Motivations for sexual risk behaviors among older men in Shanghai, China: a qualitative study

Background China’s population is quickly aging and this trend is expected to continue. Thus it is important to develop HIV interventions to help protect older Chinese from infection. Limited information exists regarding sexual risk behaviors and associated personal motivations among persons aged 50 and over in China. Methods In-depth interviews were conducted with 12 HIV-infected and 14 uninfected men aged 50 and over in Shanghai, China. Results More than 71% of heterosexual participants had engaged in commercial sex, 37.5% either had engaged in casual sex or had a steady extramarital partner. All gay/bisexual participants had engaged in casual sex with men, and 16.7% had engaged in commercial sex. Personal motivations associated with sexual risk behaviors included sexual desire and interest in sex remaining high at an older age, unfulfilled sexual desires within marriage, homosexual or bisexual orientation, need to socialize with others, peer influence, personal choice of “hobby”, and financial freedom. Conclusions This study sheds light on the sexual needs of older people. Our findings underscore the need for both greater education in order to reshape societal perceptions of sexuality among older adults and prevention strategies to help the older male population maintain a healthy sexual life.


Background
Despite the popular belief that older adults do not constitute a risk population for HIV infection, this population is most certainly at risk [1]. Recent estimates have shown that new HIV cases in China among the 50+ age group increased significantly from 2000 to 2011. In the 50-64 age group the number of cases increased from 1.6% of the total number of reported cases in 2000 to 13.8% in 2011, while in the 65+ age group the number of cases increased from 0.34% in 2000 to 7.3% in 2011 [2]. As China's population continues to age quickly, it is important to develop HIV interventions that will help protect older Chinese populations from infection. Unfortunately, limited information exists regarding sexual risk behaviors and associated motivations among persons aged 50 years and over, particularly in China.
Many studies have shown that older adults remain sexually active and maintain a level of sexual desire, even though interest in sex and frequency of intercourse generally decline with age [3][4][5][6]. A survey of 1,550 women and 1,455 men in the United States found that 73% of those aged 57-64 were sexually active, as were 53% of those aged 65-74 and 26% of those aged 75-85 [4]. Older men were more likely to be sexually active than older women [4]. Moreover, there is increasing evidence that older people, like their younger counterparts, engage in risk-taking sexual behaviors [7][8][9]. In a study of older men aged 49-80, one quarter had more than one sexual partner in the prior six months. Older individuals also are less likely than their younger counterparts to use condoms during sex [10,11].
This article reports findings from in-depth, qualitative interviews conducted with a total of 26 HIV-infected and HIV-uninfected men aged 50 years and over in China.
The present analyses sought to explore the range of personal motivators associated with sexual risk behaviors among older male adults. Greater knowledge regarding patterns of and motivations for sexual risk behaviors will aid in promoting better care and prevention as well as development of age-specific interventions for older adults.

Participants and recruitment
In 2010, we interviewed 26 older men living in Shanghai -12 HIV-infected and 14 HIV-uninfectedin order to explore causes and patterns of sexual risk behaviors among this population. The 14 uninfected participants were recruited from a voluntary counseling and testing (VCT) clinic. Seven infected participants were invited by health staff to participate, while five infected participants were recruited by HIV-infected volunteers. Participants were eligible if they were male, were aged 50 years or older. Each was paid $16 USD for completing the interview. All participants were given written consent. Beforehand the study protocol was reviewed and approved by the Institutional Review Board at Fudan University. This study adheres to the RATS guidelines on qualitative research [12].

Interview methods
Each semi-structured interview covered four topics: (1) background information (e.g., age, marital status, education, occupation, sexual orientation, and HIV status), (2) sexual risk behaviors, mainly focusing on extramarital sex (e.g., engaging in casual sex or commercial sex, and having steady extramarital partners), (3) condom use with sexual partners, and (4) motivations associated with sexual risk behaviors. For HIV-infected participants, all questions from topics (2) to (4) pertained to sexual risk behaviors, condom use, and associated motivators before confirmation of HIV diagnosis. All interviews were audio-recorded with the permission of respondents, and then transcribed verbatim. The resulting transcripts were examined by the author through an iterative process in order to identify recurrent themes and develop corresponding codes to be applied to the text. Themes were identified both inductively and deductively based on issues extrapolated from the data. Table 1 shows sample characteristics of the 26 older men who participated. All participants were between the ages of 50 and 75 years old, and most had at least a high school education (65.4%) and were currently employed (61.5%). The majority were married (61.5%), while 15.4% were never married and 23.1% were divorced or widowed. Two-thirds (66.7%) of HIV-infected and 35.7% of HIV-uninfected participants self-identified as gay or bisexual. All HIV-infected participants had been diagnosed at age 50 or older (range: 50 to 71).

