Abstract
Sexual health has always been a social matter. While the science of disease transmission remains a focus for public health stakeholders, for social scientists, the sociality of infections, both enduring and emerging, remains central. That is, friendships and relationships are core to health, risk and illness. Yet, there has been virtually no work on how friendships and their varying contours are interplaying with (increasingly) antibiotic resistant STIs. Drawing on 49 interviews with sexuality and/or gender diverse people in Australia, we argue that the sociality of sexual health is central to the development of antibiotic resistance. Our analysis highlights the importance of friends to this, including de(stigmatising) STIs, deployment of humour to regularise important meanings, striking a balance between autonomy and mutuality, and role of friends as sexual health educators. These hitherto under-recognised relational dimensions of sexual health are critical to working with communities in addressing the rise of resistant STIs.
Keywords
Introduction
The science of antimicrobial resistance (AMR) shows the proliferation of resistant strains, rising transmission and a lacklustre pipeline of new antimicrobials (Van Hal et al., 2024; WHO, 2022). Described as a ‘slow tsunami’ (WHO, 2020), rising antimicrobial resistance threatens to disrupt the effectiveness of contemporary medicine. These concerns have specifically focused on sexually transmitted infections (STIs) due to the well-documented diminishing effectiveness of antimicrobial treatments (Van Hal et al., 2024; WHO, 2025). Infections of concern include Neisseria gonorrhoeae (gonorrhoea) and Mycoplasma genitalium (M. genitalium). For example, over time, Neisseria gonorrhoeae (gonorrhoea) has become resistant to multiple classes of drugs (see Unemo and Shafer, 2014, for a detailed overview). While last-line treatments work relatively well at present, a greater number of multi-drug resistant infections are emerging, which makes treating gonorrhoea more difficult (Van Hal et al., 2024). In a similar manner, Sweeney et al. (2022) highlight studies of M. genitalium conducted before 2010 identified resistance rates of 10% to macrolides; however, by 2016/2017 this had jumped to 50%.
Alongside this, health authorities have raised concerns about the disproportionate impact resistant STIs will have on men who have sex with men (MSM) and transgender people, given the high prevalence of STIs in these populations (WHO, 2024). For example, the Fifth National STI Strategy draft in Australia (Department of Health and Aged Care, 2024) has identified gay, bisexual and other MSM as a priority population, for STI prevention, alongside trans and gender diverse people. In Australia, transgender women were found to have rates of bacterial STIs similar to cisgender gay and bisexual men, but this was lower for transgender men; however, this study did not account for other gender diverse people, such as those identifying as non-binary or agender (Callander et al., 2019).
Recent debates in Australia about the use of doxycycline for post-exposure prophylaxis (Doxy-PEP) means there has been greater discourse about antibiotic resistant STIs (Cornelisse et al., 2024). Doxy-PEP entails taking a 200 mg dose of doxycycline up to 72 hours after a sexual event, in which a condom has not been used, to reduce the chances of acquiring syphilis and chlamydia. However, concerns have been raised this will accelerate resistance; for example, Doxy-PEP may confer resistance to other drugs in gonorrhoea (Vanbaelen et al., 2023). Guidelines for prescribing Doxy-PEP in News South Wales, Australia, include a statement to consider the cost–benefits of prescription as it pertains to antibiotic resistance (Centre for Population Health, 2024).
Sociological analysis of AMR is critical here because it has been demonstrated that AMR ‘biology’ is inherently a socially mediated process. Tompson et al. (2021) highlight that AMR is produced by existent practices, structures and networks, shaped by political and economic process. For example, this includes practices such as precautionary prescription of antibiotics in case a patient cannot afford to return to a clinic, or using antibiotics in farming to ensure productivity and profit (Tompson et al., 2021). These analyses exist alongside sociological understandings of health and care more broadly as relational constructions, involving the complexities of biographies, the entanglement of subjectivities, and interpersonal negotiations, as they occur in the everyday (Mol, 2008; O’Reilly et al., 2023; Richardson, 2025). More specifically, research with adolescents and young people has noted the significance of relationality in how they navigate sexual health (Cooper and Dickinson, 2013; Meldrum et al., 2016; Waling et al., 2020). For example, Waling et al. (2020: 4) explain that ‘friends remain a significant source of sexual health information’ for young people, and shape their experiences of sexual health. Yet, sociological analysis has paid limited attention to how friendships shape experiences of AMR – or, indeed, adult sexual health experiences more broadly.
To centre the importance of everyday relational dynamics as they animate sexual health, we examine the sociality of sexual health in depth (Long, 2015; Studdert and Walkerdine, 2016). By thinking with the notion of ‘sociality’, we theoretically and empirically foreground how STIs are conceptualised and experienced by those affected. That is to say, the framework of sociality makes ‘critical’ what is often considered to be background context. This includes the way STIs are spoken about, how friends shape conceptualisations of infections and how learning takes place and is transmitted in everyday interactions. These concerns speak to sociological understandings of personal life, which emphasise that connectivity, different forms of attachment, and intimacies, play significant roles in how people experience their lives and navigate the world (May, 2011; Smart, 2007). In the context of this study, this includes STIs and sexual health.
