The frequency of kissing as part of sexual activity differs depending on how men meet their male casual sexual partners

Abstract

Previous studies have shown that men who have sex with men (MSM) who use smartphone dating applications (apps) are at higher risk of gonorrhoea, but not HIV. We have hypothesised that kissing may be a risk factor for oropharyngeal gonorrhoea. We measured differences in kissing practices among MSM who use different methods to find male casual sexual partners (CSPs). If MSM who use apps kiss more CSPs, then this may help to explain why these men are at increased risk of gonorrhoea but not HIV. This was a cross-sectional questionnaire-based study of MSM attending Melbourne Sexual Health Centre, Australia, between March and September 2015. We measured differences in kissing practices among MSM who use different methods to find male casual sexual partners (CSPs). The questionnaire included questions about numbers of CSPs, numbers of CSPs kissed, and how men found CSPs. We surveyed 753 MSM with a median age of 29 years (interquartile range 25–36). Six hundred and one men (79.8%) reported using apps to find CSPs in the last three months. Users of apps had a higher number of CSPs than non-users (5.0 vs. 3.2; p < 0.001). Users of apps kissed a higher number (4.6 vs. 2.2; p < 0.001), and a higher proportion (90.4% vs. 71.0%; p < 0.001) of CSPs compared to non-users. We are currently investigating whether kissing is a significant mode of transmission of gonorrhoea, and if this proves correct then this study suggests that users of apps would particularly benefit from health promotion that addresses this mode of transmission.

Keywords

Men who have sex with men homosexuality sexual practices gonorrhoea

Introduction

Kissing has been reported as the most common sexual practice among men who have sex with men (MSM).¹ Our group has hypothesised that pharynx-to-pharynx transmission during kissing may be a significant driver of gonorrhoea incident cases,² and this is supported by our mathematical modelling.³ Transmissibility is suggested by the finding that Neisseria gonorrhoeae can be cultured from expectorated saliva in men with pharyngeal gonorrhoea, as shown in a study of 33 MSM with culture-positive pharyngeal gonorrhoea, of whom 32 tested positive in expectorated saliva by nucleic acid amplification test (NAAT) and six tested positive in expectorated saliva by culture, within 14 days of their initial diagnosis of pharyngeal gonorrhoea.⁴ If validated, this hypothesis would help to explain why recent studies have shown that among MSM the pharynx is a frequent site of gonococcal infection.^5,6 To explain further, whilst pharynx-to-pharynx transmission would not directly increase the risk of anal or urethral gonorrhoea, the resulting higher incidence of pharyngeal gonorrhoea among MSM and their sexual partners would subsequently increase the risk of urethral and anal gonorrhoea through oro-penile sex and oro-anal sex, respectively.

Since 2010, smartphone dating applications have become the most common source for MSM to meet sexual partners.⁷ A study conducted in Los Angeles found that MSM who met their partners via smartphone dating applications were more likely to acquire gonorrhoea (analysed as gonorrhoea diagnoses at any anatomic site) than those who met their partners via internet or in-person methods such as sex on premises venues (SOPVs).⁸ Previously, it was hypothesised that men who meet partners via smartphone dating applications have more condomless anal sex, but recent research has not supported this association.⁷ Also, there is no association between the use of smartphone dating applications and a higher risk of HIV,⁸ which would be expected if men had more condomless anal sex. An alternative hypothesis is that the increased risk of gonorrhoea may be due to differences in saliva use during sex,^9,10 oral sex practices and kissing practices between men who use smartphone dating applications to meet sexual partners compared to those who do not use such applications. In this study, we measured differences in kissing practices among MSM who use different methods to find male casual sexual partners (CSPs). If MSM who use smartphone dating applications kiss more partners, then this may help to explain why men who use smartphone dating applications are at increased risk of gonorrhoea.

Materials and methods

Study population and setting

This was a cross-sectional questionnaire-based study conducted amongst MSM attending the Melbourne Sexual Health Centre (MSHC) in Victoria, Australia, between 23 March 2015 and 23 September 2015. MSHC is the largest public sexual health service in Victoria. The centre provides about 40,000 clinical consultations per year, and about 36% of the consultations are for MSM.¹¹

Study measurement

Men who had sex with men in the last 12 months and were aged 16 or above were invited to complete the self-administered questionnaire at triage. Not all MSM were asked to complete the survey, for example, men who attended our rapid-flow “test-and-go” service were not asked to complete the questionnaire as this would have disrupted service delivery.

