Risky sexual behavior and sexually transmitted infections among men who have sex with men and purchase sex attending an Israeli sexually transmitted infection clinic

Abstract

Men who have sex with men (MSM) and purchase sex (MPS) are a sub-group potentially at high risk for acquiring and transmitting sexually transmitted infections (STIs). This is a hard-to-reach population resulting in a scarcity of studies covering the issue. This cross-sectional study aimed to assess the association between purchasing sex and high-risk behaviors related to HIV/STI transmission and appraise the STI prevalence among MSM. All MSM who attended the STI clinic in Tel Aviv between 2003 and 2010 were included. Demographics, behavioral, clinical, and laboratory data were compared between MPS and non-MPS to identify high-risk sexual behaviors and STI prevalence associated with purchasing sex. Of the first visits of 2694 MSM who attended the STI clinic during the study period, 151 (5.6%) paid for sex. MPS were more commonly older and married than non-MPS. MPS were more likely to engage in behaviors associated with high risk for HIV/STI transmission, including infrequent condom use during anal sex, substance use during sex, and selling sex themselves. MPS had a higher STI prevalence than non-MPS, although this was not statistically significant (p = 0.05). These findings highlight the need to establish culturally tailored interventions for MPS addressing the potential risks associated with purchasing sex.

Keywords

Men who have sex with men prostitution sex purchasing sex workers sexual behavior

Introduction

The majority of research on men who pay for sex has been conducted within the context of heterosexual prostitution and largely focused on female sex workers (FSWs). Far less is known on men who have sex with men (MSM) and pay for sex (MPS). Most of the current publications have focused on male sex workers (MSWs) rather than on their clients. MPS are a remarkably hard-to-reach population due to its limited size, the stigma related to purchasing sex from men, and the clandestine nature of transactional sexual encounters. As such, there is a paucity in studies covering MPS in developed countries.^1–3

Different countries have different approaches that address prostitution. Some countries allow regulated prostitution (such as Nevada in the United States, parts of Australia, and the Netherlands), and others have banned prostitution.⁴ Society’s perception of prostitution has been displaying a shift over recent years, exemplified by Nordic countries who have employed a different model where it is illegal to pay for sex, but not to sell sex, i.e. the client is criminalized, but not the sex worker.⁵ In Israel, the acts of paying for and selling sex are not illegal, though nor are they regulated, whereas human trafficking and pandering are illegal. Recently, the Israeli government decided to adopt the Nordic model and penalize men who purchase sex with the end goal of decreasing sex purchasing.⁶ In light of this legal shift, this study focuses on MPS, as they are key players, driving the demand for commercial sex.

Sexually transmitted infection (STI) rates are relatively low in Israel. In 2007, gonorrhea incidence among all men in Israel was approximately 8 per 100,000 population and decreased to approximately 4 per 100,000 population in 2010 (Zohar Mor, personal communication). In 2018, 34 cases of MSM with HIV/AIDS were reported and increased to 148 cases reported in 2010. In 2010, MSM accounted for 50.9% of all men notified with HIV/AIDS.⁷

MSM are at high risk for acquiring and transmitting STIs.^8–10 MSM who engage in purchasing sex may be a sub-population with a higher risk for acquiring or transmitting STIs than MSM who do not purchase sex.^11,12 This study is the first to compare demographic attributes, behavioral characteristics, laboratory data, and STI burden in Israel between MPS and non-MPS who attended the Levinsky STI clinic in Tel Aviv, Israel. This is a walk-in community clinic, operated by the Tel Aviv Department of Health that provides counseling, testing, and treatment anonymously and free of charge.¹³ Its services are accessible to citizens and noncitizens alike. Males who attend this clinic do so as they may prefer not to disclose sensitive issues to their primary care physician, such as risky sexual behaviors, including paying for sex.

