Microsoft word - the sigma panel insight blast 9 poppers draft 2
THE SIGMA PANEL Insight Blast 9 Promoting a reduction in poppers use during receptive anal intercourse
The use of poppers (volatile nitrite inhalants) is thought to increase the probability of HIV transmission when unprotected intercourse occurs between an HIV positive insertive partner and an HIV negative receptive partner. Making It Count identifies a population level target of reducing the frequency with which men use poppers during receptive anal intercourse. This Insight Blast contains responses to questions about poppers asked of The Sigma Panel. The questions were designed to aid the development of social marketing campaigns to reduce the frequency with which men use poppers during receptive anal intercourse. In Month 10 of the Panel 1393 men were asked a series of questions related to poppers. Before being asked the questions men were told that ’Poppers’ is the street name for a variety of liquid chemicals (nitrites) sold as ‘room odourisers’ and often inhaled through the nose or mouth to produce a ‘rush’. Recency of poppers use
offered seven time periods and the option I’ve never inhaled poppers.
ago Figure 1: After how many different sex partners do you think it is reasonable to expect someone to go for an STI check-up?
over 12 months ago. The remaining 60% had used poppers within the last year, with 35%
Figure 1: When was the last time you inhaled poppers? INSIGHT: The use of poppers is normative among gay and bisexual men in England, with up to 60% having inhaled them in the last year. Frequency of use during sex
The 60% of men who indicated they had used poppers within the last 12 months were asked how frequently they had used them when having sex alone (masturbating) in the last year, and how often they had used them when having sex with other people. They were offered a five-point frequency scale. The proportions indicating each frequency for the two situations are shown in Table 1.
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Table 1: Frequency of poppers use among those using in the last 12 months
Using poppers was more common when having sex with others than when having sex alone, with 34% of men who used them in the last year saying they used them more often than not, almost always or always when having sex with others, and 59% saying they used them rarely or never when alone. This may reflect a social aspect of using poppers; with the possibility of introduction by two people making their presence more likely. Or they may be more likely to be used for sexual practices which happen more frequently within the context of sex with others (such as being penetrated by a partner or toys).
Men who used poppers more frequently in one context were more likely to have used them more frequently in the other context. (Gamma = .645, p<.001).
INSIGHT: About one third of all Panel members use poppers always, almost always or more often than not when they have sex with other people. Benefits and costs of using poppers during sex
All men were asked the open-ended question From your perspective, what are the benefits of (or good things about) using poppers during sex? and an identical question about the costs of (or bad things about) poppers. Table 2 (overleaf) summarises the range of benefits and costs Panel members identified.
Many men expressed considerable uncertainty related to poppers and many costs and benefits are associated with their use during sex. Some of these are paradoxical in that they could be seen to do different things at different times and in different contexts and benefits for some men are costs for others and vice versa. Some men find the overall experience of poppers pleasurable and arousing while others find them very unpleasant.
The most commonly reported costs include potential or theoretical harm to health, headache, unpleasant smell and potential for loss of control leading to behaviour which may leave one more susceptible to infections such as HIV and other STIs. However this loss of control and greater risk of getting HIV or STIs was not mentioned as a reason for reducing popper use amongst men who had done so.
The most commonly reported benefits include enhanced sexual experience, libido and sensation and in particular, emotional and physical relaxation allowing more pleasurable sexual penetration and more experimental, rougher or longer sex.
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Table 2: The benefits and costs of using poppers during sex [Sigma Panel Month 10] Not using poppers during sex Using poppers during sex
Avoid possible adverse health effects (on respiration,
Easier receptive intercourse (anally and orally).
cardiovascular system, immune functioning, neurological
Less likelihood of reckless behaviour leading to HIV or STI
Smell is arousing (associated with sex).
Less likelihood of rectal bleeding so less susceptibility to HIV
Increases feelings of sexual confidence.
Existing infections are not made worse (eg. herpes and HIV).
Disinhibition or feeling out of control.
Facilitates desired rougher sleazier sex.
No headache, migraine, fainting, dizziness, disorientation,
No malaise / energy sapped at time or day after.
As a message or queue to sex or intercourse.
Can take contraindicated drugs (eg. Viagra) more safely.
