Sexual Behavior and Sexual Decision‑Making Among Gay, Bisexual, and Other Men Who Have Sex with Men During the COVID‑19 Pandemic: Observations from a Rapid Ethnographic Assessment in Marion County, Indiana, October–November 2021

Abstract

From 2020 to 2021, Marion County, Indiana, USA, saw an increase in early syphilis diagnoses, primarily among gay, bisexual, and other men who have sex with men (GBMSM). This rapid ethnographic assessment combines survey data from GBMSM with data from key informant interviews with multiple groups of stakeholders, including GBMSM, to describe how COVID-19 impacted sexual behaviors, sexual decision-making, and access to sexually transmitted disease (STD) services among GBMSM in Marion County, Indiana. A total of 62 virtual, semi-structured qualitative interviews with 72 key respondents including health department staff, medical providers, community-based organization staff, and GBMSM were conducted from October 14 to November 22, 2021. Modifications to partner-seeking and sexual behaviors attributable to the pandemic were associated with the way in which individuals reacted to the pandemic in general. Some GBMSM adopted mitigation strategies to avoid COVID-19 when meeting sex partners, such as creating a “sex pod.” Effects on mental health included increased loneliness, heightened anxiety, and a sense of hopelessness regarding the perceived inevitability of acquiring COVID-19. For some, the latter prompted decreased engagement in preventive measures when engaging in sexual activity. The pandemic decreased access to STD services and significantly curtailed public health outreach efforts, which may have limited access to needed STD treatment and care. Efforts focusing on ongoing public health concerns during extreme health events like COVID-19 may want to consider the many ways these events affect ancillary behaviors, such sexual decision-making and sexual behaviors. The role of mental health is key; messaging and guidance may benefit from a trauma-informed approach.

Introduction

The COVID-19 pandemic disrupted numerous aspects of daily life for people and systems. As COVID-19 case rates rose and the strain on health-care systems increased, many US states and the federal government recommended mitigation measures or enacted stay-at-home or lockdown orders to reduce the spread of infection by limiting opportunities for personal interaction (National Academy for State Health Policy, 2022). Concomitantly, public health resources were redirected to COVID-19 pandemic response efforts and away from other ongoing public health functions (National Coalition of STD Directors, 2021; Tao et al., 2021).

In this context and during the same time (2020–2021), the state of Indiana also saw increases in syphilis state-wide, with 70 of 90 counties reporting infectious syphilis cases. Marion County, Indiana, was among the areas where the levels of early syphilis exceeded the previous year, with an increase from 317 to 536 cases (69%). Increases were primarily seen among gay, bisexual, and other men who have sex with men (GBMSM). In response to a request from the Indiana Department of Health (IDOH) and Marion County Public Health Department (MCPHD), the Division of Sexually Transmitted Disease Prevention at the Centers for Disease Control and Prevention (CDC) conducted a Rapid Ethnographic Assessment (REA) to examine increases in primary, secondary, and early non-primary/non-secondary cases of syphilis in Marion County and several surrounding counties in Indiana among GBMSM.

Early reports about the impact of the COVID-19 pandemic on sexual behaviors often indicated at least some decrease in the number of sexual partners (Gleason et al., 2021), including among GBMSM (Grov et al., 2022; McKay et al., 2023; Sanchez et al., 2020; Schumacher et al., 2022). For some GBMSM, this included less sex with casual partners (McKay et al., 2023), fewer reports of multiple new partners (Schumacher et al., 2022), and less condomless anal intercourse with casual partners (Starks et al., 2020). However, not all studies reported decreases in sexual behaviors. Across two online surveys of GBMSM from April to May 2020 and November 2020 to January 2021, researchers found a sustained mean increase in the reported number of sex partners compared to pre-pandemic reports (Stephenson et al., 2021, 2022). Early in the pandemic, perceptions of higher COVID-19 prevalence in a respondent’s county were associated with significant declines in the reported number of sex partners (Stephenson et al., 2021, 2022). GBMSM who reported a higher prevalence of COVID-19 among their friends reported significant declines in sex and anal sex partners whereas GBMSM who felt the pandemic would not end for at least 6–12 months or would never end reported increases in the number of sex partners and condomless anal sex partners.

