Public health morality, sex, and COVID-19: sexual minority men’s HIV pre-exposure prophylaxis (PrEP) decision-making during Ontario’s first COVID-19 lockdown

ABSTRACT

Experts have warned that COVID-19 control measures may amplify health inequities among gay, bisexual, queer, and other men who have sex with men (GBM). For HIV-negative GBM, concerns have been raised as to how COVID-19 will disrupt access to HIV pre-exposure prophylaxis (PrEP). Our study offers empirical findings on these issues, drawing on in-depth interviews conducted with 25 HIV-negative GBM living in Ontario, Canada during the first wave of the COVID-19 pandemic. Our thematic analysis draws from the sociology of risk to elucidate how a public health morality – a contested ethical framework determining how to be a ‘responsible’ sexual citizen during the COVID-19 pandemic – informs GBM’s sexual and PrEP decision-making. This public health morality was shaped by several factors, including: self-concern versus risks posed to others; anxiety, economic precarity, and becoming COVID-19 weary; shaming public health non-compliance; and comparisons with HIV and shaming (queer) sex. The participants significantly altered their sexual practices, with some stopping, restarting, and others stockpiling their PrEP. While some men’s sexual practices ran counter to public health messaging to avoid ‘non-essential’ contact with those outside of their households, their risk reduction strategies, including avoiding new sexual partnerships and evaluating people’s ‘common-sense’, mirrored the negotiated safety strategies earlier developed to mitigate HIV risk. Public health advice must account for the nuanced ways in which GBM are mitigating COVID-19 risks and are responding to a complex public health morality, in order to avoid stigmatization and potentially increasing COVID-19 transmission by neglecting practical risk reduction measures.

KEYWORDS:

• COVID-19
• PrEP (pre-exposure prophylaxis)
• gay, bisexual, queer, and other men who have sex with men
• sociology of risk
• public health morality

Introduction

As of July 2021, in Ontario, Canada, 546,804 (3,678.6/100,000) people have been diagnosed with SARS-CoV-2 and 9,237 (62.1/100,000) people have died from COVID-19 (Public Health Ontario, 2021). In response to COVID-19, the Canadian province of Ontario officially declared a State of Emergency on 17 March 2020, leading to its first ‘lockdown’ period which encompassed the closing of schools and ‘non-essential’ businesses, and legal restrictions on gathering sizes and congregating in public. In June 2020, various Ontario regions transitioned to Stages 2 and then 3 of lockdown, each stage involving an easing of some control measures. During this period, requirements were introduced to wear masks or facial coverings when indoors in public spaces and masks were recommended in some outdoors spaces when physical distancing was not possible. Citizens were also encouraged to limit close physical contact to social ‘bubbles’ of ten people or under. In April 2020, the Gay Men’s Sexual Health Alliance (GMSH) in Ontario created COVID-19 educational resources for gay, bisexual, queer, and other men who have sex with men (GBM), encouraging virtual sex and keeping sex to a few partners (GMSH, 2020). Nonetheless, in Ontario, minimal official public health promotion was provided regarding how to maintain one’s sexual health during the COVID-19 lockdown.

Public health and community experts warned early on that COVID-19 could amplify pre-existing health inequities among GBM (Brennan et al., 2020; Kline, 2020; Quinn et al., 2020) and could increase stigma among groups experiencing COVID-19 health inequities (Logie, 2020). In Canada, as elsewhere, GBM have higher rates of HIV and other sexually transmitted infections, and higher levels of substance use, mood disorders, and suicidality than their heterosexual counterparts (Gaspar et al., 2019). Scholars also speculated that COVID-19 could create barriers to HIV related healthcare (Brennan et al., 2020). There were particular concerns regarding how COVID-19 control measures could affect access and adherence to HIV pre-exposure prophylaxis (PrEP), which is the regular use of antiretroviral medication by HIV-negative persons to prevent HIV acquisition (Newman & Guta, 2020). Early quantitative data from Australia (Hammoud et al., 2020) demonstrated that GBM minimized their sexual contacts during the start of the COVID-19 pandemic and many stopped or reduced their PrEP use. Interest in GBM’s sexual proclivities during COVID-19 also appeared across queer media platforms. An Instagram account titled ‘GaysOverCovid’ featured posts of GBM breaking social distancing measures internationally, as a form of public shaming (Mack, 2021).