On a more pragmatic note, by paying attention to how friendship informs sexual health, including across lines of gender and sexuality, we can identify opportunities for working with GBTQ+ populations in the dissemination of public health messaging about resistant STIs. To do this, we draw on interviews with 49 cisgender and trans gay and bisexual men, trans women and gender diverse (GBTQ+) people in Australia, aged 19 to 61. In this article we explore how friendships are important to destigmatising (or stigmatising) STIs, how they provide valued support for negotiating sexual health, including the importance of humour to this, their significance as sexual health educators, including across GBTQ+ and straight friendships, and the implications of these dynamics for addressing resistant STIs.
GBTQ+ Friendships
Friendships have been, and continue to remain critical to GBTQ+ life. As Chauncey (1994/2008) notes, networks among gay men in pre-war New York provided both visibility and coded ways of connecting with vital and extensive networks, all critical to survival within an environment hostile to sexual diversity. This included chains of migration, where gay men were encouraged and supported by friends to move to New York, allowing them to take part in the vibrant ‘gay world’ of the big city (Chauncey, 1994/2008). Nardi’s (1999: 13) research in the late 20th century also underlined the centrality of friendships to gay men’s lives, describing friendship as the ‘the central organizing element’ that sustained the materialisation and reproduction of gay subjectivities, cultures and neighbourhoods – or what he called ‘invincible communities’.
The importance of friendships to sexuality and gender diverse people’s lives is also typified by the idea of families of choice (Levitt et al., 2015; Weeks et al., 2001; Weston, 1991). While not always a replacement for biological/adoptive families, these families of choice, often including friends, can critically sustain minority lives. For example, in the context of homophobia from one’s family of origin, they can provide an important ‘life-line’ (Weeks et al., 2001: 11). Such friendships take place in contexts of trust, care and openness, where people provide important emotional support to one another (Weeks et al., 2001). Importantly, this involves a ‘friendship ethic’, ‘based on notions of individual autonomy and mutual involvement’ among friends (Weeks et al., 2001: 76).
During the HIV/AIDS crisis in the 1980s/early 1990s, such friendship networks provided critical support to people who had contracted the virus, as friends and volunteers nursed people living with HIV (PLWH) until they died. This was frequently the case until highly effective antiretroviral treatments (ART) came on to the scene (Ware, 2019). As Watney (2000: 8) noted at the time, ‘AIDS activism is above all a politics of friendship, of active caring solidarity’, demonstrating the enmeshment of GBTQ+ sexual health, friendship and a sense of shared destiny when it came to HIV/AIDS.
While much of the focus on GBTQ+ friendships has been on connections between marginalised like others, more recent research from the Global North suggests greater diversity in GBTQ+ affiliations (Dean, 2014; McCormack, 2012; Morris, 2018). For example, Rumens’ (2016: 7) research on workplace friendships shows that ‘gay men can exhibit a strong preference for befriending heterosexual men and women’. For some transgender and gender diverse people, friendships with heterosexual and cisgender individuals provide a sense of being connected to mainstream society, the chance to learn normative gender expression and at times more genuine friendships that are not simply based on shared gender diversity (Galupo et al., 2014). In saying this, we do not wish to romanticise the contemporary context as devoid of queerphobia given its rise in the USA (Chao-Fong, 2024), the growth in violence against gay men in Australia (Bell, 2024) and the UK’s recent Supreme Court ruling, which potentially limits trans access to single-sex spaces based on notions of biological sex (Cochrane, 2025). Yet, despite complex headwinds, overall, it appears that the contemporary context continues to extend opportunities for friendships within and across lines of sexual and gender diversity, with implications for sexual health.
The Social Life of Sexual Health
Research on the role of friendships in sexual health gestures towards the importance of sociality to this process. This includes conversations with friends, where they talk about sexual experiences, share sexual health knowledge and resources, provide advice and remind each other about the importance of taking precautions (Byron, 2017; Meldrum et al., 2016; Muraleetharan and Brault, 2023; Mutchler and McDavitt, 2011). For example, Haire et al. (2021) show that trans and gender diverse people describe advice on medical gender affirmation from friends and queer others as more valuable than advice from formal healthcare providers. This has led us to emphasise the importance of a focus on the sociality of sexual health to provide a conceptual frame for theorising and understanding such processes. Long (2015: 854) defines human sociality ‘as the dynamic matrix of relations through which persons come into being, and which is navigated by an ethically imaginative and affectively receptive human subject’. Similarly, for Studdert and Walkerdine (2016: 30), sociality ‘is a way of describing the totality of our inter-relations with other people, with non-humans, with buildings and materiality in its widest sense, in our life together in public, no matter how small or large, in any setting.’
