key: cord-1029726-7pc0dh09
authors: Shilo, Guy; Mor, Zohar
title: COVID-19 and the changes in sexual behavior of men who have sex with men: Results of an online survey
date: 2020-08-10
journal: J Sex Med
DOI: 10.1016/j.jsxm.2020.07.085
sha: cf02e1ea9ab878c4094848b43f167f95c894dcd9
doc_id: 1029726
cord_uid: 7pc0dh09

BACKGROUND: Social-distancing in the wake of the COVID-19 pandemic may affect sexual behavior of men who have sex with men (MSM). In early March 2020, Israel imposed travel restrictions and limited social contacts to household members only. The effects of these restrictions on MSM sexual behavior and mental health are unknown. AIM: To assess sexual behaviors and mental health of Israeli MSM during social-distancing, and to compare sexual behaviors before and during social distancing, due to the COVID-19. METHODS: Data was collected through anonymous web-based questionnaires in a popular geospatial application used by MSM between March and April 2020 during the social-distancing period. OUTCOMES: The dependent variable was casual sex, in violation of Social-distancing regulations. Independent variables were demographic characteristics; sexual behaviors before and during social-distancing restrictions; and mental health. RESULTS: Of the 2,562 participants, 1,012 (39.5%) continued to meet new casual sex partners during this period. Being of a younger age, single, and with higher levels of mental distress predicted engagement in casual sex during the social-distancing period. MSM reduced their sexual risk and limited sexual repertoire – in particular, kissing with their sexual partners. Participants also spent more time in dating applications than in the pre- social-distancing, and increased their use of sex-phone, web-cams and porn consumption. They perceived the threat of SARS-CoV-2 to be greater than that of HIV: only 3.2% could imagine themselves having sex with a partner who is infected with SARS-CoV-2 compared with 30.1% in case of HIV, p<0.01. CLINICAL IMPLICATIONS: MSM reduced their risk behaviors during social-distancing, due to the threat of COVID-19. Casual sex during social-distancing was associated with negative feelings of mental distress. Future public health response in the future waves of COVID-19 morbidity should strike a balance between containment measures, and the need for social-distancing with its possible mental and social burdens. STRENGTHS AND LIMITATIONS: This is the first study in Israel, and one of the few in the world to examine sexual behavior among MSM during the COVID-19 social-distancing. It involved a relatively large sample, through convenience sampling, which limits causality. Findings should be interpreted cautiously- specifically since COVID-19 related behaviors and circumstances may change rapidly. CONCLUSION: The negative feelings of distress due to social-distancing should be considered as a potential barrier to adherence among vulnerable populations, such as MSM. Future public health response should strike a balance between containment measures and its possible mental, social and financial burdens.

The COVID-19 pandemic, caused by the coronavirus that emerged in China in December 2019, has reached Israel at the end of February 2020. The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is easily transmitted through aerosol, and to a lesser extent through physical contact. Without available vaccines, the main responses to the pandemic have been social-distancing and maintaining respiratory hygiene, as recommended by the World Health Organization 1 and European Centre for Disease Prevention and Control, 2 and adopted by many governments around the world. Social isolation, loss of income and disruption of family ties have cut off individuals from their customary social networks.

The social and behavioral restrictions due to the COVID-19 pandemic may have also affected sexual behavior -although research in this field is still limited. A recent study from China, 3 involving 459 men and women, found a drop of 44% in the number of sexual partners, and 37% in sexual frequency, during the period of COVID-19 lockdown. Younger age, being single, and high sexual drive were found to predict higher sexual frequency. 3 The study also reported a decrease in risky sexual behaviors in this period. Another study, involving 1051 men who have sex with men (MSM) in the United States, 4 found that half of the sample reduced their number of sex partners during the COVID-19 social restrictions, and many experienced adverse effects on their well-being, and difficulties in accessing HIV testing and treatment.

MSM are generally considered a social minority population, even in a relatively liberal country such as Israel. They may be at a higher risk of experiencing stigma 5 and minority stressors, both of which are known to have a negative effect on J o u r n a l P r e -p r o o f their mental health. 6 Moreover, MSM are more likely than heterosexuals to be singles 7 , which heightens mental distress and increases the sense of loneliness. Socialdistancing due to COVID-19 has also limited the support that MSM can receive from their family, friends, and the wider gay community. 8 10, 11 The purpose of this study was to assess the impact of the threat of COVID-19 on the sexual practices, behaviors, and the well-being of MSM in Israel, and to compare these among those who changed their sexual behavior during the outbreak, with those who did not. Since the MSM community typically exhibits high levels of stress in normal times, the impact of COVID-19 may be critical. We hypothesized that the social-distancing would reduce the number of casual sex encounters among the Israeli MSM, and have a negative effect on their mental health. The outcomes of J o u r n a l P r e -p r o o f this study may help decision-makers in understanding the impact of an outbreak on vulnerable populations, and in establishing support mechanisms for the MSM community in periods of social instability.