A subtext of this initial attention to GBM health inequities and COVID-19 was a concern with whether this population was adjusting their sexual practices in response to public health mandates to physically distance. Our study utilizes insights from the sociology of risk and offers empirical findings on this issue by drawing on in-depth interviews conducted with 25 HIV-negative GBM living in Ontario during the first wave of the COVID-19 pandemic.

Public health morality, the sociology of risk and sexual practice

Due to HIV, considering infectious disease risk in nearly all sexual decision-making, managing anxieties with being ‘at-risk’, and confronting uncertain, conflicting, and changing public health messages are familiar phenomena for most GBM (Gaspar, 2017). The sociology of risk has demonstrated that beyond biomedical ‘rational’ interpretations of transmission, an individual’s perceptions of health risks are shaped by multiple social factors informing which types of risk-taking they consider acceptable and how much uncertainty they can tolerate (Gaspar, 2017; Lupton, 1999). For example, trust between sexual partners can significantly affect whether a GBM considers a sexual risk worth taking (Gaspar, 2017).

Douglas (1992) has argued that discourses of risk and prevention are always about morality, blame, and taboo. Enacting prevention is an ethical act, a way to distinguish the ‘responsible’ healthy self from the ‘reckless’ unhealthy other (Crawford, 1994). Public health discourse on infectious disease risk is thus a public health morality, an ethical framework by which to determine how to be a ‘good’ responsible citizen (Petersen & Lupton, 1996). Maintaining public health is connected to ideas of social control, surveillance (discipline), deference to medical expertise and the state, and the fortification of middle-class norms of safety, individual-level autonomy, and self-control (Crawford, 1994). Failure or resistance to enact these values can be met with derision, stigma, criminalization, and pathologization, as per public health’s legacy with GBM and HIV (Gaspar, 2017).

Queer theorists have observed that some GBM may subvert dominant heteronormative moral framings of sexual health and resist the heightened public health surveillance of GBM sexuality by using ‘risker’ sex to establish identity, agency, and pleasure (Dean, 2009; Race, 2016). Biomedical advances in HIV, including the confirmed prevention benefits of undetectable viral load and PrEP, are altering perceptions of the ‘objective’ or medical ‘transmissibility’ of HIV in queer sexual exchanges (Gaspar et al., 2019; Grace et al., 2020; Race, 2016). However, these are still imbued with established understandings of condomless or ‘promiscuous’ sex as dangerous and queer sex as ‘other’. Health promotion discourse has long positioned sex as a threat to GBM’s health and GBM’s sexuality as a threat to the general population’s safety (Gaspar, 2017).

Sociologists of risk have argued that GBM have often traversed a fine line over the course of the HIV epidemic. On the one hand they must operate as biopolitically regulated neoliberal risk calculators who need to take sexual risks as a way to establish masculinity and queer identity by accruing sexual capital. However, they also need to carefully manage this risk in order to avoid HIV transmission, the stigma associated with living HIV, and being labelled irresponsible (Gaspar, 2017). Despite an increased social acceptability and ‘normalization’ of GBM citizens within Canadian society (e.g. same sex marriage) since the start of the HIV epidemic, an implicit distrust in how GBM will sexually ‘behave’ in response to public health threats, or in response to the availability of newer biomedical technologies like PrEP, remain clear motifs in public health discourse (Race, 2016).

