Age at First Anal Sex and HIV/STI Vulnerability
To our knowledge, this is the first study that links AFAI with HIV/STIs and higher risk sexual behaviour among gay men. Based on the sample in this study, the age at which men first have anal intercourse appears to be a strong marker for HIV. Those who reported being HIV positive were younger on average when they first had anal intercourse. Importantly, this association remains strong even after controlling for socio-demographic differences in AFAI, including men's age, education or whether they were victims of childhood sexual abuse. Studies linking HIV with sexual debut among Westerners are rare. However, our findings are consistent with those that show heterosexual men and women with the highest incidence of STIs tend to report early age of first intercourse. Just recently, a US study also reported links between age at sexual debut and some higher risk sexual behaviours among ethnic minority young men who have sex with men.
One factor likely to contribute to this vulnerability is the association we found between AFAI and recent experiences of higher risk sexual behaviour, including having a large number of sexual partners in the past 12 months, engaging in group sex and having receptive anal intercourse. Although no differences were found for condom use, engaging in unprotected sex with casual partners is not uncommon among gay men, which is obviously made riskier if they also have multiple partners involving receptive anal intercourse. Early sexual debut and a tendency towards having numerous sexual partners may be signs of sexual adventurism or sensation seeking. However, our findings around receptive anal intercourse are particularly intriguing. One explanation may relate to recent findings that suggest our earliest sexual experiences can set a pattern for future sexual behaviour. For example, adopting the receptive role is common among younger gay men, possibly because many of these men tend to have older partners who take an insertive role. For some, the role they take plays a major part in their sexual identity where they view themselves as either tops or bottoms. Consequently, if their earliest sexual experiences primarily involve receptive anal intercourse, some of these men may form identities around being bottoms and continue favouring receptive over insertive anal intercourse.
AFAI was also associated with other aspects of sexual health beyond HIV. While having an STI in the past year was not linked to AFAI, those who reported multiple STIs were younger on average when they first had anal intercourse than those who did not report an STI. Those with histories of hepatitis A, B and C were also younger on average when they first had anal intercourse. With all these links between gay men's AFAI and their future sexual health, placing a stronger emphasis on addressing the needs of those who had their first anal intercourse at a particularly young age may need to be an important part of preventing HIV/STIs in this population. Understanding the life histories of these men and the circumstances surrounding their first sexual experiences may also provide clues about how to target safer sex education and other forms of support.
Given our findings, it may be tempting to assume that an effective HIV prevention strategy would involve promoting delayed sexual debut among gay men. However, our data provide no information about whether a causal link exists between AFAI and future sexual health, only that it is a strong marker. Also, existing efforts to promote delayed sexual debut among young people, particularly in the USA, appear to have had little success as HIV prevention strategies. Assuming many gay youth will continue having early sexual intercourse, it is particularly important for sexuality education in schools to teach strategies for safer sex among same-sex attracted men. While it is common for secondary schools in many countries to provide sexuality education, few programmes address issues around sex between gay men. This may explain recent US findings in which a large proportion of young gay men reported having little knowledge about HIV and STIs when they first had anal intercourse. Encouragingly, the few sexuality education programmes that have included topics relevant to gay men appear to result in less risky sexual behaviour, at least in the USA. Further efforts are clearly needed to incorporate sexuality education into school education for gay youths. However, in light of the strong association we found between AFAI and poorer education, these efforts will need to be conducted sufficiently early to catch those who dropout or leave school.
Another notable finding was the sharp decline in median AFAI between men born 1944–1953 and subsequent age cohorts. Although it is highly likely that declines in AFAI are a result of changes in socio-cultural context, many of those born between 1944 and 1953 would have been sexually active during the earliest years of the HIV epidemic. This was a time when highly active antiretroviral therapy was unavailable. Some of those who were having anal intercourse at an early age may have become infected with HIV and therefore not survived, which may at least partly explain the very high median AFAI for this group.