Methods

This cross-sectional study included data retrieved from the individual medical files at the STI clinic of all MSM who were treated between 2003 and 2010. Additionally, data from an already published study on heterosexual men who attended the clinic during the same time period and purchased sex from women¹⁴ were included for a sub-analysis aiming to compare MPS with heterosexual men who pay for sex.

To comply with the cross-sectional study design, only the first clinic visit of each male clinic attendee was included. The data were collected as part of the routine intake of all patients who attend the clinic. A computer-assisted questionnaire was completed at the clinic by an experienced staff during the visit. All men were asked the reason of the visit (presence of clinical symptoms or routine screening), age of sexual debut, number of previous sex partners, gender of the partners (men, women, or both), previous STI diagnoses, sexual practices including sex purchasing, as well as condom and substance use. Medical examinations were performed by trained physicians and STI tests were conducted according to the patient’s risk behavior and the clinical symptoms (urethral secretion, burning sensation, or bleeding; sore, scratch, or penile skin changes; chest/palms/soles skin rash) presented at the visit.

MSM were defined as men who reported sexual intercourse with another man. This definition also included men who reported sexual intercourse with both men and women. MPS were defined as MSM who reported one or more occasions of purchasing sex during their lifetime. Only men between the ages of 18 and 80 years who had a complete medical file were included in the final analysis.

Risk factors associated with HIV/STI transmission examined in this study included infrequent use of condoms during anal sex (‘never used’ or ‘sometimes used condoms,’ as was indicated in the questionnaire) and performing sex under the influence of drugs.¹⁰ Multiple sex partners were defined as more than five partners during the three months prior to the clinic visit.¹⁰

Laboratory tests included serology tests of blood samples for HIV (HIV 1/2 GO, Abbott, Wiesbaden, Germany), HBsAg (DiaPro Diagnostics, Milano, Italy). Also Venereal Disease Research Laboratory (VDRL) (Becton-Dickinson, Shannon, Ireland), Treponema pallidum hemagglutination assay (TPHA) (Axis Shield, Dundee, UK), and fluorescent treponemal antibody (FTA) blood assays were used to screen for syphilis. Pharyngeal Neisseria gonorrhoeae was detected by Gram staining of oral and pharyngeal swabs. Urine was collected for nucleic acid amplification tests to detect N. gonorrhoeae and Chlamydia trachomatis. Men who presented positive serology to HIV, HBsAg, or infectious syphilis (VDRL titers higher than 1:8 with a positive FTA of TPHA), pharyngeal or urethral N. gonorrhoeae, urethral C. trachomatis during their current visit were classified as having an STI. Positivity rate was calculated as the number of positive results divided by the number of tests performed for each of the pathogens.

To determine factors associated with purchasing sex, demographic, behavioral, and laboratory data were compared between MPS and non-MPS. To determine factors associated with STI diagnoses among the study sample, demographic, behavioral, and laboratory data were compared between MSM who were diagnosed with at least one STI at the current visit to those who were STI free.

Chi square test was used to compare categorical variables, while Student’s t-test was used for continuous variables. P-value of <0.05 was considered statistically significant. Logistic regression included attributes which were statistically significant in the univariate analyses after testing for co-linearity with other independent variables and was used to identify variables associated with purchasing sex and with STI diagnoses at the current clinic visit. The results of the multivariate analysis are presented as odds ratios and 95% confidence intervals. The study was approved by the Institutional Review Board of the Israeli Ministry of Health.

Results

The first visits of 3373 MSM who attended the clinic between 2003 and 2010 were recorded, while 2694 (80.0%) met the inclusion criteria and were included in the final analysis. The average age of all men was 29.6 years (median 28, interquartile range: 23.5–33.5), the majority were single (N = 1889, 95.0%) and Israeli born (N = 2274, 86.5%). Additionally, a greater proportion of the married MSM (both MPS and non-MPS) reported vaginal sex than MSM who were single (91.0% versus 35.5%, respectively, p < 0.001). Of all the MSM who met the inclusion criteria, 151 (5.6%) reported that they purchased sex at least once in the past.