Adam (2011) has argued that public health research has often problematized GBM’s sexual decision-making and has regularly failed to account for the ways in which GBM created safer sex procedures, were sometimes put at risk by contradictions in public health messaging, and how GBM’s decisions to forego condoms were grounded in intimacy, pragmatic risk calculations, as well as social vulnerabilities. The emphasis on individual level behavioural interventions has often failed to account for the structural changes necessary to address HIV and, as such, has left some groups of GBM like Black, Indigenous and working class GBM, more vulnerable to health inequities (Gaspar et al., 2021; Lee-Foon et al., 2020). As such, Adam explicates how public health has often generated findings that are ‘resolutely asocial, ahistorical and out of tune with basic human psychology. It has no context, no sense of social interaction, and cares nothing for real risk management’ (p. 4). Against reductive epidemiological narratives, scholars have argued for the necessity of investigating GBM’s sexual decision-making within its social and temporal context, an analytic approach termed sexual practice (Kippax & Race, 2003). For example, Kippax and Race refer to the development of negotiated safety arrangements (i.e. seroadaption) early on in the HIV epidemic, where some GBM had condomless sex with other men with the (assumed) same HIV status as them. Though this went against dominant public health messaging to always use condoms and was not a guaranteed prevention effort, it turned more restrictive, top-down prevention messaging into something more pragmatic (Grace et al., 2013).

Understanding how GBM respond to novel health threats involves situating their (sexual) health decision-making in context. Such analysis includes attention to the ethical components of risk-taking and prevention to observe how individuals adopt, resist, and generate a public health morality. While GBM have long confronted a public health morality in relation to HIV, this study examines the intersections of COVID-19 and HIV, detailing the moral dimensions GBM considered early on in the COVID-19 pandemic.

Material and methods

This analysis draws upon 25 in-depth interviews conducted with HIV-negative GBM living in Toronto and Ottawa. Interviews were conducted between 11 March 2020 and 21 July 2020 for the PRIMP study. PRIMP is an implementation science study seeking to better deliver PrEP to GBM in Ontario and British Columbia. PRIMP involves longitudinal in-depth interviews with PrEP users and non-PrEP users to discuss their experiences with and interest in PrEP. An interview guide was developed in consultation with a community advisory board, which was made up of stakeholders from GBM agencies. The interview guide included questions on PrEP usage history and sexual practice. In Ontario, ethics was granted by the University of Toronto and the University Hospital Network.

A recruitment website and poster outlining the study’s objectives and link to an eligibility screener were shared over email and social media. The eligibility screener allowed us to ensure diversity in terms of age, race, gender identity, sexual identity, PrEP usage history, and city. By the third interview, Ontario had declared a State of Emergency due to COVID-19. All but one interview was conducted via online video-link or by phone. We used these semi-structured interviews to explore the impacts of COVID-19 on PrEP and sexual practice. We asked participants how COVID-19 was affecting their health, mental health, sexual decision-making, and PrEP use.

Participants provided written inform consent. The 30–90-minute interviews were conducted by the first author (whose identity as a gay man helped to facilitate rapport with the interviewees), were audio recorded, and transcribed verbatim. Participants received a $30 CAD honorarium. The transcripts were uploaded into NVivo 12 and analysed using thematic analysis (Braun & Clarke, 2006). We drew on Braun and Clarke’s (2006) notions of semantic analysis which focuses on how assumptions and ideologies that may not be explicit in the data, can be ‘theorized as shaping or informing the semantic content of the data’ (p. 84). All explicit and implicit mentions of COVID-19 were coded together, and then further analyzed and organized into the sub-themes outlined below. Participant names are pseudonyms.

Results

The mean age was 34 (range: 22 to 61). Ten participants identified as White, five as Black, four as East Asian or Southeast Asian, two as South Asian, three as Middle Eastern, and one as Latino. Twenty-one (84%) participants identified as cisgender and four as trans. Twenty identified as gay, three as bisexual, one as queer, and one as pansexual. Seventeen participants lived in Toronto and eight in Ottawa. Seventeen participants were taking or had previously taken PrEP (these participants are indicated below with ‘PrEP-experienced’ beside their pseudonyms), while eight had never taken PrEP.

PrEP use and the first COVID-19 lockdown

Echoing expert concerns about health inequities and GBM’s sexual behaviour, Lim (30s, PrEP-experienced) wondered if PrEP might lead to increases in COVID-19 among GBM:

You can be on PrEP and you can use a condom but you can still catch COVID. And I’m very curious to see if anybody does studies on this, like if the spread of COVID in the gay community was heightened at all, or is higher than other population groups. But I am worried that with PrEP there is a bit of complacency now about sexual health.

