A cross-sectional survey on attitudes of men who have sex with men towards anal self-examination for detection of anal syphilis

Between July and November 2020, a total of 3154 SMS was sent to men attending MSHC. Of those, 620 (20%) clicked the survey link and started the survey. Additionally, 89 surveys were received through social media from the community. Hence, a total of 709 responses were received. We excluded 141 participants, including 77 who did not complete surveys; 33 did not consent to participate the survey; 19 living outside Australia or declined to disclose where they lived; eight reported no sexual contact with another man in the last 12 months; and four self-identified as cis-female or female gender.

The remaining 568 men were included in the final analysis and the median age was 34 (IQR 27–45) (Table 1). The majority were cis male (98%, n = 556). Most men reported sex with men only (91%, n = 514), and a small proportion reported having sex with both men and women (9%, n = 50). There were a few men who preferred not to report their sexual orientation (1%, n = 7). About one-third of men reported they had ever performed ASE (32%, n = 183) among 557 men who answered the question on previous experience of ASE. Table 1 shows the demographic characteristics of men who had performed ASE previously and who had never performed ASE with no statistically significant differences between the two groups.

Preferences for performing self-examination among men who had ever performed ASE

The median frequency of performing ASE was one (IQR 0.2–3) per four weeks. Of 183 men who had ever performed ASE, 176 provided answers for ASE positions, and the most commonly reported position was standing (50%, n = 88), followed by squatting (45%, n = 80) (Fig. 1). There were 28% (n = 50) men who reported using more than one position for ASE, and the most common combination was standing and lying on their back (5%, n = 8).

Positions used by MSM who had ever performed ASE and positions likely to be used by MSM who had never performed ASEs. Multiple positions were selected, and the total will exceed 100%. The choices were not mutually exclusive. 95% confidence interval expressed in brackets following the proportion. Note: 176 men who had ever performed ASE and 227 who had never performed ASE answered questions on sexual positions. Six men in the ever-performed ASE chose other positions. Other positions were not asked in the never performed ASE group. This category was not included in the graph.

Most men performed ASE in the shower (61%, n = 106), followed by in the bathroom or toilet (49%, n = 85). Most men (94%, n = 163) reported using at least one accessory when performing ASE. The most commonly used accessory was lubricant including sorbolene and saliva(59%, n = 103), followed by water (39%,n = 68), soap (26%, n = 45), mirror (24%, n = 42), and gloves (11%, n = 19) during ASE (Table 2).

Of 173 men who had ever performed ASE, 47% (n = 81) had ever felt something abnormal during ASE, with more than half of these men (63%, n = 50) reported the findings as a “lump”, while 38% (n = 30) reported bleeding and 28% (n = 22) reported ulcers and/or sores (Table 2). Most (66%, n = 115) found it easy or very easy to perform ASE. Only 8% (n = 13) found it difficult or very difficult to perform ASEs (Table 2).

Men were presented with potential resources and information that might be useful for MSM who had never performed ASEs (e.g. graphics on poster or website showing how to do an examination, having a doctor or nurse speak in person and explain how to do ASE, or online videos from a trusted source, see Supplementary Material). The top resource that men indicated would likely be helpful was an instructional graphics on posters or websites showing how to do ASE (66%, n = 113) (Table 3). Men were asked about information that might be useful to learn about anal ASE and syphilis such as how to do the examination, what a healthy anus should look, or what a syphilis lesion looks like (see Supplementary Material). Most men (63%, n = 106) reported all the information related to ASE (e.g. how to perform, a healthy look of anus, and syphilis), anorectal syphilis (e.g. what a syphilis lesion looks like, what a syphilis lesion feels like), other non-STI symptoms of the anus and symptoms of anal cancer would be helpful (Table 3).

Among men who had ever performed ASE, 167 men answered the question about recommending ASE to other MSM, and 80% (n = 134) indicated that they were likely or very likely to recommend other MSM to perform ASE.

Preferences that men who had never performed ASE likely to have if they were to perform ASE

Men who had never performed ASE were asked if they would consider ASEs regularly at the recommendation of a doctor to detect syphilis sores or ulcers. Among the 374 men who never performed anal self-examinations, 68% (250) would consider anal self-examinations in the future for anal syphilis detection, while 18% (65) would like more information about the examination. Nine percent (35) were unable to decide if they would consider anal self-examination and 5% (20) did not want to perform anal self-examinations at all.

Of the 374 men who had never performed ASE, 28% (n = 105) men engaged in receptive anal sex; 52% (n = 193) men engaged in versatile anal sex. Among 298 men engaging in receptive or versatile anal sex and never performed ASE, 69% (n = 205) would consider performing ASE to detect early syphilis in the future, while 18% (n = 54) would like to receive more information about ASE before making the decision. Eight percent (n = 24) were unable to decide if they would consider performing ASE, and 4% (n = 12) did not want to perform ASE at all.

Among the men recruited from the community and never performed ASE (n = 36), 44% (n = 16) indicated they would be willing to perform ASE, while 52% (n = 19) wanted more information or unsure about performing ASE in future (data not shown in “Results”) and 3% (n = 1) did not want to perform ASE in future.

Of the 250 men who were willing to consider performing ASE in the future regardless of their sex position, the median of the preferred frequency for ASE was two times per four weeks (IQR 1–4). Among these men, 205 men engaged in either receptive or versatile anal sex, and the median of the preferred frequency for ASE was four times per four weeks (IQR 1–4).

There were 227 men who had never performed ASE indicated they would most likely prefer standing (39%, n = 88) if they were to perform ASE in the future, followed by squatting (27%, n = 61) (Fig. 1).

Of the 232 men who answered the questions on locations they most likely to perform ASE, 65% (n = 151) reported the shower as the preferred location where they were likely to perform ASE, followed by bathroom or toilet (45%, n = 105) (Table 3). Almost half (43%, n = 98) would consider having their partner (regular romantic or regular sex partners) examine their anus when men were asked if they would let their partner examine their anus. Only a few (8%, n = 17) would consider a casual partner performing the examination.

When presented with choices of who they prefer to be performing an anal examination as a screening method, 45% (n = 53) of the 117 men who answered the question preferred to have a doctor performed an anal examination to check for syphilis lesions in their anus, although some men (28%, n = 33) preferred performing anal examination themselves and 27% (n = 31) did not have a preference.

Men were asked what type of information they would like about ASE in relation to technique of ASE, recognising abnormalities, and about anorectal syphilis. Of the 328 men answering questions, all of them would like at least some information about ASE and anorectal syphilis (e.g., how to perform ASE, how to distinguish between normal and abnormal findings, what a syphilis lesion looks like) with 59% (n = 193) wanting all the information about ASE, syphilis lesions, other non-STI symptoms of anus and symptoms of anal cancer (Table 3).

Men were also asked how they would like to access learning resources for ASE such as learning from online platform, a video, or a doctor. The majority (96%, n = 315) of men who had never performed ASE would like to learn from various resources such as through a website with instructional graphics, online videos, through doctors/nurses, and a small number reported willing to learn from friends or partners, whilst only 4% (n = 4) reported not needing any resources (Table 3).

Of the 324 men who answered questions on future ASE considerations and had never performed ASE, the majority were very likely or likely to consider performing ASE in the future (89%, n = 288), whilst 2% (n = 6) chose not to perform ASE in the future, and 9% (n = 20) were unable to decide.