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These web portals serve as common entry points for a number of different services including news exchange, social networking, seeking sex partners, advertisement for gay-specific products, and research. In order to develop the online survey, we first interviewed 20 MSM and other key stakeholders, to evaluate what questions are proper to ask through online survey.

After development, the instrument was further reviewed by Chinese MSM who had previously participated in online surveys, leaders of local community-based organization CBO leaders, social media experts, physicians and public health experts [ 2 , 10 ]. The revised survey instrument was then piloted among MSM prior to the final survey. For participant recruitment, banner advisements were placed on the homepage of each web portal Northern China: In addition, advertisements for the survey were sent to registered users of the three web portals.

By clicking the banner, the participants were directly linked to the survey. Before taking the survey, participants had to first sign the online consent form. To meet the inclusion criteria, participants had to be born as biologically male, 16 years of age or older, have engaged in anal sex with man at any point, and be willing to provide their cell phone number.

Socio-demographic information regarding year of birth, occupation student or not , marital status never married or ever married , education senior high school or below, college or bachelors, or Masters or PhD , annual income less than USD, — USD, USD, — USD, or more than USD and residence urban or rural was collected from each participant. Univariate and multivariable logistic regressions were used to compare between the group sex group and the non-group sex group, while demographic characteristics, including age, residence, education, and income were adjusted for in the multivariate logistic regression models.

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We also analyzed the correlation between gay app use features and group sex among gay app users by using multivariate logistic regression. Of the 5, clicks, 1, withdrew from the survey prior to reading the consent form and were excluded for not signing the consent form. In addition, 1, did not meet eligibility requirements and duplicates were excluded by checking recorded phone numbers.

Over four-fifths Around three quarters In addition, about three-fifths If participants reported any use of gay apps to find sex partners in the last six months, they were categorized as gay app users, while others were categorized as non-users. Participants who have gender identities, expressions, or behaviors not traditionally associated with their birth sex. Among survey respondents, When engaging in anal intercourse, Moreover, Around half After adjusting for age, residence, education, marital status and income, we found that group sex was associated with engaging in condomless anal intercourse with men in the last three months OR 2.

Meanwhile, we found that gay app users overall were more likely to engage in group sex with an adjusted OR of 1. In this study, we found that gay app users were more likely to engage in group sex with an adjusted OR of 1. We therefore further analyzed the correlation between gay app use features and group sex among gay app users. Multivariate regression analyses adjusted for age, residence, education and income, Table 3 showed that the likelihood of group sex increases with the number of sex partners found through a gay app in the last 6 months, the number of receptive anal sex acts with partners met through a gay app in the last six months, and the number of insertive anal sex acts with partners; with adjusted ORs of Group sex often co-occurs with other high-risk behaviors that together create an environment conducive to disease transmission [ 6 ].

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Group sex was more common among gay app users and men living with HIV. Our study expands on the existing literature on group sex [ 13 , 14 ] by using online MSM portals, obtaining detailed information on gay apps, and exploring the correlation between group sex and gay app use. Our findings indicate that gay app use may create a virtual risk environment and facilitate group sex.

This disparity may in part derive from differences the level of acceptance towards non-mainstream sexual identities and activities. Our study found that group sex with associated with several risky sexual behaviors. For instance, one study in Australia found that men who engaged in group sex during last six months were more likely to engage in unprotected anal intercourse.

Another study in the US showed that the number of unprotected anal receptive sex acts at sex parties in the past 12 months was significantly associated with increased odds of engaging in unprotected anal sex with serodiscordant partners at the sex parties. This is consistent with observations from Australia and the US [ 9 , 17 ]. Our study did not collect targeted information about HIV serosorting. Nevertheless, our results are able to indicate a high prevalence of condomless group sex among MSM living with HIV, a concerning phenomenon with important public health implications.

Our results suggest that group sex is associated with gay app use. This finding is consistent with research from the United States [ 19 , 20 ]. Gay apps have geospatial technology that could facilitate rapid identification sex partners and networking unbound by the constraints of time or location, facilitating rapid sex encounters.

We found certain specific gay app features were particularly associated with a higher frequency of group sex. For instance, the more sex partners found through a gay app in the last 6 months, the more likely to engage in group sex. We also found an association between group sex and having sex in exchange for gifts or money.

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Among the 82 MSM who reported having sex in exchange for gifts or money in our study, 32 This finding is consistent with a study conducted in Bangladesh, which reported that group sex is common among male sex workers [ 21 ]. Our finding suggests that there is an intersection between group sex and commercial sex. We encourage future research that focuses on money boys or male sex workers to give heed to group sex behavior. There were certain limitations with internal validity and external validity of this study.

First, as this study was based on an online survey, selection bias may be an inherent part of the online recruitment approach, as it restricts those who were not able to access to Internet from participating. The MSM in our study were younger and more highly educated compared to non-online gay men [ 10 ]. However, national data [ 22 ] suggest that young gay men do carry a disproportionate burden of syphilis and HIV. A second limitation in our study is that all measured behaviors were based on self-report, and could thus be influenced by social desirability reporting bias.

Third, a large number of MSM who clicked the survey link withdrew before being screened for eligibility, which may have resulted in selection bias. Therefore, the results need to be interpreted with caution. Finally, in the present study, we did not collect more detailed information regarding how group sex occurs and what type of condom behavior occurs during these encounters.

Despite these limitations, our study demonstrated that approximately one in ten MSM are engaging in group sex, a figure slightly lower than that found in Western countries but comparable to other low-and middle-income countries LMICs. Group sex behavior may in fact be part of a syndemic[ 23 ] of interconnected high-risk health behaviors that co-occur and work synergistically to promote HIV transmission among MSM.

These implications urge us to consider future interventions that pull together comprehensive resources to address the multiple manifestations of a complex problem. They represent a potential risk factor for the spread of HIV and syphilis that can be better targeted. Future studies might focus more on exploring and defining the specifics of group sex behavior, as well as associated high-risk activities such as drug use.

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Furthermore, insight from anthropological studies may shed light on motivators and drivers of group sex, as qualitative research has better capacity to explore social and psychological aspects of behavior. Gaining a better understanding of group sex is highly relevant from a public health and medical standpoint. Sexy studs know how to arouse each other with skilled mouths and throbbing boners in the dirtiest gay videos you can ever imagine.

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