Sexual risk behaviors
Among heterosexual participants, 100% reported engaging in sexual risk behaviors, including commercial sex (n = 10; 71.4%), and casual sex or having a steady extramarital partner (n = 6; 37.5%). More than half of heterosexual participants (n = 8; 57.1%) reported never using a condom when they had sex, while four (28.6%) reported using a condom sometimes and two (14.3%) reported using a condom most of the time.
Among gay/bisexual participants, 100% reported engaging in casual sex with men, and one (8.3%) engaged in casual sex with women. Only two (16.7%) reported engaging in commercial sex: one engaged in selling sex to men, the other engaged in buying sex from a prostitute. One (8.3%) never married and one (8.3%) divorced participant reported having a stable male sexual partner. Regarding condom use, only one (8.3%) reported using a condom when having sex; the other 11 (91.7%) reported never using a condom. Among gay/bisexual participants, the most common locations for finding sex partners were bathhouses, bars, parks, and the Internet. Among heterosexual participants, the most common locations were bathhouses, brothels, parks, and the street. Among gay/bisexual participants, sexual encounters occurred most frequently in hotels, bathhouses, their own or their partner's house, and parks. Among heterosexual participants, sex tended to take place in bathhouses, brothels, hotels, and their partner's house.

Motivators associated with sexual risk behaviors
Participants reported engaging in sexual risk behaviors due to: (1) sexual desire or interest in sex remaining high at an older age, (2) unfulfilled sexual desires within marriage, (3) homosexual or bisexual orientation, (4) need to socialize with others, and (5) peer influence. A small subset engaged in sexual risk behaviors due to: (6) personal choice of "hobby" and (7) financial freedom.

Sexual desire/interest remaining high at an older age
Participants commonly reported maintaining an interest in sexual activity and felt a high level of sexual desire at an older age. For example: I'm annoyed that I have an interest in sex even though I'm almost 60 years old and am going to be retired. (N10, 58 ys, HIV-, heterosexual) I go out to visit a "xiaojie" (prostitute) because I have especially strong sexual desires. (N5, 60 ys, HIV-, heterosexual)

Unfulfilled sexual desires within marriage
Almost all of the heterosexual participants (whether HIVinfected or -uninfected) stated that the primary motivator for seeking extramarital sex was that their spouses could not fulfill their sexual desires. Many participants reported that their spouses had no interest in sexual activity, especially after getting older. For instance: My wife and I are sexually incompatible. I want sex frequently but she wants sex less frequently. (N5, 60

Homosexual or bisexual orientation
Among gay/bisexual participants, the main reason for engaging in extramarital sex or having multiple sexual partners was due to their homosexual or bisexual orientation. Eleven of the 14 gay/bisexual participants entered into marriage due to social and familial pressures when they were young. But as they aged, social pressures at work and in life reduced while simultaneously society was becoming increasingly tolerant of homosexuality. As a result, they began to spend more time with other homosexuals and engaged in gay activities in pursuit of their own pleasures. Two of three never-married gay participants reported engaging in casual sex mainly because they had no stable sexual partner(s).

Peer influence
A few participants reported being motivated to engage in sexual risk behaviors because of peer influence. They went out with others to visit prostitutes. For example: This is a human physiological need; we have sexual needs and desires. If you become part of a group where everyone is [buying sex] and doing so together, it becomes normal, and so you do it together with them. (G12, 75ys, HIV+, heterosexual) We friends hang out together, and then all of us visit a "xiaojie" (prostitute). (G3, 61 ys, HIV+, heterosexual) It is not a joke that my biologic brother and I drove together to visit a "xiaojie" (prostitute). (G9, HIV+, 57 ys, bisexual)

Need to socialize with others
Several participants reported being motivated to engage in sexual risk behaviors in order to socialize with others. Some were not yet retired and needed to socialize for business and work reasons, which promoted engaging in risky sexual behaviors. My thinking is simple: in sexual relationships, your spouse is primary. The homosexual relationship is the side relationship, like having another hobby. (N7, 55 ys, HIV-,bisexual)