Lim’s comments reflect the common belief that PrEP actively fosters increased casual sexual activity (Grace et al., 2018) and thus may increase COVID-19 transmission.

Some participants stayed on PrEP throughout the first COVID-19 lockdown, but not necessarily because of sexual risks. Kyle (30s, PrEP-experienced) was only having sex with his live-in HIV-negative boyfriend, but stayed on PrEP to avoid stopping and restarting. Dylan (30s, PrEP-experienced) stated that he would continue to take PrEP because he planned to have sex with a few partners. Ramy (20s, PrEP-experienced) stopped and then restarted PrEP in June: ‘because I know things are getting better and we’re heading soon to Stage 3 [of reopening in Ontario].’

Several participants stopped their PrEP use. Christian (30s, PrEP-experienced) halted PrEP three weeks into lockdown: ‘I mean there’s no point in me taking a pill daily if I don’t see myself having sex within three weeks, you know what I mean?’ Ricardo (30s, PrEP-experienced) explained how stopping PrEP was a mental adjustment: ‘So, it was weird now for me to not be on PrEP because it did give me a big sense of, like a peace of mind. And now getting off of it was not making me feel comfortable’. However, he decided ‘when it came to COVID then I was like, well it’s just us [i.e. him and his partner] and also nothing else – there is no risk of something else happening with someone or whatever, so I was like, I maybe just should stop and see.’ Ricardo filled his prescription in case he changed his mind. Stockpiling PrEP as a safety net was a common practice among PrEP-users.

Self-concern versus risk to others

Only a few participants discussed being concerned with getting COVID-19. Aaron (20s) noted that he was ‘worried about getting sick, or people that I care about getting sick, and then not having the … you know, having really serious complications as a result’. Zack (60s) declared that he was more ‘worried about other people than myself’, including his elderly parents and his friends living with HIV. Meanwhile, Joshua (40s) mentioned how ‘I guess I feel like if I were to get it I would probably be okay because of my health. But I am very nervous for example, of spreading it to my [elderly] neighbour who I’m helping.’

The participants expressed more concern about spreading the virus to others than with getting sick personally, reflecting how the public health morality informing early COVID-19 messaging (i.e. a ‘Team Canada’ approach to ‘flattening the curve’) emphasized the collective importance of protecting more vulnerable Canadians and not over-burdening healthcare systems (Lum et al., 2020).

Anxiety, economic precarity, and becoming COVID-weary

Many participants reported experiencing mental distress over COVID-19. Rishay (30s) described this as such:

I would say there’s definitely anxiety or feelings of uncertainty that manifest in repetitive behaviour, like checking Twitter obsessively, or taking my phone to bed and keeping up with breaking news. So, I think the first few days it was challenging to know where the boundaries of that were—what does it mean to be an updated citizen and know what public health wants of you?

Over time, most participants detailed how their anxieties eased. Lim (30s, PrEP-experienced) discussed becoming ‘cavalier’ about COVID-19 by June 2020. He ascribed this to being ‘a generational thing, like we [younger people] feel a little invincible’ and recounted how ‘initially there was quite a bit of fear about it, but now, it’s also because it’s like a few months in and we’re all a little bit COVID-weary, so I think I’m just feeling less heightened about it.’

Many participants reported experiencing mental distress related to employment insecurity – relevant for questions of PrEP access in Ontario as drug insurance is often tied to employment (Gaspar et al., 2019). As Min (20s, PrEP-experienced) stated: ‘but I feel like if I did lose my job then it would become a concern. Oh my God, where am I going to get PrEP or get access to financial benefits for PrEP?’