The questionnaire asked how men met their male CSPs, their number of male CSPs in the previous three months, the number of male CSPs they had kissed in the previous three months, and the typical duration of kissing with those sexual partners, the latter being a subjective retrospective estimate of the average time spent on kissing. Five main sources for meeting partners were predefined in the questionnaire: (1) internet; (2) smartphone dating applications (e.g. Grindr, Scruff, Tinder, etc.; but no examples listed in the questionnaire); (3) gay bars or parties; (4) gay saunas, SOPVs, or beats (public places where men meet for sex); and (5) friends. Participants could select more than one source for meeting partners. The sources for meeting partners were categorised as “yes” or “no”. Consent was implied by returning a completed questionnaire. Approval was obtained from the Alfred Hospital Ethics Committee (number 544/14).

Statistical analysis

Distributional analyses found that key reported variables were highly right-skewed, these included “age”, “number of CSPs”, “number of CSPs kissed”, and “typical duration of kissing with CSPs”. Hence, the values of these variables were natural log-transformed (y=ln[x+1]) prior to calculation of descriptive data and statistical tests.¹² The proportion of CSPs kissed was calculated by dividing the number of CSPs kissed by the total number of CSPs. Descriptive data were reported as the inverse natural log of the natural log-transformed results (x = [e^y]−1).

Two-sample t-tests (two-tailed) were used to compare the mean “number of CSPs”, “number of CSPs kissed”, “typical duration of kissing with CSPs”, and “proportion of CSPs kissed” between those who used a particular source for meeting partners vs. those who did not.

We calculated correlation coefficients between “age” and “number of CSPs”, “age” and “number of CSPs kissed”, “age” and “proportion of CSPs kissed”, and “age” and “typical duration of kissing”.

All analyses were performed using Stata version 13.1 (Stata, College Station, TX, USA).

Results

A total of 3371 MSM attended the clinic during the study period, of whom 1150 (34%) were invited to complete the survey, 989 (86%) returned it, and 753 (65%) men answered the questions on where they met sexual partners and were included in this analysis. A total of 2221 men were not asked to complete the survey, largely because this would potentially have disrupted service delivery in the clinic.

Most men used multiple sources to meet sexual partners. The most typical method by which men met their male CSPs was by smartphone dating applications (79.8%; n=601), followed by gay bars and parties (43.6%; n=328), SOPVs and beats (40.0%; n=301), internet (38.1%; n=287), and friends (35.7%; n=269) (Table 1). Two men did not use any of the aforementioned sources to meet partners. Men who met partners at SOPVs or beats were older (mean 33.4 years), whereas those who met through smartphone dating applications, gay bars, or friends were younger (means of 29.5, 29.0, and 29.1 years, respectively) compared to men who did not use these sources to meet partners (Table 1). Men who met partners at SOPVs or beats had the highest number of sexual partners in the preceding three months (mean 6.6), but men who met partners at gay bars or parties had the highest number of kissing partners (mean 5.3). Men who met partners at SOPVs or beats kissed a lower proportion of sexual partners compared to those who did not attend SOPVs or beats (77.4% vs. 92.5%, p < 0.001), whereas men who met partners at gay bars or through smartphone dating applications kissed a higher proportion of sexual partners compared to those who did not use these sources (94.0% vs. 80.5%, p < 0.001 and 90.4% vs. 71.0%, p < 0.001) (Table 1). Men who met partners at SOPVs or beats spent less time on a kissing episode during a typical sexual contact compared to those men who did not attend SOPVs or beats (8.2 min vs. 10.9 min, p < 0.001). Men who met partners through smartphone dating applications or gay bars spent more time on a kissing episode during a typical sexual contact compared to those men who did not use these methods (10.8 min vs. 6.7 min, p < 0.001 and 12.5 min vs. 8.0 min, p < 0.001, respectively) (Table 1).

Table 1.

Age, number of CSPs, number of CSPs kissed, proportion of CSPs kissed, and duration of kissing, and associations with sources used to meet CSPs, among 753 men who have sex with men attending a sexual health service in Melbourne, Australia.

