1. B. R. Simon Rosser. PhD, MPH, LP
The effects of gay sexually explicit media on the HIV risk behavior of men who have sex with men: Results from the Sexually Explicit Media study
B. R. Simon Rosser. PhD, MPH, LP
HIV/STI Intervention & Prevention Studies
Division of Epidemiology & Community Health
School of Public Health
Please hold all questions until after the presentation.

2. How does what we see influence what we do?

3. Why study SEM and MSM? Our preliminary studies showed:
SEM consumption is extremely common
97% of 517 MSM report watching cyber-SEM (Rosser et al., 2011)
Gay SEM industry is huge. Economically gay SEM is a $1.3- $6.5 Billion industry, annually. While MSM comprise 4-10% of the population, gay SEM comprises 33-50% SEM consumed in US. (Egan)
Yet, very neglected area of research. At start of study, we found only 4 papers on gay SEM use: 2 examined it causing negative body image, 1 on it causing CSB, and one small pilot on HIV risk (which found no relationship between SEM consumption and HIV risk).

4. Study Aims The Sexually Explicit Media (SEM) study (R01MH087231)
is a 33-month NIH-funded study just completed ( ) to investigate the effects of gay SEM on HIV risk behavior.
Aims:
to study gay SEM consumption.
to investigate an hypothesized relationship between SEM consumption and sexual risk.
to assess how SEM could be used in HIV prevention

5. Multi-Method Research Design
Qualitative: 13 online synchronous focus groups with asynchronous follow-up (N=73 MSM, )
Wilkerson JM, Iantaffi A, Grey JA, Bockting WO, & Rosser BRS (2014). Recommendations for Internet-based qualitative health research with hard-to-reach populations. Qualitative Health Research, in press.
New Measures Reliability study (N=241 MSM, 2010)
Grey, J.A., Schreiner, P. Erickson, D., Rosser, B.R.S. Test-retest reliability of self-reported sexual behavior and HIV/STI diagnoses in an online sample of men who have sex with men: Results from the Sexually Explicit Media (SEM). Submitted for publication.
Quantitative: online survey(N=1,391 MSM, May-August 2011)
Rosser, B.R.S., Smolenski, D., Erickson, D. Iantaffi, A., Brady, S.S., Galos, D. Grey, J. Hald, G.M., Horvath, K.J., Kilian, G., Træen, B., Wilkerson J.M. (2103). The effects of gay sexually-explicit media on the HIV risk behavior of men who have sex with men. AIDS & Behavior, 17(4):

6. Participants
Recruitment: 7.9 million impressions on Gay Ad Network – Mega-site advertising across102 gay sites with 2+ million visitors per month.
Inclusion criteria
Internet-using
MSM (male, 18+, who self-report sex with men last 3 yrs)
Living in the US
A unique individual as validated by our cross validation and de-duplication protocol.
Racial strata used to increase non-White involvement.
Process data on de-duplication and cross-validation
CTR=0.16%; 2% multiple submits and 10% invalids

7. Potential Limitations Very linear and mechanistic
Initial Theoretical Framework Simon & Gagnon’s (1973) Sexual Script Theory
References: Stulhofer A, Busko V, Landripet I. Pornography, sexual socialization and satisfaction among young men. Archives of Sexual Behavior. 2008;37.
Fisher, W. A., & Barak, A. (2001). Internet pornography: a social psychological perspective on internet sexuality. Journal of Sex Research, 38(4),
Potential Limitations
Very linear and mechanistic
Focused on early exposure to set scripts
Potentially dated (pre-Internet; pre-Stonewall)
Not based on MSM’s actual experience
According to the model, there are at least 3 ways SEM may influence the scripting process. First, the sexual depictions may be integrated into one’s sexual role, perceptions of partner’s sexual role, and expectations. Thus, a man watching SEM of anal sex may find his attraction for this behavior clarified, while learning the roles of active, passive, or versatile partner and the cultural rules governing such scenes. Whether or not safer sex is considered important or appropriate is likely determined by the degree condoms are depicted explicitly. Second, SEM may impart implicit criteria for what is “good” or “real” sex against which to evaluate one’s own situation. For example, satisfaction with and expectations of body appearance, genital size, sexual performance, condom use, intimacy and relationship experiences may be critically influenced by what SEM one views. Third, critics of (heterosexual) SEM argue that SEM may desensitize viewers by reinforcing gender stereotypes and not showing the negative consequences of sexual promiscuity. Although the gay SEM context is somewhat different, equivalent sequelae could be raised: that straight men and being butch are iconic desires in gay SEM, hypermasculine bodies are the sexual ideal, that anal sex is ultimate sex, that condom use magically happens versus being planned and negotiated, and that no one needs to communicate their needs. These scripts are then tested out in real life sexual behavior which in turn predicts both our overall sexual satisfaction and, of importance to HIV prevention, our HIV risk.

