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Adolescent men who have sex with men (AMSM) experience a dramatic health disparity in HIV, accounting for over 80% of new diagnoses among youth. Current evidence-based HIV prevention programs, however, focus primarily on adults and heterosexual youth, thereby missing the unique experiences and socio-environmental contexts of AMSM aged 13-18. To address these gaps, we used the Intervention Mapping (IM) protocol to developmentally adapt an existing evidence-based online HIV risk reduction program (i.e., Keep it Up!/KIU!), originally designed for young adult MSM aged 18-29, into a new intervention called SMART Squad. Using a hybrid of IM creation and adaptation tasks, we specified three behavioral outcomes and identified corresponding performance objectives for SMART Squad based on the original goals of KIU!. We constructed matrices of change objectives using determinants from the Information-Motivation-Behavioral Skills model, modifying them for the younger population with additional theoretical and empirical evidence and expert review. SMART Squad activities were operationalized from theory-based behavior change methods matched to the change objectives and guided by program themes, components, and scope imported from KIU!. The final SMART Squad intervention comprises 6 episodes/modules delivered in 2 sessions plus 2 booster episodes occurring 1 and 3 months after the main program. It is currently being evaluated nationally as part of a stepped-care package of 3 programs, in which the receipt and sequencing of interventions is tailored to individual AMSM development and needs. Despite substantial changes to KIU!, IM was a useful method for retaining the hypothesized essential elements of the eHealth HIV risk reduction program. Challenges and recommendations for future researchers and practitioners are discussed.

Pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy for high-risk adults and recently was given US FDA approval for use among adolescents. Yet, the barriers to medication uptake for this population are unique when compared to adult populations, as parents may be just as likely as prescribers to be gatekeepers to access. To better understand the role of parents in adolescents' attitudes towards PrEP, we surveyed 491 adolescent men who have sex with men (AMSM) ages 13-18, using forced choice and open-ended response questions. We measured perceived parent-PrEP supportiveness, hypothetical parent reactions to a request to initiate PrEP, and perceived positive and negative aspects of taking PrEP without parents knowing. A mixed-methods approach was employed. Results indicated a majority of AMSM had heard of PrEP and most reported their parents would be unsupportive of their taking PrEP. Teens perceived their parents would likely be angry, accusatory, and punitive if PrEP use was discovered, and that accessing PrEP independent of parents might increase their health autonomy, agency, and prevent awkward conversations about sex. Furthermore, a path model revealed that fears of parental reaction and poor self-efficacy to communicate with parents about PrEP significantly contributed to participants feeling PrEP was not "right" for them, and as a corollary, less interest in starting PrEP. The study suggests that improving parental knowledge of PrEP and encouraging parents to begin the conversation about PrEP could help increase uptake in AMSM.

Background: Adolescent men who have sex with men (AMSM) have a high rate of HIV diagnoses. An estimated 14.5% of HIV infections in the United States are undiagnosed; but among 13- to 24-year-olds, the rate is 51.4%. We describe HIV testing rates and identifies salient individual, family, school, and health care influences among AMSM., Methods: Data were collected as part of SMART, an ongoing pragmatic trial of an online HIV prevention intervention for AMSM ( N = 699). Measures included lifetime HIV testing, demographics, sexual behaviors, condom use, HIV education from school and family, sexual health communication with doctors, HIV knowledge, and risk attitudes., Results: Only 23.2% of participants had ever had an HIV test. Rates of testing increased with age (5.6% in 13- to 14-year-olds; 15.8% in 15- to 16-year-olds; 37.8% in 17- to 18-year-olds), and sexual experience was a strong predictor of testing (odds ratio: 6.54; 95% confidence interval: 3.95-11.49; P < .001). Most participants had a regular doctor (67.5%), but few had conversations about same-sex sexual behaviors (21.3%), HIV testing (19.2%), or sexual orientation (29.2%). Speaking to a doctor about HIV testing had a large effect (odds ratio: 25.29; confidence interval: 15.91-41.16; P < .001), with 75.4% who had such conversations having been tested, compared to only 10.8% of those who had not had such conversations., Conclusions: Despite higher risk, few participants reported ever having received an HIV test. Data indicate pediatricians are an important, but largely untapped, source of testing and could be integral to achieving testing rates needed to end the epidemic., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

