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The roundtable discussion today is about MSM, sex and Internet chat rooms. Most of us are here because we are probably familiar with the recent studies that report high rates of unprotected sex and outbreaks of STDs among men who meet other men in Internet chat rooms.

But we are here to address the questions of why this is the case, what evidence there is to support these studies and these trends, and to set out what makes Internet chat rooms different from other venues. ing me today are several individuals, all of whom either as public health officials, researchers, safe sex advocates or some combination thereof, have a particular interest and expertise in Internet chat room use among MSM. I will start with my left with Frank Strona. Frank has worked on men's sex and health issues for more than 15 years.

He is co-creator of a new website called SafeSexCity.

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To my right is Greg Rebchook. Greg is with CAPS. He is assistant research psychologist and has studied and worked on a of community-based interventions among gay men. He has conducted research on the role of the Internet in the sexual lives of MSM and has found a of interesting trends that I am sure he will share with us in our discussion today. ISIS has worked with online providers to provide online prevention initiatives. And finally is Dr. So I would like to welcome all of the panelists today and thank you for ing us here.

I am going to go ahead and begin with the first set of questions. I wanted to start the discussion more with evidence because there might be people who are skeptical or do not really understand what evidence there is out there that men who have sex with men and meet their sexual partners online have higher rates of unprotected sex and sexually transmitted diseases. So if I can get you to comment on that.

Greg, do you want to start? Greg Rebchook: Sure, I can start addressing that question about evidence that MSM recruited from online venues or using chat rooms have higher rates of, or they are reporting higher rates of, unprotected anal intercourse with their partners than men in other venues.

Several different studies have been done. National studies in the U. There are also higher rates of men reporting STD infections, who are using chat rooms, and so it is a very consistent finding that a lot of different studies and a Online sex chat city San Francisco California of different research groups are picking up that these higher rates are existing.

Our own data actually show that even when you are controlling for the of sexual partners that men are having, that Internet use still contributes to unprotected sex ificantly, even controlling for the of sex partners. If other panelists want to comment on that. Jeff Klausner: We first identified the association of Internet use and Online sex chat city San Francisco California transmission in during an outbreak investigation of a cluster of syphilis cases among gay men here in San Francisco. We did a case-control study, which is kind of your typical type of evaluation to determine what risk factors are associated with cases and non-cases.

It was actually one of the first published studies of a strong association between Internet sex partnering and syphilis transmission. As part of that study, we continued to monitor the use of Internet chat rooms and Internet sites among syphilis case patients and non-patients seen at the STD clinic in San Francisco and how about half of new cases have met recent partners online and the Internet sites have continued to be a place where we focus prevention efforts.

MV: What do you suspect makes the Internet as a venue different than any other venue where men would meet each other for sex, such as bars or bath houses? Frank Strona: One of the things to keep in mind with Internet behavior is there is a perception of anonymity. It is a cultural norm to be able to put a photograph in the profile out there that does not have a face, it does not have a name associated and I think that there is a level of personal safety that you believe you have, giving the fact that you think people cannot identify you.

So you can write your profile as a modified code, hoping other people will read it the same way and then you can have a combination of s exchanged or messages exchanged that allows you to kind of refine where and what behavior you choose to go to and then, if you want to have that next step, you can display your face.

The downside of that is, more often than not, in such small locations that we have, you end up knowing who the people are even before you see the face shot, and once you get more and more comfortable and you find less and less fear based on whatever program you are in, you start to change those images. But I really do think a lot of it is based on comfort level of perceived anonymity. Deb Levine: I would like to add one I do not want to start off by blaming the Internet and saying, you know, "This medium is the reason that there are higher transmission rates.

So, just to put that in perspective. Adding to that, though, the Internet allows men to meet each other faster. You get on line, you want to get laid, you can have somebody at your house within an hour -- probably less in San Francisco! Depending on Muni, right?! If you are experience is one that you are not crazy about, you can get back online and you can find somebody else to come over or to go to their house afterwards.

