Prevention in Focus

Spring 2010 

Reaching out in cyberspace

By Ian Woodruff

Many Canadian AIDS service organizations (ASOs) have well-established sexual health outreach programs targeting gay, bisexual and other men who have sex with men (MSM). Programs are delivered in environments as diverse as bathhouses, bars, nightclubs, youth groups, recent immigrant groups and people living with HIV/AIDS (PHA) support groups.

The Internet offers a powerful new way to deliver outreach directly to individuals online—when they want it, where they want it and, key to outreach’s success, anonymously! This article reviews the current state of gay and bisexual online outreach in Canada and suggests a framework for those considering its introduction.

Social Networking Sites

Most readers will be familiar with the increasingly popular Web-based social networking sites (SoNS), such as MySpace, Facebook, Friendster, Windows Live Messenger and Yahoo!, which permit members to keep in touch and find new friends. These services are especially popular with youth but have also gained wide acceptance with other age groups.

Sexual Networking Sites

In the last decade, the use of the Internet has grown exponentially and with it, the popularization of sexual networking sites (SeNS)—Web-based services that focus on connecting people seeking sex and are available for people of all sexual persuasions and interests. SeNS providers usually fund their operation on a dual business model of hosting advertising to cover the costs of offering free membership and paid subscriptions for members who are prepared to pay for additional features.

SeNS typically have up to three key components:

  • member profiles that can be browsed by others wanting to hook up;
  • internal communication systems that allow members to send messages to each other;
  • real-time chat rooms that allow members to chat “publicly” with all others currently in the room or “privately” by initiating a separate conversation with another person in the room.

This article will explore outreach to gay and bisexual men who use SeNS. However, the principles described may be broadly applicable to other population groups.

Sites specifically designed for gay and bisexual men that have broad appeal in Canada include gay.com, squirt.org and manhunt.net. Each of these providers offers all three of the components described above. Some sites provide narrower niche services for particular subcultures such as BDSM (bondage and discipline, dominance and submission, and sadomasochism), leather, barebacking or specific ethno-racial categories.

Who is using these sites?

Gay men are known to be early adopters of new technologies, so it is not surprising that around 45% of North American gay men have used SeNS to find a sex partner.1,2,3 It is common for these men to hold membership on several sites or even multiple identities (or “handles”) on one site. These same men also move seamlessly between SeNS and other venues (such as bars and bathhouses) when seeking sex so it is not realistic to think of them in uniquely SeNS terms.4,5

Despite the wide use of SeNS, surprisingly few papers have been published describing the characteristics of the gay and bisexual men using them.

Recent (unpublished) research at the AIDS Committee of Toronto (ACT) indicates that the ethno-racial distribution of members of the major Toronto SeNS providers broadly reflects that of the general population (see table). The ACT research also shows that the self-reported membership split on these sites is 85% gay men and 15% bisexual men. Youth are poorly represented in the membership of the sites surveyed, as are men over the age of 50.

Table: The ethno-racial distribution of members of the major SeNS providers in Toronto

Ethno-racial category

Percent of total membership

White

66%

Asian

11%

Mixed race

6%

African / black

3%

Latino

2%

Middle Eastern

2%

Other / not stated

10%

Similar findings were reported from a study of gay.com members in the United States.6

Gay and bisexual outreach on SeNS

Offering outreach through SeNS is a logical extension for ASOs that deliver outreach programs to bars, public places, special events and bathhouses. Numerous ASOs in Canada now provide outreach education and support services for gay and bisexual men via SeNS.

A key attraction of SeNS outreach is that it offers an additional access point for men who don’t often engage with outreach in other venues. Researchers have found that the following groups are potentially marginalized in mainstream “gay culture” and therefore an attractive target for SeNS-based outreach:

  • rural men;7
  • men who identify as straight, bisexual, bi-curious or married;
  • younger men;8
  • recreational drug users9 (particularly crystal methamphetamine users);
  • HIV-positive men;10
  • men from “non-white” cultural origins.11

SeNS outreach is usually viewed as a complementary service to more traditional forms of outreach rather than a replacement for them.

Peculiarities of SeNS outreach

SeNS members can be “reached” at both the membership level (messages targeting the whole site or chatroom) and at the individual level (real-time conversations with individuals), whereas other forms of outreach tend to focus primarily on the individual. Outreach workers must, therefore, be creative in crafting messages that serve both to stimulate sexual health awareness for all members (or direct them to appropriate information on Web sites) and to induce individuals into private conversations. Members who initiate private conversations are likely to be very open in their discussion because they have the reassurance of anonymity and can readily terminate a conversation if they feel threatened or uncomfortable.

