There is a wide body of literature consistent with a higher prevalence of sexual compulsion disorders among homosexuals and bisexuals, and this literature is important because compulsion disorders are mental illnesses that require behavioral therapy at the very least and pharmaceutical treatment in more severe cases. Not acknowledging the sexual compulsion factor results in a waste of resources in educating nonheterosexuals about safe sex practices. The proper solution is medical treatment, and it would be a waste of time encouraging compulsives to seek treatment on their own since many will refuse to acknowledge that they have a compulsion problem and be offended by the suggestion that they have this problem; the solution to getting these individuals to seek medical treatment is provided here.
Indulgence in risky practices in spite of full knowledge of the risks
The following studies post-date the origin of the AIDS epidemic.
- In a random-digit-dialing telephone survey of men living in selected neighborhoods of Seattle, Washington, in 1992, an interview of 603 MSM (men who have sex with men) revealed that 82% had been tested for HIV and 19% of the tested men were infected with HIV. Among the non-testers, 57% believed that their risk of infection was too low to justify testing and 52% said that they had not tested because they were afraid of learning the result. The testers and non-testers had similar rates of unprotected sexual behavior.1
- In a sample of 4,803 Canadian homosexuals in 1996, 22.9% reported at least one episode of unprotected anal intercourse (UAI) in the previous 3 months, and 63% had been tested for HIV; policy, programs, and social environment appeared to exert an important influence on test seeking but not on sexual behavior.2
- In 1998, Elford et al. investigated unprotected anal sex among 779 English homosexuals.3 124 knew that they were HIV-positive and 31% of this subgroup reported UAI. Among 452 men who said they were not infected, 26% reported UAI and 17% of 203 homosexuals who said that they had never been tested for HIV reported UAI.
- In a longitudinal study of 510 homosexuals in San Francisco (ages 18-29 years at baseline), the prevalence of reported UAI increased from 37% to 50% between 1993-1994 and 1996-1997.4 Almost half of all men who reported UAI in 1996-1997 indicated that it occurred with a partner of unknown or discordant HIV-infection status. UAI correlated with a greater number of male sex partners, use of nitrite inhalants, sex in commercial sex environments, perceived difficulty controlling sexual risk-taking, and negative emotional reactions following UAI. The increase in UAI was consistent with rising rates of rectal gonorrhea in this population.
- In a survey of 12,347 MSM in Austria, Switzerland, Germany, Denmark, France, Great Britain, Italy and the Netherlands, in 1991, the proportion of men that had engaged in UAI during the past 12 months with a partner having discordant or unknown HIV status ranged from 1/3 in East Germany to 1/6 in the U.K., and the reported HIV prevalence rate varied from less than 7% in East Germany, Italy, and the U.K. to 15% in Denmark and 17% in France.5
- Unprotected sex is common among bisexual men.6 In an investigation of 205 homosexual and 310 bisexual men, 33.58% of the homosexuals and 42.64% of the bisexuals had recently behaved in a bisexual manner; 26.8% of the homosexuals and 31.2% of the bisexuals had engaged in insertive UAI within the past 6 months; 27.3% of the homosexuals and 18.2% of the bisexuals had experienced receptive UAI within the past 6 months.7 MSM are less likely to use condoms with women than men.8
- In a sample of 547 Spanish MSM from gay/lesbian organizations, bathhouses, and sex shops in Barcelona in the mid-1990s, 37.5% reported UAI in the past month and 20.5% reported an HIV-positive status.9
- In a sample of 65 homosexual and bisexual men with AIDS, sexual practices in which there was contact with the partner's feces before they developed AIDS, such as rimming, were the main determinants of Kaposi's sarcoma risk.10 Kaposi's sarcoma developed in 18% of the men who reported never having practiced insertive rimming, in 50% who practiced it less than once a month, in 73% who practiced it between once a week and once a month, and in at least 75% who practiced it once a week. The men with Kaposi's sarcoma also tended to be more sexually active and were more likely to engage in other sexual activities that entailed contact with feces than were the men who had other features of AIDS. Kaposi's sarcoma risk was unrelated to nitrite inhalants, after controlling for insertive rimming. In 1992, a study revealed that the proportion of English homosexuals engaging in rimming had not declined since 1984.11
- In a survey of 21,857 MSM in San Francisco, from 1994 through 1997, administered by volunteers in The Stop AIDS Project (a San Francisco community-based organization), the proportion of men who reported having had multiple sex partners and UAI increased from 23.6% in 1994 to 33.3% in 1997.12
- 15 years after the initiation of the AIDS epidemic, 11% of 1,000 clients of a bathhouse in Portland, Oregon reported UAI in the bathhouse within the past 30 days.13 Men who reported UAI in the bathhouse within the past 30 days were 2-fold more likely to report being HIV-positive and 3-fold more likely to report at least 5 sex partners in the previous 30 days, compared to the other men.
