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Furthermore, research indicates that these two potential effects of negative mood vary according to gender and sexual orientation—negative mood more reliably predicts lowered sexual excitation in women than in men, while it better predicts increased problems with inhibiting sexual excitation in men than in women [ 15 ]. Further, depression was associated with greater rates of condomless sex amongst gay men while there was no such association for heterosexual men, and the effects of depression on tallies of sex partners and one-night-stands were stronger for gay men than for heterosexual men [ 16 ].

Indeed, a study of highly sexually-active gay and bisexual men found that a composite score of depression and anxiety was actually associated with increased sexual excitation, as well as with minimized self-efficacy regarding inhibiting sexual thoughts and urges, and stronger beliefs in the perceived necessity of having sex [ 17 ]. In more recent studies focusing solely on gay and bisexual men, depression has been positively associated with the odds of having recent sexual risk in a number of diverse samples, including: It should be noted that, in each of these studies, sexual risk-taking behavior was dichotomized into either having none or having any condomless anal sex CAS in a specified period of time, as was also done in Stall et al.

One possible explanation for variability in findings across studies is the variety of ways in which sexual risk has been operationalized and measured, whether as a dichotomized variable indicating no risk versus any risk, or as a continuous variable in which the count of risk events is summed or used to calculate a proportion score. Day-level behavioral risk was measured as the sum of various sexual behaviors, with each behavior weighted according to riskiness, applicable for each sex event on a given day.

Analyses found that, while state-level negative affect did not predict increased sexual risk-taking on a given day, a lack of positive affect which also characterizes depression did. In sum, counts of the number or frequency of CAS events may be more informative than a dichotomized variable when considering the role of depression, as it is possible that depression is not as strongly involved for an individual reporting a single CAS event as it might be for an individual reporting multiple or regular CAS events. When predicting CAS without distinguishing receptive from insertive positioning, Hanson et al.


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Focusing on sexual positioning as an identity rather than on counts of behavioral events, Starks et al. Although Fendrich et al. While the literature is mixed, the consideration of CAS in terms of whether it is receptive or insertive, as advocated by Jin et al. Klein [ 33 ] found that depression, while not related to actual sexual risk behaviors among gay and bisexual men, was associated with condom use beliefs which were, in turn, related to sexual risk behavior.

Perdue et al. In each of these studies, the quadratic effect was negative, such that likelihood of sex risk dichotomized was lower at the lowest and highest levels of depression, and higher at moderate levels of depression. Similarly, risk was found to be highest among MSM with moderate depression i. That sex risk might decline at severely high levels of depression was also found in a study of young MSM, among whom major depressive disorder was associated with reduced sexual risk-taking [ 39 ].

The purpose of the current study was to illustrate how variability in the operationalization of sexual risk behavior and the incorporation of quadratic effects into regression models may influence conclusions about the depression-CAS link.

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The study analyzed the three CAS outcomes separately as both dichotomized variables i. The study also considered whether depression was associated with total number of casual male partners in the past 90 days. It was hypothesized that a positive linear association would be found between depression and all three CAS outcomes both when dichotomized and treated as count variables.

In line with previous studies, it was also hypothesized that a significant and negative quadratic association would be found with depression. No hypotheses were advanced for whether depression would be associated with number of recent casual male partners. Cross-sectional data were drawn from the first wave of the One Thousand Strong panel—a longitudinal study following a national U. To reflect population densities across regions, men were invited to complete a 2-min screening survey and were deemed eligible if they: Participants also needed to report having sex with a man within the past 5 years, to have an address to receive mail that was not a P.

Box, and to have not moved more than twice in the past 6 months i. Of the Figure 1 displays these enrollment details, which are described elsewhere [ 40 ]. In total, men For the present study however, 38 men who reported having been prescribed pre-exposure prophylaxis PrEP were excluded from analyses, resulting in a final analytic sample of HIV-negative gay and bisexual men who were not on PrEP. Response options range from 0 rarely or none of the time to 3 most or all of the time. Typically, individuals are asked about the presence of symptoms within the past week, and studies have specified a cutoff of 16 or greater as being indicative of clinically meaningful depression [ 42 ].

