Early sexual experiences of adolescent men who have sex with men

Introduction

Young Australians are disproportionately affected by sexually transmitted infections (STIs).^1–4 The Australian annual surveillance data have shown that young people aged 15–19 years accounted for 16.3% of all chlamydia notifications, 8.2% for all gonorrhoea notifications and 3.5% for all syphilis notifications in 2022.⁴ More importantly, the proportion of cases of syphilis notifications among youth aged 15–19 years has increased from 1.4% in 2012 to 4.5% in 2021.⁵ Untreated STIs can cause substantial morbidity.

Gay, bisexual and other men who have sex with men (MSM) are also disproportionately affected by HIV and STIs.⁶ In 2022, the Australia Annual Surveillance Report estimated the incidence of chlamydia was 29.2 per 100 person-year, gonorrhoea was 23.9 per 100 person-year and infectious syphilis was 4.8 per 100 person-year among HIV-negative MSM.⁴ Adolescent MSM have become an emerging population that is at risk of HIV and other STIs due to early sexual debut. Sexual initiation at a younger age is associated with increased STI risk and subsequent risk behaviours later in life, including more sexual partners, higher risk-taking behaviours, a more negative attitude toward condom use, as well as unintended adolescent pregnancy.^7–14 A longitudinal study among 808 fifth graders (usually aged 10–11 years) in the United States with follow-up at ages 18 years, 21 years, and 24 years found that the STI rate was 32.5% for early initiators of sex (debut at <15 years) compared to 16.6% for later initiators (debut at >15 years).¹⁵ It has been found that early sexual initiation is one of the most robust predictors of STI among adolescents and young adults in general, not just adolescent MSM.^16–18

Repeated cross-sectional surveys have demonstrated changes in sexual practices over time. For example, the National Survey of Australian Secondary Students and Sexual Health found the proportion of Year 12 students (usually aged 17–18 years) who had experienced vaginal or anal sex has increased from 50.5% in 2013 to 68.9% in 2021.¹⁹ Furthermore, the Australian Study of Health and Relationships Surveys have revealed that there was an increase in same-sex experience in both men and women between 2001–02 and 2012–13²⁰ and this may be due to the increasing trend in sexual fluidity, where there are shifts in one’s personal comprehension of their sexual orientation identity, irrespective of whether they have shared this with others or not.²¹ This was also evidenced by a US study, which showed that 17% changed their sexual orientation or identity from one to another, and 33% changed their attraction to one or more genders with the largest change observed among youth aged 14–17 years.²² Alongside other LGBTQIA+ (lesbian, gay, bisexual, transgender, intersex, queer, asexual and other sexually or gender diverse) teenagers, sexual fluidity is more common in adolescent MSM.²³

There have been very limited studies that specifically sampled adolescent MSM and therefore, the magnitude of changes in sexual practice among adolescent MSM is unclear. There has been one Australian study examining the sexual practice and trajectory among MSM aged 16–20 years in 2010–2012.²⁴ We employed the same methodology and repeated the previous study in 2017–2018 aiming to examine the sexual practice and trajectory among adolescent MSM, to examine whether there have been any changes after 5 years.

Materials and methods

Results

There were 200 men recruited in the HYPER2 study with a median age of 18.8 years (IQR: 18.6–20.2). Most men completed secondary school (71.5%, 143/200; Table 1). The majority of participants were recruited from sexual health clinics (79.5%, 159/200), followed by community organisations and events (20.5%, 41/200). All participants in this study had ever had sex with another man (100%, 200/200), and a substantial proportion (26.0%, 52/200) of men had ever had sex with a woman.

Sex with men

The median age for any type of sexual contact with a man was 17.6 years (IQR: 16.3–18.3). The most common sexual practice with male partners was performing oral sex (97.5%), followed by receiving oral sex (97.0%), receptive anal sex (82.5%) and insertive anal sex (69.0%) (Table 2). With a male partner, the median age at the first time performing oral sex was 17.2 years (IQR: 16.0–18.2) and 17.3 (IQR: 16.1–18.3) for receiving oral sex. The median age at the first time having insertive anal sex was 18.0 years (IQR: 17.0–18.5) and having receptive anal sex was 18.0 years (IQR: 16.3–18.4). The median age at first sex in HYPER2 was slightly older compared to HYPER1: receiving oral sex (16.5 years), performing oral sex (16.4 years), receptive anal sex (17.0 years) and insertive anal sex (17.3 years).