- Although occasional condom use can be expected to provide greater protection than no condom use, in a large sample of Mexican homosexuals, a statistically significant protective effect with respect to HIV infection was found only for those who reported using a condom in all sexual encounters (5% of the sample).14 This find may not apply to white MSM, but note the low prevalence of consistent condom users.
The typical reasons given by MSM for having unprotected sex are: an inadvertent or involuntary encounter, especially resulting from drunkenness, sexual passion, emotional needs, or partner coercion; being in a relationship; and negative moods and self-images.15
Hardly changing lifestyle in spite of devastation by AIDS
If one were to discuss homosexuality and AIDS with homosexuals or homophiles, and manage to make them admit to a high incidence of AIDS among homosexuals, they would promptly point to so-called homophobia as responsible for hampering efforts directed toward risk reduction educational campaigns that target homosexuals and bisexuals. Really? The studies below are a few examples showing that many homosexuals persist with risky sexual practices in spite of good knowledge of HIV/AIDS and other risks. A caveat is pertinent here. The promiscuity of homosexuals declined from the late 1980s to the early 1990s, but this should not be seen as an example of lifestyle change. What happened was that the more promiscuous homosexuals had died of AIDS, which would naturally bring down the average promiscuity of homosexuals, and there were so many AIDS deaths that the remaining homosexuals panicked and diminished their promiscuity.
- In 1983, near the beginning of the AIDS epidemic, among 655 homosexuals in San Francisco, those in monogamous relationships more frequently reported that they had engaged in risky activity during the past year. Homosexuals had become aware of AIDS, but those visiting bathhouses showed little change in frequency of bathhouse use and in number of sexual partners in bathhouses. “Men in monogamous relationships showed little change in sexual behavior within their relationship. Men in non-monogamous relationships and men not in relationships reported substantial reductions in high-risk sexual activity, but not a corresponding increase in low-risk sexual behavior. Knowledge of health guidelines was quite high, but this knowledge had no relation to sexual behavior.”16 The authors also reported that some homosexuals used sex to release tension.
- 48% of a sample of homosexuals (n = 162) in New York, in the 1980s, continued to engage in risky sexual behavior in spite of high levels of knowledge concerning risk-reduction guidelines, although 84% had reduced their number of regular and anonymous partners.17
- During 1989-1991, 239 homosexual and bisexual male adolescents in Minnesota volunteered for an interview. (18) They demonstrated accurate knowledge and beliefs about HIV, but 63% were at “extreme risk” for prior HIV exposure due to a history of unprotected anal intercourse and/or intravenous drug use and 34% of the participants reported unprotected anal sex with at least one of the last three partners in the previous year.18
- In a 5-year longitudinal study (1986-1991) of 145 Australian homosexuals (non-clinical sample), sexual behavior hardly changed: a steady 5-10% of the sample indulged in fisting, sadomasochism, and drinking urine. There was a slight decrease in unprotected anal sex, but an increase in oral-genital contact with semen exchange, and an increase in rimming plus fingering the rectum.19
- Osmond et al. reported a household survey of unmarried men, ages 18-29 years; this survey involved a multistage probability sample of addresses in San Francisco and a follow up evaluation after a median of 8.9 months.20 Among 380 homosexual and bisexual men, 17.9% reported being infected with HIV. 63% reported one or more receptive anal intercourse partners in the previous 12 months, of which 41% did not use condoms consistently. A mere 14% reported only a single partner in the past year. HIV-negative men got infected with HIV at a rate of 2.6% per year. Risky behavior persisted in spite of knowledge of risks, HIV infection, and AIDS.
