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CONSUMPTION OF SEXUALLY EXPLICIT MEDIA AND UNPROTECTED ANAL SEX IN MEN WHO HAVE SEX WITH MEN

1. Anderson de Araújo Martins. Instituto Integrado de Saúde. Universidade Federal de Mato Grosso do Sul, Brasil. E-mail: andersonufms@gmail.com. (https://orcid.org/0000-0003-4964-3595)
2. Artur Acelino Francisco Luz Nunes Queiroz. Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Brasil. E-mail:arturqueiroz@usp.br (https://orcid.org/0000-0002-6350-1908)
3. Oleci Pereira Frota. Instituto Integrado de Saúde. Universidade Federal de Mato Grosso do Sul, Brasil. E-mail: olecifrota@gmail.com (https://orcid.org/0000-0003-3586-1313)
4. Telma Maria Evangelista de Araújo. Departamento de Enfermagem, Universidade Federal do Piauí, Brasil. E-mail:telmaevangelista@gmail.com (https://orcid.org/0000-0001-5628-9577)
5. Isabel Amélia Costa Mendes. Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Brasil. E-mail:iamendes@usp.br (https://orcid.org/0000-0002-0704-4319)
6. Inês Fronteira. Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Portugal. E-mail: ifronteira@ihmt.unl.pt (https://orcid.org/0000-0003-1406-4585)
7. Álvaro Francisco Lopes de Sousa. Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Portugal. E-mail: sousa.alvaromd@gmail.com (https://orcid.org/0000-0003-2710-2122)
Correspondence
Álvaro Francisco Lopes de Sousa
Rua da Junqueira, 100
1349-008 Lisboa
Portugal
Email: sousa.alvaromd@gmail.com

RESUMO
O objetivo deste estudo foi avaliar a influência do consumo de mídia sexualmente explícita (MSE) de modalidade bareback na prática de sexo anal sem preservativo por homens que fazem sexo com homens (HSH). Para tanto, foi criada uma página na rede social Facebook® com um link que direcionava os interessados para um questionário. Foram incluídos homens cisgênero, com 18 anos ou mais e que praticaram sexo com outro(s) homem(ns) nos últimos 12 meses. Os dados foram coletados em 2017 e analisados por meio de estatística inferencial (uni)bivariada e regressão logística multivariada. Participaram da pesquisa 2.248 HSH, com média de idade de 24,4 anos e média de 3,9 parceiros nos últimos 30 dias. Possuir múltiplos parceiros sexuais (ORa:9,4; IC95% 3,9-22,4), preferir filmes com cenas bareback (ORa:2,6; IC95% 1,5-4,6), julgar essa prática um fetiche e realizá-lo (ORa:3,52; IC95% 2,3-5,4), ter parceria casual (ORa:1,8; IC95% 1,5-1,9) e ciência do status sorológico negativo do parceiro para o HIV (ORa:1,4; IC95% 1,1-2,3) foram fatores que aumentaram as chances de envolvimento em sexo anal sem preservativo. Dessa forma, verificamos associação entre o consumo de MSE bareback e a prática de sexo sem preservativo entre HSH.
Palavras-chave: Mídia Audiovisual. Comportamento Sexual. Sexo sem Proteção. Preservativos. Minorias Sexuais e de Gênero.

ABSTRACT
This study aimed to evaluate the influence of bareback sexually explicit media (SEM) consumption on anal sex without a condom by men who have sex with men (MSM). To this end, a page was created on the Facebook® social network with a link that directed interested parties to a questionnaire. Cisgender men, aged 18 years and over, who had sex with other men in the last 12 months, were included. Data were collected in 2017 and analyzed using univariate and bivariate inferential statistics and multivariate logistic regression. A total of 2,248 MSM participated in the research, with a mean age of 24.4 years and a mean number of 3.9 partners in the last 30 days. Having multiple sexual partners (ORa: 9.4; 95% CI 3.9-22.4), preferring movies with bareback scenes (ORa: 2.6; 95% CI 1.5-4.6), considering this practice a fetish and realizing it (ORa: 3.52; 95% CI 2.3-5.4), having casual partnerships (ORa: 1.8; 95% CI 1.5-1.9) and being aware of the partner’s negative serological status for HIV (ORa: 1.4; 95% CI 1.1-2.3) were factors that increased the likelihood of engaging in anal sex without a condom. Thus, we found an association between the consumption of bareback SEM and sex without a condom among MSM.
