Design

A qualitative study design using an inductive content analysis oriented towards Graneheim and Lundman has been used to explore MSM’s sexual experience abroad.

Data collection

We conducted semi-structured interviews using open-ended questions between January and September 2016 with 15 Swedish MSM who travel to Berlin regularly or live there. In January and February 2016, we also conducted participatory observations.38 The interviewer and observer was a Swedish gay man, with a professional background in HIV prevention. He kept a research diary with immediate reflections after each interview and shared it with the author team on a weekly basis, including reflections on method, progress and analysis.

Network sampling was used for recruiting study participants. This method shares many similarities with incentivised chain sampling.39 In this study, each seed contributed with a maximum of two referrals to minimise the risk of bias due to the initial seeds being more likely to contact people they know, or people who would be more likely to be similar to them.

Three initial seeds were asked to participate from the interviewer’s Facebook network. When the third seed did not provide any referrals, a fourth seed was recruited. Wave three was reached in two of the chains. Participants were reimbursed with two cinema tickets. No extra reimbursement was given for referral of interviewees.

The inclusion criteria were:

• Swedish citizen.

• Cis-male (as in a non-trans man) citizen who have sex with men.

• Aged 18–46 years.

• Current or former residents of Berlin, or who travel to Berlin at least twice a year.

• Have had sex during the past 3 years in both Berlin and Sweden.

The second inclusion was based on generational assumptions made in the Swedish MSM 2013 study.10

Interviews

The interview guide was designed based on topics identified as priorities for in-depth analysis after conducting the Swedish MSM 2013 survey.10 The interview guide covered: arenas and purposes for meeting other men, sexual practice, HIV/sexually transmitted infection (STI) risk and risk reduction, testing for HIV/STI, alcohol and drug use and living with HIV. The interviewer used mainly open-ended questions and follow-up questions to clarify what was being described without prompting. Any tendency to bias or pose leading questions was carefully avoided.

Each interview was conducted after giving full information on the purpose of the study, the condition of participation and data storage. A written consent was acquired from each participant. The interview guide was piloted with three men who fit the inclusion criteria and thereafter slightly altered. Since no crucial changes were made to the interview guide, the pilot interviews were included in the sample.

Most interviews were conducted in the first author’s home in Stockholm or in Berlin, either face to face or through Skype/FaceTime. They lasted 45–170 min. The concept of theoretical saturation of information, that is, when no new information of relevance to the research question emerged from interviews, was discussed within the research group and the group reached a consensus that such saturation was achieved after 13 interviews. Two additional interviews verified this.

The interviews were recorded and transcribed shortly after the interview by either the interviewer or a professional transcriber. To ensure anonymity and correctness, another member of the author team reviewed the anonymised transcriptions. The audio files were stored in a locked recording devise during the process and the electronic files were deleted after the transcript had been reviewed.

Observations

The interviewer conducted participant observations at three clubs and/or sex venues in Berlin mentioned by the informants and described the settings and contexts in the diary to be shared with the other researchers. Davies and Hughes38 differentiates between non-participatory and participatory observations where non-participatory observations can be observations done from a distance in a public space, while participatory observation means that you take a role in order to melt into the setting.38 Doing observations at three sex clubs in Berlin (one sauna, one fetish club and one techno club with dark rooms) requires participatory observations since you have to be let into the club, dress or undress accordingly and take notes discreetly on the environment, cruising culture and sexual behaviour. Being open with the aim of the study would not be feasible in this setting. The observations are important for the author team to fully understand the context and add to the understanding of the environment for the participants’ sexual encounters in Berlin.40 41 No material from the observations was included in the content analysis.

Analysis

Content analysis was applied as described by Graneheim and Lundman,42 who argue that texts always have multiple meanings and that interpretation is unavoidable.42 The content analysis was executed as an iterative process. This enabled the researchers to go back and forth between the raw data, interview guide, analysis and text to gain deeper understanding of the process and meaning. NVivo was used for coding and Microsoft Excel to facilitate structure. In order to get to know the raw material, the researchers listened to the recordings, and took notes in the research diary on re-occurring or new topics and potential themes. The researchers read and re-read the transcripts during the data collection period and afterwards in order to identify patterns.43 Coding and clustering into subcategories, categories and themes were conducted over time, which enabled the researchers to review the data from different perspectives. Weekly meetings, and sometimes daily meetings, on FaceTime during the data collection and coding process ensured that the process was a collaborative process where we agreed on key decisions.

Patient and public involvement

The study did not deal with patients. The study group or the public was not involved in the design of the study.

The participants

The 15 participants ranged in age from 25 to 44 years (table 1). The mean age was 34. Most participants were born and had grown up in different places in Sweden. At some point in life they had all lived in Stockholm. Two were born abroad. Most men had an academic degree.