Additionally, as the outreach worker is “invisible,” unlike face-to-face outreach, there are no racial, generational or cultural barriers to the outreach connection. Skilful SeNS outreach workers “adopt” a language and culture suited to the situation. Since members are more likely to be chatting in a non-threatening, comfortable environment, they are likely to be more receptive than they would be in a bar or bathhouse.

SeNS outreach techniques

The same principles apply as would for other outreach modes (non-judgmental, peer-based, supportive, affirming) but there is an extra level of complexity because of the absence of body language and other non-verbal cues to attract people to an outreach exchange.12

Thus, the outreach worker uses a lure to attract chatters. The lure is usually a posting in the chatroom briefing stating a fact about sexual health. This is often accompanied by a link to a Web site containing more information so that the whole chatroom can potentially benefit from the exposure (see examples in box).

Sometimes members will start a “public” conversation with the outreach worker in the main chatroom. This provides a welcome opportunity to expose a sexual health message to the whole room without being too obtrusive. More likely, however, a member will request a “private” conversation (by individually messaging the outreach worker). The outreach worker should be armed with a range of information ready to “cut and paste” (such as HIV testing centre procedures, locations and contact details) and pay close attention to both the overt and hidden meanings in the conversation.

Information alone, however, rarely motivates behaviour change13 so, whenever feasible, members should also be “exposed” to online learning objects that reinforce motivation14 (for example, directing an injection drug user to Ontario’s Hepatitis C Self-Assessment Tool).15

Six key steps in establishing a SeNS outreach presence

1. Decide what you will offer

Typically SeNS outreach offers one or more of the following:

  • Referral: Connection to appropriate agencies and services;
  • Knowledge and support: Providing one-on-one advice and factual information about sexual health and disease transmission risk;
  • Motivation:  Support for safer sex behaviours;
  • Affirmation: A sense of belonging and acceptance (of, for example sexuality or sexual practices).

2.  Choose your SeNS provider(s)

This will define the population you can reach. Popular providers such as gay.com, manhunt.net and squirt.org will ensure widest access, whereas specialist providers (for example, the BDSM SeNS provider recon.com) will facilitate access to a more focused population.

3.  Register with the SeNS provider as an outreach service

Providers have rules about the ways that you can operate and also provide support for your outreach effort (for example, MANHUNT Cares—the outreach arm of manhunt.net—assists ASOs in setting up and conducting their outreach).

4. Choose a membership level

Decide whether you can achieve your outreach goals with a basic (free) membership or whether you need the benefits of a paid membership (for example, chatting with multiple contacts at one time, access to rooms that are already full, absence of advertisements), which may increase your ability to communicate effectively with online clients). Paid memberships for Canadian SeNS are typically about $80 to $100 per year.

5. Design your profile

Your profile is your marketing tool so it must be attractive and appealing. Avoid age, gender and race descriptors as these may alienate some demographic subgroups and also cause problems when a number of outreach workers share the same profile. Provide agency contact details for those who prefer to contact the agency directly rather than chat with you on the site. Include links to relevant sexual health resources and provide reassurance of your commitment to confidentiality. You should also avoid “personalizing” the profile as this confuses chatters when there are several outreach workers using the same profile. Consider using your agency logo for consistency, a professional look and proper branding.

6.  Decide whether to offer real-time outreach, delayed-response outreach or both

Decide whether you will offer real-time chat (you will need to be at the computer ready to respond) or whether you offer a delayed response (by replying to e-mails and messages at regular intervals)—or whether you will offer both.

Beyond the real-time versus delayed response consideration, there is also the style of approach to consider. Most ASOs advocate a passive style, whereby the outreach worker waits to be contacted. A more active approach—proactively requesting conversations with members—is culturally unacceptable on most sites. Indeed some site providers specifically forbid this style of outreach in their ASO outreach agreements. Passive outreach typically attracts two to four chatters per hour.16 Although this might, at face value, be considered a low return on the outreach investment, the periodic posting of sexual health information and resource links in the room provides the opportunity to expose others to the intended message(s).

Evaluation

Although it is very tempting to launch a service and worry about its evaluation later, this invariably creates problems. Decide upfront what data are needed to inform evaluation, and design a system to collect them before you start offering outreach.