Critical to these definitions is the elevation of everyday, or common experiences (Studdert and Walkerdine, 2016). By extension a focus on sociality centres everyday interactions where friends talk about sex, STIs, discuss partners and provide advice. This provides a frame for thinking about the quotidian ways that people inter-subjectively shape experiences of sexual health and STIs, in their ‘being together’ in ways that may appear ‘unexceptional’ or ‘taken-for-granted’, but are critical to it. In the contemporary context, this includes both online and offline spaces, and sociality as it pertains to these spheres, and the interconnections between them as well. As research on GBTQ+ people demonstrates, online spaces are important to finding like others, affirming marginalised identities and exploring one’s gender and/or sexuality (Byron, 2020; Hanckel and Morris, 2014). Thinking through these online forms of sociality provides a more capacious understanding of how friendships can be supported, and leveraged, to address antibiotic resistant STIs through the sharing of sexual health information.
Thinking about the role of sociality and friendships in constructions of sexual health also allows us to develop a more complex understanding of what sexual health entails. The World Health Organisation (WHO, 2006: 5) defines sexual health as, ‘a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity’. Working with this broad definition of sexual health means thinking about how infections are conceptualised, and how people experience the event of contracting an infection. These are very much about ‘emotional, mental and social well-being in relation to sexuality’ and not merely the absence of disease (WHO, 2006: 5). As such, examining how friends shape these processes provides a more complex understanding of the way sexual health is relationally constructed, and felt, in the everyday.
Methods
Recruitment and Interviews
In this article, we report on interviews with 49 people conducted in 2024 who were recruited through a variety of online and offline methods using a purposive sampling strategy. This included advertisement through Facebook and Instagram, ACON (Sydney-based LGBTQIA+ health organisation), sexual health services, professional mailing lists and researcher networks. The study sought to recruit gay and bi+ men, other men who are part of these sexual networks and trans and gender diverse people aged 18 and over. We did not sample cisgender women who have sex with cisgender women, given STIs that predominantly affect this population such as bacterial vaginosis (BV) and human papillomavirus (McNair, 2019), are not STIs of concern within the context of resistance, in the way gonorrhoea and M. genitalium are (see Introduction).
All participants provided informed consent before taking part in a semi-structured interview, which explored five key topics: perceptions of antibiotic resistant STIs, experiences with clinicians, population attitudes towards STIs, sexual practises and reflections on approaches to curb the rise of resistance. All interviews were conducted by Chandra who is a cisgender gay man. Pseudonyms are used throughout the article.
Participant Demographics
Demographic data are presented in desegregated form (as opposed to a table) to protect respondent confidentiality. Of the 49 interviewees, 43 were reported ‘male’ at birth, and six were reported ‘female’ at birth. Eleven people identified with a gender other than the one they were reported at birth (at times also including gender reported at birth). This included identifiers such as: genderqueer, agender, transgender man, non-binary and trans masculine. Of these 11 participants, some also identified with more than one gender; for example, one participant identified as non-binary, genderqueer and agender.
Thirty-seven participants identified as ‘gay’, and five as ‘bisexual’. One participant identified as ‘pansexual’; one as ‘gay and pansexual’; two as ‘gay and bisexual’; two as ‘bisexual and pansexual’; and one as ‘bisexual, queer and pansexual’. Ages ranged from 19 to 61. Thirty-four participants were born in Australia and 15 were born overseas.
Participants came from all Australian states and territories and were spread across urban, rural and regional locations. Self-identified ethnic backgrounds included: Anglo (17); Anglo Celtic (3); Caucasian (3); White (2); Anglo Australian (1) Australian (1); Australian-Canadian (1); Aboriginal Australian (1); Asian (1); Malaysian Asian (1); Vietnamese (1); Chinese (1); Singaporean Chinese (1); Indonesian (1); Filipino Australian (1); Pakistani (1); Indian (1); Jewish (1); Scottish and Irish (1); Spanish (1); Turkish (1); Latino (1); White American (1); Eastern European (1); Greek (1); Italian (2); and one participant had mixed ethnicity.
Drawing on in-depth interview discussions about safe sex practices, at least two people were living with HIV and the rest of the sample appear to be HIV negative. At least four participants disclosed they carried the herpes virus, while another was fairly certain he did as well.
When reporting participant quotes below, we have provided their age, gender identification and gender reported at birth (RMAB – reported male at birth; RFAB – reported female at birth).
Analysis
Interviews lasted approximately one hour in length and took place via Zoom or in person. They were audio recorded and transcribed by a professional service for analysis. Data analysis in the study drew on interpretive traditions in qualitative research. This entails a deeply explorative approach to data collection and analysis to understand participants’ subjective and complex experiences. To do this, we undertook a thematic analysis of the data (Guest et al., 2012). After each interview, detailed notes were written by Chandra, capturing key insights, observations of interest and an overview of participant experiences and reflections. During this stage, key themes were identified; this process included making connections between different interviewees’ experiences, and noting divergent, atypical and conflicting experiences (Ezzy, 2002). This process included regular discussions with the broader team and centred around exploring the five key areas of interest highlighted above (see Recruitment and Interviews).
