Sexual Decision-Making of Rural Men Who Have Sex With Men

Sunday, 30 July 2017

Jessica A. Lecea, BSN1
Peri L. Kane, BSN1
Greg A. Carter, MSN, BSN2
Desiree Hensel, PhD3
(1)School of Nursing, Indiana University, Bloomington, IN, USA
(2)School of Nursing, Indiana Univeristy, Bloomington, IN, USA
(3)School of Nursing, Bloomington Campus, Indiana University, Bloomington, IN, USA


According to the Centers for Disease Control and Prevention ([CDC], 2016b), men who have sex with men (MSM) experience greater rates of sexual transmitted infections (STIs) and sexual health disparities compared to heterosexual individuals. Sexual-orientation based discrimination, violence and stigma contributes to this issue by building larger barriers to access and utilization of sexual health services (Hubach, 2015; Satcher, Hook, & Coleman, 2015). In order to access sex without provoking physical assault, jeopardizing communal ties or creating intrapsychic dissonance, some rural MSM utilize venues and practices that are linked to flawed risk reduction behaviors and the contraction of STIs (Hubach et al., 2015; Lewnard & Berrang-Ford, 2014). While representing four percent of the national population, the MSM rate of newly diagnosed HIV cases is fourty-four times that of heterosexual males (CDC, 2016a). This disproportionately affected group lacks medical treatment with only 39% of MSM living with HIV receiving care (CDC, 2016a). The World Health Organization ([WHO], 2016) released a call to action to provide comprehensive and effective interventions aimed at HIV prevention and treatment of MSM in all countries regardless of income. Previous research stresses the importance of not viewing the MSM community as a homogenous group, but rather recognizing the existence of MSM subcultures and crafting interventions based on their individual beliefs and behaviors (Prestage et al., 2015). Yet, current literature has not fully explored factors that influence sexual decision making of rural MSM.


The purpose of this study is to explore which factors in sexual decision making are most important to men that have sex with men from rural communities.


The research study uses Q methodology, a mixed methods approach that uses a set of philosophical principles, data collection techniques and statistical procedures to quantitatively study subjective beliefs and attitudes in regards to a particular topic (Ramlo, 2016; Watts & Stenner, 2012). Q methodology begins by populating the concourse, which is a complete set of opinions a group may say or think about a specific topic (Watts & Stenner, 2012). The concourse for this study was derived from previously conducted in-depth qualitative interviews with rural MSM and extant literature on sexual decision making patterns of rural MSM. The statements reflected sexual decisions based in social/intrapsychic safety, such as “I feel as though I would be physically attacked if I was found engaging in sex with men in a rural area” and sexual health risks, such as “I am not concerned with STIs because they can be treated”. After inspection of range and repletion, a subset of 44 subjective statements were retained to create the Q sample. The Q sample was reproduced on individual cards to be used in the sorting process. The recruited sample consisted of no more than 20 men that are 18 years of age or older, have resided in a rural area during childhood (ages 3-18), and has engaged in sexual activities with men. The Index of Relative Rurality will be used to determined rurality. Eligible participants will be asked to complete a demographic questionnaire and Q sort. The Q sort involves each participant reviewing and ranking the statements based on his level of agreement and disagreement to factors in sexual decision making. Each participant will record his rankings on a -5 to +5 distribution sorting sheet. Two follow-up questions will be used to obtain deeper insight of participants’ top rankings. The study was approved through the Indiana University Institutional Review Board (IRB).


This research study is ongoing. The results of this study will reveal which factors related to sexual decision making are most important to rural men that have sex with other men. Data will be analyzed using a standard process through principle component factor analysis and varimax rotation followed by calculating factor scores (Watts & Stenner, 2012). Data analysis with be completed using KenQ web-based software. The factor array will be used to identify common factors and viewpoints. This information will be interpreted through the lens of Simon and Gagnon’s sexual scripting theory in context of the demographic questionnaires and the follow-up questions.


The results gathered from this study will inform the development of targeted sexual health-based interventions tailored to this at-risk population. As a frontline provider addressing health disparities, nurses are essential to intervening on this pressing issue. In order to do so, nurses must be informed of the STI/HIV epidemic and able to identify underlying decision-making factors perpetuating the ongoing outbreak. By engaging nurses in the care of at-risk populations to address one of the most significant and devastating epidemic in recent history, healthcare professionals will be able to optimize the health of this disportionately affected group on a global level.