The two major kinds of evaluation are process indicators and outcome indicators. In an ideal world, data for both would be collected. Outcome data are used to evaluate whether the outreach program has achieved changes in the risk behaviours and HIV/sexually transmitted infection (STI) incidence in the community it serves. Reductions in one or both of these indicators could be considered as program success. Unfortunately, it is rarely possible to isolate the outreach effort from other factors at play in the community, such as provincial or national education campaigns and alterations in the delivery of primary sexual health services.

Some researchers have advocated “controlling” for these other factors by incorporating a “before and after outreach exposure” evaluation tool into the outreach program,7,8 but this approach is typically beyond the resource capability of most ASOs. This leaves process indicators as the primary evaluation tool—with an assumption that well-delivered outreach will positively influence the outcomes described above. Process indicators commonly recorded in online outreach programs include:

Volume measures:

  • Number of people exposed to outreach messages in the chat room;
  • Number of people initiating conversations with the outreach worker;
  • Number of messages/e-mails that the outreach profile generates.

Reach measures:

  • Proportion of people in each demographic category (for example, age and ethno-racial groupings) that the outreach program “reaches”;
  • Proportion of people in various risk groups (for example, recreational drug users, rural men).

Quality measures:

  • The duration of each chat (measured either in minutes or in number or words);
  • The range of issues covered in each chat;
  • Successful resolution of issues raised in each chat (by retrospective review).

Beyond Sexual Networking Sites

Internet outreach can be a useful tool to help service providers interact with specific or hard-to-reach populations. The Internet can be used to deliver targeted messaging and support to individuals who otherwise may be missed by traditional outreach programs. Although we have talked about outreach on sexual networking sites for gay and bisexual men, the principles described can be transferred to other social networking sites used by the populations that you serve.

Further information

SeNS outreach protocols

Sexual Health Educator Internet Resource (2008) AIDS Committee of London.12 This manual was adapted by the AIDS Committee of London from a manual produced by Legacy Community Health Services (formerly Montrose Clinic), Houston, Texas. It includes guidelines and procedures being used by Ontario Internet outreach programs. The guide was funded by the AIDS Bureau, Ontario Ministry of Health and Long-Term Care, Government of Ontario and distributed to attendees of the 2009 Gay Men’s Sexual Health Summit in Toronto.

AIDS Committee of Toronto Online Outreach Manual17

Western Australian Internet Outreach Manual (2006) Curtin University Perth, Western Australia.16 This manual brings together the experiences of an Internet outreach project conducted by the Western Australian AIDS Council (WAAC) and the Western Australian Centre for Health Promotion Research (WACHPR) at Curtin University of Technology along with other selected research. It presents guidelines on the development and implementation of Internet outreach programs for health promotion practitioners and peer education workers.

Some Canadian organizations that offer SeNS outreach services 

Organization

Web site

Contact details

Broad MSM focus

AIDS Committee of London

www.aidslondon.com

Daniel Pugh
dpugh@aidslondon.com
(519) 434-1601 ext 230

AIDS Committee of Simcoe County

www.acsc.ca

Mal Rice
acscsheir@rogers.com
(705) 722-6778

AIDS Committee of Ottawa 

www.aco-cso.ca

Cory Wong
mens.health@aco-cso.ca
(613) 238-5014 ext 229

AIDS Calgary

www.aidscalgary.org

HIV Education and Awareness Today (HEAT) worker
heat@aidscalgary.org
(403) 508-2500

