Surveys, statistics & fearmongering about gay sex (part 1)

Is risky sex widespread among gay men in Ireland? A recent article in the Irish Independent told us that a new survey shows it is.

It’s true that there’s been a dramatic increase in new HIV diagnoses among gay and bisexual men in Ireland over the last decade—clearly something troubling is happening. There’s no doubt that we should be doing more to reduce the number of new infections.

One of the challenges we face is that we lack reliable information about what precisely is happening. We tend to see only rough figures that lack detail or context, figures that are easily framed by the media in ways that are alarming but misleading.

So what does this new survey actually say about the kind of sex gay and bisexual men are having? Does it shed any light on why new diagnoses are rising so dramatically?

The Survey

Healthy Ireland (HI) is the Department of Health’s newish prevention and wellbeing-focused “framework”. In 2014, the Department commissioned the first Healthy Ireland Survey and it recently released a Summary of Findings. The survey of 7,539 people living in Ireland aged 15 and up covered a wide range of topics, from the obvious (frequency of doctor’s visits, drinking and smoking, sexual behaviour) to the less obvious (access to public transport, how much rubbish is in one’s immediate environment).

Given the breadth of the survey and the massive amount of data collected, it’s not surprising that the Summary provides little in-depth analysis and offers mostly top-level data: gross percentages indicating how many people reported this or that answer to a question. While that can give us some idea of how things broadly look in Ireland, it also presents an opportunity for journalists to generate alarming headlines based on pretty scant information.

Here’s what the Summary has to say about gay and bisexual men:

  • 54% of men who most recently had intercourse with another man did not use a condom
  • 66% of men who most recently had intercourse with another man were in a relationship with that man
  • 6% of men report that their last sexual partner was a man

That’s about it.

What is “sex”?

The Independent article zeros in on that first bullet point and summarizes it this way: “More than half of men who recently had sex with another man did not use a condom.” But what does that mean? Is that true?

First maybe we can clarify what “sex” means here. Does this figure include all sexual activity or only anal sex?

The Summary refers to “intercourse,” but elsewhere explains that respondents reported the gender of their “last sexual partner.” What did the questionnaire actually ask? How did it define sex? What did the people responding to the question think it meant?

We honestly can’t tell from what’s reported in the summary, but lets assume for a moment that it means just anal sex, since that’s the kind of sex that presents a significant risk for HIV.

It might come as a surprise to some people, but gay and bisexual men don’t have anal sex every time we have sex. Some of us never have anal sex, others only rarely. Many men are more likely to have anal sex only with a steady partner but not with a casual partner.

The most recent survey of gay and bisexual men in Ireland that we have information for found that about 90% of respondents reported having anal sex with another man at least once in the last year. That’s during the whole year—not every time, or even in the most recent sexual encounter. When asked about their most recent sexual encounter with a casual partner, only 62% of men reported having anal sex.

So if that 54% figure includes only men who had anal sex, we can make a pretty good guess that the overall number of gay men who had anal sex without a condom the last time they had sex is between 33% and 48% (from the lowest rate of 62% to the highest of 90%). Even at the highest end it’s still less than half of all men, and likely much lower.

If, on the other hand, that 54% includes oral sex or other forms of sexual activity with little or no risk of HIV transmission and for which condoms are not commonly used, then there’s really no way to guess what proportion includes anal sex, but it could be even lower. For example, if only 62% of the men in this survey had anal sex with their last partner you’d need to subtract the other 38% from the 54% figure, leaving only 16% of the total having anal sex without a condom.

Already we see that it’s actually pretty unclear what’s being reported here. One thing we can be pretty confident of is that less than half of gay and bisexual men reported condomless anal sex in their last encounter, and likely much less.

What is “risky sex”?

Even if a significant number of gay and bisexual men are having anal sex without a condom, should we presume that it’s “risky sex”? Are those men necessarily “practising unsafe sex” as the headline frets?

Certainly anal sex without a condom is the most common way that HIV is sexually transmitted between men, but there are a multitude of other factors that affect the level of risk in any particular encounter. Even 30 years ago men knew that two HIV-negative people didn’t necessarily need to use a condom and devised ways to enjoy condomless sex safely. Now we have a much better understanding of when and how HIV can be transmitted and ways to reduce the chance of that happening.