Table 2.Sexual practices with men among 200 adolescent MSM in the HYPER2 study.

Sexual practices	Statistics, median (IQR range)
Sex with men
Had male sexual partners in lifetime, n (%)	200 (100%)
Number of male sexual partners in lifetime	10 (2–25)
Had male sexual partners who did not grow up in Australia in lifetime, n (%)	92 (46%)
Number of male partners who did not grow up in Australia in lifetime	3 (1.5–6)
Tongue kissing
Number of tongue-kissed male sexual partners in lifetime	12 (5–30)
Performing oral sex A
Had performed oral sex with men in lifetime, n (%)	195 (97.5%)
Age at first performing oral sex	17.2 (16.0–18.2)
Number of performing oral sex partners in past 12 months	5 (2–10)
Number of performing oral sex partners in lifetime	8 (3–20)
Receiving oral sex B
Had received oral sex with men in lifetime, n (%)	194 (97%)
Age at first receiving oral sex	17.3 (16.1–18.3)
Number of receiving oral sex partners in past 12 months	5 (2–10)
Number of receiving oral sex partners in lifetime	8 (3–20)
Insertive anal sex C
Had insertive anal sex (defined as sex with a man where the participant’s penis is in the partner’s anus, the participant was on top) with men in lifetime, n (%)	138 (69%)
Age at first insertive anal sex	18 (17–18.5)
Number of insertive anal sex partners in past 12 months	2 (1– 5)
Number of insertive anal sex partners in lifetime	4 (2–10)
Used a condom during last insertive anal sex, n (%)	80 (58%, 80/138)
Number of insertive anal sex partners in past 12 months using a condom all the time (100%)	1 (1– 4)
Number of insertive anal sex partners in lifetime using a condom all the time (100%)	2 (1–7)
Receptive anal sex D
Had receptive anal sex with men in lifetime, n (%)	164 (82.5%)
Age at first receptive anal sex	18 (16.3–18.4)
Number of receptive anal sex partners in past 12 months	3 (1– 6.5)
Number of receptive anal sex partners in lifetime	4 (2–10)
Used a condom during last receptive anal sex, n (%)	94 (57.3%, 94/164)
Number of receptive anal sex partners in past 12 months using a condom all the time (100%)	2 (1–5)
Number of receptive anal sex partners in lifetime using a condom all the time (100%)	2 (1– 8)
Age mixing
Had male partners who were older than the participant in lifetime, n (%)	187 (93.5%)
Number of male partners who were older than the participant in lifetime	6 (3–20)
Age (years) difference with the oldest man	14 (8–27)
Had male partners who were younger than the participant in lifetime, n (%)	87 (43.5%)
Number of male partners who were younger than the participant in lifetime	2 (1–5)
Age (years) difference with the youngest man	3 (1.5–6)
Had male partners who were the same age as the participant, n (%)	138 (69.0%)

^A Performing oral sex is defined as sex with a man where the penis was in the participant’s mouth.

^B Receiving oral sex is defined as sex with a man where the participant’s penis was in another man’s mouth.

^C Insertive anal sex is defined as sex with a man where the participant’s penis is in the partner’s anus, the participant was on top.

^D Receptive anal sex is defined as sex with a man where the partner’s penis is in the participant’s anus, the participant was the bottom.

By the age of 19, 89.5%, 81.7%, 74.9% and 62.0% of men had receptive oral sex, insertive oral sex, receptive anal intercourse and insertive anal sex with men, respectively (Fig. 1a).

Fig. 1.

(a) Age at which teenage MSM first engaged in specific sexual behaviours with men. (b) Age at which teenage MSM first engaged in specific sexual behaviours with women.

More than half (59.0%, 118/200) had ever engaged in all four types of sexual activities with another man. Only a small proportion of men (1.5%, 3/200) had ever engaged in only one activity (i.e. receiving oral sex). All men who had had anal sex also had oral sex (Fig. 2).