All but two men had full-time jobs. Six men had experience of living in Berlin and the other nine were frequent travellers to Berlin from Stockholm. All had tested themselves for HIV and STIs in the past year. One participant reported living with HIV but all participants except for two had a history of one or more STIs. Most of the informants stated that they had experience of open relationships. The vast majority of the participants had experienced sex on drugs or taken drugs in a club setting both in Sweden and Berlin.

Theme 1: perceptions of sex in Sweden and Berlin

This theme consists of two categories: Normative Environments and Accessibility of partners and sexual practices.

The perception of sex and sexual practice was a combination of various factors based on the cultural norms and the accessibility of partners and sexual practices and sexual arenas. These perceptions differed if the participants described Sweden or Berlin. Differences in cultural norms between Sweden and Berlin seemed to be key motivators to leave Sweden and travel or move to Berlin. The British author, Christopher Isherwood’s publications such as Goodbye to Berlin—later turned into the musical Cabaret 44 —were mentioned by some of the informants as a factor in creating a perception, or an idea of Berlin with a very different normative environment from home.

I had a very romanticized image of Berlin, based upon literature, movies, Cabaret, gay stories told by friends and acquaintances. I had probably constructed an image of Berlin as a city that could offer some lovely decadence and sin. (Informant 2)

Other references creating the idea of Berlin included history, language and more contemporary aspects like the techno scene and the art world. The participants had a close to homogenic description of Sweden as a narrow-minded place creating push factors for leaving. Equally homogenic was the description of Berlin as a liberal place, creating pull factors (box 1). A sense of increased sexual freedom and liberation was a re-occurring topic for many of the participants.

My life feels so much more interesting with all of this surrounding me, not only what is offered sexually but also culturally, artistically, music, social media, fashion. (…) It’s so relevant and progressive. (Informant 13)

Accessibility of partners and sexual practice (category) was important to the men in this study. Place of birth and/or Stockholm was perceived small and often too small both in number of available men and too small to host less mainstream sexual practices like sex on drugs or BDSM practices. One informant perceived Berlin as the fisting capital of Europe. Sweden was perceived as ‘Small’ with limited access of partners and sexual practice and Berlin as ‘Big’ with endless access of partners and sexual practice.

However, size is only one aspect and other aspects seemed to play important roles as well. Berlin stood out from other larger gay travel destinations and was the main choice of destination. Being away from home, being on holiday and spending time in a larger city were important aspects of changes in sexual behaviours, but Berlin itself played an important role in the equation. The choice to spend time there rather than in other European gay destinations was deliberate and no coincidence for the men in this study.

Some of the informants had spent time in other larger European cities like Paris, London and Barcelona but to them Berlin provided a sexual culture that differed from other cities and included the leather scene, fetish, fisting and open-minded cruising culture. One informant compared Paris with Berlin:

It would be like: We kiss, we walk around being all cuddly, Victorian chandeliers and yada yada and in Berlin it’s more like: ‘Concrete and Cock’. (Informant 1)

There was consensus among the participants that sex overall was easier to access in Berlin than in Sweden and it was mainly considered as positive.

There is a never-ending stream of people you can meet. God, it’s like you’re a kid in a candy store. (Informant 13)

Theme 2: sex and sexual practice in Sweden and Berlin

The second theme consists of two categories: Sexual behaviour and Contextual explanations (figure 1). The perception of Berlin among the informants correlated with their actual experiences. There was no major difference between what they believed Berlin would be and the Berlin they got to travel to.

The men reported a large number of sex partners; some could not make an estimation, others estimated up to 200 sexual partners per year.

I probably have sex with my boyfriend twice or three times per week. And I’m blowing… one to four guys per week. More or less. (Informant 12)

The majority of the informants said that they had more sex in Berlin than they had in Sweden.

From time to time, I meet quite a lot of people in Stockholm as well. But when I go to Berlin, I want to get the most out of it. (Informant 9)

Several informants stated that they already had a sexual life in Stockholm as in high number of partners, experience is threesomes/group sex among other things, but that it may still differ from Berlin.

I have a very dissolute sexuality in Stockholm as well. […] The difference may be due to logistic reasons since there are not as good sex clubs in Stockholm. (Informant 9)

Perceived moralistic norms in Sweden had an inhibiting effect on the men in this study and were a key reason for wanting to experience more in terms of sex. Berlin became a place for retreat from the limitations of Sweden.

The men in this study were well-informed about HIV and safer sex and all of them did to varying degrees and in different ways always or sometimes practised safer sex.

I have no idea about… if one should assess risk…how common HIV is in Berlin compared with HIV in Stockholm. (…) One shouldn’t use that kind of statistics when it comes to protecting oneself. (Informant 3)

Neither did the men who were aware of the higher prevalence of HIV in Berlin use statistics in order to assess risk. The vast majority of the men had the same safer sex practice in Sweden as in Berlin. However, one informant stated:

Since my perception is that there are more diseases circulating in Berlin I get more anxiety from (having anal sex without a condom) there than here. (Informant 9)

Nonetheless, this expressed anxiety did not alter his safer sex behaviour. He knew that every sexual encounter in Sweden or Berlin could possibly be either with or without a condom—not necessary planned but part of the overall equation or balance of pleasure and safety.