Financial freedom
Financial freedom was also a reason for engaging in extramarital sex among older men. Among these men aged 50 or older who were neither poor nor rich, some enjoyed spending money to satisfy themselves. For example:

Discussion
The purpose of this study was to explore the personal motivators associated with engaging in sexual risk behaviors among older men in China. Respondents in our study reported engaging in a variety of HIV risk-related sexual activities, including low rates of condom use and having casual sex partners, commercial sex partners or stable extramarital sex partners, which corroborate findings obtained previously among older adults [7,8,13]. Given both the growing number of new HIV cases reported among those aged 50 years or older in China [1] and that all prevention interventions target young adults while neglecting older adults, there is an urgent need for HIV prevention interventions designed specifically for older adults.
We noted that heterosexual older men were more likely to engage in commercial sex, while gay/bisexual older men were more likely to engage in casual sex; this pattern is similar to that of heterosexual and gay/bisexual young men in China [14,15]. Such a pattern may depend primarily on the availability of casual and commercial sex partners; it is easier for gay/bisexual men to find casual sex partners but easier for heterosexual older men to find commercial sex partners. This difference underscores the need to tailor HIV prevention interventions specifically for heterosexual and gay/bisexual older persons.
The most commonly-reported personal motivators for engaging in extramarital sex among heterosexual participants were continued high levels of sexual desire and interest into later life and unfulfilled sexual desires within marriage. This finding was consistent with those from other studies where a majority of older men remained sexually active and considered sex to be an important part of life [4]. China has seen increasingly open attitudes toward sex and greater freedom of sexual expression in recent years, yet there remains a stereotype that older people have no sexual interest and desire, and a belief that older adults should not engage in any sexual behaviors. Such misconceptions might play a role in preventing older persons from enjoying healthy and safe sex lives. Compared with older men, older women tend to have less sexual desire and interest [4]. Our participants reported this to be the major reason for sexual incompatibility within their marriage, and further motivated men to engage in extramarital sex. Therefore, sexuality among older adults should receive greater societal attention. Efforts to reshape perceptions of sexuality and aging among both older people and society in general are needed in all forms of media. Greater education of health care providersparticularly those working with older peoplewill increase understanding and awareness of older peoples' sexual needs.
The primary motivator for gay/bisexual participants to engage in sexual risk behaviors was their homosexual/bisexual orientation. Unlike in Western societies where a small percentage (an estimated 1.5-6%) of men who have sex men (MSM) are married to women [16,17], approximately 70-90% of MSM in China marry a woman due to societal and parental pressures [18,19]. We found that 78.5% of our older gay/bisexual participants were ever married, which is higher than rates found for younger MSM in China [19,20]. Similar findings had been observed previously in China, where older MSM were more likely to have married [19]. With greater tolerance for homosexuality, younger MSM likely feel less societal and familial pressure to marry, while a growing number of older, married MSM are beginning their own sexual relationships with other males.
Similar to the motivations reported for initiating drug use among drug users [21,22], peer influence and the need to socialize with others were two common motivators cited by older persons for engaging in sexual risk behaviors. Other motivators include personal choice of "hobby" and financial freedom. Older men in large and medium-sized cities in China usually experience less financial pressure compared to younger men in paying for housing and raising children. Thus, it is important for older adultsparticularly those who are retiredto develop healthy hobbies and interests. Family and community members should take a more active role in helping older adults to live healthy and happy lives. The community, for example, could organize more social activities for older adults.
There are limitations to our data which should be considered when interpreting and evaluating the results. Because these data were gathered from a convenience sample, the findings should not be considered generalizable. All participants were either HIV-infected or recruited from VCT centers, thus all had engaged in sexual risk behaviors. However, our findings could reflect the motivations for engaging in sexual risk behaviors among the older male population. Also, our results were based on selfreported data, which depend on the veracity of the respondents.

Conclusions
Our study's findings contribute to the vital mission of understanding the sexual risk behaviors and associated personal motivations among older males in China. The data suggest that older people are sexually active and engage in sexual risk activities. Education is needed in order to reshape societal perceptions of sexuality among older adults. Although sexual activity among these older adults is now more widely accepted, it still should be remembered that sexual risk encounters may result in HIV/STD infection. Our findings also emphasize the need for developing prevention and intervention programs that will help the older male population maintain healthy sexual lives.