Data for this cross-sectional study was collected through anonymous webbased questionnaires, that were distributed through a popular geospatial dating app used by MSM who seek dating in Israel (Atraf Dating) and other social networks (Facebook and WhatsApp groups) between late March and the month of April 2020.

On March 19, 2020, the Israeli government declared a national state of emergency, and between March 25 th and May 1 st , movement restrictions were imposed (e.g., not venturing more than 100 meters from home; maintaining social-distancing of at least 2 meters with non-household members; limiting outings; store closings), including periodic lockdowns.

Participants for this convenience sample were MSM older than 18 years of age. They were offered to provide their e-mail address to partake in a lottery for a US$60 coupon. The purpose of the study was stated on page 1 of the questionnaire:

To study the sexual practices of men who have sex with men during the COVID-19 pandemic and the emotional impacts of the pandemic. Participants were also asked to provide consent electronically before completing the questionnaires. The study was approved by the Institutional Ethical Review Board of Tel Aviv University (#1281-1).

The questionnaires included demographic characteristics and participants were asked how they self-identify (heterosexual, gay, bisexual/multi-sexual); their level of education (elementary, high school, or higher academic education. Scores were dichotomized by median to non-academic and academic degree); monthly income J o u r n a l P r e -p r o o f (which was dichotomized in relation to the average monthly income in Israel); their COVID-19 status (current diagnosis and isolation; being in a close contact with confirmed cases); sexual activity with other males before and after social-distancing restrictions (number of male sexual partners during sexual isolation; sexual practices; alcohol and drug use during the sexual activity; preferred meeting venues for sexual partners; frequency of using sex-phone/webcam or porn for sexual satisfaction -both on a 5-point scale ranging from Never = 1 to Very often = 5). All questions were referred to sexual behaviors with other males.

To assess their mental health, participants were asked to complete the Mental Health Inventory (MHI short version), 17 that gauges mental distress (8 items, such as:

"Being a very nervous person", "Being anxious or worried", "Feeling depressed" ) and well-being (7 items, such as : "Being a happy person", "My daily life has been full of interesting things", "Feeling emotionally stable"). Items were rated on a six-point scale ranging from 1 (Strongly disagree) to 6 (Strongly agree). Participants were asked to rate the degree to which these statements reflected their feelings and emotions in the past month, since the imposition of social-distancing restrictions.

Scores for mental distress and well-being were then calculated as the sum of item measures for each of the scales: the higher the score, the greater the distress and wellbeing. The present study demonstrated a reliability of α = 0.92 for the distress scale and α = 0.89 for the well-being scale.

Sexual risk behavior was calculated as a sum of three practices: anal intercourse without a condom/PrEP; use of drugs; and use of alcohol before or during sex (No = 0; Yes = 1), as in previous studies. 18, 19 The overall sexual risk ranged from 0 to 3: the higher the score, the higher the risk. The present study demonstrated a reliability of α = 0.80 for the Sexual Risk Behavior scale.

The dependent variable for this study was meeting a new casual-sex partner during the social-distancing period, in violation of social-distancing restrictions. This included single MSM who met a new partner, as well as those who were in a steady relationship and took up casual sex partner(s). Independent variables were compared by the Chi-square or the Student's t-test for categorical and continuous variables, respectively. P values below 5% were considered statistically significant. Variables whose p < 2% in the univariate analyses were included in the multivariate analysis, to identify attributes associated with casual sex during the social-distancing period. The sexual behaviors of participants who engaged in casual sex during the COVID-19

restrictions were compared with their sexual behaviors before social-distancing restrictions were imposed, using paired Student's t-test in cases where the variables were continuous, and by the McNemar's Chi-square test for categorical variables. The Pearson correlation coefficient was used to assess correlations between continual sexual behavior variables and mental distress. Data analysis was performed using SPSS 25 (IBM, 2017).

During the social restriction period, 2,562 (85.8%) participants of the 2,987 men who first responded completed the entire questionnaire. Their average age was of 37 years (SD = 11.3, range: 18-76). Most (N=1,970, 76.9%) self-identified as gay; 21 .5% (N = 551) self-identified as bisexuals; 1.6% (N = 41) self-identified as J o u r n a l P r e -p r o o f heterosexuals, even though they had sex with men. Nearly a quarter (N = 642, 24.9%) were in a steady relationship at the time, while 61.4% (N=394) of those reported at least one concomitant casual sex partner. Of all participants, 13 (0.5%) had tested COVID-19-positive; 10 (0.4%) shared household with someone who had tested positive, and 369 (14.4%) had been ordered to self-isolate due to exposure to a confirmed case.