In the univariate analysis, MPS were more commonly older, married, and non-Israeli born compared to the non-MPS (Table 1). MPS were more likely to perform vaginal sex in addition to sex with men and used condoms irregularly during vaginal and anal sex compared to non-MPS. MPS reported an earlier sexual debut, a greater number of sex partners in the three months preceding the clinic visit, used drugs more commonly, and got paid for sex themselves compared to the non-MPS. MPS were more likely than the non-MPS to visit the clinic due to STI-related symptoms or due to sexual intercourse with a partner whom they suspected of having an STI. They were also more likely to be diagnosed with an STI at the current visit than non-MPS, but this difference did not reach statistical significance (positivity rates of 10.0% versus 6.5%, respectively, p = 0.05). Further analysis of individual STIs revealed higher C. trachomatis positivity rates among MPS compared to non-MPS (positivity rates of 4.5% versus 2.0%, p = 0.03) (Figure 1). No significant differences were found for positivity rates for HBV, HIV, urethral or pharyngeal N. gonorrhoeae, and infectious syphilis between MPS and non-MPS.

Table 1.

Characteristics of MSM who purchased sex versus MSM who did not purchase sex visiting the STI clinic between 2003 and 2010.

	Univariate analysis				Multivariate analysis
	Paid for sex151 (%)	Did not pay for sex 2543 (%)	OR (95% CI)	P	OR (95% CI)	P
Age (years)
18–29	61 (41.0)	1570 (62.0)	1 (ref)	<0.001	1 (ref)	<0.001
≥30	89 (59.0)	961 (38.0)	2.3 (1.7–3.3)		2.8 (1.7–4.7)
Country of birth
Israel	116 (79.0)	2158 (87.0)	1 (ref)		1 (ref)	0.7
Other Countries	31 (21.0)	323 (13.0)	1.7 (1.1–2.6)	0.006	1.1 (0.6–2.0)
Relationship status^a
Single (single, divorced, and widowed)	97 (83.0)	1792 (95.5)	1 (ref)	<0.001	1 (ref)	0.003
Married	20 (17.0)	83 (4.5)	2.4 (1.2–4.2)^a		2.9 (1.4–5.9)
Reason for attending clinic
Symptomatic or sex with a symptomatic partner	27 (18.0)	315 (12.5)	1.5 (0.9–2.3)	0.05	1.1 (0.6–1.9)	0.7
Self-referral screening	124 (82.0)	2228 (87.5)	1 (ref)		1 (ref)
Age sexual debut <16 years	57 (44.5)	467 (24.0)	2.5 (1.7–3.6)	<0.001	1.4 (0.8–2.3)	0.1
≥11 sexual partners (during lifetime)^a	122 (90.0)	1904 (83.0)	1.3 (0.7–2.3)	0.35
≥6 sexual partners (within the last three months)	54 (38.5)	586 (24.5)	1.9 (1.3–2.7)	<0.001	0.9 (0.5–1.6)	0.9
Performs oral sex	146 (97.0)	2420 (98.5)	0.5 (0.1–1.5)	0.2
Performs vaginal sex	98 (77.0)	536 (36.0)	6.0 (3.9–9.2)	<0.001
Performs anal sex	134 (90.0)	2327 (94.5)	0.5 (0.2–0.9)	0.02
Irregular or no use of condom during vaginal sex	72 (79.0)	321 (63.0)	2.2 (1.3–3.8)	<0.001
Irregular or no use of condom during anal sex	89 (72.0)	1154 (53.5)	2.1 (1.4–3.2)	<0.001	2.6 (1.5–4.4)	<0.001
Performed sex with a non-Israeli partner within the last three months	12 (31.0)	174 (21.0)	1.6 (0.8–3.3)	0.1
Performs sex under the influence of drugs	709 (47.0)	768 (30.0)	2.0 (1.4–2.7)	<0.001	1.7 (1.1–2.8)	0.01
Uses shared syringes	4 (5.0)	15 (1.0)	5.2 (1.7–16.1)	<0.001
Provided sex for money	27 (18.0)	101 (4.0)	5.3 (3.3–8.5)	<0.001	3.1 (1.3–7.6)	0.01
Reported a previous STI diagnosis^a	33 (22.0)	499 (20.0)	0.9 (0.6–1.4)	0.7
STI diagnosis at current visit^b	16 (10.0)	165 (6.5)	1.7 (0.9–2.9)	0.05	0.7 (0.3–1.6)	0.4