However, to align with the period of sexual activity reported in the current study i. Participants reported the number of male casual sex partners during the past 90 days, and the total number of anal sex events whether receptive or insertive, and whether or not condoms were used with casual partners in the past 90 days.

Inclusion of education, but not income, as a covariate in the following analyses was decided due to redundancy in the models. Both depression and the quadratic term for depression were entered alongside the relevant control variables: Additionally, a negative binomial regression, also controlling for the covariates listed above, tested whether depression and quadratic depression was associated with total number of casual male partners in the past 90 days whether with or without condoms.

The final sample of men was mostly White Ages ranged from 18 to 79 years, with a mean of Further demographic details are displayed in Table 1 , along with comparisons of depression scores. The average score on the CESD was Of the 1, men, reported at least one CAS event with a casual male partner in the past 90 days range 1— Some CAS was reported by The addition of the quadratic term for depression showed no significant findings with respect to any of the three dichotomized CAS outcomes. In other words, the strength of the association between depression and number of events increased with depression scores.

This indicates that depression is not associated with a greater number of casual male partners overall. The various findings of the current study highlight the importance of considering how the outcome of CAS with casual partners among HIV-negative gay and bisexual men is operationalized when investigating associations with depression. These considerations include: When dichotomized as having none versus any CAS, depression was not associated with increased odds of having any CAS—but, when treated as a count variable that tallied the number of CAS events, depression was found to be positively associated with a greater number of events, and furthermore there was a positive quadratic effect for depression.

Importantly, depression was not associated with total number of recent casual partners whether involving condoms or not —in other words, depression was not associated with having a greater or lesser number of recent casual partners, but was associated with the frequency of CAS with those casual partners. When dichotomized CAS was operationalized without regard for positioning, no effect for depression was detected—however, when CAS was separated, depression was found to predict the odds of receptive CAS, but not insertive CAS.

When CAS events were tallied without regard for positioning, depression was positively associated with total number of events—however, subsequent analyses showed that the strength of this association was greater for receptive CAS events than for insertive CAS events, the latter of which became non-significant with the addition of a quadratic term for depression.


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  • This may in part explain why some previous studies have not found effects for depression on CAS. The finding that depression appears more strongly involved in the prediction of receptive CAS is of great importance given the increased risk of HIV transmission posed by being the receptive partner in CAS [ 27 ]. In these studies, sexual risk-taking may have included both vaginal and anal sex, and in the five studies that focused specifically on HIV-negative gay and bisexual men, CAS was treated as a dichotomous none vs.

    The current findings are, however, in line with numerous studies published since which, focusing on gay and bisexual men, have shown a positive association between depression and CAS [ 5 , 6 , 19 , 20 ]. The findings also accord with research on the dual control model [ 14 , 43 ], which found that depression did not reduce sexual excitation in gay and bisexual men as had been observed in other populations, but may simultaneously impair the capacity to inhibit sexual response. In qualitative interviews [ 44 ] with a sample of mostly HIV-negative gay and bisexual men, depression was associated with increased sexual interest, often prompting the seeking of sexual contact as a source of mood repair and validation.

    Some men also reported increased risk-taking in sexual situations when depressed due to a reduced concern about adverse consequences. In a study of highly sexually-active gay and bisexual men, depression was associated with increased sexual excitation, minimized self-efficacy in resisting sexual thoughts and urges, and a strengthened belief in the necessity of having sex [ 17 ]. Further, greater depression is consistently observed among sexually compulsive gay and bisexual men, among whom the sense of feeling out-of-control and powerless in the face of sexual fantasies, urges, and behaviors is commonly reported [ 45 — 48 ].

    The finding of a positive quadratic association between depression and total number of casual CAS events, indicates that CAS increased more steeply at higher levels of depression in the current sample. This may be due to differences in how CAS was defined across studies. Differences in sample characteristics and study purpose may also be involved—although ours was a national sample of HIV-negative gay and bisexual men participating in an online survey, the Koblin et al. It is possible that our sample did not contain enough people at severely high levels of depression to detect the reduction in risk that has been observed elsewhere.