In defiance of social-distancing restrictions, 1,012 (39.5%) had met a new casual sex partner during that period. Most of these (N=850, 84%) had had up to three sexual partners, while 21 (2.1%) met over 10 sexual partners, and 24 (2.4%) reported taking part in in-house orgies.

Men who engaged in casual sex despite the social-distancing regulations were more commonly younger, singles, and less educated compared to participants who abstained from casual sex (Table 1 ). They also exhibited higher levels of mental distress and lower levels of well-being compared to those who abstained from casual sex.

Logistic regression analysis revealed that being of a younger age, single, and with higher levels of mental distress predicted engagement in casual sex during the social-distancing restrictions due to the COVID-19 (Table 2) . Being single and having higher levels of mental distress were the strongest predictors of engaging in casual sex.

Study participants who engaged in casual sex during the social-distancing restriction period were asked to report their sexual activities before and during that period. Of those who had casual sex during the social-distancing period, 72.1% J o u r n a l P r e -p r o o f reported that the number of casual sex partners was lower than in the pre-socialdistancing period. Participants also reported having reduced their sexually risky behaviors in comparison with the pre-social-distancing period (Table 3) . Specifically, they were less likely to engage in kissing with their sexual partner, or indulge in practices such as anal and oral sex, consume illicit drugs or alcohol during sex, or paying or being paid for sex. During the social-distancing period, they were more likely to use condoms or PrEP in casual sexual intercourse than in pre-pandemic times. Since the imposition of social-distancing rules, participants met sexual partners mainly through online dating apps and social media, and increased their use of sexphone, web-cams, and porn in relation to the pre-COVID-19 outbreak.

While 90% (2,310) of all participants used MSM dating apps during the social-distancing period, over a third (N=966, 37.7%) reported that they spent more time in dating applications in search of sexual partners than in the pre-restriction period. Interestingly, 23.1% (N=591) reported that their sexual desire diminished under the social-distancing regime compared with pre-pandemic period.

Men who engaged in casual sex during the social-distancing period were compared to men who used to have casual sex before social distancing, but opted to stop meeting new sexual partners after the COVID-19 outbreak, on their sexual behaviors before the COVID-19 pandemic (Table 4 ). MSM who continued to engage in casual sex despite the social restriction regulations were also more likely to engage in higher sexually risky behaviors before the outbreak of COVID-19; to perform more anal sex; to use toys in sexual encounters; and to pay or being paid for sex frequently before the COVID-19 pandemic than men who abstained from casual sex during the social-distancing period.

Among all participants, a significant correlation was found between mental distress and the use of sex-phones or webcams (r=0.11; p<0.01) and porn (r=0.10; p<0.01) during the social-distancing period.

Participants were asked if they were willing to have sex with someone who is known to have HIV, or with someone diagnosed with COVID-19 (Table 5) . Only a very small percentage of participants (N=83, 3.2%) were prepared to have sex with a partner diagnosed with COVID-19, while significantly more (N=722, 30.1%) were potentially prepared to have sex with a partner diagnosed with HIV.

In this study -one of the first studies to assess changes in sexual behavior among MSM during social-distancing restrictions due to the COVID-19 -39.6% (N=1,012) reported having met a new sex partner in defiance of distancing regulation.

Some of them were among the 28.6% of participants who reported having steady relationships, despite the potential risk of transmitting SARS-CoV-2 from the new casual partner to their committed steady partner. These findings are in line with the few other studies that have examined sexual practices among heterosexuals and MSM during the COVID-19 pandemic 3,4 . However, participants in this study who had casual sex during the social-distancing period sought to reduce the risk of contagion by limiting their sexual repertoire in relation to their pre-social-distancing sexual behavior -in particular, by avoiding kissing their partner. They also reduced their use of drugs or alcohol and used condoms or PrEP more often. It seems that those who violated social-distancing restrictions sought to minimize physical contact with their sexual partners, and modified their sexual behavior, in a bid to reduce their exposure to the virus.