To systematically organise and analyse data, interviews were coded by Chandra using NVivo14 software, taking an inductive approach that drew on the notes, observations and team discussions allowing for in-depth exploration of the data, and to reflect on the development of codes. More formalised coding involved two stages: first, the identification of broad overarching codes/themes, and then a second stage where broader codes were ‘broken down’ into sub-codes to create a more nuanced understanding of the data. Undertaking systematic coding of data after the initial exploratory stage of analysis ensured themes that were identified during later interviews could be sought out and coded in earlier data, as could diverging experiences. This allowed us to group data that may have appeared unrelated at first, draw connections, and complicate themes further. In our exploration of population attitudes to STIs, we spoke to participants about friends’ perspectives on STIs, and we also discussed how friends might play a role in helping address resistant STIs. Moreover, given the semi-structured nature of the interviews, people also spoke about friends when discussing instances when they had contracted STIs. As a result, we identified ‘friendship’ as a broader theme, which included the sub-themes: ‘destigmatising/stigmatising STIs’, ‘support’, ‘humorous conversation’, ‘peer-to-peer education’ and ‘straight–queer possibilities’. We discuss these themes, which form the basis of our results sub-sections below.
Results
(De)stigmatising STIs and Friendly Support
Findings show that GBTQ+ people’s perceptions and experiences of STIs are inseparable from their friendships. Given that STIs are generally stigmatised in mainstream heteronormative discourse, everyday conversations with friends were critical in not only de-stigmatising STIs, but also in their normalisation. Lachlan (30 yrs, man, RMAB) said, ‘[i]t’s [STIs] just sort of come up casually. You know, if anything [. . .] reduced stigma or reduced, yeah, how controversial they are.’ Being able to talk about STIs with friends in everyday conversation made such infections ‘unexceptional’, akin to other aspects of life, and therefore critical to overcoming shame. In such instances, it was the ‘mode’ of this sociality – everyday casualness – which seemed to disarm the stigma. The destigmatisation and normalisation of STIs was also important to the active support friends provided one another in addressing any emotional distress when people did contract an STI. Such support was experienced as an important aspect not only of GBTQ+ friendships (Weeks et al., 2001), but of contemporary friendships more broadly (Blatterer, 2015). For example, Abdul (23 yrs, man, RMAB) explained: Like this is the first STD [sexually transmitted disease] I’d had, so [. . .] I spoke to my other friend [. . .] So, he’s had like a, like a more extensive history of STDs [. . .] than me. So, and he kind of like calmed me down. He was just like, ‘Oh, it’s no big deal.’ And I was just like, ‘Okay, yeah. It’s just a week course of antibiotics’, like whatever.
A few participants spoke about how they shared practical support as well, such as what to do when one contracts an STI, and ways to take care of oneself in such instances. For example, Oliver (35 yrs, man, RMAB) explained: when I first had chlamydia, for example, like I messaged a couple of friends going like, ‘What do I do?’ And they were like, ‘Do this! [. . .] Don’t be sexually active for a while. Go tell the person’, those type of things.
Critically, as highlighted by Abdul, participants were constructing STIs as a rite of passage, a ‘shared experience’, demonstrating how sociality is ‘sourced within a field of commonality and enacted in particular and specific instances’ (Studdert, 2016: 624). Such commonality with friends, and the transformation of STIs from their association with wider moral judgements, misinformation and shame to a kind of ‘casualness’, is critical to ‘emotional, mental and social well-being’ pertaining to sexual health (WHO, 2006: 5). This means the construction of STIs among friends is also a deeply affective experience. Simon (32 yrs, man, RMAB) said such support from friends would ‘[d]efinitely’ play an important role in the context of rising resistance in STIs. However, it was acknowledged that there is also the potential for resistant STIs to introduce new stigmas. As Mia (19 yrs, woman, RMAB) explained, ‘this idea of something that we don’t now have a cure for again, could potentially introduce stigma around people who get something like that’.
As suggested, there could be limits to support provided between friends, and normalisation existed alongside instances where friends could also stigmatise STIs. For example, Beau (33 yrs, man, RMAB) explained: ‘I have a friend who’s made jokes about like having herpes or getting herpes. He doesn’t know that I have herpes. But like I guess there’s just a bit of stigma around it.’ In a similar manner, Julian (29 yrs, man, RMAB) said: Every now and again there’s just offhanded remarks where someone will say, you know, ‘Oh, this person’s, you know, riddled with X.’ Or, you know, ‘They got this’, [. . .] I wouldn’t say snarky comments but, but not positive comments [. . .] they could always just not make any remark at all. But, also, I can talk to my friends about some STIs they’ve got and all that sort of jazz, and they’ll be like, ‘Oh, yeah, yeah.’ They’ve all had them as well.