Vicarious enjoyment because enhances partners pleasure.
No awkwardness in using them. Partners are more attractive not using them. Greater control of sex. Sex feels more natural. Not having to keep using them to get the effect. No disappointment at poor (unreliable) quality product. Not being addicted or dependent. Absence of social costs Avoid stigma attached to drug use. Avoiding being seen by others as childish. Absence of monetary cost Money not wasted or more to spend. Not having to replace stale product. Their quality is variable, uncertain or reduced. No burns or stains on clothes, furniture, bedding.
Absence of desirable physical effect of poppers
Less ease of receptive intercourse (anally and orally).
Adverse health effects (possibly on respiration, cardiovascular
system, immune functioning, neurological system).
Detrimental effect on sexual performance.
Increased reckless behaviour leading to HIV or STI
Not experiencing arousal from the smell.
Increased likelihood of anal bleeding (increasing susceptibility
Less sensation of intimacy or sexual focus.
Exacerbation of existing infections such as oral herpes or HIV.
Less feeling adventurous or experimental.
Less likely to have desired rougher sleazier sex.
Headache, migraine, fainting, dizziness, disorientation,
Malaise / saps energy at time or day after.
Need to find other cue to sex or intercourse.
Other drugs are contraindicated (eg. Viagra).
Missed vicarious enjoyment from enhanced pleasure of
Missing out on social or shared experience.
Awkward to use effectively and safely. Partners using them are less attractive. Sex feels artificial or contrived.
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Their effect is short lived so they need to keep being used. Disappointment at poor (unreliable) quality product. Becoming addicted or dependent on them for sex. Social costs Stigma attached to drug use. Perceived as childish (something to grow out of or a phase). Monetary cost They are expensive or poor value for money. They become stale quickly and need replacing. Their quality is variable, uncertain or reduced. Burns or stains on clothes, furniture, bedding.
Health promotion could address the uncertainty around potential harm to health and offer alternatives to emotional and physical relaxation and confidence and avenues to more comfortable, easier and enjoyable penetration. Social marketing could reinforce the value of ‘natural’ sex without drugs as being an end in itself and not needing enhancement. However this may not work in a context where there are other ‘artificial’ technologies (such as condoms) promoted to decrease HIV and STI transmission risk. The benefits of avoiding poppers should be maximised and the costs of avoiding them minimised. Previous restrictions have resulted in changes to the chemical formula which have made poppers less attractive to some.
There were no active benefits to avoiding poppers use, only the absence of the costs of using them. This provides social marketing with little positive material on which to promote the avoidance of poppers. Negative social marketing could reinforce negative perceptions of poppers, such as their uncertain and unreliable nature, or by representing them as unfashionable and childish.
All Panel members were asked Have you bought poppers in the last 12 months (for yourself or others)? Overall, 37.9% of men said they had done so, increasing to 63.5% of those who had used poppers in the last year. This meant that over a third (36.5%) of those who used poppers in the last year had not themselves purchased them, underlining the social and sharing nature of poppers use.
Those who had purchased poppers in the last 12 months were asked where they had done so. They were offered four (non-exclusive) sources for purchasing poppers, and the option of specifying other places.
Table 3: Places where poppers were bought in the last 12 months [Sigma Panel Month 10] Where have you bought poppers in the last 12 months? % (N=524) (Men who had bought them in the last 12 months)
Gay sex stores were by far the most commonly used suppliers of poppers, with twice the number of men using them as the next most common supplier, the internet. Smaller numbers of men had purchased poppers in scene locations where sex may occur (eg. saunas) or where men may have sex, but more frequently meet before retiring to another location for sex (eg. bars and clubs).
A range of venues were reported within the ‘elsewhere’ category, including: local or convenience stores (n=12, or 2.3% of those buying poppers in the last 12 months), market or market stall (n=6), newsagent (n=4), friends (n=3), pride events (n=3), legal high/drug paraphernalia shop (n=2),
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tobacconist (n=2), tattooist (n=2), hardware store (n=2), unspecified shop (n=2), seaside gift-shop (n=1) and a petrol station (n=1).
