Purpose The purpose of this study was to explore the perceptions and experiences of sex among Swedish Men who have Sex with Men (MSM) in Berlin.
Background MSM are disproportionally affected by HIV.
Berlin is also a key destination when looking into where Swedish MSM sero-convert, while travelling.
Method A qualitative study with semi-structured interviews using open-ended questions with participants recruited through network sampling. Data were analysed with content analysis.
Participants 15 Swedish cis-men (as in non-transgender) who have sex with men aged 25–44 years, who travelled to or were living in Berlin. To be included in the study, the participants had to be cis-MSM, Swedish citizens, spending time in Berlin and having sex in both settings.
Results For a majority of the participants, sex was the main reason for going to Berlin but cultural aspects like art and the techno scene were also important. Berlin was perceived as a sex-oriented city providing venues where respondents did not have to care about reputation and status and where social and sexual spaces co-existed side by side. This in sharp contrast to Sweden, which represented a limiting environment both in culture and what was available culturally and sexually.
Conclusion The men interviewed experienced multiple partners and had a broad sexual repertoire both abroad and at home. However, the behaviour was amplified in Berlin. The men did not alter their safer sex practice depending on if they had sex in Sweden or Berlin. The high mobility and vulnerability for HIV/sexually transmitted infection (STI) among these men highlights the need of increased access to antiretroviral treatment, pre-exposure prophylaxis for HIV and low-threshold HIV/STI testing services in Europe.
- public health
- qualitative research
- men who have sex with men
- travel medicine
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Strengths and limitations of this study
The design included interviews complemented with participatory observations in clubs and sex clubs in Berlin.
The interviewer balanced between emic and etic approaches in order to gain trust from the participants and at the same time gain deep understanding of the culture described in the interviews.
A limitation is that the group of Swedish men who have sex with men travelling to Berlin was not compared with Berlin visitors from other countries or Swedes who travelled to other destinations.
Gay men and other men who have sex with men (MSM) carry a disproportional burden of HIV infection in Europe.1 Each year in the period 2010–2014, on average five Swedish MSM contracted HIV while travelling to Germany and in 2017, on average one Swedish MSM a week reported having contracted gonorrhoea in Germany (Source: Public Health Agency of Sweden, Sminet database). The HIV prevalence in Germany and Sweden differs, although not drastically. It is estimated at 5.0%–7.5% in MSM and below 0.2% among the total adult population in Germany2 as compared with 3%–6% in MSM and 0.07% in the total adult population in Sweden.3 The Joint United Nations Programme on HIV/AIDS data suggest that Germany has a high concentration of MSM in larger cities. This could be due to MSM-oriented meeting places, such as saunas and clubs, which provide high numbers of sexual partners.2 Some MSM in Berlin describe the city as the ‘HIV capital of Europe’. In one study, the participants estimated that between 20% and 90% of all MSM living in Berlin were HIV positive.4 Despite such information, there are no state-sponsored programmes for distribution of condoms. Other free condom distribution activities exist but there is still inadequate availability of condoms making them difficult to access at sex venues.4 The sexual health needs of the gay community is mostly catered for by non-governmental organisations.5
Pre-exposure prophylaxis (PrEP) for HIV is a highly effective tool for prevention of HIV.6 7 At the time of the data collection, PrEP was approved in the European Union but no programmes responded to the PrEP needs of MSM in Sweden8 or Germany.9
Surveys on Swedish MSM’s sexual health have been conducted on a regular basis for the past 10 years but sexual practice while travelling has only been explored in detail in the most recent Swedish national survey (data collected 2013).10 Barebacking (defined in those surveys as pre-agreed, condomless anal intercourse) was more common in Sweden compared with abroad (31% compared with 17%) but group sex was practised more often abroad than in Sweden.10 The most common countries to have had sex while travelling abroad were Germany.
Travelling is an important part of many gay men’s lifestyle and increased globalisation and cheap airline tickets facilitate that lifestyle.11 Over the last decade, several attempts have been made to study sex and travel among MSM with contradictory results. Many of the identified studies are based on surveys. Recent studies on travelling MSM cover topics such as examining risk profiles,12 13 prevalence of condomless anal intercourse and other high-risk sexual practices,14–18 HIV knowledge and HIV preventive needs19 20 and sexual identity.21 22 Several studies provide knowledge on risk behaviour, and drug use while away.23–25 Zablotska et al 15 point out that ‘little is known about the travel-associated risky sexual practices in community-based samples of gay men, nor of the factors that shape these practices’. There is a need for further studies explaining the purpose of travel for MSM and ‘context-related characteristics ‘that lead MSM to be sexually active while being abroad,14 not least to design interventions that target this group.