Julian’s reflections demonstrate tensions, where GBTQ+ friends are people who potentially stigmatise STIs, yet they are also individuals who normalise them and will share their experiences of contracting infections to reduce stigma, revealing how STIs are ‘still a semi-taboo’ (Julian) despite the work being done via friendships.
For some, their friends’ different sexual practices appeared to lead to judgement about contracting STIs. Mason (24 yrs, man, RMAB) explained he felt judgement from a non-binary identifying friend, who was in a long-term monogamous relationship, when he contracted an STI. He said it was not verbal, but rather ‘like maybe with their reaction/body language/wanting to avoid the topic’. Harry (30 yrs, man, RMAB) also explained there is ‘a little bit’ of judgement from gay friends in closed relationships regarding STIs. He said: Because I mean they’re happy to joke about it but [. . .] sometimes they might joke too much about it. Like they may focus too much on it. And so I feel like that comes from a place of judgement or just not understanding. Like one of those in that closed relationship, he’s actually a doctor and he, he doesn’t understand.
While not suggesting that all GBTQ+ people in closed monogamous relationships stigmatise STIs, the narratives collected revealed there were still notions of a moral hierarchy among GBTQ+ people, with implications for contracting STIs. ‘Better’ GBTQ+ people are in closed monogamous relationships, while ‘worse’ GBTQ+ people have multiple sexual partners and contract STIs (Race, 2018). Despite this, Mason and Harry were comfortable with their sexual practices, and did not appear to share the same beliefs as these friends about STIs. Significantly, thinking about the importance of sociality, and being together with friends, demonstrates how ‘offhanded’ remarks, topic avoidance or jokes, perpetuate stigmatising understandings of STIs, and sexual ‘excess’. In light of the findings above, ‘casualness’ both destigmatises STIs, but is also the mode through which it is stigmatised as well, occupying a paradoxical position. This suggests friends can play a role in destigmatising, or potentially stigmatising resistant STIs should they start to become more ubiquitous.
Humorous Framings
In some interviews, humour emerged as an important frame through which to make sense of and negotiate STIs. Other scholars have noted humour makes conversations around safe sex easier, and assuages the seriousness of talking about sexual health (Byron, 2015; Cooper and Dickinson, 2013; McDavitt and Mutchler, 2014). Elliot (21 yrs, man, RMAB) explained that he normalises STIs among friends by using humour when sharing his own experiences: ‘You normalise it, you don’t have to be scared of it. You don’t have to be embarrassed. I think being able to joke about it helps with that to keep it normal. Keep it all in good fun.’ Others also said humour plays a role in how STIs are navigated within friendships, including instances where one contracts an STI, or when providing sexual health advice: I think [friends] definitely like destigmatised it [. . .] And I guess it wasn’t making fun of the STI, it was making humour of the situation because it’s like, ‘This isn’t so scary or so serious.’ [. . .] it took the shame out of it I suppose. It was just funny. (Simon, 32 yrs, man, RMAB) we were having beers with the rugby boys [from the queer rugby team] and one of them was off to go for a hook up and we jokingly – someone had said – the flamboyant one of the group [. . .] ‘Make sure you wrap it up, sweetie. The syph’s [syphilis] doing the rounds.’ [. . .] as a sort of like cunty joking comment as he was about to leave for his hook up. (Leon, 36 yrs, non-binary/genderqueer, RMAB)
Humour among friends plays a ‘norming function’ in the conceptualisation and experience of STIs by reducing the sense of shame and stigma that may be associated with them, and creating positive experiences of sexual health. That is to say, it ‘is a mechanism for defining reality’ (Robinson and Smith-Lovin, 2001: 125), and in this case STIs. Importantly, as suggested by Leon, humour also provides a way to pass on sexual health advice in ways that are light-hearted and potentially mitigate accusations of being ‘preachy’. For example, Caleb (24 yrs, man, RMAB) explained that he and his heterosexual female friends will joke about STI testing: if they have a casual partner, like the rest of us are always like, ‘Make sure you get tested. You don’t know where they’ve been’, sort of thing. So it’s definitely talked about in a sort of a serious way, but like made light-hearted at the same time. So it’s like we’re kind of joking about it, but we’re also like very, ‘Make sure you actually get tested, just to be on the safer side.’
This approach can help to maintain a sense of equality within friendships, which respects the ‘friendship ethic’ based on balancing autonomy and involvement (Weeks et al., 2001). However, this dynamic also entails tensions. Martin (34 yrs, man, RFAB) explained that he and his partner have spoken to other sexuality and/or gender diverse people about antibiotic resistant STIs, stating ‘I think it’s more like a warning, a joke in, you know, yeah, great, you can get the shot now but . . ..’ However, Martin also went on to explain: Although, now that I reflect on it, I do need. Well, I don’t need to [laughing]. I should have a serious conversation with one of my peers and just check his knowledge of gonorrhoea and, and that being resistant or will be resistant at some point.
