Background: The “Married Men who have Sex with Men (M2M) Study” aims to understand the social, sexual and demographic aspects of MMSM, to guide a better understanding of this group to optimize healthcare and inform the community.

The study seeks to investigate the sexual networks and examine the concept of sexual fluidity within the context of sexual ambiguity of Married Men who have Sex with Men (MMSM). Subjects are being recruited through community organizations, activities, networks, snowballing (passive), advertising and personal contacts.

There has been much research in this area and the use of “beats, bars / clubs and sex on premises venues (SOPVs)” have been identified as common places of contacts for “men who have sex with men” (MSM), some of whom are married.

Using an ethnographic approach of naturalistic observation and personal experiences the study will describe the settings in which MMSM meet sexual contacts such as public places, sex clubs, saunas and backrooms often known as sex on premises venues (SOPV). These locations are also frequented by men who identify as homosexual. Not only are SOPVs pivotal in the study recruitment, they are sometimes the first point of contact for MSM and so have a potentially important role to play in the prevention of HIV and Sexually Transmitted Infections (STIs). Many MMSM use these premises frequently as they provide a safer environment therefore it is imperative that the environment is conducive to the prevention of disease and the promotion of health. Liaison with SOP venue operators and staff was vitallyimportant to facilitate availability of the questionnaires.

Saunas: After paying an entry fee men are provided with a locker and generally remove their street clothes to change into a towel or robe. Lunch time visits are popular with venues providing discounted entry. Saunas are usually separated into wet areas consisting of showers, steam rooms, dry sauna room, spas and dry areas with private cubicles furnished with vinyl mattresses. Communal areas such as “orgy” rooms, dark mazes, pornographic video rooms and areas with glory holes are also common. Socialising occurs in the cafe and lounge areas, which usually provide pool and TV. Consensual Sex can happen in a number of places. Each sauna has different variations of facilities and size however the larger establishments are more popular. Saunas like most SOPVs are also conducive for group sex participation between consenting individuals. Special areas or rooms are available for group sessions. Saunas are primarily isolated only for men (MSM) but in Sydney some new establishments do not “discriminate” and permit women on the premises often in arranged group meetings of bisexuals or couples.

SOP Venues: are places where patrons pay entry to meet and engage in consensual sex together. These are sex clubs/cruise areas or movie venues, men typically keep their clothes on (though nudity can be an option if facilities permit). Places for sex are similar to that of saunas minus the “water” amenities and tend to be smaller premises with limited provision of private cubicles. Theme rooms are common, such as a sling room below. A device used to enhance penetration.

Public Toilets (known as “Beats” in Australia) Richly described by Laud Humphreys in the controversial “Tearoom Trade Impersonal Sex in Public Places ” the male public toilet has been used throughout history and society as an accessible place for sexual contact between men. Exposure of a penis in a toilet necessitates urination at a communal urinal, however it is also an opportunity to view another penis and in some cases initiate sex in a covert manner ending in masturbation, oral sex and at times anal intercourse. Toilet cubicles may be used for privacy or sex between cubicles via glory holes or gaps under adjoining walls or doors. Modern toilets attempt to prevent sexual activities with single automated cubicles, installation of metal panels lining the walls and doors of cubicles as well as frequent security surveillance. Toilets which have limited public access but are accessible appear to be popular such as in shopping complexes, arcades, car parks, parks and beaches. Unfortunately public places including toilets can be a major risk for being caught in a compromising situation by law enforcement or a safety issue for individual harm and at times blackmail.

Parks, Beaches, Bush Tracks: Generally any outdoor public place can be used for sex by MSM but it is the more isolated or non assessable are popular (but also pose a safety risk) . These are often known by MSM as places for sexual contact and are well frequented during work hours. Nude beaches and their surrounding environments attract covert sexual behavior. There are a number of Gay specific beaches, coastline and native fauna areas which are known “beats”.

Potential Risks: As well as unprotected anal intercourse and oral intercourse, which represent a potential risk for transmission of STIs, including HIV, other sex practices at SOPVs or public places that may sometimes occur in the context of group sex may also be potential health risks for MSM, including MMSM:

The use of one condom by the insertive partner during anal intercourse with more than one receptive partner; Ejaculation on one recipient by several partners simultaneously (sometimes referred to as “bukkake”). Such sex practices that occur in the context of group sex may carry potential health risks that would not be the case in sex encounters between two partners. Group sex encounters have not been investigated in detail, so the prevalence and potential risk for HIV and STI transmission is relatively unknown. Levels of lighting tend to vary in SOPVs, making it difficult to identify physical symptoms of STDs.

Further research into these specific sex practices and hypothesis in the context of group sex is warranted.

Discussion: Knowledge about the settings where MMSM seek and have sex is important as it makes health professionals aware of the extent MMSM will satisfy their desire and the risk they may place themselves in pursuit of sexual activity with men. It is also necessary for the community to accept reality that these sexual activities occur in order to support and promote health education at all locations including public places. It is vitally important that MMSM are informed of their vulnerability to STIs and HIV when having sex with men as they may not always have the same level of access to health care information as do gay men through gay community sources of information. There is also the potential risk to their wives /female partners who are generally unlikely to be aware of their spouse’s / partner’s sexual activities.

Health professionals require information about the risks posed MMSM and their partners. Additionally there is a need for researchers to explore these risks which may account for the increasing rates of unprotected anal intercourse

Acknowledgements: The authors would like to thank the study participants and SOP venues for their contribution to this study. Further Information: For more information about this study or a copy of this paper please email jhud4328@usyd.edu.au