Some researchers and practitioners expressed heightened concern for the health and well-being of sexual minority populations as a result of social correlates of the pandemic (Akre et al., 2021; Nelson et al., 2020). For some, stay-at-home and lockdown orders may have meant that they were spending more time at home with family or other cohabitants who did not know about or were not supportive of their sexual orientation. Relatedly, these orders may have limited contact with social support networks some sexual minority individuals depended on to replace relationships strained by familial rejection. One study found that sexual minority participants were more likely than heterosexual participants to report “more than usual” levels of depression, anxiety, and alcohol use (Akre et al., 2021). Others described high rates of loss of income, food hardship, and problems affording housing as a result of the pandemic among sexual minority individuals (Sanchez et al., 2020; Timmins et al., 2022).

The COVID-19 pandemic was also associated with decreased access to STD and HIV testing and associated sexual health-care services. An analysis using health plan data found a drastic decrease in STD testing in the first 3 months of the pandemic; for syphilis, this decrease was 24% lower compared to the rate during the prior year while positivity increased by 19% (Chang et al., 2022). A comparison of testing using a large national laboratory dataset found that STD testing levels did not rebound to 2019 levels until mid-September of 2020, roughly 5 months after the US declared COVID-19 to be a national emergency (Tao et al., 2022). Reports from PrEP-using GBMSM indicated that a portion stopped using PrEP or took fewer doses (Grov et al., 2022; Pampati et al., 2021). Many STD clinics were forced to reduce service offerings (Berzkalns et al., 2021; Johnson et al., 2021; National Coalition of STD Directors, 2021; Tao et al., 2021), and nationally, STD cases diagnosed at emergency departments or urgent care clinics increased while STD cases diagnosed at STD clinics decreased (Pagaoa et al., 2021).

The objective of this REA was to generate a comprehensive understanding of factors contributing to the increases in syphilis in Marion County and several surrounding counties in Indiana (hereafter, Marion County) through the integration of multiple perspectives from state and local health department (HD) staff, health-care providers (public and private), staff from agencies/organizations that serve GBMSM, and GBMSM with a previous syphilis infection or who were at increased risk for syphilis infection. Among the areas of foci for the REA were an examination of the possible impact of the COVID-19 pandemic on sexual behaviors, sexual decision-making, and access to STD care and treatment. This assessment reports on findings from key informant interviews among multiple groups of stakeholders, including GBMSM, to describe how the pandemic impacted sexual behaviors, sexual decision-making, and access to STD services among GBMSM in Marion County.

Method

Participants

Using a team-based, REA approach, a four-person team of behavioral/health scientists from CDC conducted 62 virtual, semi-structured qualitative interviews with 72 key informants in Marion County between October 14 and November 22, 2021. Although the team sought to interview key informants individually, some organizations requested the inclusion of multiple staff resulting in more key informants than unique interviews. Key informant interviews generated a comprehensive understanding of factors contributing to the increases in syphilis in Marion County through the integration of multiple perspectives from state and local health department staff (HD), health-care providers (public and private), staff from agencies/organizations that serve GBMSM, and GBMSM with a previous syphilis infection or at increased risk for syphilis infection.

Measures and Procedure

All interviews were conducted in English, with one team member as a primary interviewer and a second as a note-taker. We obtained verbal consent to participate and be audio-recorded prior to interviews. This analysis focuses on findings specific to individual or public health responses to the COVID-19 pandemic. Of the five research questions guiding the overarching REA, the question addressed by this analysis was: Have there been changes in patterns of behavior, including changes in sexual practices, networks, app use for partner-seeking, intravenous methamphetamine use, condom use, and receipt of sexual health services since COVID?

We contacted medical providers who had diagnosed a case of syphilis in the previous year, public health staff and high-priority partners providing sexual health services in Marion County, and individuals in key community-based organizations (CBOs) with ties to the GBMSM community. Key informants and MCPHD assisted with the recruitment of members of the GBMSM community. In some cases, respondents who were contacted for their professional role were also members of the GBMSM community and were encouraged to draw from their personal experience; such respondents are not reflected in the count of GBMSM community members. Respondents were IDOH and MCPHD HD staff (n = 13/72, 18%), medical providers (n = 29/72, 40%), CBOs/partners (n = 24/72, 33%), and GBMSM community members (n = 6/72, 8%).

Data Analysis

We analyzed key themes using the Matrix Method (Groenland, 2014). For this analysis, rows in the matrix represented questions asked in the semi-structured interview guide which directly addressed the research question specific to COVID-19. Columns represented interviewee type. Following a broad, introductory “grand tour” question which was inclusive of COVID-19 (Sangaramoorthy & Kroeger, 2020), interviews for community members included four COVID-19 specific questions; all other interview guides included one COVID-19 specific question. Immediately following the interview, the notetaker abstracted information from interview notes which addressed the primary research question and recorded them in the Matrix. Information was sorted into themes by the REA team during twice-weekly meetings. One team member was assigned to analyze the themes identified for this research question.