This response illustrates the complexities entailed in talking to friends about STIs, resistant or otherwise, where humour is used to address ‘uncomfortable’ subjects; however, this also has the potential to temper the seriousness of the conversation. Moreover, Martin’s laughter also captures the tensions entailed in respecting autonomy within friendships, while attempting to educate his friend about rising resistance so it is taken seriously. When these findings are read alongside reflections from Beau and Harry, who felt jokes about STIs could be stigmatising, it becomes clear that humour and the role it plays in shaping experiences of STIs is complex, and dependent on context and interpretations. As Kuipers (2008: 368) notes, ‘the functions of humor are not fixed, but very much dependent on type of relation, social context, and on the content of the joke’. Importantly, the significance of humour suggests it is an important idiom through which public health messaging about resistant STIs may be communicated.
Friends as Educators
A number of participants felt education between friends would be critical to addressing antibiotic resistant STIs should they become more ubiquitous. Among interviewees, there were varying degrees of knowledge about the issue. For example, participants like Tim (51 yrs, man, RMAB) had a deep grasp of the topic, as he explained: gonorrhoea already has become resistant to all classes of antibiotics. We’ve kind of only got one treatment left and that’s the injectable. One injection called ceftriaxone and even resistance to that has started to occur. I know that Australia and the world has seen multi-drug resistant gonorrhoea cases.
On the other hand, someone like Axel (22 yrs, man, RMAB) said ‘I hadn’t necessarily heard of resistant STIs’. Despite varying degrees of understanding about resistant STIs in the sample, friends are an important resource through which education about the issue can take place, as they are people participants trusted and felt a sense of comfort with: Yes, I mean that’s a really useful tool [education among friends]. Just like what we were talking about, just about having conversations with friends when you have an STI or may have an STI. It’s that comfort and that sort of freedom [. . .] that sort of personal element that you don’t get from like a campaign. (Glen, 35 yrs, trans male, RFAB) you feel more comfortable talking to a friend. Sometimes you feel more comfortable. There’s more trust, more of a rapport there than if you ask a doctor or something. (Hamish, 29 yrs, man, RMAB)
As suggested by Hamish, authorities, including the government, may be viewed with a sense of scepticism or mistrust. As a result, information from friends was thought could be of greater value: I think the peer-to-peer is incredibly important because we, as humans, have this particular need to bond and connect. And if we see that somebody we view as important is giving us information, there is a personal aspect to it. And we don’t think, ‘It’s the government trying to give me their agenda.’ (Avery, 28 yrs, transgender man, RFAB)
Despite participants’ trust in government sources of information and doctors, histories of discrimination against sexual and gender minorities, including police and legal persecution in Australia (Willet, 2000), means friendships offer safe spaces, where people feel comfortable with and trust their friends, making it easier to pass on, and process sexual health information. This speaks to key dimensions of contemporary friendships, which include ‘care, support, and affection in the context of trust and respect’ (Blatterer, 2015: 29). As such, ‘intangibles’ such as comfort and trust provide the critical resources through which sexual health comes to take shape. However, while conversations about sexual health were common for participants, this was not universal. Archie (46 yrs, man, RMAB) explained that for him, ‘a resource on how [. . .] to bring this [resistant STIs] up in conversation or how to have a conversation with your peers could also be quite useful’. In light of this, participants explained that resources about antibiotic resistant STIs could work with friendships, especially considering the opportunities afforded by online spaces (Albury and Hendry, 2023).
Online spaces are an important medium in contemporary sociability with friends (Byron, 2020), and were identified by some participants as an opportunity for ongoing peer education. Charlie (32 yrs, man, RMAB) explained he currently does not have ‘in-person queer mates’ close by, and so ‘the majority of my conversations around STIs are on my phone’. Diego (34 yrs, man, RMAB) said that when he was thinking about taking PrEP,
1
‘One of my friends just sent me a link in my WhatsApp and said, “You can use this and this.”’ Mia (19 yrs, woman, RMAB) said the online Discord server for her university queer club is a space where people talk about sexual health, including access to services: for example, at the uni we get condoms [. . .] People will share the fact that we have those and just remind people to engage in safer sex. Sometimes someone might ask about PrEP or whatnot. [. . .] I think a lot of our conversations are – when they’re not in person, are on Discord. That’s where a lot of community discussion of that regard happen. People will share links or share what they know or share where you can locally access resources and comment on experiences.
Mia highlighted that this Discord server could be a place where information was shared about resistant STIs, stating: ‘It’d be really nice if there was [. . .] a resource from ACON 2 or something like that. Just somewhere that you can be like, “Cool, here’s a wall of information. Read into it. It’s important.”’