Although HIV is a life-long condition and its health outcomes in younger patients without medical treatment are usually worse than those of COVID-19, a significantly more participants could imagine having sex with a partner who was diagnosed with HIV than with someone diagnosed with SARS-CoV-2. Perhaps the uncertainty surrounding COVID-19 in the absence of an effective vaccine or medical treatment, coupled with the distressing news about it on the media, intimidated MSM more than the threat of HIV. Indeed, one as yet unpublished study has found that people in Israel perceived the threat of COVID-19 to be higher than that of a terrorist attack or street crime 20 . Accordingly, the MSM in this study responded by reducing their sexual risk. One might ask whether COVID-19 has succeeded in restraining risky sexual behaviors among MSM more effectively than four decades of continual interventions to prevent HIV. It appears that the familiar risk of HIV has been superseded by a new threat, that is perceived to be more dangerous. MSM have independently developed several risk-reduction techniques to protect themselves from HIV-such as "sero-sorting" and "strategic positioning". 16 It is possible that MSM who continued having casual sex have used that experience and adopted risk-reduction techniques against SARS-CoV-2, to assume control of their health by weighing the risks of being infected against their sexual needs. For example, they decreased -but not entirely eliminated --the number of their sexual partners, and limited their SARS-CoV-2 exposure by reducing the frequency with which they kissed their sexual partner(s). Not surprisingly, as a result of these responses to the external threat of COVID-19, the MSM in this study (as in others 21 ) also reduced their risk of catching HIV or other sexually transmitted diseases by limiting their sexual repertoire, and using condoms more often..

MSM who engaged in casual sex during the social-distancing period due to the COVID-19 pandemic were younger, more likely to be single, and demonstrated riskier sexual behavior before the pandemic, compared to those who complied with social-distancing regulations. They also exhibited lower levels of well-being, and higher levels of distress. The association between higher levels of mental distress, being single, and having casual sex during the social-distancing period, highlights the burden of loneliness -especially during imposed isolation due to the COVID-19.

These findings echo concerns about the vulnerability of sexual minorities to depression and negative mental health outcomes 6,19 -particularly in times of social distancing, when essential support, intimacy, and shared experience with their family and friends are no longer available. 8 Loneliness is a prime indicator for low levels of well-being, and a risk factor for mental disorders -such as depression, anxiety, adjustment disorder, stress, and insomnia. 22 These negative feelings may have driven some MSM to engage in casual sex, despites regulations, while putting themselves and their household members at risk of possible SARS-CoV-2 infection. As MSM are generally more likely than heterosexuals to be singles, 7 they are more likely to report a feeling lonely and susceptible to emotional distress, 6 while lacking the mental resources needed to comply with social distancing. As one of the study participants put it in private comment with the authors, as he was trying to explain why he had sex during the restrictions period: "Social isolation" he wrote, "defeated the fear of COVID-19".

As expected, 23 men increased their use of remote sexual satisfaction options, such as sex-phone, webcam sex or porn consumption, in relation to the pre-socialdistancing period. These behaviors were also correlated with higher levels of mental distress -suggesting that pornography during social-distancing due to COVID-19 J o u r n a l P r e -p r o o f served not only as a means of self-satisfaction, but also used as a coping mechanism to reduce the stress of uncertainty and insecurity. 23, 24 Although remote devices of sexual satisfaction could ease the sense of loneliness, porn consumption and the use of webcams or sex-phones were not found to be predictors of abstaining from casual sex during the social-distancing period. Interestingly, while dating apps and web-based social venues were the main means of meeting other MSM during social-distancing period, only 40% used them to find sexual partners. This suggests that these applications are part of the social landscape of the gay and MSM communities, and MSM use these platforms for chats and social gatherings, as well. As such, it is a useful means within the gay community to communicate health messages.

This study has several limitations. Although the sample for this study is large, especially for a small country such as Israel, the use of convenience sampling limits causality. In addition, findings should be interpreted cautiously, especially since COVID-19 related behaviors and circumstances can change rapidly. Further studies on the impact of COVID-19 on MSM population are needed to clarify this study finding.

This study demonstrated that social-distancing due to the COVID-19 pandemic has changed sexual behaviors among MSM. Participants -including those who continued to engage in casual sex -reduced the number of their sexual partners, and limited their sexual repertoire. Having casual sex in defiance of social-distancing regulations was associated with mental distress. Negative feelings of loneliness due to social isolation is thought to be one of the serious consequences of COVID-19, specifically among vulnerable populations, 25 and should be considered as a potential barrier to adherence to regulations among other vulnerable populations, such as MSM. Future public health response in future waves of COVID morbidity should weigh the benefits of containment measures against the mental, social, and financial burdens that they may entail. 26 ; c Participants were asked who knows of their sexual orientation (0 -some/all acquaintances and family know; 1 -no one knows); d Mental Health Inventory score; SD = Standard Deviation 

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