AIDS Committee of Cambridge, Kitchener, Waterloo & area

www.acckwa.com

Leesa Stephenson
outreach@acckwa.com
(519) 570-3687 ext 306

AIDS Committee of Guelph & Wellington County

www.aidsguelph.org

Harm Reduction Program
(519) 763-2255

AIDS Committee of Toronto

www.actoronto.org

Paul McCarty-Johnston
pjohnston@actoronto.org
(416) 340-8224 ext 234

Specific communities

Substance use, homelessness
BC Centre for Disease Control Street Outreach

www.bccdc.ca

Harm Reduction Program
(604) 707-2400

Positive Youth Outreach
AIDS Committee of Toronto

www.positiveyouth.com

Angel Parks 
pyo@actoronto.org
(416) 340-8484 ext 281

Asian men
Asian Community AIDS Services Toronto

www.acas.org

MSM Program Coordinator
men@acas.org
(416) 963-4300

Black, African and Caribbean Men
Black CAP

www.blackcap.ca

Antoney Baccas
men2gether@black-cap.com
(416) 977-9955 

French-speaking men
Action Séro Zéro

www.sero-zero.qc.ca

info@sero-zero.qc.ca
 (514) 521-7788

Spanish-speaking men
Centre for Spanish-speaking People

www.spanishservices.org/

Diego Mcias
dmcias@spanishservices.org
(416) 925-2800

Portuguese-speaking Men’s Outreach
AIDS Committee of Toronto

www.actoronto.org

Andre Ceranto
aceranto@actoronto.org
(416) 340-8224 ext 242

References

  • 1. Bolding G, et al. Use of gay Internet sites and views about online health promotion among men who have sex with men. AIDS Care. 2004. 16(4): 993–1001. 
  • 2. Trussler T. Sex Now Survey report. 2008 [cited 2009. Available from: sexnow.cbrc.net/files/1170000000/SNIndex07final.pdf]. 
  • 3. Rebchook G, A. Curotto A, Levine D. How does the Internet affect HIV prevention?  2007. 14 June 2009 [cited 2009; Available from: www.caps.ucsf.edu]. 
  • 4. Hospers HJ, et al. A new meeting place: chatting on the Internet, e-dating and sexual risk behaviour among Dutch men who have sex with men. AIDS. 2005. 19: 1097–1101. 
  • 5. Spence G. Netreach, in Making Links. 2005. Sydney, Australia. 
  • 6. Roser BRS, et al. HIV Sexual Risk Behavior by Men Who use the Internet to Seek Sex with Men: Results of the Men's INTernet sex Study - II (MINTS - II). AIDS Behavior. 2009. 13: 488–498. 
  • 7. a. b. Bowen AM, Horvath K, Williams ML. A randomised control trial of Internet-delivered HIV prevention targetting rural MSM. Health Education Research. 2007. 22(1): 120–127.
  • 8. a. b. Bull S, et al. Effects of an Internet-based intervention for HIV prevention: The Youthnet Trials. AIDS Behavior. 2008. 13: 474–487.
  • 9. Mimiaga MJ, et al. Experiences and behaviors of HIV-infected MSM who acquired HIV in the context of crystal methamphetamine use. AIDS Education and Prevention. 2008. 20(1): 30–41.
  • 10. Offer C, et al. Responsibility for HIV prevention: Patterns of attribution among HIV-seropositive gay and bisexual men. AIDS Education and Prevention. 2007.; 19(1): 24–35.
  • 11. Poon MK, et al. Psychosocial experiences of East and Southeast Asian Men Who Use Gay Internet Chatrooms in Toronto: An Implication for HIV / AIDS Prevention. Ethnicity and Health. 2005. 10(2): 145–167.
  • 12. a. b. ACOL. Health Educator Internet Resource. 2008 [cited 2009; protocol for the establishment of an MSM internet outreach service].
  • 13. Fisher J, Fisher W. Changing AIDS-risk behavior. Psychological Bulletin. 1992. 111: 455–474.
  • 14. Ellis G, Grey A. Prevention of Sexually Transmitted Infections (STIs): A review of reviews into effectiveness of non-clinical interventions. 2004 [cited 10 June 2009; Available from: www.nice.org.uk/page.aspx?o=502657].
  • 15. MOHLTC. Hepatitis C Self-Assessment Tool. 2009  [cited August 30 2009]; Interactive self assessment tool to determine hepatitis C virus transmission risk. Available from: www.hepcontario.ca/en/self.html.
  • 16. a. b. Hallett J, et al. Internet Outreach – A Guide for Health Promoters and Peer Educators. 2006 [cited 2009; Available from: www.wachpr.curtin.edu.au].
  • 17. ACT. Gay men's Internet Outreach Protocol.  2009  [cited 2009; Available from: www.actoronto.org].

About the author(s)

Ian Woodruff is a health services researcher at the Royal Melbourne Institute of Technology University in Australia, who was volunteering with the AIDS Committee of Toronto (ACT) during an extended stay in Canada. His background includes clinical and management roles in hospital and community health, health systems research and international aid program development and delivery.

He was privileged to have spent several months as Coordinator of ACT’s Gay Men’s Online Outreach Program. Although circumstances drew him back to Australia prematurely, he left with great respect for the passion and dedication of the staff and volunteers in Canada’s diverse AIDS Service Organisations.

Ian can be contacted at ian.woodruff@rmit.edu.au.

Paul McCarty-Johnston succeeds Ian as Coordinator at ACT and is contactable at pjohnston@actoronto.org.