There were some limitations to this study that need to be considered when interpreting our findings. First, because this study involved a self-selected sample, we cannot claim it is representative of all Australian gay men. That said, our sample appeared to be diverse, with all of the main socio-demographic categories well represented. This diversity may have kept sampling bias to a minimum. Additionally, almost all significant associations involving AFAI were highly significant, so alternative sampling methods may not alter these findings.
Second, this study involved an online retrospective survey. Especially for older men, recalling their AFAI may incur a degree of recall error. Nevertheless, the first experience of anal intercourse is likely to be a significant event for many men and therefore memorable. Recall biases are also likely to be randomly distributed, at least within age groups, and therefore unlikely to affect comparisons between groups of men based on their AFAI. It should also be acknowledged that one benefit of an online survey is that it guarantees anonymity, so respondents are perhaps more likely to answer honestly, which is not always the case in other survey modes involving questions about sexual behaviour.
Third, this survey targets men who had experience with sex or relationships. This is a particular issue for the 1984–1993 cohort as some may not yet have had sex. That said, recent data shows a majority of young people are now having sex before age 17, including same-sex attracted adolescents, so future studies are likely to produce a similar median AFAI to that found in our study. Moreover, while this limitation points to a need for further research, it is unlikely to have affected the main findings of this paper. That is, of men who have had anal intercourse, those with poorer sexual health outcomes tend to report an earlier AFAI.
In summary, findings from this nationwide online survey reveal strong links between age at first anal intercourse and future sexual health and behaviour. In the sample presented in this paper, those who became HIV positive, engaged in higher risk sexual behaviour and reported other poorer sexual health outcomes tended to have had their first anal intercourse at a younger age than other men. With the median age of sexual debut continuing to decline, clinicians and other health service providers, as well as researchers, need to pay particular attention to gay men's earliest sexual experiences. In particular, men who report having anal intercourse at a young age are likely to be at heightened HIV vulnerability and therefore require additional education and support for ensuring a healthier sex life. Further education around safer sex practices that specifically targets gay-identified youth may also be required to ensure their sexual debut does not lead to poorer sexual health outcomes.
Discussion
To our knowledge, this is the first study that links AFAI with HIV/STIs and higher risk sexual behaviour among gay men. Based on the sample in this study, the age at which men first have anal intercourse appears to be a strong marker for HIV. Those who reported being HIV positive were younger on average when they first had anal intercourse. Importantly, this association remains strong even after controlling for socio-demographic differences in AFAI, including men's age, education or whether they were victims of childhood sexual abuse. Studies linking HIV with sexual debut among Westerners are rare. However, our findings are consistent with those that show heterosexual men and women with the highest incidence of STIs tend to report early age of first intercourse. Just recently, a US study also reported links between age at sexual debut and some higher risk sexual behaviours among ethnic minority young men who have sex with men.
One factor likely to contribute to this vulnerability is the association we found between AFAI and recent experiences of higher risk sexual behaviour, including having a large number of sexual partners in the past 12 months, engaging in group sex and having receptive anal intercourse. Although no differences were found for condom use, engaging in unprotected sex with casual partners is not uncommon among gay men, which is obviously made riskier if they also have multiple partners involving receptive anal intercourse. Early sexual debut and a tendency towards having numerous sexual partners may be signs of sexual adventurism or sensation seeking. However, our findings around receptive anal intercourse are particularly intriguing. One explanation may relate to recent findings that suggest our earliest sexual experiences can set a pattern for future sexual behaviour. For example, adopting the receptive role is common among younger gay men, possibly because many of these men tend to have older partners who take an insertive role. For some, the role they take plays a major part in their sexual identity where they view themselves as either tops or bottoms. Consequently, if their earliest sexual experiences primarily involve receptive anal intercourse, some of these men may form identities around being bottoms and continue favouring receptive over insertive anal intercourse.