It is a lot harder when you are working face-to-face because you have to sort of summon up the effort to talk to somebody and to break the ice and to ask them to come home with you; whereas the Internet, everybody is there for the same reason; it is very quick, it is very easy. The other reason why I think that there are problems with communication via the Internet, is -- and I think it is really just a continuum of what is happening offline -- is that safer sex does not seem to hold much meaning on the Internet anymore.

Whereas a lot of people in their profiles will put down "safer sex only," then they meet up, that means we do not have to have a discussion about it because, let's say I responded to an ad that said "safer sex only" or we both wrote "safer sex only. That is probably not the best example, but let's say for the other person, let's say they won't even have oral sex without a condom.

Okay, so then you get together and you think that you are going to have a particular kind of experience, you are already there, you are already aroused, you give up some of the discussion because it is much easier to just follow through and then afterwards you are like, "Man, you know? That wasn't my idea of safe sex! Then you go out and try to Online sex chat city San Francisco California somebody else who potentially has your same thoughts and beliefs. So communication. It seems clear online and it is not. MV: So, is there a misperception with the Internet where it seems clear that you can say, "I'm HIV-negative, STD-free" but that does not get into when you were last tested or what that means for you, and so that it appears that it is all out there in the open but it is really not being addressed?

So these five A's of accessibility. The Internet is very accessible to many people, particularly in this demographic, particularly here in San Francisco. Internet access to places where you can meet sex partners is very affordable.

It is a lot cheaper to just go online and go to a chat room than to get up, go out of the house and go to a bar or a club or some other venue. The Internet affords anonymity There is a great New Yorker slide that says, "On the Internet, no one knows you're a dog. Internet partnering has become very acceptableso that it has become the new relative norm of how to meet partners.

GR: I just want to add that we have been doing online qualitative interviews with gay and bisexual men or men who have sex with men they meet in Internet chat rooms, or that we were recruiting from Internet chat rooms, and even the guys in rural America are saying that, you know, "I can get online, and in 45 minutes, I can have someone tied up to my bedpost And we really ask people how they thought the Internet was affecting their sexual behaviors and to the T, almost everyone said that it has been increasing the of partners they have and then either look at that as something really positive-that it is convenient, it is accessible, that it is sort of the greatest thing-and other people are sort of indicating some level of frustration with that, well, while they can get their physical needs met pretty easily, sometimes their unexpressed needs around intimacy might not be getting met, although that can be true in other venues as well, but I think the explosion in the of partners people are meeting online is really changing that for some of the guys that we have been interviewing.

MV: So, what sort of comparisons can we make between Internet chat rooms and other venues where the goal the sort of the same and very obvious, such as sex clubs; there are sex clubs in the City and a lot of other cities. What sort of trends or similarities do you see in terms of behavior, safety, and expectations? GR: I think there are a few things.

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One is I do think it is important to recognize that when people are hooking up, when they are meeting each other online and then going home, that it is happening in an environment that has traditionally been isolated from HIV prevention messages and that whatever your perceptions are of the campaigns that are going on currently in the bars and bath houses, there are posters there; there are condoms available there; there are very visible and active campaigns happening in many communities across the U.

And at some point, in some of the communities where we were asking people online if they were aware of online HIV prevention campaigns, many of the participants said they were not aware or they had not seen them because, I mean, I think the Internet is so large that it takes a really concerted effort to make your presence known and so that when hookups are being arranged completely outside of the arena that HIV prevention campaigns have hit, I think that is worth talking about.

PS: It is also important, I think, to keep in mind that these websites are businesses -- the owners are out making money. What differs from the local sex club, though, in one factor is they are not community-based. The owners could be in New York or be in Ohio and that is where they launched your national website from, and you could have people all over the country using the site.

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That does not make you a "local" community organization tied to that particularly community, which then creates a challenge in terms of working with the local sex venue to say, "Okay, we would like you to put up more posters. JK: In our work, it seems that people who attend sex clubs and seek sex at sex clubs seem to be somewhat different than people who are seeking sex online, different from people who may seek sex through more kind of casual street-based or social encounters, and surprisingly, there is actually not a lot of overlap.

People tend to shop in the same store; they go to the same place for sex partners. So, it may be somewhat of a generalization, but people who seek sex in clubs or bookstores generally keep going back to clubs and bookstores; people go on the Internet, go to the Internet. These different venues somewhat attract and bring together different sexual networks.