Ramy (20s, PrEP-experienced) recounted how his mental health deteriorated when he was laid off at the beginning of the pandemic. Robert’s (30s, PrEP-experienced) anxiety worsened when he was told that he was an ‘essential worker’ who had to go in physically to work. And Joshua (40s) discussed how being in the ‘gig economy’ was precarious for his health: ‘There’s no [health insurance] benefits, there’s no paid sick leave, there’s no – if I were to break my leg or something there’s no … yea, I don’t know what I would do.’ Conversely, participants who remained steadily employed and who worked from home began to adjust to the ‘new normal’. Kyle (30s, PrEP-experienced) described not being ‘overly anxious’ because he was working from home, isolating with his partner, and staying on PrEP.

Shaming public health non-compliance

Reflecting the moral dimensions of risk and public health discourse (Petersen & Lupton, 1996), several participants were critical of what Kyle (30s, PrEP-experienced) described as a ‘weird shame culture around people who are not staying home’. He argued that ‘people’s need for interaction during COVID is going to look different for different people.’ He noted how this was especially relevant for GBM: ‘I’ve seen lots of straight people be like, “well I’m gonna go back and live with my parents until this is over, right?” And so, for a lot of queer men that’s not an option for them, that’s not a safe environment.’

Zack (60s) also observed an increasing public health morality determining ‘superior’ decision-making:

Even in queer community stuff, like there’s a bit—the Winter Party in Miami that all sorts of [gay] men went to and [then] there’s lots of judgey queens [queer men] going, ‘oh they shouldn’t have gone there and la, la, la, la.’ Lots of judgements and that reminds me also of what the AIDS epidemic was like in its worst years. There were kind of pissy, pissy queens that were thinking they were all smug because they didn’t get HIV because they were somehow morally superior in the choices that they made.

Zack also expressed concerns that the use of policing to control the pandemic would target the most vulnerable, including racialized communities, street involved people, and people who use substances.

William (20s) labelled the media coverage of COVID-19 as ‘super aggressive’, with COVID-19 presented as ‘something that can also socially like alienate you, you know, like if you don’t practice social distancing.’ William described a ‘witch hunt’ for people not following public health protocols: ‘I’ve never seen cops do that kind of surveillance, like they were doing their rounds [in the park] and they were handing out tickets.’ He felt growing tensions in public spaces because of social distancing rules, which were confounded by issues of race and racism:

Plus, the social climate where everything is, there’s the whole Black Lives Matter [movement], and being a Black man, I’m feeling like eyes are kind of on me, not in a negative sense but there’s just more … I know that like my Caucasian counterparts are more attentive to that, so like our interactions are a lot more intense, even when there’s no need to be.

William’s and Zack’s comments demonstrate how broader discourses on social inequity and racial justice could play a role in how lockdown protocols were experienced.

Comparisons with HIV and shaming (Queer) sex

Several participants drew on their experiences with the HIV epidemic to make sense of COVID-19 (Quinn et al., 2020). Zack (60s) noted how reactions to COVID-19 reminded him of the ‘palatable fear’ of AIDS.’ However, he noted a key distinction:

There’s a COVID-19 panic and crisis so every healthcare system steps in and begins to work. That didn’t happen in the AIDS epidemic. We had to fucking fight, and fight, and fight, and fight, to get the most basic things for people. So that feels really different because this affects that general population, not [just] stigmatized people in the same ways that [it did] in the early years of the AIDS epidemic.

Ricardo (30s, PrEP-experienced), drew on his history of managing anxiety about HIV to make sense of his apprehensions after physically reconnecting with friends:

I haven’t been at ease ever since that happened [i.e. hanging out with friends]. Kind of like back in the day [before taking PrEP] how I’d feel after having unprotected sex with someone and then being like, ‘oh my God, am I okay?’

Cameron (30s) also reflected on the intersections of HIV and COVID-19 risks: ‘Child, back in the day you had to ask [before sex], are you [HIV] positive? But now when you say positive, you mean COVID-positive, right?’ He was critical of how a public health morality could be used to stigmatize queer sex:

They were putting out articles of stuff like, urging gay men to make better choice [regarding COVID-19]. […] And it’s sort of like, queer sex will always be on the other side of wellness. Like it will always be a pathology. It will always be a problem. It will always be like, an illness, regardless of what’s at play in the collective arena. So, HIV will be long gone and there will be a new risk to queer communities, right? We’ll never escape that.

