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    The ways in which these men are already coping with this issue also suggest several opportunities for effective sexual health and HIV prevention educational interventions. You speak about frozen; which other positions do you negotiate? Putting the spotlight on this issue may yield added and renewed health and wellness benefits to individual men, but is also potentially an important part of HIV and STI prevention efforts focused on this population. A few studies have considered the relationship between sexual role preferences and gender expression in MSM e. Health service utilization by men who have sex with men in South African cities. When you are having sex do you negotiate what type of sex you want and do you also give the other person a chance to voice what he wants? Perhaps some Black South African MSM are unlikely to switch their sexual roles to manage sexual pain given the importance of sexual role to overall sexual and gender identity. Participants commonly described these experiences as painful. Mareka also referred to the ability of lubricants to both increase comfort during RAI and prevent condom failure:

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    And then I was like, I became relaxed anyway for him to do his job. Yet the fact that many participants in this study recognized their same-sex attractions well before engaging in any same-sex sexual behavior suggests that there is an opportunity to deliver the relevant information before men first engage in anal intercourse. The pain alerted me to go to the toilet, I felt like defecating. When a guy is too rough, you can feel the pain and ask him to stop. Journal of Public Health Policy. First same-sex sexual experiences Participants reported on their first same-sex sexual experiences and how old they were at the time. Alcohol and sexual risk behavior among men who have sex with men in South African township communities. We wish to thank OUT Well-being, the communities that partnered with us in conducting this research, and the study 28 participants for their contributions. Some participants set sexual boundaries specifically related to lubricant use, saying that they would not engage in anal intercourse if lubricant was not available. From social silence to social science: These strategies are discussed in further detail below. A small number of participants used strategies that would not fall into either of these categories. As has been shown in other studies, the lack of formal sex education resources targeted to MSM may lead them to alternative sources of information, such as sexual partners, MSM peers, web-based resources, and pornography Kubicek et al. Prevalence, predictors, consequences and the development of DSM diagnostic criteria. It was pain from behind. In South African townships, where gay community spaces are non-existent Osmand et al. HIV vulnerability among male sex workers in Mombasa, Kenya. So I will tell him to think of something. Gendered power dynamics appear to play an important role, but further study is needed to better understand the way in which such dynamics shape sexual encounters and relationships. Have they done it by force to you without lubricant? You speak about frozen; which other positions do you negotiate? A smaller group of men described them as both painful and pleasurable. For example, although a larger number of participants had generally discussed alcohol use as a context for painful RAI, two participants reported using alcohol purposefully to prevent the pain associated with RAI. We also thank study staff at all participating institutions for their work and dedication. As Kabelo also explained:

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