How many of the encounters in that 54% involved steady partners who were both known to be HIV-negative? How many involved men of different HIV status where the HIV-positive man had an undetectable viral load? What percentage of these encounters involved two HIV-positive men? What percentage of men used another risk-reduction strategy such as sero-positioning or PrEP? How recently have the HIV-negative men in this group had an HIV test?

All of these things affect how “risky” a sexual encounter might be, independent of whether condoms are used. In many situations a condom can significantly lower the rist of HIV transmission, but in others it won’t make any difference at all.

Obviously people often fail to effectively translate what we know about risk-reduction into practice, but ignoring the variety of strategies that men have developed to reduce their risk of acquiring HIV misses important parts of the picture.

In early 2014, the US Centers for Disease Control announced that it would no longer use the term “unprotected sex” to refer to sex without a condom and instead use the more precise and accurate “condomless sex”. An excellent paper from earlier this year argues that measures of condom use for anal sex alone are no longer sufficient to evaluate sexual risk:

“Gay and other [men who have sex with men] engaging in [condomless anal intercourse] demonstrate clear patterns of HIV risk reduction behavior. As HIV prevention enters the era of antiretroviral-based biomedical approach, using all forms of CLAI indiscriminately as a measure of HIV behavioral risk is not helpful in understanding the current drivers of HIV transmission in the community.”

Sadly, the Summary does exactly what this paper warns against, providing a figure about condoms with no context. And the Independent only to eager to latch on to that figure and tout it as a clear indicator of “unsafe sex”.

What about everyone else?

The Independent makes much of the 54% figure, but how does it compare to overall figures for condom use? Are gay men especially unlikely to use condoms?

Actually, no. The overall figure for people who didn’t use a condom in their most recent intercourse (including all men and women with any partner) is 67%—that’s 25% higher than the figure for gay and bi men.

Even taking these ambiguous figures at face value, gay and bisexual men are more likely to have used condoms the last time they had intercourse.

We aren’t told in the summary exactly how many men did use condoms for their last intercourse with a man, only that 54% didn’t. Some might have reported that they don’t remember or that they didn’t want to say if they used a condom. If we assume that about the same percentage of men who has sex with a man gave those two answers as gave those answers overall (9%) we could make a rough guess that about 37% of men used condoms for their last intercourse with another man.

In contrast, the overall figure for people who used condoms the last time they had sex is only 24%.

Rather than suggesting gay men are unusually prone to “risky sex” one might instead choose to note that “gay men are 50% more likely to practise safe sex.”

There is one other group that the Independent (following the Summary) singles out as also having risky sex: “people who are not in committed relationships” and not using contraception.

Of course the Summary doesn’t mention “committed relationships,” only relationships, or sometimes “steady” relationships. That—like the aside that “men are more promiscuous than women”—is a subjective interpretation by the authors of the Independent article, not something that appears in the Summary.

Oddly, the rate of condom usage for gay and bisexual men for sex with someone who’s not a steady partner is not mentioned. The Summary says that the rate of condomless sex among gay and bisexual men is of “particular concern considering the higher prevalence amongst this group of sex with someone just recently met” but gives us no numbers to show us how high this “prevalence” is.

Gay and bisexual men, like the population generally, are more likely to use condoms with casual partners than steady partners. It would be interesting to know how the rate of condoms use varies by relationship type for gay and bisexual men. Instead, all gay and bi men not using condoms, in whatever contexts, are simply lumped in to the category of “risky” with a small section of the population with a very specific behavioural risk.

To be honest, the real reason that condomless sex between men is a concern isn’t the higher prevalence of sex “with someone just recently met,” it’s the higher prevalence of HIV. But this survey doesn’t seem to have asked any questions about HIV directly. Not whether or when respondents might have been tested. Not whether they might be HIV-positive.

Instead it offers one ambiguous figure about men who didn’t use condoms for some kind of sexual activity as if that speaks for itself.

Next: Is this anything new and how does it help us stop the spread of HIV?

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