In May 2018, the US Food and Drug Administration approved daily oral pre-exposure prophylaxis (PrEP) for adolescents under age 18. Although this is an important step toward HIV prevention for adolescents assigned male at birth who have sex with males (AMSM), limited research exists to gauge their awareness of PrEP as a prevention option. Additionally, the attitudes and perceived barriers regarding PrEP among this population have not been well studied. We conducted an online survey from February to April 2018, in which 219 AMSM age 15-17 read a description of PrEP, and then answered questions about PrEP awareness, perceived barriers, and demographic and behavioral correlates. A slight majority (54.8%) had heard of PrEP before, and 56.1% did not know how they would access PrEP. Of those who had heard of PrEP, 2.5% had ever used it. Most had first learned about PrEP online, through media or geosocial networking (GSN) applications to meet male partners. Those who had heard of PrEP were more likely to be older, to have used GSN applications, and to have greater HIV knowledge. Not knowing how to access PrEP was predicted by having had more partners, lower HIV knowledge, and never having talked to a provider about PrEP. Believing that one could not afford PrEP was predicted by greater perceived risk of HIV. Findings suggest moderate awareness of PrEP among AMSM, that youth at greater risk of HIV may perceive greater barriers, and that online spaces can play a significant role in increasing PrEP knowledge and reducing implementation barriers.

HIV disproportionately impacts young men of color who have sex with men. Keep It Up! (KIU!) is an online intervention that addresses the needs of this population. The study objective was to examine intervention acceptability and engagement. Outcomes of interests were qualitative and quantitative acceptability and engagement measures, content ratings, and paradata. On average, participants rated content (4 out of 5 stars) and acceptability (3.5 out of 4) highly. Compared to White participants, Black participants found KIU! more useful, engaging, and acceptable; Latino participants found KIU! more engaging; and other non-White participants found KIU! more engaging and acceptable. Participants with high school or less education found KIU! more useful, engaging, acceptable, and deserving of five stars than college graduates ( p values = .047, <.001, .002, .01) and graduate degree holders ( p values = .04, .001, <.001, .004). KIU! is a promising prevention tool for highest risk populations.

Across much of the gay and bisexual male research on sexual position self-label (i.e., calling oneself a top, bottom, or versatile), there exist two commonalities: (1) studies tend to focus almost entirely on individual, relationally single androphilic men; (2) studies rarely account for relationships and relationship dynamics. In response, we explored the role of self-label over sexual and relationship satisfaction among gay and bisexual partnered men. Specifically, we looked at whether adopted sexual position identities were consonant or dissonant (i.e., matching or mismatching) with enacted behavior in relationships and how that impacted men's attitudes toward different relational attributes. Through an online survey, we sampled 169 men in same-sex relationships, asking them questions about their ideal penetrative role identities and their reality penetrative roles with their partner. We then asked them to rate their relationship on 10 sexual and interpersonal attributes. Multiple regression modeling suggested ideal-reality penetrative role dissonance was predictive of sexual dissatisfaction among tops who bottomed in their relationships and, to a lesser extent, bottoms who topped. In contrast, penetrative role dissonance was predictive of relationship satisfaction among tops who bottomed in their relationship, but not bottoms who topped. We conclude that a potential reason for this paradox among tops who bottom may be sexual altruism. That is, men may be satisfied with other aspects within their relationships, understand their partner's anal sex preferences, and accommodate that position in response to their initial relationship satisfaction.

Using latent class analysis (LCA), we examined patterns of participation in multiple scenes, how sexual risk practices vary by scene, and psychosocial factors associated with these patterns among 470 gay, bisexual, and other men who have sex with men (GBM) recruited from Toronto. We calculated posterior probability of being in a class from participation in nine separate scenes. We used Entropy, the Bayesian information criterion and the Lo-Mendel-Rubin likelihood ratio test to identify the best fit model. Fit indices suggested a four-class solution. Half (50%) of the GBM reported no or minimal participation in any scene, 28% reported participating in the dance club scene, 16% reported participating in the BDSM, bear, and leather scenes, and 6% reported participating in circuit, party and play, and sex party scenes. Compared to GBM who did not participate in scenes, GBM participating in the BDSM-Bear-Leather scene were more likely to be older, white, to report higher sexual self-esteem, and to engage in condomless anal sex; Party and Play scene members were more likely to be of Asian origin, and to use drugs before and during sex, whereas Dance Club scene members were more likely to be younger and to report lower self-esteem but higher hope. LCA allowed us to identify distinct social niches or micro-cultures and factors characterizing these micro-cultures. GBM differ in their risk for HIV and STIs according to characteristics associated with participation in distinct micro-cultures associated with scenes. Tailored interventions may be needed that focus on reducing HIV risk and promoting sexual health in specific contexts such as the BDSM-Bear-Leather and Party and Play.

