Objectives The aim of this study was to examine the willingness of men who have sex with men (MSM) to change their behaviours to potentially reduce the risk of pharyngeal gonorrhoea transmission and acquisition.
Methods A cross-sectional questionnaire-based study was conducted among MSM attending the Melbourne Sexual Health Centre, Australia, between March and September 2015. Participants were asked how likely they would change their behaviours to reduce the risk of pharyngeal gonorrhoea. Six different potential preventive interventions were asked: (1) stop tongue kissing; (2) stop having receptive oral sex; (3) stop performing rimming; (4) stop using saliva as a lubricant during anal sex; (5) use of condoms during oral sex; and (6) use of alcohol-containing mouthwash daily.
Results Of the 926 MSM who completed the questionnaire, 65.4% (95% CI 62.3% to 68.5%) expressed they were likely to use mouthwash daily to reduce the risk of pharyngeal gonorrhoea, 63.0% (95% CI 59.8% to 66.1%) would stop using saliva as a lubricant, and 49.5% (95% CI 46.2% to 52.7%) would stop rimming. In contrast, 77.6% (95% CI 74.8% to 80.3%) of MSM expressed they were unlikely to stop tongue kissing. MSM who were younger and had less male partners expressed they were unlikely to use mouthwash daily as an intervention to reduce risk of pharyngeal gonorrhoea acquisition.
Conclusions The practices MSM are willing to change to reduce the risk of pharyngeal gonorrhoea transmission and acquisition vary greatly; however, the majority of men are likely to use mouthwash daily to reduce the risk of pharyngeal gonorrhoea.
- Men who have sex with men
- harm reduction
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Gonorrhoea rate continues to increase among men who have sex with men (MSM) in Australia and worldwide, particularly among young MSM.1 Gonorrhoea can infect the pharynx, rectum and urethra in men.
It has been theoretically proposed that the burden of gonorrhoea in MSM could potentially be reduced by increasing condom use during oral and anal sex.2 However, the majority of MSM would not use condoms during oral sex,3 and it is even more unlikely that MSM will start using condoms during oral sex in the era of HIV pre-exposure prophylaxis. A mathematical model has further demonstrated that the prevalence of gonorrhoea at all sites cannot be eliminated even if there were 100% condom use for anal sex,2 suggesting there are factors other than condomless anal sex that cater for the burden of gonorrhoea among MSM.4 There are several studies showing gonorrhoea can be cultured in saliva5 and transmitted or acquired through kissing, rimming (oro-anal sex) and oral sex.6 7 Many individuals who are infected with pharyngeal gonorrhoea are unaware of their infection because pharyngeal gonorrhoea infection is often asymptomatic and cleared spontaneously within a short period of time. Gonorrhoea can be spread by untreated individuals and results in the highest prevalence and incidence in the pharynx compared with other sites.4
Reducing the transmission of pharyngeal gonorrhoea in MSM will require either a reduction in at-risk sexual practices or a novel intervention that does not rely on condoms, such as using antiseptic mouthwash.8 The aim of this study was to explore the willingness of MSM to change sexual practices and use a mouthwash to reduce the risk of pharyngeal gonorrhoea transmission and acquisition. Understanding the willingness to change behaviours would have a great public health benefit to reduce the burden of gonorrhoea in MSM.
A cross-sectional study was conducted at the Melbourne Sexual Health Centre (MSHC), Australia, between 23 March and 23 September 2015. All MSM attending MSHC during the study period were invited to complete a paper-based questionnaire. Return of a completed questionnaire implied consent to participate in this study. MSM were defined as a man who had any sexual contact with another man in the previous 12 months.
Participants were asked how likely they would change their behaviours to reduce the risk of gonorrhoea transmission and acquisition. Six different potential preventive interventions were asked: (1) stop tongue kissing with partners; (2) stop having receptive oral sex from partners (partner’s penis in participant’s mouth); (3) stop rimming partners (participant’s tongue in or around partner’s anus); (4) stop using saliva as a lubricant during anal sex; (5) use of condoms during oral sex; and (6) use of alcohol-containing mouthwash daily. Responds were categorised as ‘likely’, ‘neutral’ or ‘unlikely’. The proportion of MSM who reported ‘likely’ to change their behaviour was stratified by age and number of partners in the previous 3 months. Age was categorised into four different groups based on their risk of pharyngeal gonorrhoea acquisition1: ≤24, 25–34, 35-44 and ≥45. Number of male partners were categorised into four different groups: 0–2, 3–5, 6–8 and ≥9.
Descriptive and frequency analyses were reported for participants’ responses on all six different behaviours. A χ2 trend test was conducted to examine whether age and number of partners would influence the likelihood of behavioural change for all six preventive interventions. All analyses were conducted using Stata (version 13, College Station, Texas, USA). This study was approved by the Alfred Hospital Ethics Committee, Melbourne, Australia (number 544/14).
A total of 1150 MSM attending MSHC were invited to complete this questionnaire during the study period; 989 (86%) returned the questionnaire, and 926 (81%) with complete responses were included in the final analysis. The age of participants ranged from 19 to 77 years, with a median age of 29 (interquartile range [IQR] 25–36) years. The median number of male partners in the previous 3 months was 5 (IQR 2–5).