This project was determined to be exempt from IRB review by the Centers for Disease Control and Prevention as it was part of a larger outbreak response.

Results

Respondents described a variety of perceived COVID-related behavior changes that could explain the observed increase in syphilis among the GBMSM community. Overall, many speculated that modifications to partner-seeking and sexual behaviors attributable to the pandemic were specific to the individual and to the way they reacted to the pandemic in general, their sense of personal vulnerability to COVID-19 infection, and concerns about exposing family or loved ones to COVID-19 infection.

Mental Health

Respondents frequently spoke of the mental and emotional toll of the pandemic and resulting social isolation, and how those, in turn, could have affected GBMSM. Some described how the pandemic exhausted people, both in terms of concern for their own health but also in their motivation to practice safer sex behaviors or mitigate COVID-19 infection risk. Some GBMSM respondents felt that acquiring COVID-19 was inevitable. This sense of fatalism was discussed in the context of the perceived inevitability of negative outcomes resulting from the pandemic. According to some respondents, this influenced sexual decision-making:

Some guys have mindset of “we’re going to die anyway,” so why not do whatever [sexually]. (GBMSM respondent);

[The] pandemic put life in perspective for some and they want to live life to the fullest now. [I] think people [were] having more sex during COVID than before. (GBMSM respondent)

Loneliness was also often mentioned as a consequence of the pandemic and as a perceived reason for GBMSM to seek out companionship and sex to cope with mental health challenges:

Loneliness is epidemic right now. (Medical Provider); Many are struggling with mood and anxiety… Every social stressor is going up, which leads to people trying to make even temporary connections. (Medical Provider)

The latter respondent, whose patient population was primarily individuals living with HIV, further described how the stressors that usually impact their patient population had been made worse by consequences of the pandemic, including the loss of close family members, more transient housing situations, and job loss. Others discussed the perceived impact of the pandemic on individual behavior, noting that the pandemic produced high anxiety, which also may have influenced sexual behavior:

People may have tried to alleviate that anxiety through sex, including higher risk activities and more partners. (Medical Provider)

Although some felt that the pandemic had not changed sexual behaviors, others surmised that lockdowns and restrictions imposed by public health mitigation efforts prompted people to engage in more risk behaviors. Several respondents felt that the pandemic created a sense of recklessness in some GBMSM. One GBMSM respondent said that he felt that people’s standards for sexual partners had changed during the pandemic and that they were engaging with partners, they would not have engaged with before, including partners engaging in fewer prevention measures to safeguard their sexual health. Others felt that sexual behaviors remained relatively unchanged, though the pandemic may have enhanced already existing trends, such as increased condomless anal intercourse, using dating apps to find sexual partners and/or sex with anonymous partners.

Although respondents described relatively few changes, either increased or decreased, to drug use during the pandemic, some felt that the pandemic may have prompted a return to drug use for some individuals.

I know people who had stopped for years, but in the middle of COVID, with loneliness and an inability to get to meetings, they started using again. (CBO respondent)

Access to STD Testing and Treatment

Notably, a number of respondents described the ways in which COVID-19 affected health-care seeking. They noted difficulties accessing care, with many health-care providers limiting the number of patients seen or seeing only those patients with serious symptoms, particularly when COVID-19 case rates were high. Many talked about the shutdown of access to care during COVID-19 and the difficulty reaching those in the highest risk categories (e.g., substance users and sex workers) to bring them into care. Some talked of how the mitigation measures taken during the pandemic had removed some of the flexibility needed by patients with barriers to accessing care, such as after hours and walk-in appointments.

Respondents discussed how the majority of public health-focused outreach efforts were curtailed as part of COVID-19 public health mitigation measures, and many of the venues which had previously hosted STI/HIV screening events, such as bars and clubs, were closed, limiting the ability to reach GBMSM in non-clinical settings. One HD respondent talked about the lingering effect of COVID-19-related changes on patient load, indicating that the number of patients seen had not yet returned to pre-pandemic numbers.