Fig. 2.

A four-set Venn diagram illustrating the combination of different sexual practices with men among 200 adolescent men who have sex with men in the HYPER2 study.

Study participants were more likely to have older male partners than younger male partners. Among those who reported having older male partners (93.5%, 187/200), a median of six partners (IQR: 3–20) were older and partners were a median of 14 (IQR: 8–27) years older than the study participants. Among those who reported having younger male partners (43.5%, 87/200), a median of two partners (IQR: 1–5) were younger and partners were a median of 1 (IQR: 1–2) years younger than men in the study. In addition, 138 study participants (69.0%, 138/200) reported having male partners of a similar age. Moreover, almost half (46.0%, 92/200) reported having male partners who did not grow up in Australia, with a median number of 3 (IQR: 1.5–6) male partners who did not grow up in Australia.

Discussion

In this study, we found that most adolescent MSM, who had a median age of 18.8 years, had engaged in oral sex first, followed by anal sex with their male partners. Most men performed and received oral sex around the same age: however, men experienced receptive anal sex before engaging in insertive anal sex (Fig. 1a). This contrasts with the experience with female partners where performing oral sex, receiving oral sex and vaginal sex occurred around the same age.

Most adolescent MSM had engaged in both oral and anal sex, with only three men only having oral sex but not anal sex, suggesting anal sex is common among adolescent MSM. We also found that there is a temporal sequence of different sexual practices among adolescent MSM with their male sexual partners. MSM tends to engage first in receiving oral sex, followed by performing oral sex, receptive anal sex (bottom) and insertive anal sex (top), this temporal sequence is consistent with the HYPER1 study, a cohort with similar demographics and recruitment strategy recruited in Melbourne, 2010–2012.²⁴

Adolescents view oral sex as a way to improve their romantic relationships.²⁶ Oral sex may aid in an individual’s sexual exploration and facilitate orgasm as their sexual experience progresses, especially in those who perform oral sex.²⁷ However, we found that there was, in general, a small delay in first-sex activity in the HYPER2 cohort compared to HYPER1 although the number of partners in the past 12 months was the same between the two cohort studies.²⁴ Additionally, we also saw an increase in condom use between the two studies, the proportion of MSM who used condoms during the last insertive anal sex increased from 35% to 58%, and receptive anal sex from 38.2% to 57% in HYPER1 and HYPER2, respectively. This is important to note that almost half of adolescent MSM did not use condoms for anal sex. Sexual health education on condom use, regular HIV/STI check-ups and other prevention strategies (e.g. HIV pre-exposure prophylaxis) should be tailored and targeted adolescent MSM specifically.

Approximately one in four (26%, 52/200) adolescent MSM has also had sex with a female and this proportion was lower than in HYPER1 (42.5%, 85/200).²⁴ Similar patterns on delayed sexual debut were also observed among men who had sex with women in HYPER2 compared to HYPER1.²⁴ The findings from HYPER1 are also similar to the IMPRESS study, a cohort of 191 heterosexual men aged 17–19 years in Melbourne in 2014–2015, showing the median age of first oral sex was 16.4 years and vaginal sex was 16.9 years.²⁸ The delayed sexual debut is also supported by a national population survey of 20,094 Australian men and women 16–59 years old from 2001–2002 and 2012–2013, where the proportion of men reporting first vaginal intercourse before age 16 years fell from 22% to 19%, and the median age at first vaginal intercourse among men rose from 17.6 years to 17.9 years.²⁹ However, our Kaplan–Meier curve shows that there were some changes before and after the age of 18. It appears that men at the age of 15–17 years received oral sex first, followed by performing oral sex and vaginal sex with their female partners. However, this pattern disappeared after the age of 18 years. Oral sex is perceived to be less risky than vaginal sex in terms of health, social, and emotional consequences and current literature suggest that a far greater number of adolescents engage in oral sex than vaginal sex at young ages.³⁰ It has been suggested that adolescents engage in oral sex to achieve sexual pleasure and intimacy, while avoiding pregnancy and STIs²⁶ and they perceive oral sex as more acceptable than vaginal sex for those who are under 18 years and are less of a threat to their values and beliefs.³⁰ Previous studies have found that teenagers see oral sex as a way of preserving their virginity while allowing intimacy and sexual pleasure.³⁰