Of the six possible preventive interventions, the majority of MSM (n=606; 65.4% (95% CI 62.3% to 68.5%)) expressed that they were likely to use mouthwash daily to reduce the risk of pharyngeal gonorrhoea transmission, followed by stop using saliva as a lubricant during anal sex (n=583; 63.0% (95% CI 59.8% to 66.1%)) and stop performing rimming (n=458; 49.5% (95% CI 46.2% to 52.7%)) (figure 1A). About one in five MSM were willing to stop having oral sex or use condoms during oral sex. In contrast, the majority of MSM (n=719; 77.6% (95% CI 74.8% to 80.3%)) expressed they were unlikely to stop tongue kissing. Figure 1B shows that young MSM were more likely to use mouthwash daily compared with older MSM (ptrend<0.001). There were no significant associations between age and the likelihood of changing sexual practices. Similarly, figure 1C shows that MSM with a lower number of partners were more likely to use mouthwash daily compared with MSM with a higher number of partners (ptrend=0.02). Furthermore, MSM with a low number of sexual partners were more likely to stop performing rimming, using saliva as a lubricant during anal sex and condoms during oral sex, compared with MSM with high number of partners.
With the low uptake of condom use during oral sex and the potential for no further increase in condom use for anal sex, a novel intervention is necessary to control gonorrhoea among MSM.8 This study has shown that MSM were unlikely to stop tongue kissing, stop having oral sex or using condoms during oral sex to reduce gonorrhoea transmission to other men and also reduce their risk of acquisition from other men. However, a substantial proportion of MSM expressed they were willing to stop using saliva as a lubricant during anal sex, stop rimming or use an alcohol-based mouthwash daily as a preventive measure for pharyngeal gonorrhoea.
Our study has a number of limitations. First, we only surveyed MSM attending a single urban sexual health centre and our result may not be generalisable to all MSM in the community. However, MSM attending our centre were at greater risk of STIs than MSM in the community. Second, although this study only examined the intention and willingness of behavioural changes but not the association between willingness and intention, a previous longitudinal study has shown high adherence to daily use of mouthwash over a 2-week period.9 Third, we did not collect other demographic characteristics such as education level, socioeconomic status and history of STI in our survey; these factors might be linked to the willingness to change their behaviours. Fourth, we only included six possible preventive interventions; however, other preventive interventions such as using dental dam during rimming could also reduce STI acquisition but were not asked in our survey.
The most effective way to prevent and control gonorrhoea is to stop individuals from engaging in activities that increase the risk of acquiring gonorrhoea. Research has shown that gonorrhoea can be cultured in saliva,5 which suggests activities involving saliva (such as tongue kissing) are associated with pharyngeal gonorrhoea.4 6 We show that tongue kissing is the practice that MSM are least willing to stop to reduce the risk of both gonorrhoea transmission and also acquisition. Kissing has been reported as the most common activity among MSM,10 and it has been considered an important component of an intimate relationship.3 Oral sex is another common practice that MSM would not be willing to stop nor use condoms for, presumably because MSM consider condomless oral sex to be of negligible risk compared with condomless anal sex.3 The majority of men do not enjoy performing rimming,3 and this may possibly explain why more men were willing to stop performing rimming as a preventive intervention. Similarly MSM may be more willing to stop using saliva as a lubricant during anal sex as they may prefer to use commercial lubricants.
A recent randomised controlled trial has shown that a one-off use of antiseptic mouthwash has a short-term inhibitory effect against gonorrhoea on the pharyngeal wall.8 Our findings show that the majority of men were willing to use a mouthwash daily to reduce the risk of pharyngeal gonorrhoea transmission. It is worth noting that younger MSM are at higher risk of pharyngeal gonorrhoea,1 and our findings show that younger MSM were more likely to use mouthwash daily as a preventive intervention. It is hypothesised that the use of mouthwash could potentially reduce the duration of infectiousness of gonorrhoea in the pharynx, and hence reduce further transmission to other men. If this is true, the overall burden of gonorrhoea in MSM, particularly younger MSM, could be reduced. However, findings from this randomised controlled trial are preliminary, and a large trial is warranted to confirm any long-term public health benefit on using mouthwash daily.
Contributors CKF conceived the idea that Listerine may be used as an alternative intervention to reduce the risk of pharyngeal gonorrhoea. EPFC and CKF contributed to the conception and design of this study. EPFC performed the data analysis and wrote the first draft of the manuscript. SW coordinated the study, was involved in study recruitment and assisted with data management. TP was involved in data management including data collection, data entry and data cleaning. All authors were involved in data interpretation, revised the manuscript critically for important intellectual content and approved the final version.
Funding This work was supported by the National Health and Medical Research Council (NHMRC) programme grant (number 568971). EPFC is supported by the NHMRC Early Career Fellowship (number 1091226).
Competing interests None declared.
Patient consent Informed consent was implied by receipt of completed questionnaires.
Ethics approval Alfred Hospital Ethics Committee (544/14).
Provenance and peer review Not commissioned; externally peer reviewed.