Some provider respondents felt that providers in general were less likely to do comprehensive STD testing during the pandemic, even for those patients able to secure appointments. Providers were “only doing what was absolutely needed which, by definition, would vary from provider to provider.” (Medical Provider) One provider noted that they had seen the highest rates of gonorrhea, they had ever seen during lockdown, which may have been because they were seeing patients, and especially asymptomatic patients, who reported being unable to get in to be seen elsewhere. Other providers noted supply shortages which impacted testing, including one provider who said that they had run out of swabs at one point during the pandemic. On the patient side, respondents discussed how restrictions in services and economic hardships linked to the pandemic may have made it more difficult to secure transportation or to afford medical care costs, which may have exacerbated their inability to seek and receive health care above and beyond health-care infrastructure-associated limitations.

Dating Apps

COVID-19 lockdowns were described as impeding the ability of people to meet partners at the bars and venues at which they normally found partners. Some respondents felt that this may have contributed to increased use of dating apps such as Grindr compared to before the pandemic.

There was a notion at [the] local level, with COVID and stay-at-home [orders], that people would be having fewer sexual encounters, and that was not a great assumption. We’ve only seen rises. There was nothing else to do, especially during the 1st year. More people may have met on dating apps to pass the time. (CBO respondent)

Other respondents were less sure about whether the increased use of apps led to increases in meeting people in off-line spaces:

During COVID, it was off the table at the time. I was on the apps before COVID. When COVID hit, I was like “hell the fucking no.” Things got looser after we got the vaccine. Of the people that I saw online, I saw a lot of “not meeting.” (GBMSM respondent)

Mitigation Strategies

Some GBMSM respondents described methods adopted to work within COVID-19 mitigation efforts. For some, this involved creating a “pod” of sexual partners for sexual encounters during the pandemic. One GBMSM respondent described this phenomenon as a greater reliance on people known to the individual or with whom they have had sex before rather than adding new people to the mix. Still others suggested that people had fewer partners early in the pandemic, but that the pandemic was perceived to have created a “pent up demand for socializing” (Medical Provider) and GBMSM later “made up for lost time.” (Medical Provider) Some described this as a perceived “stir-crazy” energy (Medical Provider) that built up during lockdown, which resulted in a sexual release once restrictions eased and vaccinations became available. This was substantiated by GBMSM themselves:

We were starved for physical connection in lockdown… [Then it was like the] “Roaring 20’s”—coming out of COVID, people have more pent-up desire and more sexual activity. (GBMSM respondent)

Conversely, others adopted methods to circumvent COVID-19 mitigation efforts. Multiple respondent types noted an increase in sex parties or reports of an increase in sex parties since the usual venues for meeting and socializing had limited accessibility due to COVID mitigation measures.

Discussion

Our findings add to the growing literature exploring the ancillary effects of the COVID-19 pandemic on other health behaviors. We described how COVID-19 and the pandemic impacted sexual behaviors, sexual decision-making, and access to STD services among GBMSM in Marion County. Overall, much like individual responses to the COVID-19 pandemic varied widely, decisions regarding sexual behavior during COVID-19 also varied. Some of the key factors influencing individuals’ decision-making regarding sexual behaviors were in line with their decision-making in response to the pandemic overall. Despite that, the effect of the pandemic on mental health was perceived to play a key role in decisions about sexual behaviors and sexual encounters. Respondents spoke often about the heightened state of anxiety that the pandemic provoked, about the sense of fatalism it engendered in some, and about the intense desire for personal connection—especially after long periods of lockdown.

Findings from our key informant interviews revealed important nuances in the perceived impact of COVID-19 on GBMSM’s sexual decision-making, behavior, and access to STD services, including the role of perceived personal vulnerability to COVID-19. For example, as one GBMSM respondent described, he and others were unwilling to meet men using dating apps earlier in the pandemic, when lockdown orders were still in place, but more willing to do so after the introduction of the vaccine. In contrast, however, perceived negative effects on mental health were discussed frequently, including isolation, loneliness, and a sense of pandemic-related fatalism alongside reports of increased anxiety and pandemic fatigue. For some GBMSM, the sense of fatalism derived from living in a state of constant uncertainty regarding the course of the pandemic and impending illness was described as a prompt to disregard COVID-19 risk and seek the immediate gratification of connection and companionship. This connection between fatalism and the desire to live fully despite the pandemic has been documented by others working with GBMSM (Braksmajer & Cserni, 2021; Garcia-Iglesias & Ledin, 2021). These findings suggest the need for greater adoption of trauma-informed approaches to messaging and guidance for ongoing public health concerns occurring in the context of a larger public health emergency, and especially one like the COVID-19 pandemic, which was accompanied by ongoing loss of life, sickness, grief, and socioeconomic hardship (Heris et al., 2022).

