Abstract
Smartphone dating applications have become a primary source for men who have sex with men (MSM) to meet sexual partners. It has been found that MSM who used smartphone dating applications are at higher risk of gonorrhoea, but the reasons remain unknown. This study aimed to investigate whether MSM who met their partners via smartphone dating applications are more likely to engage in sexual practices such as rimming (oro-anal sex), and use of partner’s saliva as a lubricant, that are associated with the risk of gonorrhoea. A cross-sectional study was conducted among 1672 MSM attending the Melbourne Sexual Health Centre, Australia, between 31 July 2014 and 30 June 2015. Multivariate logistic regression was conducted to examine the associations between sources of meeting partners and the two aforementioned sexual practices. MSM who used smartphone dating applications were 1.78 (95% CI: 1.38–2.28) times more likely to get rimmed, and 1.63 (95% CI: 1.27–2.09) times more likely to use partner’s saliva as a lubricant during anal sex, compared to other sources, after adjusting for age and other sources for meeting partners. These practices are highly associated with gonorrhoea.
Keywords
Introduction
The number of gonorrhoea cases among men who have sex with men (MSM) has been increasing in recent years in Australia. An Australian study using culture for gonorrhoea detection showed that this increase was associated with neither a higher number of sexual partners nor a reduction in condom use for anal sex from 2007 to 2013. 1 Most of the gonorrhoea cases occur in the oropharynx among MSM.2–5 Previous studies have shown gonorrhoea can be detected in saliva6–8; hence, men can acquire anorectal gonorrhoea through sexual activities that involve saliva such as rimming (oro-anal sex) and saliva use as a lubricant during anal sex even when a condom is used.9,10 A previous study showed that the odds of having anorectal gonorrhoea were 2.5 times higher among MSM who used their partner’s saliva as a lubricant during sex (including penile and finger penetration) compared to those who did not, and the odds of having anorectal gonorrhoea were 1.6 times higher among MSM who received rimming compared to those who did not. 9 Furthermore, receptive penile-oral sex (partner’s penis in participant’s mouth) is a significant risk factor for oropharyngeal gonorrhoea acquisition.2,11,12 MSM with anorectal gonorrhoea are at higher risk for HIV acquisition compared to other sexually transmitted infections (STIs) such as anorectal chlamydia and syphilis.13–15
Since the 2010s, smartphone dating applications such as Grindr have become the most common source for meeting partners in the MSM community in Australia. 16 A study in Los Angeles has found that MSM who use smartphone dating applications to meet sexual partners have higher odds of acquiring gonorrhoea, but not HIV, compared to those who meet their partners on the internet or in-person. 17 However, there has been no explanation on these findings to date. Therefore, we aimed to examine whether MSM who met partners via smartphone dating applications have engaged in some practices (such as rimming and saliva use as a lubricant) that are at higher risk of gonorrhoea compared to those with other sources for meeting partners, in order to provide an explanation of the discrepancy in rates of infection.
Methods
A cross-sectional questionnaire-based study was conducted at the Melbourne Sexual Health Centre (MSHC), Australia, between 31 July 2014 and 30 June 2015. The sources of the study data have been previously described elsewhere. 16 This was part of a larger study which aimed to examine the associations between saliva use as a lubricant during anal sex and anorectal gonorrhoea, the findings of which have been published elsewhere. 9 Males were eligible to participate in this questionnaire if they (1) were aged 16 years or above and (2) self-reported having any sexual contact with another man. Transgender individuals were not eligible but there was no restriction on other demographic characteristics such as nationality and area of residence. Receipt of a completed questionnaire implied consent to participate in the study. MSM attending MSHC during the study period were invited to complete a short questionnaire on how they met sexual partners. This was asked, ‘In the last three months, how often have you had sex with men you met at or through (1) the internet sites, (2) smartphone dating applications, (3) gay bars or parties, (4) gay saunas, beats, or sex on premises venues (SOPVs) and (5) friends.’ In addition, two sexual practices that involved saliva were asked about: (1) ‘How many sexual partners have rimmed you in the last three months’ and (2) ‘With the partners who put their fingers/penis into your anus, did they use their saliva as a lubricant?’ Responses for receptive rimming (study participant’s anus being licked by their partners; and use of partner’s saliva as a lubricant when the partner inserted their finger or penis briefly into the participant’s anus (known as ‘dipping’) were categorised into binary ‘yes’ or ‘no’.
Two separate logistic regression models were built to examine the associations between the two sexual practices (i.e. receptive rimming, and use of partner’s saliva as a lubricant) and the sources for meeting partners. Given that the sources for meeting partners varied in different age groups, and the majority of MSM used more than one source for meeting partners, the analyses were also adjusted for these potential confounders. 16 Sensitivity analyses were also performed in comparing MSM who used any combination of dating sources excluding versus including smartphone dating applications. All analyses were conducted using Stata version 13 (Stata Corp., College Station, TX, USA). The Alfred Hospital Ethics Committee approved this study (number 324/14).