Nonetheless, Cameron noted that when his gay friend told him that they were still having casual sex, he reacted: ‘me being very like, (gasps) clutch pearls! You of all people! You’re a doctor, right?’, reflecting an ethical critique of this friend’s sexual behaviour.

Finally, William (20s) stated that during the first lockdown a lack of sexual intimacy was the ‘biggest thing that I dealt with, honestly’. However, he was hesitant to admit this because ‘I’m out here worrying about not having or making love to someone when there’s people who don’t even know how they’re going to eat.’ Physical distancing requirements thus caused some GBM to be apprehensive to admit their fundamental need for sex.

Stopping sex to avoid COVID-19 risks

Many participants discussed not having sex with casual partners because of COVID-19. James (20s, PrEP-experienced) was only having sex with his live-in boyfriend, stating that ‘tempting as it is, we’re trying to behave’ – indicating a positive moral evaluation of complying with public health protocols. Joshua (40s) said that sex was ‘off the table I guess. Aside from one like, Facetime sex encounter’. Kyle (30s, PrEP-experienced) mentioned that a few people have asked him to hook-up on sex apps but he declined. While Min (20s, PrEP-experienced) elaborated on how: ‘people are kind of confused about what to do during this time, or whether they can have sex, or should have sex’.

Cameron (30s) mentioned that it was difficult for GBM to make ‘relational choices, sexual choices’ when there is ‘not even like a clear direction’ provided by public health experts. While some participants were critical of how public health discourse could stigmatize, pathologize, and criminalize queer sex, many expressed an ambivalent relationship to public health authority – a desire for public health systems to respond to GBM’s health needs (with PrEP and a COVID-19 vaccine) on the one hand, and a scepticism with how public health rationales could limit sexual freedoms due to COVID-19, on the other.

Minimizing sexual partners to reduce COVID-19 risks

Many participants discussed having sex with regular partners that were established before COVID-19. Sanjay (40s, PrEP-experienced) stated: ‘I have a few people, guys who I trust to have common sense. I have a regular fuckbuddy, I’ve known him for years.’ Hyun (20s, PrEP-experienced) described having sex with one ‘friend with benefits’. He speculated that ‘I guess once things start lifting up it will probably be rare to hook-up, I guess. But I could see maybe, like if it’s good enough, I guess it will probably go back to normal.’ Lim (30s, PrEP-experienced) also wondered how another wave in the pandemic would affect his sex life: ‘[if] there’s another wave then, dude, what do we do? Sex with masks, I guess?’ He stated that in order to mitigate COVID-19 risks: ‘I think I’d probably try some of my regulars, like sex with my regulars. But I think I’d be very cautious about meeting strangers, like [for] one-time hook-ups.’

Assessing and mitigating COVID-19 risks during sexual hook-ups

Christian (30s, PrEP-experienced) had sex with a regular partner during the first lockdown. He described not being too concerned about COVID-19, though his comments illustrate an implicit risk calculus since ‘like he’s not having sex with other people so I didn’t think too much about the transmission of COVID.’ Sanjay (40s, PrEP-experienced) discussed how he assessed COVID-19 risks with a few sexual partners:

Because they’re people I’ve known for a while I already kind of trust them that they would tell me if anything – and we joke about it. Have you travelled? Do you have a fever? But basing it on judgment from knowing them already and the kind of people that they are, that we would tell each other.

When one of his partners went to a family gathering, Sanjay decided ‘Ok, I’m not going to see you for a long time. So, you kind of know who has common sense, and who doesn’t.’