Keywords: Audiovisual Media, Sexual Behavior, Unprotected Sex, Condoms, Sexual and Gender Minorities

INTRODUCTION
Sexually explicit media (SEM) comprise any type of material describing genitals or explicit sexual acts of any nature, causing or modifying the viewer’s sexual feelings or thoughts1. Technological advances allowed the expansion and facilitated access to SEM, especially among male individuals, including men who have sex with men (MSM), and their consumption is widely accepted among them2.
The effect of SEM consumption on MSM’s sexual health is controversial in the literature. Some studies have identified positive influences of SEM consumption on sexual development and sexual practices in MSM, as many adolescents and young people use these media as a source of information to learn about sexual identity, how to have sex with other men, understand their desires3,4, improve self-efficacy in condom use and increase interest in safe sex5. However, others report negative influences on sexual behavior, such as the acceptability of having sex without a condom as something common6. The differences found between studies may be associated with recent SEM changes regarding the use of condoms in the scenes, although there is no consensus on this association.
Alarmed by the AIDS epidemic, gay porn studios produced almost exclusively condom films until the late 1990s and early 2000s. From the second half of the 2000s, however, the homoerotic industry saw an increasing trend in the production of bareback films, an English term that refers to a horseback riding style in which the “cowboy does not use a saddle”. The expression has been widely used by MSM to designate sex in which condoms are intentionally given up12-14.
These films often show semen exchange between actors, which has now become an almost universal practice among gay MSE producers7,8. In the U.S., one of the largest SEM producers in the world, only two of the major studios (GayHoopla and GayRoom) continue to use condoms, and most new sexual scenes among gays are bareback9.
One of the reasons for this expanded SEM without a condom is the need to meet the increase in search of viewers for videos that portray this practice, which report that they represent the most natural sex, that is, closer to reality, and that they can carry different meanings depending on the scenario or context presented, the characteristics of the actors involved and the power relationships observed in the scene8. Other factors that favored the growth of this type of SEM were the advances in antiretroviral therapy (ART), the emergence of PrEP with the combination of Emtricitabine and Tenofovir as pre-exposure prophylaxis for HIV, and serological testing to ensure the production of bareback movies and the sexual health of actors10,11.
In this sense, the term bareback has become common in SEM, ceasing to be one of the categories for gay audiences and becoming the norm. However, the increase in this practice may be contributing to a higher prevalence of HIV and other STIs in MSM15,16.
SEM consumption is significant in Brazil. A report by the Pornhub website, one of the largest erotic video platforms globally, registered 81 million daily visitors, with 28.5 billion yearly visitors. Brazil ranked tenth among the countries that most accessed Pornhub, with a predominant search for gay pornography18. In parallel, it was the only Latin American country with higher levels of new infections in the latest UNAIDS report and is the territory with the largest number of people living with HIV/AIDS in the Latin American region17.
Since no studies evaluate this object in the country, we aimed to assess the consumption of bareback SEM by men who have sex with men in Brazil and its association with anal sex without a condom.
MATERIALS AND METHODS
This is an observational, cross-sectional, analytical study, using an online national (Brazil) survey conducted with MSM. An intentional sample was used based on the population of 3.5% of MSM recommended by the Brazilian Ministry of Health19. The sample size calculation also considered a maximum tolerable error of 5% and a significance level of 5%, and the final sample was fixed at 2,248 participants. The eligibility criteria were living in Brazilian territory, identifying as a cisgender male, aged 18 years or older, and having had at least one sexual relationship with another man in the last 12 months.
A page was created on Facebook® (https://www.facebook.com/taafimdeque/) with a fixed post containing details of the survey and an invitation to participate in order to collect data. This post was boosted to reach online participants in all Brazilian regions. Concomitantly, the research was published in Facebook® groups focusing bareback or SEM. Users had access to a link that directed them to the study questionnaire hosted on Google Forms. Internet users who met the selection criteria were included, signed the Informed Consent Form online, and filled out all the questionnaire items. Participants should inform the e-mail to avoid duplicate responses.