Simon (32 yrs, man, RMAB) also explained that a friend of his is an avid TikTok user, and that videos on the platform from organisations such as ACON or New South Wales Health would be helpful, because: it’s like if there was a quick TikTok or something about the risks, like I feel like those ways that are more third party – it’s like communicating health information to anyone, it’s going to be more successful if it’s from a official person or body or it’s like resource than from a friend because people just dismiss. . .
As suggested by participants, online spaces provide existing infrastructures, which people can use to educate their friends, and this can be leveraged by government health departments or community bodies, so they are working with the forms of sociability people are engaging in. Drawing on our earlier discussion, these online spaces also appear to provide a way to engage with friends that respects their autonomy, while also showing care; it allows for education without seeming overbearing. As such, regardless of what friends know (or do not know) about resistant STIs, these connections are an important infrastructure through which public health messaging and information can be disseminated, as suggested by interviewees. Moreover, reflections also suggest that as communities may become more educated about resistant STIs in the future, friends show openness to learn from one another.
Considering these observations, a few participants also spoke about the potential spread of misinformation among friends. Julian (29 yrs, man, RMAB) explained that ‘I’m not sure I’d trust getting my medical advice from friends’. While Miles (23 yrs, man, RMAB) felt peer education was important, he also highlighted that: It’s probably the hardest one to rely upon though. [. . .] I reckon a lot of misinformation from COVID got spread through peer-to-peer communication. Someone saw a conspiracy theory on the internet or saw this obscure trial that shows that the vaccine causes heart failure. So then they tell everyone as much as they can that it’s horrible, when that was misinformed.
When read alongside reflections on the significance of friends for sexual health information, these observations illustrate that trust is ‘checkered’ within GBTQ+ populations. However, despite this, the context of trust, comfort and care among friends opens important opportunities for addressing resistant STIs, including across lines of gender and sexuality too.
Sexual Health Possibilities of GBTQ+ and Straight Friendships
Like HIV/AIDS, bacterial STIs are not limited to GBTQ+ people, and this exists alongside the diversification of GBTQ+ friendships, where GBTQ+ individuals and non-GBTQ+ people befriend each other. As articulated by our participants, such friendships present an opportunity for sexual health education among friends across lines of gender and sexuality, on which there has been very limited scholarly consideration. Interviewees explained that in comparison with GBTQ+ friends, or GBTQ+ people more broadly, STIs seemed to be more taboo for heterosexual people, who also tested less regularly for STIs. Interviewees said: And I do talk about it [STIs] with some of my straight friends, particularly the girls [. . .] some of them are as promiscuous as me, if not more. And they just like hardly ever get tested, or anything like that. (Beau, 33 yrs, man, RMAB) I get the sense that STIs are both in much less common conversation and they’re a much bigger deal among straight people. [. . .] I think it’s bigger stigma. (Charlie, 32 yrs, man, RMAB)
Participants felt this was tied to GBTQ+ sex cultures, which meant STIs were more prevalent in these populations, or ‘because of HIV having like the history’ with GBTQ+ populations (River, 28 yrs, man, RFAB).
The idea that GBTQ+ people were better versed with STIs informed their friendships with heterosexual peers. For example, a few participants explained that heterosexual friends had come to them for sexual health advice based on the assumption they would be well informed because they identified as GBTQ+. For example, Tommy (31 yrs, man, RMAB) explained ‘a straight friend told me that his friend got something and asked me, “How does that work?” They think gay guys know more.’ In a similar manner, River, who has both queer and non-queer friends, said that a female friend, who appears to be heterosexual in the context of the interview, was going to have sex with a man who also has sex with other men, and recently reached out to ask him about the types of questions he asks sexual partners: she was like, ‘[. . .] I was wondering like what do you ask people to like talk about sexual health?’ [. . .] I think it’s because like a few weeks prior to that we’d had a conversation about like me being like very frank with people.
Of note here is the way that everyday sociability – and, specifically, a conversation from a few weeks prior – acted as an ‘invitation’ for River’s friend to ask him questions about safeguarding sexual health. Importantly, in a context where cases of antibiotic resistant STIs may begin to proliferate, GBTQ+ friends may be important to addressing risks in heterosexual populations. For example, Beau explained he is particularly comfortable talking to heterosexual female friends about STIs, stating ‘I do try and encourage my straight friends to go get tested.’ Sean (39 yrs, man, RMAB) who is also comfortable talking to his straight female friends about STIs, said ‘Yes, I definitely would [talk to straight friends about resistant STIs] [. . .] and I do talk to them about it [STIs] even now.’ These examples show the contemporary context, defined by the diversification of GBTQ+ friendships, presents an opportunity where GBTQ+ people’s expertise in matters of sexual health allows them to play an educative role for their heterosexual friends. This means sexual health knowledge can ‘snowball’ across populations, and increase its potential for impact, which is an important consideration in the context of rising AMR within STIs.