Hugh (20s, PrEP-experienced) described hooking-up with a stranger once as ‘an impulsive decision’: ‘it’s not that I was concerned [about COVID-19], because had I been thinking about it I probably would have been concerned enough about others getting it that I probably wouldn’t have gone through with it.’ Meanwhile, Cham (40s, PrEP-experienced) mentioned how his worsening mental health facilitated ‘actively looking for a while during the height of the pandemic for sex’. On sex apps, Cham noticed that some people ‘didn’t care’ about COVID-19 while others were more ‘conscious and cautious’:

I tried to pair up with those people who were more aware of the situation and who wanted to—if they knew they were sick they didn’t want to take any risks or what have you. […] I found that it was not too difficult to see the people who didn’t really care versus the people who sort of gave a shit, so to speak, about the virus and the pandemic.

Cham described a contradiction between not wanting to hang out with friends indoors but being willing to have sex with strangers: ‘Oddly enough, I hook-up with guys [for sex] at the same time, so it’s really … I don’t know where my mind truly is at yet.’ While his sexual practices put him at heightened risk for COVID-19 exposure, he mitigated COVID-19 risks among family and friends by maintaining strict physical distance.

Discussion

During the first wave of the COVID-19 pandemic in Ontario, Canada, most of the GBM we interviewed altered their sexual practices in order to avoid the novel coronavirus. Some participants’ sexual practices countered public health messaging to avoid all ‘non-essential’ contact with people outside of their households. However, the participants’ risk reduction strategies, including minimizing the number of sexual partners, avoiding making new sexual connections, and relying on knowledge of a potential partner’s adherence to public health guidelines, mirrored the negotiated safety strategies earlier developed by GBM to mitigate HIV (Kippax & Race, 2003). The participants created small networks of sexual partners before government mandates to form social ‘bubbles’. From a sexual practice perspective, these men applied some form of COVID-19 risk reduction. As with negotiated safety for HIV, these strategies were not guaranteed prevention efforts. Nonetheless, they demonstrate how people modify top-down and restrictive public health messaging into more pragmatic practices.

As with HIV, our participants sexual decision-making was predicated on determining ‘common-sense’ and establishing trust (Gaspar, 2017). A sexual partner who one trusts and who displays common-sense, not only makes one feel safer about having sex, but also provides an ethical defence if not always a direct public health logic to rationalize potential exposures to COVID-19. Everyday health behaviours are not merely guided by what is biomedically sound, but also by what is morally justifiable and socially permissible (Gaspar, 2017).

Some participants may have been exposed to COVID-19 through their sexual contacts. However, outside of these situations they discussed following physical distancing protocols and wearing masks. Problematizing all casual sex because of COVID-19 can miss how sexually active individuals may be reducing COVID-19 risks and protecting their communities in non-sexual contexts. The potential for COVID-19 transmission through sex must also be weighed against the health benefits of sex and the unsustainability of abstinence for most. Neglecting this reality can create public health messaging that fails to respond to the needs of sexually active people (queer or otherwise). Ignoring the necessity of sex can stigmatize and heighten anxieties associated with GBM sex, and potentially increase COVID-19 risks by neglecting to communicate practical prevention measures.

Several participants expressed apprehension when admitting that they had sex with casual partners or a desire for sexual intimacy. This may be explained by what several men described as a growing shaming culture regarding COVID-19 public health compliance. Yet, this also represents a form of shaming and public health morality common to GBM sexuality and is likely a product of the historical legacy of GBM being associated with increased infectious disease risk and public health compliance discourse being used as a way to shame and regulate queer sexuality (Dean, 2009; Gaspar, 2017; Race, 2016). The axiomatic suspicion that GBM sexuality is a potential serious source of COVID-19 risk emerges as an intelligible public health problem in the broader context of GBM sexuality being understood as a threat to population health. This suspicion was not necessarily based on unequivocal evidence indicating that GBM were breaking physical distancing rules (for sex or any other reason) more than any other population. Our argument here is not that GBM did not sometimes break COVID-19 lockdown rules to have sex or to meet friends. However, the way this was problematized through a concern with their sexuality and potential uneven PrEP use, demonstrates a different moral appraisal of queer populations versus their heterosexual counterparts. Though GBM may now be more accepted members of Canadian society, like with HIV and inconsistent PrEP use, COVID-19 has further cemented GBM sexuality as a public health problem to be tightly observed.