CI: confidence interval; MSM: men who have sex with men; OR: odds ratio; STI: sexually transmitted infection.

^aOR adjusted to age in the univariate analysis.

^bHIV, HBsAg, infectious syphilis, pharyngeal or urethral N. gonorrhoeae, urethral C. trachomatis.

Figure 1.

STI positivity rates – by sex-purchasing habits among MSM attending the clinic during 2003–2010. Hepatitis – 2/101(MPS) versus 14/1527 (non-MPS); HIV – 3/127 (MPS) versus 50/1596 (non-MPS); C. trachomatis – 6/130 (MPS) versus 39/2258 (non-MPS); urethral N. gonorrhoeae – 2/130 (MPS) versus 37/2259 (non-MPS); pharyngeal N. gonorrhoeae – 4/119 (MPS) versus 32/1927 (non-MPS); infectious syphilis – 0/145 (MPS) versus 8/2436 (non-MPS).

In the multivariate analysis, determinants associated with purchasing sex among MSM included older age, being married, infrequent condom use during anal sex, performing sex under the influence of drugs, and providing sex for pay.

Table 2 compares MSM who were diagnosed with an STI to those who were STI free. Those who had an STI during the current clinic visit were more likely to be older, non-Israeli born, and noncircumcised than the MSM who were STI free. MSM who were diagnosed with an STI were also more likely to present with typical STI-related symptoms, engage in risky sexual behavior, use condoms inconsistently during vaginal and anal sex, have a greater number of sexual partners, report a previous STI diagnosis, and were more likely to purchase sex as compared to men who were STI free in the current visit. In the multivariate analysis, determinants which were significantly associated with STI diagnoses at the current visit included STI-related symptoms, a greater number of sexual partners, irregular use of condoms during anal sex, and a previous STI diagnosis. Purchasing sex did not reach statistical significance.

Table 2.

Characteristics of MSM with at least one STI diagnosis versus those without an STI diagnosis,^a visiting the clinic between 2003 and 2010.