8. Identify partners and engage in behavior
Fig.1 The SEM Risk Behavioral Model: How what we see influences what we do1
Reference: Wilkerson, J.M., Iantaffi, A., Smolenski, D.J., Brady, S.S., Horvath, K.J., Grey, J.A., and Rosser, B.R.S. (2012). The SEM Risk Behavior (SRB) Model: A new conceptual model of how pornography influences the sexual intentions and HIV risk behavior of MSM. Sexual and Relationship Therapy. 27(3):
Antecedents: Cultural norms, online access, mood, SEM and sex experience, relationship status
Sexual norms & intentions
View
SEM
Exposed to new behavior No
Yes
Is behavior arousing?
Maintain sexual norms, intentions and behaviors No No
Yes
Identify partners and engage in behavior
Modify sexual intentions, maintain behaviors No
Yes
Is behavior pleasurable?
Do you trust partner?
Modify sexual intentions, norms and behaviors
Yes
Yes

9. Results Aim 1: To study gay SEM consumption (N=1,391 US MSM; May-Aug 2011)
SEM Consumption by MSM is:
Almost universal: 98.5% participants reported recent viewing of SEM.
Very high consumption: Mdn=2.9 hrs per wk (=24.9 min per day);
Range: hrs per week.
The #1 sex activity online: sex-seeking Mdn=1.0 hr per week.
High across all demographics: Younger MSM were not higher SEM consumers (OR=1.12, 95%CI: 0.87, 1.42).
Cyber-SEM focused: % accessed SEM via computers;
45.4% used DVDs and
41.4% also on mobiles.
SEM is a central yet almost unstudied part of MSM’s sexual behavior
Reference: Rosser, B.R.S., Smolenski, D., Erickson, D. Iantaffi, A., Brady, S.S., Galos, D. Grey, J. Hald, G.M., Horvath, K.J., Kilian, G., Træen, B., Wilkerson J.M. (2013). The effects of gay sexually-explicit media on the HIV risk behavior of men who have sex with men. AIDS & Behavior, 17(4):

10. Results Aim 1: To study gay SEM consumption (N=1,391 US MSM; May-Aug 2011)
In SEM, MSM like looking at actors who are similar demographically:
% Participants in each comparison who prefer
Prefer Actors who are OR
95% CI
Young (88.3%)
Older (71.9%)
Younger
2.96
2.19
3.99
HIV+ (81.5%)
HIV- (48.9%)
HIV+
4.61
2.73
8.15
Average looking (19.8%)
Handsome (7.3%)
Average-looking
3.11
2.18
4.45
Well-endowed (27.5%)
Average-endowed (14.8%)
Well-endowed
2.17
1.60
2.98
But all race/ethnicities preferred White actors, and:
MSM of Color (73.4%)
White MSM (56.5%)
White
2.12
2.82
Reference: Galos DL, Smolenski DJ, Grey JA, Iantaffi A, Rosser BRS. (2012). Sexually-explicit viewing priorities among men who have sex with men (MSM): Findings from the sexually explicit media (SEM) study. Paper presented at: XIX International AIDS Conference, ; July 22-27; Washington, DC. (Paper also in review).

11. Results Aim 1. To study gay SEM consumption (N=1,391 US MSM; May-Aug 2011)

12. Aim 1: To study gay SEM consumption (N=1,391 US MSM; May-Aug 2011)
Results
Aim 1: To study gay SEM consumption (N=1,391 US MSM; May-Aug 2011)
Q. How do MSM evaluate the effects of their SEM watching?
A. Almost all rate it as positive:
97% viewed their SEM use in the neutral-to-positive range.
Top benefits cited to watch gay SEM: increased knowledge of gay sex, increased sexual interest and enhanced masturbation
Only 3% reported a small negative effect (mainly decreased body image).
Only 2% scored as sexually compulsive and 4% as having compulsive SEM consumption patterns.
Categorical outcomes
Reference: Hald GM, Smolenski D, Rosser, B.R.S. (2013). Perceived effects of sexually-explicit materials among men who have sex with men and psychometric properties of the pornography consumption effect scale. Journal of Sexual Medicine, 10(3):

13. Aim 2. What is the relationship between SEM consumption and HIV risk behavior?

14. Results
Aim 2: What is the relationship between SEM consumption and HIV risk behavior?
Nearly all MSM (89.4%) report watching bareback SEM on a daily-to-weekly basis.
Categorical outcomes
Bareback SEM has become extremely common and almost unavoidable
Reference: Rosser, B.R.S., Smolenski, D., Erickson, D. Iantaffi, A., Brady, S.S., Galos, D. Grey, J. Hald, G.M., Horvath, K.J., Kilian, G., Træen, B., Wilkerson J.M. (2013). The effects of gay sexually-explicit media on the HIV risk behavior of men who have sex with men. AIDS & Behavior, 17(4):

15. Results Aim 2: What is the relationship between SEM consumption and HIV risk behavior?
What kind of anal sex do MSM prefer to see in SEM?