- Van de Ven et al. reported no relationship between age and HIV-risk behaviors in a sample of Australian homosexuals, i.e., older homosexuals, while expected to be more mature and knowledgeable, did not practice safer sex compared to younger homosexuals.21
- In a cohort of 553 Belgian homosexual men, young homosexuals perceived protected anal sex as safer and had a higher appraisal for and gratification from both insertive and receptive anal sex with a condom, but were not different from older homosexuals with respect to risky behaviors.22
- Kegeles et al. recruited homosexual men from Eugene, Oregon and Santa Barbara, California to participate in a risk reduction program that had four components: peer outreach, wherein young homosexual men encouraged other men to engage in safer sex; peer-led small groups; a publicity campaign; and a young men's center.23 319 homosexuals were recruited but only 247 agreed to an interview of their sexual habits for a payment of $10. About 34% of the sample did not participate in an immediate follow-up after the meetings and outreach activities, and 44% had fallen out of the study within a year of the intervention. In Eugene, 39% of the homosexuals reported not using condoms during anal sex at the beginning of the program and 38% reported the same a year after the intervention. In Santa Barbara, the figures for unprotected anal sex were 36% at the beginning and 31% a year after the club-intervention; the reduction was primarily in sex with non-primary partners.
- An HIV prevention activity targeted (1993-1995) homosexuals attending a lesbian and gay pride festival held in London every June. An evaluation of 1,000-plus homosexuals attending the pride parade over 3 years revealed no change in the prevalence of any measure of sexual behavior. Every year, 1 in 3 homosexuals reported unprotected anal sex with at least one male partner in the preceding year, and 1 in 10 had done so with multiple partners.24
- In 1992, three London STD clinics reported that almost half of their homosexual patients who knew they were infected with HIV went on to get rectal gonorrhea.25 Many homosexuals don’t let HIV infection interfere with pleasure seeking behavior, thereby infecting others in the process too.
- Weatherburn et al. followed almost a thousand British homosexuals (median age, 29 years) for three years starting from 1987. 11 homosexuals became HIV-positive over the course of the study, out of which 8 got it through anal intercourse with a regular partner and 2 got it through anal sex with a casual partner. In this sample, 270 homosexuals had engaged in anal intercourse in the previous month, and during this period, 39% had always used a condom but 50% never had. The majority of the men in the study claimed to have first heard of AIDS by 1983 and of safer sex by 1985, which predates government intervention and general media interest in AIDS. Factors such as social class, educational qualifications, political beliefs, religion, knowledge of HIV transmission routes plus safer sex practices; and issues surrounding regret, disclosure and “outness” had no effect on condom use during anal intercourse.26
Good knowledge of AIDS among sexually active individuals with mental illnesses such as schizophrenia often coexists with risky sexual behaviors,27 and homosexuals/bisexuals are much more likely than heterosexuals to be mentally ill.
Clustering of paraphilic and sexual compulsion disorders
Literature from the clinical, forensic and general population samples abundantly illustrates a positive correlation between paraphilias and sexual compulsion disorders, in addition to a tendency for multiple paraphilias to co-occur. It would be remarkable if the prevalence of sexual compulsion disorders were not higher among homosexuals and bisexuals given an association of same-sex attraction/homosexual behaviors with paraphilias such as pedophilia, sadomasochism, zoophilia, etc.
Disinhibited sexual practices
The sexuality section within this site cites plenty of evidence for higher rates of various disinhibited sexual practices among homosexuals and bisexuals. It is unlikely that developmental processes disinhibiting nonheterosexuals toward various atypical sexual practices would not also tend to disinhibit libido.
Some insist that the greater promiscuity of male homosexuals simply reflects the fact that they are not limited by female availability like heterosexual men are. This notion fails to take into account the nature of the sexual behaviors of male homosexuals such as a higher prevalence of paraphilic behaviors and greater indulgence is sexual practices that would normally require some level of disinhibition. Even if heterosexual men are limited by female availability and female willingness to indulge in atypical sexual practices, a number of heterosexual men have the option to satiate their desires by using female prostitutes, but to the best of my knowledge, there is no literature showing that heterosexual men indulge in insertive oral-anal sex and anal sex with female prostitutes at rates anywhere close to the prevalence of these practices among homosexual/bisexual men. It is also difficult to argue that heterosexual men's behaviors with prostitutes are limited by fear of venereal diseases. The HIV/AIDS epidemic originated among MSM, not female prostitutes, just as outbreaks of various STIs are often documented among MSM. Sex with MSM is more risky, yet MSM are more likely to indulge in risky sexual practices than heterosexual men.
It may be argued that elevated promiscuity among homosexuals does not reflect a stronger sex drive, but the libido rejuvenating effect of a novel partner. However, no homosexual can be promiscuous unless he comes across a large number of other homosexuals. Given the rarity of homosexuality, how would it be possible for a homosexual to come across a large number of homosexuals? An easy answer is to move to a big city, and cruise for sex, both of which a number of homosexuals do. Therefore, a parsimonious explanation of elevated promiscuity in homosexuals is that more intense sexual desire drives them to satiate their desires.