    A further possibility is that the link between depression and CAS operates differently in gay and bisexual men depending on their HIV status because CAS generally represents a greater health risk for HIV-negative men than for HIV-positive men, and may thus hold a range of different meanings. Further, a HIV-positive man struggling with depressive symptoms may experience sex with casual partners as a reminder of his HIV status [ 22 ], and this may dissuade him from engaging in casual sex with the same frequency as a depressed HIV-negative man. These numerous possibilities should be explored in future research.

    The current findings suggest that, while depression may not be a reliable predictor of the mere presence or absence of recent sexual risk which in many cases may be referring to a single CAS event , it can be more reliably expected to predict higher tallies of risk events, indicating repeated or regular risk-taking, both among single and partnered gay and bisexual men. Depression is often linked with a variety of factors or features which may be involved in impaired self-regulation such as emotion dysregulation, impulsivity, and reduced self-efficacy [ 17 ], external locus of control [ 49 ], and as mentioned above, sexual compulsivity [ 45 , 47 , 48 ].

    Accordingly, it may be that depression, in part, impels people to seek out sources of positive affect and distraction [ 46 ], while also depleting their capacity for self-regulation in the face of sexual risk.

    It may also be that the experience of depression involves dramatic fluctuations in self-esteem, and that this self-esteem instability predicts increased sexual risk-taking among gay and bisexual men [ 50 ]. The strengths of our study should be considered in light of the following limitations. Data for our study were cross-sectional, thus causality cannot be inferred.

    Recruitment parameters were set based on U. Census estimates of the distribution of same-sex couples across the country. The participants were all voluntarily participating in regular online survey research, had at-home Internet access, and were residentially stable, and the relatively high levels of income and education in the current sample may further limit generalizability.

    Further, the current study focused on sexual risk-taking with casual partners—future research should also consider the impact of depression on sexual risk-taking among HIV-positive men and between main partners, as well as other forms of sexual risk-taking and risk reduction practices e. In closing, the current study contributes to a growing body of recent studies showing evidence of a link between depression and increased sexual risk-taking among gay and bisexual men, and does so by focusing on HIV-negative men and CAS with casual partners.

    The findings provide support for the utility of measuring CAS as a count variable in which number of risk events are summed, rather than as a dichotomized variable indicating any CAS versus no CAS, and for delineating between receptive and insertive CAS.

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    The authors would like to acknowledge the contributions of the other members of the One Thousand Strong Study Team Dr. Ana Ventuneac, Dr. Jeffrey T. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Conflict of Interest The authors declare that they have no conflict of interest.

    Informed Consent Informed consent was obtained from all individual participants included in the study. National Center for Biotechnology Information , U.

    Sex and the Internet: gay men, risk reduction and serostatus.

    AIDS Behav. Author manuscript; available in PMC Jun 1. Brett M. Millar , 1, 2 Tyrel J. Starks , 1, 2, 3 Christian Grov , 1, 4 and Jeffrey T. Parsons 1, 2, 3. Tyrel J. Author information Copyright and License information Disclaimer.

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    Parsons, ude. Copyright notice. Particularly useful when looking for information on a specific issue, rather than exploring a wider topic. Supporting sexual health and relationships for people with learning disabilities 18 December In relationships, sex and sexual health, people with disabilities often face The authors investigated whether use of pre-exposure prophylaxis PrEP influenced partner selection on an online dating application.

    PrEP status was not a significant factor for HIV-positive men when it came to selecting sexual partners. PrEP usage has had divisive effects, either being seen as a responsible preventative measure or an enabler of risky sexual behaviour amongst MSM. The authors used vignettes in order to assess social attitudes of MSM on a popular geo-location sex app.

    Participants were presented with stories depicting gay male characters as either sexually promiscuous or monogamous and either taking PrEP or not. None of the characters used condoms. Participants were asked whether they would be friends, date, or have sex with the characters. A total of men from nine US cities completed the full survey years old, average age 37 in July Most of the men in the sample were white PrEP users also rejected promiscuous men for dating, and appeared to prefer to date men on PrEP, but this difference was once again not significant.

    They largely rejected promiscuous characters not taking PrEP.