Research on gay and bisexual men's sexual position self-label (i.e., being a top, bottom, or versatile during anal sex) has revealed only independent snapshots of its development by focusing primarily on the influence of penis size. Moreover, the basic chronology of development of the sexual position self-label has barely been addressed. In response, we implemented a survey of 282 gay and bisexual men that measured demographics (including height and penis size), age of sexual recognitions, sexual position self-label, and attitudinal constructs suggested by previous literature as important (e.g., pleasure, control, anxieties, and gender typicality). Results suggested that men's sexual position self-label was learned over a 15-year timespan. Ages of first same-sex genital manipulation and first anal sex experiences were related to age at first self-labeling. With respect to predictors of labels, a multivariate path model was created. The model did not support the direct importance of penis size, but identified indirect paths that linked penis size to top/bottom identification (e.g., smaller penis sizes leading to topping-anxieties and thus, a bottom label). Finding bottoming to be pleasurable and the importance of sexual control dynamics were the only two direct predictors. The path model substantiated the reliance both bottoms and tops show towards seeking (or not seeking among tops) gender typical, sexually dominant partners. It also supported previous evidence regarding race; specifically, while race may activate differences in sexual behavioral dynamics, it is not a great predictor of the sexual position self-label. This study shows that sexual position self-labeling has enormous complexity and cannot be reduced down to penis size.

The Bear community exists as a subculture in reaction to the larger gay community. It rejects the normative idealized male beauty revered by mainstream gay men. While qualitative data document such self-identifiers as masculine-acting gay men who weigh more and have more body hair, there has to date been no quantitative analysis of this group's characteristics. In response, we conducted two large-scale studies of gay men identifying as Bears (n = 469) to survey their self-reported physical, behavioral, and psychological traits. Our studies indicated that Bears were more likely to be hairier, heavier, and shorter than mainstream gay men. They reported wanting partners who were hairier and heavier. They were less likely to reject sexual partners and the partners they did reject were more likely to be young or weigh too little (i.e., were not bearish). Bears were more likely than mainstream gay men to enact diverse sexual behaviors (e.g., fisting, voyeurism) and were comparatively more masculine. Bears had lower self-esteem but were no less (or more) hypermasculine than non-Bears. We concluded that Bears are intensely sexual. We speculate that Bears are viewed as less attractive than what is traditionally considered to be attractive. The partners they can attract may be limited and, in response to this limitation, they may be particularly attuned to seek out partners who will not reject them. This condition may produce the low self-esteem exhibited and may explain how the Bear culture developed to ensure that even the heaviest, hairiest, and/or shortest individual can partner. Future analyses of the community's health are warranted.

Most studies on men seeking men and who use the Internet for sexual purposes have focused on the epidemiological outcomes of Internet cruising. Other research has only focused on online sexual behaviours such as cybersex. The present study examines men who find the acts of Internet cruising and emailing to be erotic as self-contained behaviours. We surveyed 499 men who used craigslist.org for sexually-oriented purposes, and ran an ordinary least squares multiple regression model to determine the demographic characteristics of men seeking men who found Internet cruising erotic. Our results showed that younger compared to older men seeking men found the acts erotic. Likewise, men seeking men from mid-sized cities and large cities compared to men from smaller cities found Internet cruising and emailing to be erotic. Most notably, bisexual- and heterosexual-identifying men seeking men compared to gay-identifying men found these acts to be more erotic. Our results suggested that self-contained Internet cruising might provide dual functions. For some men (e.g., heterosexual-identifying men), the behaviour provides a sexual outlet in which fantasy and experimentation may be explored without risking stigmatization. For other men (e.g., those from large cities), the behaviour may be an alternative to offset sexual risk while still being able to 'get off'.