Results
A total of 6406 MSM were eligible and invited to participate in the survey. Of the 2599 (41%) men who agreed to participate in the study, 415 were excluded due to incomplete data, and a further 282 men were the same individuals with repeated visits and only the first visits were included. Of the 1902 men who completed the questions on the sources for meeting partners, 1672 men reported they had sex with another man in the last three months and were included in the final analysis. The age of the 1672 men ranged from 17 to 78 years, with a median age of 29 (interquartile range: 25–37). Among the five sources for meeting partners, 74% (n=1232) MSM reported using smartphone dating applications to meet partners in the last three months, compared to 47% (n=793) via friends, 42% (n=698) on the internet sites, 39% (n=653) via gay bars, and 35% (n=587) via SOPVs.
Of the 1672 men, 70% (n=1168) reported receptive rimming, and 69% (n=1148) reported the use of partner’s saliva as a lubricant. Model 1 showed that MSM who met their partners via smartphone dating applications were more likely to have receptive rimming (aOR: 1.78; 95% CI: 1.38–2.28) and use of partner’s saliva as a lubricant during sex (aOR: 1.63; 95% CI: 1.27–2.09), after adjusting for age (Table 1). There was no significant association between saliva use (including both rimming and use of partner’s saliva as a lubricant during sex) and men who met partners at gay bars. The sensitivity analysis (Model 2) showed that MSM who met partners using any combination of dating source, including smartphone dating applications, were more likely to have receptive rimming (aOR: 2.21; 95% CI: 1.75–2.78), and use of partner’s saliva as a lubricant during sex (aOR: 2.05; 95% CI: 1.63–2.58) compared to those who met partners using any combination of dating source, excluding smartphone dating applications, after adjusting for age (Table 1).
Associations between how men met their male sex partners and sexual practices.
MSM: men who have sex with men; CI: confidence interval.
a‘Yes’ represents occasionally or often used the source, and ‘No’ represents never used the source in the last three months.
Discussion
This study examined the association between the sources for meeting sexual partners and sexual practices that involve saliva use in an MSM population. There were differences in sexual practices in MSM who met their sexual partners through different sources. In general, those who met their partners via smartphone dating applications are more likely to engage in receptive rimming, and using partner’s saliva as a lubricant during sex, while MSM who met partners in gay bars were not.
A more thorough understanding on saliva-involved sexual practices should facilitate a better understanding of the transmission of pathogens commonly found in the oropharynx such as gonorrhoea. Our study may provide some possible reasons for this. Firstly, the majority of HIV cases are acquired from condomless penile-anal sex. Although MSM who met their partners via smartphone dating applications are five times more likely to have more than three partners in the last three months, they do not have a higher odds of having condomless sex (aOR: 1.09; 95% CI: 0.87–1.37) compared to MSM who met their partners via other sources such as the internet sites, gay bars and SOPVs. 17 Given that condom use is similar across different partner sources, this may explain why MSM who used smartphone dating applications are not at higher risk of HIV, as suggested elsewhere. 17 Secondly, our study shows that MSM who met their partners via smartphone dating applications are more likely to engage in rimming and use of partner’s saliva as a lubricant during sex, and these activities have been found to be risk factors for gonorrhoea, but not HIV.9,10 This may explain why MSM who used smartphone dating applications have a 1.42 times greater odds of having gonorrhoea compared to those who met their partners through the internet in Beymer et al.’s study. 17 However, it is unclear why individuals who use smartphone dating applications are strongly associated with rimming and saliva use during sex. Further research such as qualitative study is required to understand the reasons behind this observation.
This study has several limitations. Firstly, all participants were recruited from a single urban sexual health clinic in Melbourne, which may not be generalised to all MSM in Australia or in other countries. Secondly, we did not examine other sexual practices that are known risk factors for oropharyngeal gonorrhoea, such as kissing and oral sex.2,13,18 Thirdly, we did not collect data to identify whether saliva is used as a lubricant during unprotected or protected penile-anal sex. Fourthly, a certain proportion of MSM (59%) declined to participate in this study. It is possible that sexual practices may be different between those who participated in the study compared to those who did not, and thus selection and reporting bias may have occurred. Fifthly, it was possible that saliva may be used differently during fingering compared to dipping; however, we were unable to distinguish between these two practices from this study. Sixthly, some internet sites also have a version of smartphone applications. Different participants might have interpreted this area of questioning differently and reporting bias may have occurred.
The sources by which MSM meet sexual partners have changed over time from physical venues (i.e. gay bars and SOPVs) to internet sites and then to the smartphone dating applications. Given that smartphone dating applications have become a medium for MSM to meet partners, it is possible that this technology could be utilised by public health professionals to promote sexual health messages such as safe sex, HIV/STI testing, and inform those most at risk of potential epidemics.
Footnotes
Acknowledgment
The authors would like to acknowledge Jun Kit Sze and Afrizal Afrizal for data extraction.
Authors’ contributions
EPFC and CKF designed the questionnaire. EPFC undertook the statistical analyses and wrote the first draft of the manuscript. All authors assisted with data interpretation, contributed to the interpretation of the study findings and contributed to the drafting and revising of the manuscript.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Health and Medical Research Council (NHMRC) programme grant (number: 568971). EPFC and TRHR are supported by the Early Career Fellowships from the Australian NHMRC (EPCF number: 1091226, TRHR number: 1091536).
Ethical approval
Ethical approval was obtained from the Alfred Hospital Ethics Committee, Melbourne, Australia (number 324/14).