INSIGHT: Many men who used poppers in the last year had not bought them, but frequent users are more likely to be purchasers. Gay sex stores are the most commonly used suppliers of poppers. Changes in use of poppers
All men were asked Has your use of poppers changed at all in the last few years? They were offered the three options in the table below, which also shows the proportion giving each answer overall, and according to how recently men had used poppers.
Table 4: Changes in poppers use by recency of use
When was the last time you inhaled poppers?
The majority of men (56%) said their use of poppers had not changed in the last few years. However, almost four times as many men said their use of poppers had declined (25%) in the last few years as said it had increased (6%). Only among the group who used poppers in the last 24 hours did more men say their use had increased Other answers generally referred to irregular, sporadic or singular use in which a pattern of regular use has yet to establish itself and therefore it is difficult for men to discern a change in use. (e.g. “I never used them hardly in the first place, just bought them to try a few times.”)
Reasons for increased use
Men who had increased their use of poppers in the previous years were asked why they had done so. Most commonly they referred to changing sexual practice or context. They were now having more sex, more frequent sex, sex with more partners or with different partners and were thus more likely to use them given an increase in volume and opportunity. For some men the type of sex they were having had changed and poppers were now used more, because they helped to achieve or improve this new type of desired sex (masturbation or being penetrated or rougher, harder or more experimental sex or a greater focus on pleasure).
Another reason for increased use was through increased opportunity; men were offered poppers by new partner/s, or buying them had become easier through greater accessibility or ability to purchase them.
Some men reported increased use with experience, familiarity, dependence, appreciation and enjoyment. They had experienced benefits or good results so used them more to achieve the results they expected.
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A couple of men referred to a perceived reduction in the efficacy (or impact) of poppers, which required using more to get the same effect. A couple of men referred to a more relaxed personal attitude to taking poppers and drugs in general.
Reasons for decreased use
Men who had decreased their poppers use in the previous years were asked Why do you think your use of poppers has changed over the last few years? Most commonly men referred to changes in the ‘formula’ of poppers over time and a perceived reduction in efficacy, longevity or benefits and/or an increase in negative side effects.
As with increases in poppers use, men commonly referred to changing sexual context and practice to account for a decrease in poppers use, particularly in relation to decreased libido, sexual frequency, casual sex, anal sex, receptive anal sex, use of sex toys and attendance at clubs or sex clubs. Given poppers strong connection with a sexual context this reduction in sex and penetrative sex resulted in less use. The influence of friends and sexual partners also sometimes led some men to reduce their use either because they now had partners who did not use or appreciate them, or because poppers had become unfashionable in their social circle.
INSIGHT: Changes in poppers use often follow changes in sexual practices rather than driving them.
There appears to be a relationship with age and poppers use. Some men were more reluctant to use them with increasing age and age related ailments such as heart disease. They had greater concern with potential health impacts of poppers and increasing concern with erectile dysfunction and use of erectile enhancing drugs which are incompatible with popper use. They also reported a context of less drug use, getting older, growing up, becoming wiser or more responsible, losing the novelty value of poppers and being less able to cope with negative effects.
The attraction of poppers for some decreased with time and familiarity, they were bored with them or saw them as a prop. Some men had replaced some of the functions of poppers with new, more novel or preferable drugs and others had grown more confident sexually and no longer felt a need for their perceived confidence boosting properties. A few men reported that they were less accessible in relation to availability and affordability. Interestingly none of the men who reduced their poppers use reported doing so to gain greater control of sexual behaviour or to reduce their susceptibility to, or likelihood of engaging in sex with a risk of contracting, HIV or other STIs.
INSIGHT: Poppers were rarely avoided in order to reduce HIV risk - appealing to HIV risk in order to encourage men to reduce poppers use will probably have little impact at the population level.
Suggested Citation: Sigma Research (2012) The Sigma Panel Insight Blast 9: Promoting a reduction in popper use during receptive anal intercourse. London: Sigma Research. June 2012.
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Final report for IFAR project 2008 Proposal code: 267IFAWAN. Name of Applicant: Dr. Mohamed El-Sayed Mohamed El-Boushy Assistant Professor of Clinical Pathology Faculty of Veterinary Medicine, El Mansoura University, Egypt. 1. Proposed Work Program: The possible impact of common zoonotic and food borne bacteria on fish and human health with suggestive control measures The