Factors associated with gay male couples' concordance on aspects of sexual agreements remain understudied. The present study examined which relationship factors, self-reports of UAI, and patterns of HIV testing may be associated with men who were concordant about having a sexual agreement, the same type of sexual agreement, and adhering to their sexual agreement with their main partner. Various recruitment strategies were used to collect dyadic data from 142 gay male couples. Concordance on aspects of sexual agreements varied within the sample. Results indicated that relationship satisfaction was significantly associated with couples who were concordant about having and adhering to their sexual agreement. Predictability and faith of trusting a partner, and value in one's sexual agreement were also positively associated with couples' adhering to their sexual agreement. More research is needed to better understand how relationship dynamics, including sexual agreements, affect HIV risk among gay male couples in the U.S.

Sociological, psychological, and public health studies document that many gay and bisexual men may self-label by their anal penetrative role (i.e., bottom or exclusively receptive; top or exclusively insertive; or versatile, both receptive and insertive during anal intercourse). Yet, what orients men to think of themselves as tops, bottoms or versatiles is poorly understood. We surveyed 429 men engaging in same-sex anal intercourse to investigate the degree to which anal penetrative self-identity was concordant with actual penetrative behavior. Additionally, the roles of masculinity and physical body traits (e.g., penis size, muscularity, height, hairiness, and weight) were tested as correlates of anal penetrative identity and identity-behavior concordance. Tops and bottoms showed a high degree of concordance between identity and enacted behavior; however, only half of versatiles reported concordant identity and behavior (i.e., wanting to be versatile and actually reporting versatile behavior). Generally, tops reported larger penises than bottoms. They also reported being comparatively more masculine than bottoms. Versatiles fell somewhat between the tops and bottoms on these traits. Of the six independent variables, penis size and masculinity were the only two factors to influence concordance or discordance between identity and penetrative behavior. Our study suggests that the correlates of gay men's sexual self-labels may depend on objective traits in addition to the subjective pleasure associated with receptive or insertive anal intercourse.

Research suggests that self-esteem in gay and bisexual men may be linked with sexual risk-taking behaviors. As part of a larger investigation into the sexual practices of gay and bisexual men, we assessed serostatus, self-esteem, condom use, and HIV disclosure to sexual partners. Among HIV-negative men, no relationships were found between their self-esteem and tendency to discuss their and their partners' HIV status. However, among HIV-positive men, there was a positive relationship between self-esteem and disclosure to receptive and insertive anal sex partners. These results suggest greater attention to the self-esteem of HIV-positive men by attending healthcare workers and social support groups.

There exist many subcultures of men who have sex with men (MSM), all with differing values and health behaviors. The Leathermen comprise one such subculture, which is characterized by a heightened valuation of hypersexuality and adherence to sexual control dynamics (i.e., submission and dominance). No previous research has specifically examined this community for differences in sexual health (e.g., HIV rates) and sexual health behaviors (e.g., condom use). We conducted a large survey of men (N = 1,554) at one leather and non-leather event, collecting data from 655 Submissives, Dominants, Switches, and non-orienting Leathermen. Leathermen were 61% more likely to be HIV-positive than non-Leathermen. Decreased condom use found in HIV-positive Leathermen (relative to HIV-positive non-Leathermen) was a potential factor contributing to heightened HIV rates. Universal low condom use in Submissives engaging in receptive, and Dominants engaging in insertive, anal intercourse was an additional trend that potentially contributed to increased numbers of HIV-positive Leathermen. Our recommendation is for heightened awareness of the risks associated with sex among Leathermen, especially unprotected anal intercourse with sero-uncertain Submissives.

Prior research suggests that sex typicality (especially femininity of females, but also masculinity of males) relates to perceptions of attractiveness, for both heterosexual and homosexual individuals. Using videos from childhood and adulthood, we investigated how different components of sex typicality contributed to this effect, whether the sex of the evaluator or of the target moderated the effect, and how the relationship of attractiveness with sex typicality varied across the lifespan. In Study 1, videos of 45 female and 50 male heterosexual and homosexual adult targets (ages 18-30 years) were judged by 56 female and 65 male heterosexual and homosexual raters (ages 18-30 years). Results suggested that both heterosexual men and lesbians viewed more feminine women as more attractive. Femininity of appearance was a primary contributor to this relationship. Masculinity was not related to men's attractiveness. Study 2 used similar methodology (44 male and 46 female heterosexual and homosexual targets and 22 male and 20 female heterosexual raters). Study 2 replicated results of Study 1. In addition, Study 2 included ratings of childhood videos of targets (ages 0-15). Results suggested that childhood femininity related to attractiveness of both young girls and young boys and that the relationship became stronger for girls as they got older. The impact of femininity on attractiveness may, therefore, depend on both targets' sex and their maturity.

