysfunction may sometimes be about poor drug-use management strategies, or it may be due to a desire to bottom. Again, this is not dysfunction per se.

To the degree there is a problem here, it has to do with managing sexual difficulty, as well as managing HIV risk [51]. The problem with serosorting in casual sex is how to establish seroconcordance with any reliability (seroguessing'), especially if it is accompanied by participants departing from their own risk-reduction practices. There is a well-founded recognition in health promotion of the need for multi-level prevention practices. Some men who engage in intensive sex partying may report symptoms of sexual dysfunction. Interventions can target those particular symptoms but can also provide an opportunity to work with these men in the context of risk management.

ACKNOWLEDGEMENTS

The National Centre in HIV Epidemiology and Clinical Research Centre and the Australian Research Centre in Sex, Health and Society are funded by the Australian Government Department of Health and Ageing.

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Correspondence to: Dr Garrett Prestage, National Centre in HIV Epidemiology er Clinical Research, Faculty of Medicine, University of New South Wales, UNSW Sydney, NSW 2052, Australia. Email: gprestage@nchecr.unsw.edu.au

Michael Hurley * and Garrett Prestage ([dagger])

* Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Australia.

([dagger]) National Centre in HIV Epidemiology and Clinical Research, The University of New South Wales, Sydney, Australia.
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Title Annotation:LEADING ARTICLE
Author:Hurley, Michael; Prestage, Garrett
Publication:Journal of HIV Therapy
Geographic Code:8AUST
Date:Jun 1, 2007
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