The research questionnaire was subdivided into four sections: (i) personal characteristics, (ii) socio-cultural characteristics, (iii) health issues, and (iv) sexually explicit media consumption. Regarding SEM consumption, the participants were asked: a) if they preferred films with scenes with or without condoms; b) the age they started watching pornography; c) how many scenes they usually watched each week (considering that a scene contains an average of 20 minutes); d) how many minutes of bareback pornography they watched each week (considering that a scene contains an average of 20 minutes); e) the main access route to pornography; f) if, in their perception, bareback pornography consumption changed their sexual practice; g) if bareback sex was considered a fetish; and h) if bareback sex was considered a realizable fetish, that is, performed. Issues related to sexual posture (insertive/receptive/versatile) and anal sex without a condom (30 days to 6 months before the survey) were also raised by direct questions with a binary outcome (yes or no). Data was collected in September 2017.
The descriptive analysis of the numerical and categorical variables was performed with the IBM® Software Statistical Package for the Social Science (SPSS) version 26.0. The chi-square or Fisher’s exact tests were used for the bivariate analysis of the variables of interest regarding the preference for bareback SEM, and variables with p<0.50 were carried forward to the multivariate logistic regression model. The crude and adjusted odds ratios (OR) (ORa) were obtained to assess factors related to the likelihood of engaging in unprotected anal sex, adopting the binary outcome “did you engage in anal sex without a condom? (Yes, No)”. Variables with p<0.20 were admitted for constructing the logistic regression model adjusted with the forward conditional input method. The level of significance was set at 5%, with 95% confidence intervals. The best performance was considered of the multivariate model with aspects of accuracy, sensitivity, and specificity (Receiver Operating Characteristic - ROC), proving that the statistical performance developed was better than random.
The study complied with national and international human research ethics standards and was approved by the Research Ethics Committee of the Federal University of Piauí, Brazil, under Opinion N° 1.523.003.
RESULTS
A total of 2,248 MSM participated in the study, with a mean age of 24.4 years (SD±5.6). The most frequent among the MSM studied was being single (69.1%), having higher education (81.9%), having a casual sexual partner (68.9%), identifying themselves as gay (85.3%), and having a negative serological status for HIV (49.1%). On average, the participants had 3.9 partners in the last 30 days, and a considerable percentage (33.3%) had more than three partners (Table 1).
TABLE 1
Table 2 shows the results of the association between sociodemographic and behavioral characteristics with the outcome of sex without a condom at least once in the six months before data collection. Except for HIV serological status (0.103), all variables were statistically significant.
TABLE 2
Table 3 shows the association between sex without a condom and the preference for consuming bareback scenes, in which all variables were statistically significant.
TABLE 3
We opted for the logistic regression model to evaluate the influence of social, demographic, behavioral, and consumption characteristics on unprotected anal sex, by which we observed that the likelihood of engaging in anal sex without condoms increased: (i) having had three or more partners in the last 30 days (ORa=9.4 times); (ii) having bareback as a realizable fetish (ORa=3.5); (iii) preferring SEM with bareback scenes (ORa=2.6); (iv) having a casual sexual partner (ORa=1.8); and (v) knowing about the partner’s negative serological status for HIV (ORa=1.4). On the other hand, protective factors were (i) not considering bareback as a fetish; (ii) being in a relationship; and (iii) having a relationship with an HIV-positive partner (Table 4).
TABLE 4
DISCUSSION
This nationwide study recorded an association between preferring to watch bareback SEM and engaging in anal sex without a condom among Brazilian MSM. The number of partners, the type of sexual partnership established, the protection strategies adopted, and bareback fetishization seem to considerably increase the likelihood of individuals engaging in anal sex without a condom.
The preference for bareback movies was significantly associated with sex without condoms among participants, with insertive/receptive anal sex, and oral sex, increasing 2.6 times the likelihood of MSM engaging in anal sex without condoms. This data is similar to what has already been described by other authors in the U.S.6, Norway20, and Australia21, corroborating the existence of a direct link between the preference for bareback scenes and the intentions of engaging in sex without a condom.