Past studies have shown that increased sexual education is associated with delayed sexual initiation, reducing the risk of teenage pregnancies, the frequency of sexual intercourse, and increasing the use of condoms and other contraceptive methods.^24,26,27 In 2014, the national curriculum was developed by the Australian Curriculum Assessment and Reporting Authority for sex and respectful relationships in Australian schools, which included key points including ‘reproduction and sexual health practices that support reproductive and sexual health (contraception, negotiating consent, and prevention of STIs and blood-borne viruses)’.³¹ The addition of this curriculum may have led to some behavioural changes among the Australian population; however, we were unable to conclude this causality as this study was not designed to answer this research question. Although there were no outcome measures of the curriculum change, one international study in Mexico examined the impact of having a comprehensive sexual education program and they found that students at control schools (i.e. schools that did not have a comprehensive sexual education program) had high odds (OR = 4.77, 95% CI: 2.41–9.43) of early sex debut compared with those intervention schools (schools that received a comprehensive sexual education program).³² Therefore, further implementing comprehensive sexual education programs may be a key strategy. These programs should cover topics such as sexual and reproductive health, contraception, negotiation of consent, and prevention of STIs. These programs could empower young people to make informed decisions before sex. Future research can determine the impact of these programs over time, providing valuable insights into their effectiveness and informing future policy decisions.

Sexual mixing refers to whom individuals choose as sexual partners and is described as assortative on a characteristic, if individuals tend to choose partners similar to themselves for that characteristic.³³ We found that our study participants tend to have partners with different ages and countries of birth, which is similar to other previous studies.^34–36 This should be a consideration for the benefits of a universal gender-neutral vaccination scheme/one that includes men. A Canadian study has found a higher than expected number of heterosexual partnerships where partners have similar characteristics for age, country of birth, ethnicity, financial situation growing up, smoking behaviour and lifetime number of sex partners.³³ This may be reflected in the data collected or may reflect the multicultural and diverse nature of the Australian population, since 29.3% of Australia’s population, excluding those with a birthplace not stated) were born overseas in the 2021 Census.³⁷

It is important to note that this study has several limitations. First, most of the men recruited were from sexual health clinics in Australia, which may have been biased towards sexually active men, and therefore, our data may not be generalisable to all teenage MSM in Australia. Second, one of the inclusion criteria for HYPER2 was the participants had to be residents of Australia since 2013 to ensure they were eligible for the national HPV vaccination program. However, Australian residency was not part of the eligible criteria in HYPER1, and therefore, the comparison between the two cohorts is also possibly due to more restricted inclusion criteria in HYPER2, although there was no difference in the number of male sex partners in the past 12 months between the two studies. Additionally, our data may not be generalisable to other groups, including individuals from linguistically and culturally diverse backgrounds and in other countries and settings. Finally, self-reporting and recall bias may have occurred in this study since participants were required to recall their first sexual experience.

Conclusion

We found that there is a delay observed in first-sex activity across all sexual practices (performing and receiving oral sex, performing and receiving anal sex with men, performing and receiving oral sex and performing vaginal sex with women) reported in the HYPER2 (performed in 2017–2018) cohort compared to HYPER1 (2010–2012). Additionally, we also saw an increase in condom use between the two studies. This may be due to increased education in sexual health: therefore, future government initiatives on sexual practice and sexual health education could be implemented to increase condom usage even further. Although a higher proportion of HYPER1 participants reported sexual contact with females, those who reported sexual contact with females in HYPER2 had engaged in more sexual practices with more female partners. This may reflect sexual fluidity and reflect a change in attitudes between the two study cohorts. This provides further evidence that sexual education programs should include discussions of all potential sex practices between people of any sexual or gender identity to be more effective.

STIs continue to rise in Australia, particularly among MSM: understanding their sexual practices is important for STI prevention and the development of future interventions. Although delayed sexual initiation and increased condom use were seen in the HYPER2 cohort, this population still sees high levels of STI rates in the wider Australian context.