Discussion and Conclusions
Our examination of sociality among friends illuminates how relational dynamics inform the everyday processes that shape sexual health, and how STIs are affectively co-experienced. It centres the role of ‘commonality’, ‘shared experiences’ and ‘casualness’ as important frames of meaning making that shape how STIs are experienced (i.e. as simply a part of life). These processes shape ‘emotional, mental and social well-being in relation to sexuality’ (WHO, 2006: 5), and therefore sexual health, by (de)stigmatising STIs, illustrating the importance of everyday connectedness to how sexual health is produced. This suggests that were resistant STIs to become more ubiquitous, friends would be important for making sense of the implications of drug resistant infections, including the potential for (de)(stigmatising) them. We argue that aspects of friendship, such as care, trust, support, humour, openness and sharing (Blatterer, 2015), which may appear to be unremarkable, are essential ‘ingredients’ for sexual health. For example, comfort and trust among friends can imbue education about resistant STIs with greater significance. Importantly, thinking about the sociality of sexual health allows us to theoretically centre how these ‘informal’ aspects of everyday life and relationality shape experiences of sexual health.
As noted by Long (2015: 854), sociality includes a ‘dynamic matrix of relations through which persons come into being’. In this regard, friendships can be conceptualised as relations that produce subjectivities, which foster attitudes towards STIs (i.e. not a big deal) and, by extension, how people experience sexual health. Yet this includes an important consideration about individual agency and involvement where friends attempt to educate, and advise one another, while respecting the other person’s autonomy (Weeks et al., 2001). In such a context, humour becomes an important device through which friends can be involved with one another, while also respecting each other’s agency, especially when it comes to providing advice on STIs.
Importantly, while GBTQ+ people are often framed as ‘at risk’ for STIs, this study illustrates there is greater complexity to the narrative. Notwithstanding that GBTQ+ people do experience a greater burden of STIs (WHO, 2024), it also appears they may be more adept at navigating sexual health in comparison with heterosexual counterparts. Arguably, this is an important part of GBTQ+ sexual cultures, where there is greater openness to experimentation and exploration, with sexual pleasure, risk and safety, and balancing these to live fulfilling sexual lives (Race, 2018). This allows GBTQ+ friends to function as ‘resources’ for heterosexual friends, who may draw on them to navigate sexual health. As such, this dynamic challenges deficit understandings of GBTQ+ individuals, to cast them as important supports by virtue of their being sexuality and/or gender diverse. Of course, we do not wish to reduce all GBTQ+ people to caricatures or stereotypes. Such a framing, however, allows us to move beyond deficit-based models and think through the possibilities of sexual health education across divisions of gender and sexuality. This may be critical in the context of rising antibiotic resistant STIs, which will not discriminate based on whether someone identifies as GBTQ+.
Implications
The implications of this study are that friendships need to be taken seriously when thinking about interventions and messaging in the context of antibiotic resistant STIs; they are a critical informal health infrastructure. This includes designing material (offline and online) with the assumption that friends may be sharing them with one another, and making it easier from them to be dispersed through networks. For example, resources may directly address the fact that resistant STIs may be discussed among friends or may include prompts to share the information with friends. Importantly, while people may trust friends for sexual health information, reputable organisations, such as LGBTQ+ community groups, also need to ensure reliable information is accessible to communities (see also Byron, 2017), and create greater capacity for friends to learn together. Humour, which is an important idiom for conveying sexual health information/advice among friends, may be leveraged in sexual health messaging to communicate information about antibiotic resistant STIs.
While for GBTQ+ people conversations about STIs with friends are common, this may not be the case for all people. In such instances, resources on how to address antibiotic resistant STIs with friends may also be useful for some. Importantly, shareable resources among friends appear to work with the need to balance autonomy and involvement, by providing a way to address resistant STIs in ways that do not seem overbearing. This means that the design of educational material, especially that which may be shared within friendship networks, should be mindful of this dynamic and work with it.
Limitations and Future Studies
This study focused on Australia, and therefore further research is required in more diverse contexts, including developing countries, to understand how friendship dynamics may differ or be similar in the way STIs are negotiated and made sense of. Moreover, given our focus on GBTQ+ populations, there is also scope for further research with heterosexual cisgender populations, including comparisons between friendship dynamics and attitudes towards STIs within and across these groups. This will provide a deeper understanding of how antibiotic resistance may need to be addressed differently within heterosexual cisgender populations, notwithstanding the importance of GBTQ+ friends as educators for these groups as has been discussed.
Footnotes
Funding
The authors disclosed receipt of the following financial support for the research, authorship and/or publication of this article: this project was supported by the Australian Research Council (grant number IH190100021).
Ethics Statement
Ethics approval was sought and granted from The University of Sydney Human Research Ethics Committee (reference number: 2024/060) and the ACON Ethics Committee (reference number: 202336).