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So right now, in terms of STD transmission, which is a lot easier to monitor than HIV transmission, we can find these high risk networks associated with Internet use, which we really do not see with the sex clubs or the adult bookstores anymore. GR: I think there are data that were presented at the National HIV Prevention Conference last year showing that in California, the proportion of new syphilis diagnoses that were ed for in bath houses and other sex clubs was shrinking while the proportion of syphilis diagnoses that were attributed to men meeting in online venues was increasing and that that shift was really documented now.

Mark, can I ask, is there a way for other people to give their input in the audience as well? MV: Sure, people can do that and perhaps we could just repeat the comments or the questions. JK: I really see it as a shift. I see the Internet as really opening up a whole new world of sexual networks to a lot of people who maybe never felt comfortable going into sex clubs or never felt comfortable about going into specific bars or venues to meet partners, and this whole thing really started, for me at least, in the Spring ofwhen I was seeing a patient in the clinic and I said, "How many sex partners have you had in the past two months?

You can't believe it! Online sex chat city San Francisco California unbelievable! AUDIENCE: So is it possible that perhaps there is a demographic change where younger people tend to be more involved in the Internet and older guys go to bookstores and things like that? JK: Yes, I think that is a reasonable idea, but I don't think it's been well studied.

PH: I do not think that those are clearwith bath houses here, Internet here. There are a of sex venues and sex partners that happen whose only mode of recruitment is through the Internet. I can go online right now and probably find, especially since it is Pride Weekend, 10 sex parties that are happening in hotel rooms, people's garages, out in places like Martinez But one of the things our project is trying to do is we are trying to hookup with Online sex chat city San Francisco California people who go to these sex parties.

So increasingly you have people not just hooking up one-on-one through the Internet, but they are ing onto Yahoo! MV: Yes, I guess, that is sort of my puzzlement. I mean, Dr. Klausner, said that there is often not a lot of overlap -- and I can see where that is true -- but then in cases like this, there is a lot of overlap. So sometimes I think a lot of the distinctions are perhaps made artificially and so there is some overlap, it seems.

FS: I think you might also want to look at the fact that there is collaboration. There are guys who are saying, "I am going to be at XYZ club tonight. Meet me there. FS: That is part of the availability but I think if you do some research in terms of bar owners and their receipts over the last years, they have shown a marked decrease in clients and some of that has been smoking, lack of smoking, some of that is-at least in this city-economics are such that people are working more hours per day and their personal time is more important to them and if they know that their goal is to get off, then they may be less likely to have the bar venue as a social event.

Maybe they will save that for the Saturday or Sunday night but on a Monday or a Tuesday, Happy Hour is not as important as "I know I can get off efficiently and economically. So I think it is important to also look at some of those dynamics and where this process is making it more convenient and more attractive. DL: I want to speak to the age issue for a second, and this is hypothetical based on we put together a community advisory board to build a website recently and one of the younger people on the board was basically saying that he was invited to a sex party that he learned about from the Internet and he went, and, however months later, he got the "you may have been exposed to We didn't even talk about it.

You know, it was just like, 'Hey, you going Saturday night? We'll checked out, da-da-da-dah, and then we'll go; we'll party" and afterwards, everybody would show up again. This guy basically said, "I had no idea! So, and not in a In a scary way as opposed to in a "I'm taking care of my health" way.

So, it is just to think about the age and the communication and again, the difference between online and offline and how norms are changing.

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GR: I guess I just want to add sort of a personal anecdote, taking off my researcher hat and putting on my "Gay Man in San Francisco" hat. A few years ago when I was online a lot, I think that it was interesting to me to sort of observe how in one night being online, I could get asked maybe 15 or 20 times if I barebacked and if I would have sex without a condom or guys that were really hot and cute, and then they would talk about wanting to fuck without condoms and you know, at some level, that starts to almost be the normative behavior that I was experiencing at least.

And maybe it was something about my profile, I do not know -- even though it had that I use condoms in my profile -- but you know, when I went to a bar, that same experience was not happening to me. It was not like people kept coming up to me and asking me, "Do you want to fuck without condoms?

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