16. ≠ HIV risk behavior As predicted, in multivariable models*: Results
Aim 2: What is the relationship between SEM consumption and HIV risk behavior?
As predicted, in multivariable models*: ≠
* Maximum likelihood regression models using natural log transformation of exposure and ordinal measures of unprotected vs protected anal sex. Adjusted for age, education, race/ethnicity, HIV status, relationship status, #male partners, drug use, affect, social desirability, CSB and internalized homonegativity
PRR= Prevalence rate ratio POR= Prevalence odds ratio
HIV risk
behavior
Categorical outcomes
Reference: Rosser, B.R.S., Smolenski, D., Erickson, D. Iantaffi, A., Brady, S.S., Galos, D. Grey, J. Hald, G.M., Horvath, K.J., Kilian, G., Træen, B., Wilkerson J.M. (2013). The effects of gay sexually-explicit media on the HIV risk behavior of men who have sex with men. AIDS & Behavior, 17(4):

17. Selected Results 2:
What is the relationship between SEM consumption and HIV risk behavior?
In multivariable regression models* a preference for watching bareback SEM predicted:
insertive UAI with multiple men: PRR = 1.70 (1.22, 2.38)
receptive UAI with multiple men: PRR = 1.71 (1.21, 1.34)
Conversely, a preference for safer sex SEM predicted markedly decreased risk:
for insertive UAI multiple men: PRR = 0.53 (0.32, 0.87)
for receptive UAI multiple men: PRR = 0.37 (0.21, 0.66)
* Adjusted for age, education, race/ethnicity, HIV status, relationship status, #male partners, drug use, affect, social desirability, CSB and internalized homonegativity
PRR= Prevalence rate ratio
Categorical outcomes
Reference: Rosser, B.R.S., Smolenski, D., Erickson, D. Iantaffi, A., Brady, S.S., Galos, D. Grey, J. Hald, G.M., Horvath, K.J., Kilian, G., Træen, B., Wilkerson J.M. (2013). The effects of gay sexually-explicit media on the HIV risk behavior of men who have sex with men. AIDS & Behavior, 17(4):

18. Selected Results
Aim 2: What is the relationship between SEM consumption and HIV risk behavior?
A dosage effect between bareback SEM and risk was observed:
Viewing bareback SEM was associated with:
insertive UAI with multiple partners: PRR= 1.11 (1.01, 1.21)
receptive UAI with multiple partners: PRR= 1.18 (1.07, 1.31)
and also serodiscordant UAI: POR= 1.29= (1.13, 1.48)
* Adjusted for age, education, race/ethnicity, HIV status, relationship status, #male partners, drug use, affect, social desirability, CSB and internalized homonegativity
PRR= Prevalence rate ratio POR: Prevalence odds ratio
Categorical outcomes
Reference: Rosser, B.R.S., Smolenski, D., Erickson, D. Iantaffi, A., Brady, S.S., Galos, D. Grey, J. Hald, G.M., Horvath, K.J., Kilian, G., Træen, B., Wilkerson J.M. (2013). The effects of gay sexually-explicit media on the HIV risk behavior of men who have sex with men. AIDS & Behavior, 17(4):

19. Robustness & Reliability
Selected Results
Robustness & Reliability
While we were conducting this study, Dylan Stein et al. published a study on 821 high risk MSM in New York. Key findings:
77% participants reported recently viewing bareback SEM
MSM who consumed mainly bareback SEM had elevated odds ratios (ORs: ) of UAI compared to safer sex SEM consumers.
But used slightly different measures, population, and analyses.
Conclusion: Findings are ROBUST and RELIABLE.
Categorical outcomes
Reference: Stein D, Silvera R, Hagerty R, Marmor M. (2012). Viewing pornography depicting unprotected anal intercourse: Are there implications for HIV prevention among men who have sex with men. Archives of Sexual Behavior. 41(2):