The category Contextual explanation which aim to describe why their sexual practice differentiates between Sweden and Berlin and consists of three subcategories: Cultural characteristics describes the cultural differences between Berlin and Sweden which add to the push and pull factors described in box 1. Home and away describes more general aspects of travelling or being away from one’s usual context and is not Sweden/Berlin specific. The third relates to practicalities, related to what is available in each country.

One of the informants explained that the limited availability of partners in Stockholm was due to the Stockholm community being smaller and that cultures differed in relation to how and how easily it could be done to hook up with someone, making difference in sexual culture part of the cultural characteristics:

I think people generally in Stockholm are more hesitant to meet compared to people in Berlin. There is more of a culture of quick hook-ups for sex in Berlin than there is here. (Informant 9)

The informants described that it was easier to flirt with men in the public spaces in Berlin like at a gallery opening, while in Sweden they had to rely on dating apps to hook up. Another key aspect of the Cultural characteristics of Berlin was how the social club scene and sex scene was interlinked via the darkrooms and other sexual spaces where one can have casual sex.

Maybe you are dancing with someone on the dance floor, a little bit of chitchat, maybe dancing tête-a-tête and maybe a snog (…) Maybe ask ’Wanna go to the darkroom?’ or you just take the person’s hand and lead it in that direction. (Informant 8)

For this participant, there was a freedom in sexual practice in Berlin that he did not experience in Sweden. ‘Moralistic’ norms had an inhibiting effect on the men in this study and were a key reason for leaving Sweden as they wanted to experience more in terms of sex than Sweden could offer. Berlin became a place for retreat from the limitations of Sweden for the men interviewed. Some participants stated that, due to the liberal atmosphere in Berlin, they allowed themselves to try new sexual practices in Berlin such as fisting, sex with women and role play which they would not allow themselves in Sweden.

You can smell the freedom. (…) My perception of Berlin, the faded old whore, is that she is fucking forgiving. (…) She has seen it all, that’s probably why. (Informant 5)

There were clubs open 7 days a week facilitating an attractive lifestyle of party and sex for all ages, catered to those into non-mainstream subcultures within the gay scene.

Stockholm was a smaller city compared with Berlin, limited the number of possible arenas for meeting other men and potential sex partners, especially for those who are into the BDSM, fetish and fisting scenes:

It’s probably harder in Stockholm if you are into bondage and stuff like that because then you can go out Thursday nights every week or something like that and it’s the same men who are there. (Informant 3)

The participants agreed that the Swedish sex clubs did not appeal to them due to a difference in practicality. Beside the dislike of Swedish ‘decadence’ at a social level, the sex clubs were perceived as unclean and lacked spaces for social interactions. The Berlin sex clubs were seen as having a more diverse clientele and their freshness made sexual adventures there more acceptable. One of the informants spoke highly of the decadence he had experienced solely in Berlin and when asked if he had similar feelings in Sweden he replied:

If you go to a sex club or something, which I don’t find very fun in Sweden, it’s so very shameful, it’s dark, the lights are switched off, smells like shit, people don’t look into each other’s eyes, there is like no sense of pride. (Informant 2)

Hence, the Swedish decadence did exist but its characteristics had less positive connotations compared with Berlin’s.

Other differences in practicalities did create different sexual patterns depending on if one was at home or away that is, not going to sex clubs in Sweden but in Berlin. One could have reoccurring ‘fuckbuddies’ at home and temporary partners in Berlin, attending private sex parties at home but not being able to do that in Berlin due to lack of networks.

While Cultural characteristics describe the cultural difference between Berlin and Sweden, home and away describes changes focusing on being away or being somewhere else from your everyday routines, not specifically Berlin, even though Berlin facilitated the practice. For informant 2, being on vacation fuelled sexual adventures and he further explained:

I still feel that part of being on vacation is to let go of things and enter some kind of decadence, absolutely. Sexually, relationship-wise… (Informant 2)

Some participants described sex in Sweden in the light of social positioning at home.

Others care about what social position you have, what job you have, where you hang out, who you hang out with, and in Berlin it is… it’s maybe because I’m not from Berlin, I’m not German, but it feels different (in Berlin). (Informant 1)

The smaller size of Stockholm compared with a larger city was associated with lack of anonymity, and anonymity was only considered possible there. Also, being at home was to some men linked to concerns about reputation, which created inhibitions. Travelling provided a solution to this problem; going to a place where there was a smaller chance of being recognised and therefore able to act more freely.

I inhibit myself since I am closer to my everyday life. I am closer to the social position I traditionally have in Stockholm, which I most likely will have next week as well. (Informant 2)

Some informants tried though to incorporate these new positive sides of themselves into their everyday persona back home, despite inhibitions and different settings.