Health promotion within a public sex environment : exploring sexual cultures, health and behaviours

This thesis collects together six peer review papers which i) examine the sexual (health) behaviours of men who 'cruise' public sex environments (PSEs) to engage in sex with men and ii) evaluate sexual health outreach conducted therein. It is based partly upon a year long, mixed methods evaluation of the 'Street Outreach Service', which provides sexual health promotion to men who have sex with men within one large PSE in southern England. The first chapter introduces this work, demonstrating the interrelationship of the submitted publications through a critical analysis. Chapter two presents our systematic review of quantitative PSE literature which, while suggesting high sexual health risks within PSEs, revealed serious methodological shortcomings of the established evidence base. Next, three quantitative data driven papers are presented which detail the results of our in situ PSE survey, which demonstrated far greater methodological rigour than previous quantitative research. In chapter three, the sexual risk behaviours, HIV testing and infection rates of PSE users are examined. High HIV testing and prevalence were found, along with patterns of sexual risk taking which highlighted the importance of in situ targeted HIV prevention. Chapter four considers the wider sexual health of PSE users focusing on their experiences of STIs other than HIV. Our study suggested that whilst PSEs do not represent centres of endemic STI transmission, users' sub-optimal STI clinic attendance and frequent sexual contacts may mask undiagnosed infection. Evaluating an established health promotion intervention precludes the generation of baseline data necessary for randomised controlled trial evaluation. Consequently, chapter five investigates the value of 'contact efficacy' to evaluate ongoing service provision where no baseline data exist, employing one-off, cross-sectional survey data. Contact efficacy provided a useful means to assess this established health intervention, though since causality cannot be inferred from the design, triangulation of results with other evaluative methodologies was recommended. Indeed, by bringing together survey, interview and systematic review data, this thesis demonstrates value of such triangulation. However quantifying the frequency of PSE sexual acts only confirms that behavioral risks occur. A more critical sexual health psychology argues that, in order to develop culturally appropriate health interventions, we need to understand both the social organisation in which such risks occur and the opportunities to negotiate sexual interactions therein. Therefore, the final two papers within this thesis focus on experiential aspects of PSE- based sexual health promotion, to explore the value of sexual cultures theory in understanding PSE behaviours and in situ health promotion. In chapter six, our systematic review of qualitative PSE research argues that a generic, shared PSE sexual culture emerges from the literature, across locations, countries and decades, due to the importance of concealment and common structural constraints upon PSEs sex. However, differences in local geography and facilities may transform key features of this, resulting in specific, local sexual cultures emerging for individual locales. The closing chapter analyses interviews with outreach workers, volunteers and PSE users to explore how respecting these local sexual cultures is central to the success of innovative in situ PSE sexual health promotion. In conclusion, the central argument of this thesis is that whilst PSEs likely represent sites of increased STI transmission through high partner availability and disassortative sexual mixing, sexual health outreach therein must respect the local sexual cultures for acceptability and success. Moreover, this work demonstrates the importance of, and strengthens the evidence base for, targeted PSE-based sexual health promotion.EThOS - Electronic Theses Online ServiceGBUnited Kingdo