AFAI was also associated with other aspects of sexual health beyond HIV. While having an STI in the past year was not linked to AFAI, those who reported multiple STIs were younger on average when they first had anal intercourse than those who did not report an STI. Those with histories of hepatitis A, B and C were also younger on average when they first had anal intercourse. With all these links between gay men's AFAI and their future sexual health, placing a stronger emphasis on addressing the needs of those who had their first anal intercourse at a particularly young age may need to be an important part of preventing HIV/STIs in this population. Understanding the life histories of these men and the circumstances surrounding their first sexual experiences may also provide clues about how to target safer sex education and other forms of support.
Given our findings, it may be tempting to assume that an effective HIV prevention strategy would involve promoting delayed sexual debut among gay men. However, our data provide no information about whether a causal link exists between AFAI and future sexual health, only that it is a strong marker. Also, existing efforts to promote delayed sexual debut among young people, particularly in the USA, appear to have had little success as HIV prevention strategies. Assuming many gay youth will continue having early sexual intercourse, it is particularly important for sexuality education in schools to teach strategies for safer sex among same-sex attracted men. While it is common for secondary schools in many countries to provide sexuality education, few programmes address issues around sex between gay men. This may explain recent US findings in which a large proportion of young gay men reported having little knowledge about HIV and STIs when they first had anal intercourse. Encouragingly, the few sexuality education programmes that have included topics relevant to gay men appear to result in less risky sexual behaviour, at least in the USA. Further efforts are clearly needed to incorporate sexuality education into school education for gay youths. However, in light of the strong association we found between AFAI and poorer education, these efforts will need to be conducted sufficiently early to catch those who dropout or leave school.
Another notable finding was the sharp decline in median AFAI between men born 1944–1953 and subsequent age cohorts. Although it is highly likely that declines in AFAI are a result of changes in socio-cultural context, many of those born between 1944 and 1953 would have been sexually active during the earliest years of the HIV epidemic. This was a time when highly active antiretroviral therapy was unavailable. Some of those who were having anal intercourse at an early age may have become infected with HIV and therefore not survived, which may at least partly explain the very high median AFAI for this group.
There were some limitations to this study that need to be considered when interpreting our findings. First, because this study involved a self-selected sample, we cannot claim it is representative of all Australian gay men. That said, our sample appeared to be diverse, with all of the main socio-demographic categories well represented. This diversity may have kept sampling bias to a minimum. Additionally, almost all significant associations involving AFAI were highly significant, so alternative sampling methods may not alter these findings.
Second, this study involved an online retrospective survey. Especially for older men, recalling their AFAI may incur a degree of recall error. Nevertheless, the first experience of anal intercourse is likely to be a significant event for many men and therefore memorable. Recall biases are also likely to be randomly distributed, at least within age groups, and therefore unlikely to affect comparisons between groups of men based on their AFAI. It should also be acknowledged that one benefit of an online survey is that it guarantees anonymity, so respondents are perhaps more likely to answer honestly, which is not always the case in other survey modes involving questions about sexual behaviour.
Third, this survey targets men who had experience with sex or relationships. This is a particular issue for the 1984–1993 cohort as some may not yet have had sex. That said, recent data shows a majority of young people are now having sex before age 17, including same-sex attracted adolescents, so future studies are likely to produce a similar median AFAI to that found in our study. Moreover, while this limitation points to a need for further research, it is unlikely to have affected the main findings of this paper. That is, of men who have had anal intercourse, those with poorer sexual health outcomes tend to report an earlier AFAI.
In summary, findings from this nationwide online survey reveal strong links between age at first anal intercourse and future sexual health and behaviour. In the sample presented in this paper, those who became HIV positive, engaged in higher risk sexual behaviour and reported other poorer sexual health outcomes tended to have had their first anal intercourse at a younger age than other men. With the median age of sexual debut continuing to decline, clinicians and other health service providers, as well as researchers, need to pay particular attention to gay men's earliest sexual experiences. In particular, men who report having anal intercourse at a young age are likely to be at heightened HIV vulnerability and therefore require additional education and support for ensuring a healthier sex life. Further education around safer sex practices that specifically targets gay-identified youth may also be required to ensure their sexual debut does not lead to poorer sexual health outcomes.
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