20. Results 3:Needs Assessment
Target population finds SEM-based HIV prevention acceptable
85.7% participants state using SEM for HIV prevention is highly acceptable (true across age, race/ethnicity and HIV status)
64.6% would participate in future SEM-based HIV prevention studies.
HIV prevention in SEM is not a priority for MSM
Consumers rank #1 cost (free), #2 availability (online), #3 access (non membership), #4 sex act (preferred), #5 actors looks. Of 9 priorities, seeing condoms came in 9th (lowest).
MSM want focus to be on anal sex and condoms only
Highly acceptable: Pre-roll ads and actors modeling use of condoms and lubricants for anal sex.
Not acceptable: oral sex with condoms or analingus with dental dams
Categorical outcomes
Reference: (1) Wilkerson JM, Iantaffi A, Smolenski DJ, Horvath KJ, Rosser BRS. Acceptability of HIV-prevention messages in sexually explicit media viewed by men who have sex with men. AIDS Education and Prevention. 2013;25(4): (2) Iantaffi A, Wilkerson JM, Grey JA, Rosser BRS. The acceptability of sexually explicit messages in HIV prevention among men who have sex with men. submitted for publication.

21. Results 3:Needs Assessment
Latent profile analysis show MSM divide into three groups
17% - Resistant. No to any HIV prevention in SEM.
54% - Focus on all anal sex with condoms and lube shots
29% Use SEM to promote all HIV risk reduction strategies
PrEP; Home testing
Categorical outcomes
Reference: (1) Wilkerson JM, Iantaffi A, Smolenski DJ, Horvath KJ, Rosser BRS. Acceptability of HIV-prevention messages in sexually explicit media viewed by men who have sex with men. AIDS Education and Prevention. 2013;25(4): (2) Iantaffi A, Wilkerson JM, Grey JA, Rosser BRS. The acceptability of sexually explicit messages in HIV prevention among men who have sex with men. submitted for publication.

22. Discussion Contribution to the field:
Only selected findings highlighted here due to time constraints
We have over 24 peer-reviewed publications in process of publication, including:
Methodological papers (protocols, measures, reliability results)
Outcome papers (on SEM, HIV risk and other areas)
Needs assessments (on MSM priorities)
Related topics (secondary investigations)

23. Discussion These results pose at least 4 key questions to the field:
1. Is there a disconnect between a clinical industry which tends to emphasize the dangers of Internet porn and MSM’s actual experience which concludes Internet SEM is healthy and helpful? Hopefully our results can be used to balance “third person” effects in gay SEM.
2. Is there a way to harness SEM consumption for HIV prevention? At a time when MSM are described as “disengaged” from HIV prevention, they spend 24.9 min per day dosing themselves with SEM.

24. Discussion These results pose at least 4 questions to the field:
3. What would SEM-based HIV prevention look like? We have good acceptability data on what is acceptable, but need to discover what is effective.
4. Is watching bareback SEM causing risk behavior? Given we have only two studies of gay SEM and HIV risk, but both show impressive associations between bareback SEM consumption and risk, and ours also shows a strong association between safer sex SEM and low risk.

25. Chief Limitations
The literature is sparse. Only two studies (Stein et al., 2012; Rosser et al., 2013).
The data are all self-report, raises questions of accurate recall and bias.
Convenience samples were used, so generalizability is unknown.
The data are cross-sectional, so causality cannot be inferred. (However in our qualitative data we had some anecdotes of SEM causing unsafe sex).

26. Future Research Directions 1
We need to study causality. We need to study gay SEM consumption structurally. What happens if we restrict MSM to only safer sex SEM or only bareback SEM? Practical and ethical challenges

27. Future Research Direction 2
Future Research Direction 2. What are the implications for building young MSM’s sexual health?
Showmehow.co.uk

28. Future Research Directions 3 How to recruit and retain in highly sexually explicit sex environments?
University Sex Study click here

29. Acknowledgements
Investigators, Staff and Consultants:
B. R. Simon Rosser, PhD
Sonya S. Brady, PhD
Darin J. Erickson, PhD
Dylan Galos, MPH
Jeremy Grey, MA
G. Martin Hald, PhD
Keith Horvath, PhD
Gunna Kilian, BA
Syed W. Noor, PhD
Joe Konstan, PhD
Derek Smolenski, PhD, MPH
Bente Træen, PhD
Richard Weinmeyer, MPhil
J. Michael Wilkerson, PhD, MPH
The SEM Study was funded by the National Institute of Mental Health
R01 MH
(PI: Rosser).

30. B. R. Simon Rosser, PhD, MPH, LP rosser@umn.edu
Thank you and wishing
you good sexual health!
B. R. Simon Rosser, PhD, MPH, LP