In Australia, sexually transmitted infections (STI) are highly prevalent among men who have sex with men (MSM), including those visiting sex-on-premises venues (SOPV).1^–5 Some studies have suggested that MSM using sex venues may engage in higher risk sexual behaviours, providing an environment in which STI transmission is potentially enhanced.6^–9

The Health in Men Study found that approximately one-third of anal STI in MSM occurred in men who did not report penile–anal intercourse, suggesting that other activities may be responsible for their transmission.10 Other possible forms of penile–anal contact were not, however, reported in that study.

No recent published studies have exhaustively documented the entire range of sexual activities engaged in by MSM while at commercial venues and the frequency with which these are practised. The aim of this study was to describe in detail the types and frequency of sexual practices men engaged in while visiting SOPV in Melbourne, Australia.

METHODS

This study was conducted at six SOPV in Melbourne, Australia, between December 2006 and March 2007. Eligible participants were men who had engaged in sex at an SOPV and who could self-complete an anonymous, written questionnaire in English unassisted.

The questionnaire used plain language, sometimes including colloquial terms together with definitions. Examples included: “nudging” (touching or rubbing of another man’s anus with the penis without a condom in which there was not anal penetration); “dipping” (partly inserting or briefly inserting the penis into the anus without a condom, followed by immediate withdrawal); and “docking” (pulling one’s foreskin over another man’s penis).

Participants were reimbursed with two free cinema tickets.

RESULTS

Of 604 men approached about the study, 200 (33%) agreed to participate. The median age of participants was 43 years (range 19–83).

The median number of visits to SOPV that participants had made in the previous month was three (range 1–30). The median number of men participants reported having had any form of sexual contact with during the visit was two (range 0–28). The frequency of each sexual practice at the SOPV is shown in table 1.

Of the 53 men (26.5%) who reported unprotected insertive penile–anal touching or rubbing (“nudging”), 20 (38%) reported no anal intercourse or “anal sex”. Similarly, of the 40 (20%) who reported unprotected receptive penile–anal touching or rubbing, 16 (40%) reported no anal intercourse. Twelve men (6%) reported transient, unprotected, insertive anal intercourse (“dipping”) with other men, two of whom reported no anal intercourse. Ten men (5%) reported transient, unprotected, receptive anal intercourse, two of whom also reported no anal intercourse.

Ninety-three men (46.5%) reported having a regular sexual partner. Eighty-three men (41.5%) had a regular male partner, with whom 37 (45%) had unprotected anal intercourse. Fourteen men (7%) reported having a regular female partner, with whom 11 (79%) had unprotected vaginal or anal intercourse.

Ninety-nine men (49%) also reported sex with a casual male partner outside of SOPV in the previous month. The median number of casual male partners reported outside the venues in the previous month was three (range 1–20).

Thirty-seven (37%) of the men who reported sex with a casual male partner outside of SOPV reported unprotected penile–anal touching or rubbing (whether insertive or receptive) with such a partner. Fourteen (38%) of these men reported no anal intercourse or “anal sex”. Of the 15 men (15%) who reported transient, unprotected anal intercourse (whether insertive or receptive) with a casual male partner outside of SOPV, one reported no anal intercourse.

Compared with their sexual practices with casual male partners outside SOPV (data not shown), men engaging in sex at SOPV were significantly less likely to engage in: oral intercourse (OR 0.3; 95% CI 0.1 to 0.8, p<0.01); unprotected receptive oral intercourse with ejaculation (OR 0.4; 95% CI 0.2 to 1.0, p = 0.04); unprotected receptive anal intercourse (OR 0.3; 95% CI 0.1 to 0.8, p = 0.01); and insertive rimming (OR 0.5; 95% CI 0.3 to 0.9, p = 0.01). Men were, however, significantly more likely to engage in group sex when they were at an SOPV (OR 2.0; 95% CI 1.1 to 3.6, p = 0.03).

DISCUSSION

Although certain higher risk practices were identified among MSM attending SOPV, the frequency with which some of these occurred was actually higher with casual male partners outside of these venues. Substantial penile–anal contact that did not involve anal intercourse occurred at SOPV. These activities may explain anal infections in the absence of reported anal sex.

The study has some limitations. There were at least 10 SOPV operating in Melbourne and our study only included six. Recruitment took place at times when outreach services providing free STI screening were in operation, which may have biased towards any men or groups using venues at those times. It is also possible there was a bias towards those at lower sexual risk, contributing to the low rates of unprotected anal sex, as those at higher risk may have felt reluctant to disclose these. Also, all data were self-reported. We do not know why only 33% of men agreed to the study; however, it is possible some may have had concerns about their confidentiality, or simply did not see the survey as a priority.

The frequency of intimate penile–anal contact without anal penetration is significant, as in clinical sexual health settings MSM are often asked about anal intercourse or “anal sex” without further enquiry about other forms of penile–anal contact. In the Health in Men Study, 34% of diagnoses of anal gonorrhoea and 36% of diagnoses of anal chlamydia occurred in men who did not report unprotected anal intercourse.10 Among men not reporting unprotected anal intercourse, anal gonorrhoea was associated with receptive fingering, fisting and rimming, whereas anal chlamydia was associated with receptive fingering and the use of dildos.10 Although it is possible that some or indeed most of these infections were the result of practices not involving penile–anal contact, it is also possible that some did, but that this was not specifically elicited.

Screening for anal infections should be offered to all MSM, including those who do not report anal intercourse. Future research should examine why MSM who use SOPV appear to engage in higher risk sexual practices with partners outside of venues.