COVID-19 has the potential to further stigmatize GBM sex by again associating queer sexual pleasures with ‘unnecessary’ risk-taking. These dynamics echo Douglas’ (1992) assertions that risk has become a symbolic replacement for sin and taboo. As citizens who have historically been understood as vectors of infectious disease, reckless deviants, and threats to the heteropatriarchal social order (Conrad & Schneider, 1992), GBM’s sexual activities in the context of COVID-19 can be a priori interpreted and pathologized through these homophobic frames. While some behaviours should be discouraged (e.g. non-essential travel, large social gatherings, no consideration for COVID-19 in sexual hookups), it is also necessary to be mindful of how homophobic logics and stigma can inform moral panics to ‘public health non-compliance’.

Our participants expressed more concern about giving someone COVID-19 than about getting it themselves. Since COVID-19 was not framed as a unique threat to GBM – a community used to infectious disease threats ‘targeting them’ – the participants did not feel especially ‘at-risk’. This represents an important blurring of the epidemiological lines that have traditionally divided GBM communities from the ‘general population’. Rather than GBM being separated out from the rest of society because of an infectious disease risk, GBM are considering themselves as members of a broader society with a responsibility to non-GBM communities. However, as several participants highlighted, COVID-19 discourse can reify understandings of GBM sexuality as a threat to the ‘general population’. While participants were critical of the moral and legal consequences of public health compliance, no participant discussed actively seeking to break COVID-19 protocols as a form of queer subversive politics.

Our data substantiates research indicating that decision-making around PrEP is rarely linear or fixed (Newman et al., 2018). GBM’s PrEP use alters in relation to their fluctuating sexual practices. PrEP taking – though commonly envisioned and prescribed in Ontario as a continual daily regimen – is more of a ‘periodic’ or ‘episodic’ practice, with GBM regularly stopping and restarting it. More education can be provided to promote PrEP use in this way.

Participants’ accounts of stockpiling PrEP and taking PrEP despite no sexual activity, demonstrates that PrEP use is not always tied to HIV risk, but can be used to alleviate anxieties related to HIV and queer sex (Gaspar et al., 2019). The link between PrEP access with having health insurance benefits connected to one’s employment creates clear problems when GBM lose their jobs or are self-employed. These barriers can be corrected through a national pharmacare plan and attention to the fundamental factors causing income inequities and employment insecurity among GBM (Gaspar et al., 2021).

This study was not initially conceptualised as a COVID-19 study. Our findings are limited by being based on interviews about PrEP with HIV-negative GBM living in urban locations, and being comprised of somewhat younger men who were not at high risk for serious COVID-19 complications. Our sample was made up of men who could be considered ‘health-conscious’ with connections to health services and our analysis lacks the viewpoints of men living with HIV. However, the data captured these men’s explanations of their changing sexual practices during a period of incredible uncertainty (e.g. before vaccine approval), rather than representing their post-hoc interpretations of prior actions.

Starting 23 November 2020, many of the loosened COVID-19 restrictions were rolled back in Ontario leading to another State of Emergency declared on 12 January 2021. Our analysis cannot predict the sexual behaviours of GBM during this ‘second wave’ (or the third wave, fourth wave, etc.) of the pandemic. However, what our data do demonstrate is that the ethical decision-making around sex within the context of an uncertain and extended pandemic is complex and needs to be attended to with critical attention. As such, we should be wary of simplified narratives of GBM sexuality that may further stigmatize their behaviours. Questions of effective risk management are also moral questions of outstanding citizenship, morality, and belonging (Petersen & Lupton, 1996). As researchers continue to collect and interpret knowledge about GBM and create community education on COVID-19, HIV, and PrEP, we need to keep these underlying socio-political currents in mind, lest we once again position GBM as vectors of disease.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the Canadian Institutes of Health Research [# CTW 155346]. DHST is supported by a Tier 2 Canada Research Chair in HIV Prevention and STI Research. NJL is supported by a Michael Smith Foundation for Health Research Scholar Award [#16863]. DG is supported by a Canada Research Chair in Sexual and Gender Minority Health.