We investigated factors that might moderate the association between sexual behavior desires and sexual behavior enactments in gay men. Condom eschewal, number of STIs, HIV serostatus, age, and relationship status were each hypothesized to moderate this association. An Internet survey collected data from 219 self-identifying gay men. Results indicated that sexual behavior desires and enactments were highly correlated, and of the five moderators tested, four varied this association. Condom eschewers had a stronger association between desires and enactments than condom users. Gay men with fewer STIs/STDs (excluding HIV) also had a stronger association between the two variables. HIV serostatus did not exclusively moderate the association. Rather, a three-way interaction was produced such that HIV-positive men with STIs had a stronger association between sexual behavior desires and enactments than HIV-negative men with STIs. Finally, gay men in monogamous relationships were least likely to have their desires associated with enactments. Age was not found to be a significant moderator. Overall, we concluded the moderators representing sexual health and sexual health behaviors were most influential over the enactment of sexual behavior desires.

The incidence of both eating disorders and sexually transmitted diseases (STD) is relatively high among men who have sex with men (MSM). Yet, only one study has explored the influence of body mass index (BMI) on sexual risk-taking behaviors in this population. The objective of this study was to reexamine the practice of anal intercourse among overweight and obese MSM and to assess the consistency with which condoms were used. MSM who had placed same-sex sexual advertisements were asked to complete a brief online survey. A total of 576 MSM completed the survey, which assessed: age, HIV-status, height, weight, rejection of sexual partners, number of anal intercourse partners, and condom use during anal intercourse. Increased BMI was associated with a lowered likelihood of rejecting sexual partners and decreased number of actual anal intercourse partners. Increased BMI was also associated with decreased condom use. In addition to cardiovascular disease, obese MSM may be at a higher risk for STDs relative to normal weight MSM. There was some evidence to suggest that inconsistent condom use in such men may be an expression of the overexcitement concomitant with the comparatively rare event of acquiring an anal intercourse partner.

Negative attitudes of heterosexual people toward same-sex marriage relate to the degree to which they are homophobic. However, it has been understudied whether there exists a gender difference in this association. Our results indicated that homophobia was the best predictor of attitudes toward gay male and lesbian marriage, and this was equally true for both heterosexual men and women. However, the attitudinal difference between gay male and lesbian marriage was related to homophobia in men but not in women. That is, for men only, being less homophobic toward lesbians than toward gay men was associated with favoring lesbian over gay men marriage. Considering these results, the role of gender in attitudes toward same-sex marriage seems to be as an important moderator of homophobia.

Objective: In recent years, Internet-based or online counseling has emerged as an effective way to assess psychological disorders and discuss destructive behaviors with individuals or groups of individuals. This study explores the application of online counseling to HIV/STD risk-taking behavior among men who have sex with men (MSM)., Methods: PowerON, an organization that provides sexual health information to MSM exclusively online, used instant message technology to counsel MSM in real time through computer-mediated means. A sample of 279 transcripts of instant message exchanges between PowerON counselors and Gay.com users were recorded and qualitatively analyzed., Results: Approximately 43% of the instant message sessions discussed information about HIV/STD testing. Risk-taking behaviors were addressed in 39% of the sessions. Information about HIV/STDs and general counseling were given in 23% and 18% of the counseling sessions, respectively., Conclusion: The data showed these instant message sessions to be a potentially feasible forum for HIV/STD counseling., Practice Implications: Information ordinarily disseminated at health clinics could be successfully distributed through the Internet to MSM., (2009 Elsevier Ireland Ltd.)

This study attempted to authenticate the existence of a controversial subculture of gay men, the 'bug chasers', whose main attribute is an active desire to voluntarily contract the human immunodeficiency virus (HIV), and examine the tenacity with which this subculture actually searches for seroconversion. Using a quasi-randomized survey of personal profiles, bug chasers were compared against barebackers, a culture of gay men that practice intentional unprotected anal intercourse. Bug chasers were authenticated as an observable subculture of barebackers where most reported apathy to the serostatus of their partner or an active want of a serodiscordant partner, and a preference towards practicing unprotected anal intercourse. As anticipated, two subgroups with varying tenacities were found within the sample of bug chasers. Apathetic chasers were found only to be in search of partners with sero-ambiguous status. Ardent chasers were found only to be in search of certifiably serodiscordant partners.