Berlin has represented gay culture and sexual freedom for more than a century.26 German MSM outside Berlin choose Berlin for its extensive gay community and liberal attitudes towards sex.4 It is also a common leisure travel destination for European MSM, offering a variety of meeting places and public sex venues catering specifically to them, including a range of annual parties during Easter and Folsom Europe (bondage/discipline, dominance/submission and sadism/masochism (BDSM) and leather fetish week in September). Germany and Spain have been listed in surveys among top destinations by both Swedish and European MSM when having sex abroad.27 28 The proximity and relatively cheap travel and accommodation facilitate travelling between Sweden and Berlin. There are however more gay travel destinations known for facilitating different sexual preferences like sexualised drug use (chemsex) in London, UK29 and circuit parties all over the world.30–33 A circuit party is a large gay dance event, professionally produced and attended by thousands and attracts visitors from all over the world. They are also known for being sexualised spaces and drug use.
Sociocultural research on travel and risk has noted that at home is often explained as a stable context guaranteeing good health for its insiders, but it has also been observed that travellers from other places as well as community members travelling and returning home are perceived as potential threats to health.34 Schütz argues that being a stranger in a specific context is to stand outside the insider group and being an outsider requires that you adjust to some extent to the insider group and its culture, thereby changing yourself. However, Schütz also means that once you become the homecomer—when you return home after travelling—you are no longer the same as before travelling and you have to adjust to home.35 Other academics build on Schütz’s theories and describe the concept of finite provinces of meaning with relevance in terms of tourism and travel: ’Compared with the reality of everyday life, other realities appear as finite provinces of meaning, enclaves within the paramount reality marked by circumscribed meanings and modes of experience’.36 Hennig37 suggests that therefore travelling in itself should be regarded as a finite province of meaning. A tourist can to a greater extent be free while travelling than when at home: ‘tourists’ actions have largely no impact. For precisely this reason, their ideas, as in daydreams, can generally be given free rein’.37 Against this background, it was decided to conduct a study with the purpose to explore Swedish MSM’s perceptions and experience of sex in Berlin and Sweden.
A qualitative study design using an inductive content analysis oriented towards Graneheim and Lundman has been used to explore MSM’s sexual experience abroad.
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:
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
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.
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.
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.
Two themes emerged: Perceptions of sex in Sweden and Berlin and Sex and sexual practice in Berlin and Sweden (figure 1). Together they present an image of the sexual lifestyle of the men participating in this study in relation to travelling. In order to provide as complete information as possible on the participants, we describe their characteristics before going to the two themes.
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.
Summary of push and pull factors associated with Sweden and Berlin
Push factors (Sweden)
Swedish culture focused on career and growing up
Pull factors (Berlin)
More potential partners
Better flirting culture
Better sex clubs
Liberal city in all aspects
Sense of freedom
Everything is allowed
Club scene/techno scene
Contemporary art scene
History and language
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.
The aim of this study was to explore the perceptions and experience of sex in Sweden and Berlin among Swedish MSM spending time in Berlin. For the majority of the participants, the choice of Berlin was not coincidental. Berlin functioned as a finite province of meaning, a liberal place away from home, permissive of sexual preference and a place where people can forget about routines and reputation.36 For the study participants travelling to Berlin regularly it was evident that Sweden was perceived as home and that ‘at home’ was the place where the men had routines and a reputation to consider—but not necessarily a place perceived as stable or healthy in all aspects for MSM.34 The concept of being away would be applicable to any destination, but our results suggest that gay men choosing to travel to Berlin may be more interested in new practices and a sexual liberal lifestyle than those travelling to other cities.
The participants generally had a clear idea of what Berlin was before arriving to Berlin regarding the city’s culture, lifestyle and sexual scene. This is in line with previous findings on German MSM migrating to Berlin from other parts of the country.4 26 The expectations of the city as a space for sexual liberation and freedom correlated with the experience of the men in the study. Berlin allowed new sexual practices due to the liberty of the city that facilitated a more outgoing and active sexual lifestyle. By contrasting Berlin to Sweden, the participants deliberately sought to ‘change themselves’ when visiting Berlin.35 Our data show that Berlin facilitates new sexual practices and lifestyles even though the men interviewed had to a varying degree experienced sex at clubs, group sex and sex at private and commercial sex venues in Sweden as well. Overall, they were men with a broad sexual repertoire even before being introduced to Berlin, and some broadened it further in Berlin.
They admitted that Berlin changed them and was a place that facilitated their ideas and preferences to ‘be given free rein’.37 A non-Berlin context-specific explanation could also be that more free time is available when on holiday, as described by Kaufman et al.12
Looking at the number of partners of the participants in the present study they stand out from the Swedish average. We saw that the participants did not go from being an average MSM in a larger Swedish city with four partners the past 12 months10 to 100 partners, as described by the men in this study, just because they visited Berlin. They had high numbers of partners in Sweden, and the amount increased for both visiting and living in Berlin. Again, free time could be an explanation but a previous study comparing the number of partners per 6 months among those visiting a gay resort (five, seven partners) and those who did not (three, four partners) did not find extreme differences.12 Even though it is difficult to compare qualitative and quantitative studies, our data suggest that the number of partners in this study rather correlates with the MSM participating at circuit parties,30–33 rather than gay resorts.