Bisexually behaving women are more heterosexually promiscuous than exclusively heterosexual women.28 What explains this apart from a less inhibited libido?
A classic study on male homosexual couples by McWhirter and Mattison on The male couple revealed that open relationships were the norm among male homosexual couples, at sharp odds with heterosexual couples among whom such relationships are rare. Among heterosexual couples even if one partner wanted to be promiscuous, he/she would typically not want his/her partner to also be promiscuous, but among homosexual couples this is typically not applicable, which is another type of disinhibition pertaining to sexuality that is more prevalent among them. After the initiation of the AIDS epidemic, confirmation of McWhirter and Mattison's pioneering study has come in the form of the interesting observation that homosexuals are more liable to get infected with HIV by a stable partner than by a casual sex contact:
- In 1987, only 23% of homosexuals in London reported sexual exclusivity in the month before assessment. Those infected with HIV were more apt to have regular partners than non-infected homosexuals and more likely to have disclosed their homosexuality to others (84%) than non-infected homosexuals (76%).29
- In 1989, among 127 Italian homosexuals attending an AIDS clinic, 12% of those without steady partners, 28% of those with steady partners, 8% of male prostitutes, and 23% of non-prostitutes were HIV-positive.30 The investigators remarked, “To our surprise, male prostitutes did not seem to be at increased risk, whereas homosexuals who reported a steady partner (i.e., the same man for the previous six months) carried the highest relative risk.”
- Among 719 homosexual men in Oslo during the period 1983-1987, those in a homosexual relationship lasting 0.5-4 years were 2.3 times as likely, and those in a homosexual relationship lasting 5 years or more were 3.1 times as likely to be HIV-positive compared to homosexuals not in a relationship.31
- A 2003 report from the Netherlands found that about 86% of new HIV infections in homosexual men were occurring among homosexual men having steady partners.32
The finds above would be curious if not for the fact that homosexual relationships are typically open and homosexuals are more likely to indulge in unprotected anal intercourse with a stable partner; some examples:
- Reece and Segrist did not find any differences between either ongoing or recently separated male homosexual couples with respect to the variables of self-disclosure or the number of sexual experiences outside the primary relationship.33
- Among 385 English homosexuals that recorded their sexual experiences in diaries, those in monogamous relationships practiced more anal intercourse and rimming than those without a steady partner.34
- During the early 1990s, among 677 English homosexuals, those who had regular partners reported more unprotected anal sex than homosexuals reporting casual sex, a result that could not be explained in terms of mutual HIV status knowledge.35
- ^ Campsmith ML, Goldbaum GM, Brackbill RM, et al. HIV testing among men who have sex with men--results of a telephone survey. Prev Med 1997;26(6):839-44.
- ^ Myers T, Godin G, Lambert J, et al. Sexual risk and HIV-testing behaviour by gay and bisexual men in Canada. AIDS Care 1996;8(3):297-309.
- ^ Elford J, Bolding G, Maguire M, et al. Combination therapies for HIV and sexual risk behavior among gay men. J Acquir Immune Defic Syndr 2000;23(3):266-71.
- ^ Ekstrand ML, Stall RD, Paul JP, et al. Gay men report high rates of unprotected anal sex with partners of unknown or discordant HIV status. Aids 1999;13(12):1525-33.
- ^ Bochow M, Chiarotti F, Davies P, et al. Sexual behaviour of gay and bisexual men in eight European countries. AIDS Care 1994;6(5):533-49.
- ^ Weatherburn P, Reid D. Sexual behaviour of men. Survey shows unprotected sex is a common behaviour in bisexual men. Bmj 1995;311(7013):1163-4.
- ^ Stokes JP, Vanable P, McKirnan DJ. Comparing gay and bisexual men on sexual behavior, condom use, and psychosocial variables related to HIV/AIDS. Arch Sex Behav 1997;26(4):383-97.
- ^ McKirnan DJ, Stokes JP, Doll L, et al. Bisexually active men: social characteristics and sexual behavior. J Sex Res 1995;32:64-75.
- ^ Wang J, Rodes A, Blanch C, et al. HIV testing history among gay/bisexual men recruited in Barcelona: evidence of high levels of risk behavior among self-reported HIV + men. Soc Sci Med 1997;44(4):469-77.
- ^ Beral V, Bull D, Darby S, et al. Risk of Kaposi's sarcoma and sexual practices associated with faecal contact in homosexual or bisexual men with AIDS. Lancet 1992;339(8794):632-5.