As elsewhere, our respondents described an epidemic of loneliness and of the compounding stressors, the pandemic added to the lives of already vulnerable individuals, such as GBMSM living with HIV (Akre et al., 2021). Individuals who were already experiencing deprivation or who were at increased risk for negative outcomes as a result of COVID-19 infection because of pre-existing conditions have been found to be less resilient, with longer-term, negative impacts on their mental health (Killi et al., 2023; Pierce et al., 2021). Medical providers and mental health professionals should continue to monitor and address the lingering effects of the COVID-19 pandemic in this population.

We found that some GBMSM developed methods to mitigate COVID-19 risk while continuing to identify opportunities for sex during the pandemic, such as creating “sex pods.” The concept of “pods” of sexual partners and of preferring partners with whom they had a previous sexual relationship instead of new partners, described by GBMSM in this assessment, has also been described elsewhere (Braksmajer & Cserni, 2021; Gilbert et al., 2021). Remarkably, this behavior—to incorporate and adapt general mitigation guidance to limit individual risk for COVID-19 infection but also maintain opportunities for sexual encounters—emerged among GBMSM in the absence of widespread comparable guidance from public health officials and demonstrates a flexible, nimble approach by some in the GBMSM community to limit the spread of COVID-19.

Key informants described several challenges and barriers to accessing health care, and especially STD testing and care, during the pandemic, similar to other studies (Berzkalns et al., 2021; Johnson et al., 2021; Tao et al., 2021). It is possible that the decrease in STD testing resulting from restricted access to health care or because of concerns regarding health-care seeking during the pandemic may have played some role in increased rates of syphilis seen in Marion County. Data collected here cannot verify or quantify this possibility. However, when combined with the perception that the pandemic did not change sexual behaviors or may have prompted changes which increased risk for STD infection for some community members, it is possible that GBMSM with contagious undetected or untreated syphilis may have encountered more partners than usual had prevention, treatment, and outreach efforts not been severely limited by the pandemic.

When weighing findings, it is important to remember that REAs are not intended to measure the extent of an issue and cannot be considered an indicator of magnitude. Instead, they provide insight and contextualize what is happening within a community. Relatedly, the questions asked, and the people interviewed and surveyed were specific to Marion County. Although the findings may be of value to other communities, we would caution against extrapolating too broadly. In the case of HD, medical provider, and CBO respondents, observations represent perceptions of changes, attitudes, beliefs, and behaviors among GBMSM and may be colored by unconscious biases and assumptions. Although we tried to match themes across respondent type where possible, these possible biases and assumptions should be considered when considering the findings. The intent of the REA, to provide actionable feedback to the MCPHD to guide program improvement, necessitated that the assessment be developed, implemented, and analyzed quickly. The research team made concentrated efforts to recruit key informants from each of the identified sectors, including GBMSM community members. Despite these efforts, recruitment of GBMSM community members proved difficult, and this set of key informants had the fewest members. Insight from this section of the community was bolstered by key informants who were part of the GBMSM community but who were contacted because of their primary role. However, the limited reach to this community should be considered when interpreting findings from the GBMSM community.

The COVID-19 pandemic was a disruptive and transformative event, and its effect on health-care systems, social networks, and individual behavior was pervasive. The results of this REA provide insight into how ongoing and rising syphilis transmission among GBMSM interacted with individual, systemic, public health, and health-care system responses to the pandemic in Marion County. This example illustrates patterns that were likely occurring in other jurisdictions as well, with the pandemic curtailing public health outreach and limiting access to key health care and other supportive services despite steady or increasing numbers of STDs, including syphilis. Future widespread infectious disease responses can benefit from what has been learned. We have seen here and elsewhere that while many GBMSM reported no change or a decrease in protective sexual health behaviors in response to the pandemic, others worked to adapt mitigation guidance to reduce their risk. The impact of the pandemic on mental health was profound, creating for some an intense desire for companionship despite possible COVID-19 risks. For others, the perceived inevitability of a COVID-19 infection and a possible negative outcome may have prompted them to disregard all risks. Public health professionals should consider ways to work within these contexts to tailor and frame messaging and target outreach. These findings underscore the need for STD programs and sexual health clinics to routinely seek timely information about behavioral changes from priority populations to guide clinic and outreach activities.

Availability of Data and Materials

Data are not available for reasons of confidentiality.