	Univariate analysis				Multivariate analysis
	Men diagnosed with at least one STI181 (%)	Men without an STI diagnosis2513 (%)	OR^b (95% CI)	P	OR (95% CI)	P
Age (years)
18–29	96 (53.0)	1535 (61.5)	1 (ref)	0.1	1.00 (ref)	0.3
≥30	85 (47.0)	965 (38.5)	1.2 (0.9–1.6)		0.7 (0.4–1.3)
Country of birth
Israel	134 (76.0)	2140 (87.5)	1 (ref)	<0.001	1.00 (ref)	0.09
Other Countries	142 (24.0)	312 (12.5)	2.5 (1.6–3.3)		1.8 (0.9–3.8)
Relationship status^c
Single (single, divorced, and widowed)	156 (97.0)	1733 (94.5)	1 (ref)	0.07
Married	5 (3.0)	98 (5.5)	0.4 (0.1–1.0)
Reason for attending clinic
Symptomatic or sex with a symptomatic partner	68 (37.5)	274 (11.0)	4.9 (3.5–6.8)	<0.001	6.9 (3.8–12.6)	0.00
Self-referral screening	113 (62.5)	2239 (89.0)	1 (ref)		1 (ref)
Age sexual debut <16 years	48 (29.5)	476 (25)	1.2 (0.8–1.7)	0.2
≥11 sexual partners (during lifetime)^c	164 (93.0)	1862 (83.0)	2.7 (1.4–5.0)	<0.001
≥6 sexual partners (within the last three months)	62 (35.0)	578 (24.5)	1.8 (1.3–2.5)	<0.001	1.9 (1.0–3.5)	0.03
Performs oral sex	175 (98.0)	2387 (98.5)	0.6 (0.2–1.9)	0.4
Performs vaginal sex	50 (43.5)	584 (39.0)	1.1 (0.7–1.6)	0.5
Performs anal sex	172 (96.5)	2284 (94.0)	2.2 (0.9–5.3)	0.05
Irregular or no use of condom during vaginal sex	40 (81.5)	353 (63.5)	2.0 (0.9–4.3)	0.07
Irregular or no use of condom during anal sex	115 (69.0)	1128 (53.5)	1.9 (1.3–2.7)	<0.001	3.9 (2.0–7.7)	0.00
Purchased sex	16 (9.0)	135 (5.5)	1.5 (0.8–2.6)	0.1	0.3 (0.08–1.8)	0.2
Performed sex with a non-Israeli partner within the last three months	19 (24.5)	167 (21.0)	0.9 (0.5–1.6)	0.7
Performs sex under the influence of drugs	75 (42.0)	763 (31.0)	1.6 (1.2–2.2)	<0.001	0.6 (0.3–1.2)	0.2
Provided sex for money	17 (9.5)	111 (4.5)	2.8 (1.6–5.0)	<0.001	2.0 (0.5–7.4)	0.2
Circumcised	60 (80.0)	527 (87.0)	0.4 (0.2–0.9)	0.03	0.5 (0.2–1.0)	0.08
Reported a previous STI diagnosis^c	66 (36.5)	466 (19.0)	2.1 (1.5–3.0)	<0.001	2.2 (1.2–4.1)	0.006

CI: confidence interval; MSM: men who have sex with men; OR: odds ratio; STI: sexually transmitted infection.

^aHIV, HBsAg, infectious syphilis, pharyngeal or urethral N. gonorrhoeae, urethral C. trachomatis.

^bAdjusted to reason for attending clinic in the univariate analysis.

^cAdjusted to age in the univariate analysis.

Table 3 compares MPS with heterosexual men from the same clinic who paid for sex from women by using previously published data.¹⁴ MPS were more likely than the heterosexual payers to be Israeli born and single. MPS were also more likely than the heterosexual men to engage in risky sexual behavior which included an earlier sexual debut and a greater number of sexual partners. They were more likely to report a previous diagnosis of an STI and were also more commonly diagnosed with an STI at the current visit compared with heterosexual men who paid for sex.

Table 3.

Characteristics of MSM who purchased sex versus heterosexual men who purchased sex visiting the STI clinic between 2003 and 2010.

	MSM paid for sex 151 (%)	Heterosexual men who paid for sex 1,649 (%)	P
Age (years)
18–29	61 (41.5)	681 (40.5)	0.8
≥30	89 (58.5)	964 (59.5)
Country of birth
Israel	116 (79)	1083 (66.5)	0.002
Other countries	31 (21)	543 (33.5)
Relationship status^a
Single (single, divorced, and widowed)	97 (83)	1014 (75.5)	0.068
Married	20 (17)	331 (24.5)
Reason for attending clinic
Symptomatic or sex with a symptomatic partner	27 (18)	378 (23)	0.156
Self-referral screening	124 (82)	1271 (77)
Age sexual debut <16 years	57 (44.5)	456 (29)	0.000
≥11 sexual partners (during lifetime)	122 (89.5)	1134 (72)	0.000
≥6 sexual partners (within the last three months)	54 (38.5)	303 (19)	0.000
Irregular or no use of condom during vaginal sex	72 (79)	1234 (79.5)	0.9
Irregular or no use of condom during anal sex	89 (72)	430 (77.5)	0.16
Performs sex under the influence of drugs	70 (47)	741 (45.5)	0.7
Uses shared syringes	46 (31)	422 (26)	0.1
Reported a previous STI diagnosis	33 (22)	263 (16)	0.058
STI diagnosis at current visit^a	16 (10.5)	85 (5)	0.005

MSM: men who have sex with men; STI: sexually transmitted infection.