		Age of men (years)		Number of CSPs		Number of CSPs kissed		Proportion of CSPs kissed		Duration of kissing^a
Sources for meeting partners	Number of men	Mean	p*	Mean (95% CI)	p*	Mean (95% CI)	p*	Mean (95% CI)	p*	Mean (95% CI)	p*
Internet
No	466	30.5	0.177	4.3 (4.0–4.7)	0.054	3.9 (3.6–4.3)	0.396	88.2% (84.0–92.5)	0.138	10.1 (9.1–11.1)	0.322
Yes	287	31.5	0.177	4.9 (4.4–5.5)	0.054	4.2 (3.7–4.6)	0.396	83.1% (78.1–88.4)	0.138	9.3 (8.2–10.6)	0.322
Smartphone dating applications
No	152	36.8	<0.001	3.2 (2.7–3.7)	<0.001	2.2 (1.9–2.6)	<0.001	71.0% (62.8–79.7)	<0.001	6.7 (5.3–8.3)	<0.001
Yes	601	29.5	<0.001	5.0 (4.7–5.4)	<0.001	4.6 (4.3–4.9)	<0.001	90.4% (87.0–93.8)	<0.001	10.8 (9.9–11.6)	<0.001
Gay bars and parties
No	425	32.4	<0.001	4.0 (3.6–4.3)	<0.001	3.2 (2.9–3.5)	<0.001	80.5% (75.9–85.2)	<0.001	8.0 (7.2–9.0)	<0.001
Yes	328	29.0	<0.001	5.5 (5.0–6.1)	<0.001	5.3 (4.8–5.8)	<0.001	94.0% (89.9–98.3)	<0.001	12.5 (11.3–13.8)	<0.001
Sex on premises venues and beats
No	452	29.3	<0.001	3.6 (3.8–3.3)	<0.001	3.4 (3.1–3.7)	<0.001	92.5% (88.0–97.1)	<0.001	10.9 (9.9–12.0)	<0.001
Yes	301	33.4	<0.001	6.6 (6.0–7.3)	<0.001	5.1 (4.5–5.7)	<0.001	77.4% (73.0–81.8)	<0.001	8.2 (7.3–9.3)	<0.001
Friends
No	484	31.9	<0.001	4.3 (4.0–4.7)	0.047	3.6 (3.3–4.0)	<0.001	82.6% (78.5–86.8)	0.003	8.7 (7.8–9.6)	<0.001
Yes	269	29.1	<0.001	5.0 (4.5–5.5)	0.047	4.8 (4.3–5.3)	<0.001	93.1% (87.9–98.4)	0.003	12.1 (10.8–13.6)	<0.001

CI: confidence interval; CSPs: male casual sex partners in the last three months; SD: standard deviation.

Note: All continuous variables were highly right-skewed, and hence natural log(1+x) transformed prior to analysis. After analysis, descriptive variables were anti-natural log transformed prior to reporting.

^aNumber of minutes spent on kissing during a “typical” episode of sex (participant recall).

*p values obtained by two-sample T-test (two-tailed).

Younger men kissed more sexual partners (r = −0.09, p = 0.02) and kissed a greater proportion of their sexual partners compared to older men (r = −0.17, p < 0.001). However, there was no correlation between age and number of sexual partners (r = 0.015, p = 0.68) nor between age and typical duration of kissing (r = −0.01, p = 0.778).

Discussion

This study found that kissing is a more common practice for men who met sexual partners through smartphone dating applications, and gay bars or parties compared to men who did not use these sources to meet sexual partners. We are currently investigating whether kissing is an important mode of transmission of gonorrhoea among MSM, as suggested by our mathematical modelling.^2,3 If this is validated, then this may explain the previously reported finding that men who meet partners via smartphone dating applications are at higher risk of gonorrhoea but not HIV compared to those who met sexual partners in person.⁸

In contrast, men who met sexual partners at SOPVs or beats kissed a lower proportion of sexual partners compared to those men who did not meet sexual partners at SOPVs or beats.

Limitations of this study include that it was conducted at a single sexual health service and may not be generalisable to other settings. Furthermore, this study likely underestimates the number of partners that men kiss, as we asked only about kissing with sexual partners. We have previously shown that men kiss more men than they have sex with,² and they may not consider these additional “kissing only” partners to be sexual partners, and hence they may have excluded these from their answers to our survey. Future studies should assess all kissing partners and not just those with whom men also have sex. Finally, not all men attending our centre completed the survey and this may have introduced a degree of selection bias.

In addition to being a convenient way to meet sexual partners, smartphone dating applications provide a convenient method to deliver health promotion messages. Previous research has shown that men will not stop kissing to reduce their risk of catching gonorrhoea,^13,14 but may be willing to increase the use of mouthwash,^14,15 which is currently being investigated as a preventive measure for gonorrhoea.^16,17 If this proves to be effective, then it may be worthwhile to promote this intervention to men who use smartphone dating applications.

Key messages

Men who use smartphone dating applications to meet male sexual partners kiss a larger number of sexual partners than men who do not use these applications.

Men who use smartphone dating applications kiss a larger proportion of their male sexual partners than men who do not use these applications.

Users of smartphone dating applications have an increased risk of gonorrhoea but not HIV. We argue that differences in kissing practices may help to explain this.

Footnotes

Authors’ contributions

EPFC and CKF designed the study. VJC conducted the data analysis. VJC and DP wrote the first draft of the manuscript. SW and TP were involved in data collection and management. All authors contributed to the interpretation of the study findings, revised the manuscript critically for important intellectual content, and approved the final version 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 is supported by the Australian NHMRC Early Career Fellowship (number 1091226). VJC is supported by an RTP stipend from the Australian Government.

Ethics approval

This study was approved by the Ethics Committee of Alfred Hospital, Melbourne, Australia (number 544/14).

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