Broadening one’s sexual repertoire and embodying new behaviours is usually interpreted as solely risky.34 Still we should remind ourselves that travel, new experiences and change of mindset can also have protective dimensions for the individual as well as the community. For example, the availability of harm reduction measures, PrEP and on-site preventive measures will differ in different settings, thereby possibly introducing travellers to new protective behaviours that they can bring back to Sweden as homecomers.35 Berlin arenas facilitated an active sexual lifestyle, which included becoming part of a queer community and networks of like-minded and getting invitations to new places. These experiences were perceived as improving self-confidence and self-awareness.
A factor in this was the specific culture and characteristics of Berlin that go beyond sex. The city catered for a lifestyle and for sexual arenas that appealed to the MSM in the study, a less mainstream gay lifestyle that was unavailable in Sweden or assumed to be so elsewhere in Europe. We can assume that Berlin attracts other than Swedish men from Europe for similar reasons. Our findings may well be applicable to other European MSM travelling to Berlin but may also be applicable to circuit party settings.
It is worth mentioning that despite the availability of more sexualised gay travel destinations in terms of the chemsex scene in London45 and circuit parties in Barcelona,30 our participants had Berlin as sole destination. This points to the need for further research to compare perceptions of sex and experience of sex among Swedish MSM who chooses other destinations with similar characteristics.
In the most recent Swedish MSM health survey, several practices associated with having a broad sexual repertoire were more common while travelling abroad than when at home.10
The in-depth analysis of that data suggests however that travelling per se does not alter sexual practice,46 which is aligned with the results in this study since our informants stated that safer sex strategies did not depend on whether they had sex in Sweden or Berlin. This contradicts other findings but in different ways. One study suggested higher levels of condom use locally compared with international travel.15 Another study highlighted the complex process of safer sex by describing how travel was associated with lower condom use but with a change in sexual practice in order to compensate.18 Several suggest more anal sex without a condom while travelling.14 33 Further research is needed in order to understand this complex process. However, for the men in our study who did not use a condom or were not on PrEP, more sexual partners in a setting with higher prevalence of HIV implies increased risk of HIV exposure. Therefore, efforts to strengthen HIV prevention like condoms and lubrication, PrEP and postexposure prophylaxis for HIV, antiretroviral therapy, testing and counselling and to evaluate to which degree visitors can access these services. Due to the mobile character of highly sexually active MSM, international collaborative HIV and STI preventive interventions, including availability of PrEP and antiretroviral treatment that are offered based on needs and not conditioned on citizenship or legal status, should be a priority for European countries. Also, international research collaborations is needed to fully understand the difference in sexual behaviour depending on the concept of vacation, and the idea of the sexual culture somewhere else.
Studying MSM in Berlin forced the interviewer to reflect on the dynamics of emic and etic, and how to benefit from both perspectives in a structured way.47 A positive aspect of being an insider was the knowledge about the culture. However, on the potential negative side was that having a preconceived perception about the culture could influence the data collection and the analysis. One member of the research group read the transcripts continually during the data collection in order to provide feedback on the balance between emic and etic. It is our conclusion that the information that was given in the interviews would have been similar to another interviewer. If anything, more facts came out in these interviews as would have been the case if the interviewer had not been an insider in the MSM community.
A strength of the present study was that participatory observations were undertaken in Berlin, providing a rich contextual description of the setting in which the participants are sexually active. Throughout the process, efforts were made to include all aspects of trustworthiness.42 This included describing the process, having the same person conducting all the interviews, discussing sampling, assessment of theoretical saturation and other key topics within the research team.
An inclusion criterion for participation was age 18–46 years but none of the participants were younger than 25 years. The age range of 25–44 years with an average age of 35 is similar to several previous studies on MSM and travel.13 14 18 21 28 48 This is also in line with the fact that those aged 16–24 years usually are less prone to take part in Swedish public health surveys than older age groups.49
The authors would like to thank all the participants in this study for sharing their experiences.
Contributors ND, KIP, ST and BCF conceived and planned the overall study. ND recruited the participants, conducted the interviews and coded the interviews using NVivo. The interview process and coding process were conducted by ND and supervised by ST. ND did the analysis in close collaboration with KIP and with inputs from ST and BCF. KIP reviewed the transcripts and coding in relation to the interviews and provided additional interpretation. KIP prepared the first draft of the manuscript and ND completed it after comments made by KIP, ST and BCF. All coauthors reviewed and commented on drafts and approved the final manuscript. BCF is the corresponding author.
Funding The data collection was funded by the Public Health Agency of Sweden.
Competing interests None declared.
Ethics approval Ethical approval was achieved from Ethical Review Board in Stockholm, reference number 2016/32-31.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement The full data supporting the findings of this study are not available in order to protect the integrity of the participants.
Patient consent for publication Not required.