^aHIV, HBsAg, infectious syphilis, pharyngeal or urethral N. gonorrhoeae, urethral C. trachomatis.

Discussion

Of all the MSM who attended the STI clinic, 5.6% were MPS. MPS were more likely to engage in risky sexual behaviors, including infrequent use of condoms during anal sex, performing sex under the influence of drugs, and providing sex for money compared with non-MPS.

The rate of purchasing sex in this study was lower than that seen in other studies.^3,15 In the European Men who have Sex with Men Internet Survey, ∼7% reported purchasing sex in the previous year.¹ In Australia, where sex work is largely decriminalized, it was reported that ∼3% of the gay and bisexual men in Sydney and Melbourne paid for sex in the previous year.^16,17 Those studies referred to purchasing sex in the past year only, where the current study referred to sex purchasing over one’s lifetime. However, those other studies utilized anonymous online surveys, whereas in this current study, data were collected by face-to-face interviews and were subject to reporting bias. It is therefore speculated that the rate for sex purchasing in the study population may be higher than that reported.

MPS were more likely to be married and more commonly performed vaginal sex than non-MPS. One may conclude that the married men included in the sample were married to female partners, as during the study period gay marriages were less accepted in Israel. The finding that 91% of all the married MSM included in this study performed vaginal sex supports this assumption. Other studies have indicated that men who have sex with both men and women are more likely to engage in purchasing sex than MSM only.^11,12,18 Similar findings were reported from a study in Israel examining sexual behavior and sexual orientation. Mor and Davidovich¹⁵ showed that MSM, who defined themselves as heterosexuals yet were either attracted to or engaged in sex with men, were more likely to purchase sex than MSM who defined themselves as gay or bisexual (41.7% versus 14.6%, p < 0.001). MSM who are married to women may be closeted, less active in the gay networks, and thus may opt for discreet routes for obtaining sexual contact with men, including purchasing sex. This sub-population requires further attention because they have a greater potential for ‘bridging’ STIs to their regular female sexual partners, as it is likely that they do not use condoms with them.

MPS in our study were more likely to provide sex for pay than the non-MPS. This is consistent with previous research performed among MSWs in Tel Aviv, where they were more likely to purchase sex themselves than MSM who were not paid for sex.¹⁹ This phenomenon was seen in an additional publication, where MSM who reported receiving money, drugs, or shelter for sex were also more likely to report providing commodities in exchange for sex.²⁰ MSM who engage in reciprocal transactional sex may do so as an expression of sensation-seeking tendencies or reflect sexual adventurousness. Alternatively, they may exchange sex for money out of economic necessity and more complex psychological reasons.^3,19

MPS displayed a greater risky sexual behavior profile than non-MPS, which included performing sex under the influence of drugs and infrequent use of condoms. Studies focused on MSM in Israel and other countries showed that substance use before or during sex is associated with various risky sexual behaviors, including earlier sexual debut, unprotected anal intercourse, being paid for sex, and a high number of sexual partners.^1,21,22

MPS had a borderline statistically significant higher STI burden than non-MPS in the univariate analysis (10% versus 6.5%, p = 0.05). However, in the multivariate analysis, purchasing sex was not significantly associated with an STI diagnosis. These combined results indicate that the act of purchasing sex itself may not be the cause for the increased risk for acquiring STIs, but rather that MPS are more likely to take sexual risks, e.g. unprotected anal sex and performing sex under the influence of drugs and these sexual practices subsequently place them at risk for contracting STIs. Furthermore, as the MSM in this study were not necessarily attending the clinic immediately following a commercial sex encounter, it might be difficult to associate purchasing sex with a current STI diagnosis.

