Open in a separate window Analysis Initially, we categorized the interview results into a series of similar themes [ 6 ]. Then, we modified these categories to obtain coded data through the open coding, axial coding, and selective coding procedures described by Strauss and Corbin [ 7 ]. The study used open coding to compare the primary categories with the raw interview data.
We used axial coding to analyze each category's systematic connection with sexual behavior and partner selection processes.
Selective coding was used to determine the core concept that offers the most integrated explanation of the relationships among the partnering categories. N vivo 8 software was used during the coding processes and for conceptual analyses. According to a methodological guideline presented by Frieze, NVivo 8 software eliminates specific coding process disparities [ 8 ]. Inter-coder reliability, determined by calculating kappa values for each code, is summarized in the Appendix 1.
We reviewed the credibility and fittingness of the analysis output by applying the evaluation criteria reported in a qualitative study reported by Sandelowski [ 9 ]. Ethics Statement This study was approved by the institutional review boards of the College of Health Science at Korea University and is consistent with the principles of the Declaration of Helsinki. All participants gave written informed consent to participate. Participant 1 spoke of how his sexual identity problems began with his feminine attitude Appendix 2.
MSM discover themselves to be different from others during the course of feeling affection for members of the same sex. The more patriarchal a society is, the stronger the relationship between sex and gender. Consequently, when gender roles are diminished, the possession of a MSM identity is accompanied by cognitive distress. However, contrary to stereotypical attitudes, MSM do not necessarily realize their sexual orientation through their femininity, nor are all of them effeminate.
Some participants in this study ascertained they were MSM, whereas others determined they had a bisexual disposition Participant 4, Appendix 2. Possessing an identity as a MSM can result in voluntarily adopting the everyday life activities, self-adornments, and interests of a MSM.
Participant 9 pointed out that as one becomes acquainted with different MSM people, an internal intimacy develops, and partnering occurs during that development Appendix 2. However, such MSM partnering is often orientated toward sexual contact.
Unlike the straight community, members of the MSM community do not have the opportunity to meet other MSM in a wide variety of places; thus, the basis of their social life activities is mainly directed at satisfying their sexual desires. They do not confine 'sex' to an activity for reproduction; rather they seek to attain sexual pleasure as a natural activity.
A dominant feature of MSM partnering is that outward countenance has become an important criterion applied during partner selection. In the case of heterosexuals, socioeconomic factors other than outward countenance play a key role in partner selection, whereas sex appeal is an important factor in the MSM community. Regardless, partner selection reflects individual tastes rather than indicative of an ideal or standardized body shape Participant 23, Appendix 2.
Unlike straight relationships, sensual and sexual satisfaction have significance for MSM therefore, MSM may not prefer long-term or exclusive relationships with a partner.
In the MSM community, MSM may participate in unrestrained and diverse types of partnering to maximize their sexual pleasure. Among heterosexuals, engagement and marriage are important, and legal regulations and ethical codes exist to protect against extramarital affairs.
For MSM, however, the period of partnering may be much shorter even with the selection of primary partners, and the rules and ethical codes are less strict. Participant 20 in his description of his relationship with his primary partner Appendix 2. Having a primary partner does not necessarily mean MSM would not have concurrent sexual partnerships.
Eleven of the 19 participants who said they had primary partners stated that they had more than ten sex partners in the past year. Some participants said that they had two or more primary partners. Thus, having a primary partner did not indicate exclusivity in their sexual relationships. A primary partner may have a supportive role in maintaining a pattern of flexible, short-cycled serial monogamy. Participant 20 described temporal changes in his sexual partnering Appendix 2.
In such situations there may be intentional shunning of the other partner; moreover, the primary partner may define themselves as having a bisexual identity. Such people clearly manifest a sexual desire for both sexes, and some have sexual experiences with both sexes while determining their sexual identity Participant 18, Appendix 2. Another significant element in understanding partnering is the type of sexual behavior. Because MSM partners have the same body structure, they must develop sex techniques that allow each partner to achieve sexual pleasure.
The participants offered many comments on this topic. In general, sexual behaviors exhibited within a relationship between partners were based on mutual consent and personal adjustment.
With regard to anal intercourse, there was a difference among the participants between those that liked or disliked anal intercourse. Among the bisexual participants there was a preference for penetrative sex Participant 13, Appendix 2. MSM partnering is not solely dependent on having a primary partner.
Partnering is also affected by individual attitudes toward condom use and sexually transmitted disease. Most interviewees expressed a worry about HIV infection, but there were large differences in their practice of safe sex i. Among those who have anal intercourse there was recognition of the necessity of condom and lubricant use. However, some participants attempted to prevent HIV infection by restricting their sexual partnering rather than by using a condom Participant 14, Appendix 2.
Thus, the MSM community and MSM social networks have relied on the use of individual behavioral preferences for HIV infection prevention rather than on developing specific community-based norms for safe sex. When it is difficult to communicate with a partner about the use of a condom, some MSM people will seek safety from infection by restricting their sexual relationships to reliable partners.
However, this situation can be more difficult for those with HIV as it can lower their capacity to cope with social stigma and discrimination. Consequently, solidarity in the approach to infection prevention in the MSM community is weakened by the differences in attitudes toward HIV infection within that community. Regardless, sexual relationships in the MSM community occur even though the community may not offer aid or capacity-building programs related to sexual partnering.
Types of MSM Partnering The presence of a primary partnership and the practice of anal intercourse were the most influential factors in MSM partnering. Our analysis included positioning mapping, which placed each interviewee's stated sexual orientation and HIV infection status on two axes Fig.
The results indicated the presence of three types of partnering. The first type represented MSM who have a primary partner and do not perform anal intercourse group 1. Some members of that group had a large number of sex partners, but they also recorded a high level of safe sex. The second type included MSM and bisexuals who have a primary partner and perform anal intercourse group 2 and 4.
Despite their participation in that risky sexual activity, they exhibited restricted partnering. The third type included bisexuals without a primary partner group 3.
The majority of that group was HIV positive. Among the above three types, the group 1 members had the most cautious safe-sex relationships, whereas the group 3 bisexuals formed the least cautious safe-sex relationships.