- ^ Elford J, Tindall B, Sharkey T. Kaposi's sarcoma and insertive rimming. Lancet 1992;339(8798):938.
- ^ CDC. Increases in unsafe sex and rectal gonorrhea among men who have sex with men---San Francisco, California, 1994--1997. MMWR Morb Mortal Wkly Rep 1999;48:45-8.
- ^ Van Beneden CA, O'Brien K, Modesitt S, et al. Sexual behaviors in an urban bathhouse 15 years into the HIV epidemic. J Acquir Immune Defic Syndr 2002;30(5):522-6.
- ^ Izazola-Licea JA, Avila-Figueroa RC, Gortmaker SL, et al. [The homosexual transmission of HIV/AIDS in Mexico]. Salud Publica Mex 1995;37(6):602-14.
- ^ Adam BD, Sears A, Schellenberg EG. Accounting for unsafe sex: interviews with men who have sex with men. J Sex Res 2000;37(1):24-36.
- ^ McKusick L, Horstman W, Coates TJ. AIDS and sexual behavior reported by gay men in San Francisco. Am J Public Health 1985;75(5):493-6.
- ^ Siegel K, Bauman LJ, Christ GH, et al. Patterns of change in sexual behavior among gay men in New York City. Arch Sex Behav 1988;17(6):481-97.
- ^ Remafedi G. Predictors of unprotected intercourse among gay and bisexual youth: knowledge, beliefs, and behavior. Pediatrics 1994;94(2 Pt 1):163-8.
- ^ Kippax S, Crawford J, Davis M, et al. Sustaining safe sex: a longitudinal study of a sample of homosexual men. Aids 1993;7(2):257-63.
- ^ Osmond DH, Page K, Wiley J, et al. HIV infection in homosexual and bisexual men 18 to 29 years of age: the San Francisco Young Men's Health Study. Am J Public Health 1994;84(12):1933-7.
- ^ Van de Ven P, Kippax S, Crawford J, et al. No relationship between age and HIV risk behaviour among Sydney gay men. Aids 1997;11(5):691-3.
- ^ Vincke J, Bolton R, Miller M. Younger versus older gay men: risks, pleasures and dangers of anal sex. AIDS Care 1997;9(2):217-25.
- ^ Kegeles SM, Hays RB, Pollack LM, et al. Mobilizing young gay and bisexual men for HIV prevention: a two-community study. Aids 1999;13(13):1753-62.
- ^ Hickson FC, Reid DS, Davies PM, et al. No aggregate change in homosexual HIV risk behaviour among gay men attending the Gay Pride festivals, United Kingdom, 1993-1995. Aids 1996;10(7):771-4.
- ^ Newell A, Russell J, McLean KA. Sexually transmitted diseases and anal papillomas. Bmj 1992;305(6866):1435-6.
- ^ Weatherburn P, Hunt AJ, Hickson FCI, et al. The sexual lifestyles of gay and bisexual men in England and Wales. London: Project SIGMA, 1992.
- ^ McKinnon K, Cournos F, Sugden R, et al. The relative contributions of psychiatric symptoms and AIDS knowledge to HIV risk behaviors among people with severe mental illness. J Clin Psychiatry 1996;57(11):506-13.
- ^ K. A. Fenton et al., J Infect Dis 191 Suppl 1, S127 (Feb 1, 2005).
- ^ Hunt AJ, Christofinis G, Coxon AP, et al. Seroprevalence of HIV-1 infection in a cohort of homosexually active men. Genitourin Med 1990;66(6):423-7.
- ^ Franceschi S, Serraino D, Vaccher E, et al. Homosexual role separation and spread of AIDS. Lancet 1989;1(8628):42.
- ^ Eskild A, Magnus P, Thorvaldsen J, et al. [Steady homosexual relationship and HIV infection]. Tidsskr Nor Laegeforen 1995;115(13):1638-41.
- ^ Xiridou M, Geskus R, De Wit J, et al. The contribution of steady and casual partnerships to the incidence of HIV infection among homosexual men in Amsterdam. Aids 2003;17(7):1029-1038.
- ^ Reece R, Segrist AE. Association of selected masculine sex-role variables with length of relationship in gay male couples. J Homosex 1981;7(1):33-48.
- ^ Coxon AP, Coxon NH, Weatherburn P, et al. Sex role separation in sexual diaries of homosexual men. Aids 1993;7(6):877-82.
- ^ Dawson JM, Fitzpatrick RM, Reeves G, et al. Awareness of sexual partners' HIV status as an influence upon high-risk sexual behaviour among gay men. Aids 1994;8(6):837-41.