Interestingly, in another study which focused on heterosexual men attending the same STI clinic in Tel Aviv, it was found that 26.7% had paid for sex¹⁴ compared to only 5.6% observed in the current study population of MSM. These differences may mirror the gender variance seen among the population of sex workers, where MSWs are fewer in number than FSWs.^23,24 In Israel, according to a National survey performed in 2014, there are an estimated 525 MSWs (5%) and 10,463 (95%) FSWs, with the majority located in the Tel Aviv metropolitan area²⁴ which is the catchment area of the Levinsky STI clinic. This smaller supply and demand among MSM may reflect different attitudes and possible stigma associated with commercial sex among MSM in comparison to heterosexuals. The stigma of men who pay for sex with men is not only associated with transactional sex, as is the case with females, but also with homosexuality.²⁵ Sex purchasing represents an additional deviance from normative heterosexual behaviors and may incur additional embarrassment associated with purchasing sex among MSM. As such, it is possible the power dynamic between MPS and the MSW is different than that between the heterosexual MPS and the FSWs, and thus the stigma related to sex work in the gay community may be different than that of the heteronormative world. From the results observed here, MPS display an even greater risky sexual profile than heterosexual payers that includes a greater number of sexual partners and higher STI burden. These findings indicate that MPS are a high-risk group distinct from their counterpart among heterosexual men and have a greater potential of both acquiring and infecting others with STIs.

This study is subject to several limitations. First, a selection bias is possible, as MSM who attended the clinic may belong a priori to a higher risk population precluding making assumptions on the general MSM population. Additionally, MSM who are HIV-positive may seek medical treatment for STIs at their regular HIV clinic and were underrepresented in this study. Second, there was a potential reporting bias, as sexual behaviors, particularly purchasing sex, are associated with negative stigma and thus one may feel uncomfortable discussing said behaviors in person. To alleviate discomfort, the medical interview was completed by the clinic’s experienced staff using a respectful approach. However, underreporting, if it exists, most probably led to differential misclassification of MPS and non-MPS underestimating the actual association. Third, recall bias may also exist, though to minimize this bias, men were questioned about their sexual behavior performed three months prior to their clinic’s visit. Fourth, samples for STI testing were routinely taken from throat cultures or urine, potentially missing anally-acquired STIs. This may explain the insignificant difference in the rate of STIs between MPS and non-MPS. Fifth, the patients were questioned on previous sex purchasing without specifying the gender of the sex worker. Additionally, the definition of purchasing sex may have been too narrow as it was based on paying for sex and did not include exchanging commodities for sex which is common among MSM (such as exchange of sex for drugs). Finally, paying for sex may not be directly related to the current cause of the visit to the clinic. Last, the study design was cross-sectional, such that a causal link between sex purchasing and STI prevalence may be limited.

In conclusion, MPS who attended the STI clinic engaged in behaviors associated with risk factors for STI transmission more so than non-MPS. MPS also had a higher STI burden than non-MPS. The riskier sexual profile of MPS demonstrated in this study highlights the need to target public health efforts toward this sub-population. Although access to MPS may be difficult, future research directions should investigate the perception and motivation for purchasing sex in the wider context of masculinity and gender in the gay culture. STI clinics can be used to reach MPS and potentially provide counseling workshops, tailored services, and advice to MPS. In view of the new legislation to penalize men who pay for sex in Israel, mechanisms should be implemented to enable open dialog between MPS and their healthcare providers which protects their privacy and encourages open discussion about previous sexual contacts and sex-purchasing habits. It is also recommended that medical professionals actively inquire of purchasing sex behaviors as part of the medical intake for men who are seeking medical care for STIs.

Footnotes

Acknowledgments

We acknowledge Ms Yael Goor for her assistance and insight in this research study.

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 received no financial support for the research, authorship, and/or publication of this article.

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