Sexual Health Knowledge, Attitudes, and Perceptions Among Men Who Have Sex With Men During Co-Occurring Sexually Transmitted Infection Epidemics in Toronto, Canada: A Qualitative Study.

Background Our objective was to explore the sexual health knowledge, attitudes, and perceptions of men who have sex with men (MSM). Methods In-depth interviews were conducted with 31 MSM who lived, worked, or socialized in Toronto in June and July 2016. Participants were asked about concepts of risky sex and knowledge of, and attitudes toward, sexually transmitted infections (STIs), especially syphilis, and potential interventions. Thematic analysis was used to analyze interview transcripts. Results The prevention of STI relied on HIV prevention strategies. No one used condoms for oral sex, nor did they intend to. Pre-exposure prophylaxis was perceived as both threatening and liberating. Concepts of risky sex included emotional risk. Conversations with partners about STI testing were easier than STI status. Stigma and concealment of sexual identity were barriers to sexual health care. None of the participants recommended sexual behavior or sexual health interventions. Instead, recommendations centered on social changes to reduce or eliminate shame, embarrassment, stigma, and discrimination around both STIs and sexual orientation. Conclusion Participants were thinking about sexual risk and using a variety of ways to prevent STI transmission, although most relied on HIV prevention strategies, possibly because they knew little about other STIs, and other STIs were perceived as curable, especially syphilis. Interventions promoting conversations about STI testing may be promising and will also reduce stigma as STI testing is normalized. Social and clinic interventions focused on creating psychologically safe spaces to disclose sexual identity and providing sexual orientation affirming health care may reduce STIs and improve sexual health for MSM.