According to the literature, MSM in a relationship with a steady partner tend to consume more bareback SEM and have more sex without a condom than single individuals with multiple partnerships and casual sex22. Such behavior can be explained because couples are more insecure and more likely to protect themselves at the relationship’s onset. However, as partners becomes long-lasting, trust and familiarity with partners increase, decreasing the perceived risk and causing those involved to decrease condom use frequency or not use condoms in their sexual intercourse with a steady partner23.
However, we observed that bareback SEM visualization could contribute significantly to an increase in anal sex without a condom among those with a stable relationship and those engaging in casual sex and with multiple partners, especially the youngest24,25.
Our findings show that almost half of the participants reported knowing about the negative HIV status of the last partner, which was associated with a greater likelihood of engaging in anal sex without a condom and may be due to the current serosorting, a term used to describe the choice of sexual partners based on HIV status26. Studies show that MSM have widely used this practice as a determinant for having sex without condoms among seroconcordant individuals, both in seronegative and seropositive individuals, especially when partners are familiar with each other27,28.
Among the survey participants, 47.7% reported not being aware of the status of the last partner. Of these, only a third reported having bareback sex in the last 30 days, reinforcing that unawareness of partners’ status may make these individuals prefer sex with condoms27.
However, there is evidence that the increase in serosorting related to anal sex without condoms in MSM can contribute to the higher incidence of other STIs, such as syphilis29, chlamydia, gonorrhea30, and hepatitis C31, besides HIV, considering the existence of immune window periods and the associated risks. SEM play a vital role in this process, as seronegative men consuming bareback SEM are more tempted to perform it than those consuming SEM in a protected relationship32.
This connection is based on the fact that human behavior has a potential basis for imitation, that is, individuals tend to reproduce consciously or unconsciously other people’s attitudes, influenced by social, cognitive, emotional aspects, which directly or indirectly translate their preferences, even if they represent some health risk33,34. In this way, bareback SEM exposure can arouse interest in the viewer in the long or short term, making them direct their desire/fantasy for this practice, making it a fetish and stimulating curiosity in doing it.
Interestingly, we found that the number of participants who considered bareback a fetish was similar between those who engage in it and those who do not, which corroborates previous research20,35, suggesting that having bareback as a fetish may be a positive factor when perceived as a replacement for reality (real anal sex), that is, they have this practice as a fetish, but they do not realize it, so they keep on just wishing it. On the other hand, fetish can lead to excessive and problematic consumption of these media, enabling the tendency to see this behavior as a stimulus to practice, seeking new sensations, which increases the likelihood of having anal sex without a condom16,24.
Therefore, further research is required to investigate better whether MSM prefer bareback SEM either because they already engage in this type of sex, or because this predilection corresponds to an internal desire or fantasy, but does not represent their sexual behaviors, just as it is necessary to rethink prevention strategies for this population, with an emphasis on measures addressing safe sex eroticization and the clarification of pre-existing sexual beliefs, especially among the youngest, and that consider the new HIV prevention methods and strengthen the importance of condoms in preventing other STIs.
This study has some relevant limitations. First, the information was self-reported and subject to biases in memory and social desirability. Although there may be reservations about data from the viewpoint of information accuracy, the literature is full of studies that reinforce the feasibility of studying subjects that involve taboos and diseases laden with stigma and prejudice, such as HIV/AIDS, especially in not very accessible populations, through self-reported data36,37. Second, the incomplete responses were not saved in Google Forms. Third, the disclosure in specific groups on the Facebook® social network, focused on sexual practices among MSM, may have implied sample selection bias and influenced the results.
We also highlight that, although the research was carried out in all states of the five Brazilian regions, the absence of sample calculation hinders generalizing the data. Finally, the research was carried out when Pre-exposure Prophylaxis (PrEP), which could provide interesting findings related to the management of anal sex without a condom, was not freely available in Brazil.
CONCLUSION
We found an association between the consumption of bareback SEM and engaging in sex without a condom among MSM, in which the preference for media that portray this type of sex, the idea of considering it a fetish, the type of sexual partnership, and knowledge of the partner’s serological status for HIV may increase the likelihood of engaging in anal sex without a condom.
This study and much of the research already carried out on SEM’s influence on the sexual behavior of MSM considered only sex without a condom, excluding PrEP and other combined prevention methods. Thus, further studies are suggested to assess the relationship between the use of new prevention methods, the consumption of SEM, and the MSM’s sexual behavior.

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