Harm reduction approaches to casual sex during the COVID-19 pandemic
Prepared by Jessica Michaels, Benjamin Riley, Scott McGill, the Taskforce’s Sexual Health Cluster Group and the Taskforce Chair, June 2020
UPDATED ON: 22 June 2020
Disclaimer: The recommendations provided here are the opinions of the authors and are not intended to provide a standard of care, or practice. This document does not reflect a systematic review of the evidence but will be revised to include relevant future systematic review findings of the National COVID-19 Clinical Evidence Taskforce and other relevant information.
This ASHM document is designed for clinicians and other healthcare workers to support the health and wellbeing of their patients who are having casual sex during the COVID-19 pandemic.
Despite social distancing remaining in place, some individuals continue to engage in casual sex. ASHM recently reported that although both attendance and positivity rates of some sexually transmitted infections (STIs) have fallen in Sexual Health Clinics around Australia, people continue to present with STIs. As social distancing restrictions ease it is likely that an increase in casual sex will occur. In line with its approach to other areas of health, ASHM believes it is crucial during the COVID-19 pandemic to support clinicians and other healthcare workers to promote harm reduction strategies. It is also crucial to engage communities in health seeking behaviours, in ways that recognise the needs and experience of those communities. Information for the community about how to adopt a harm reduction approach to casual sex during the COVID-19 pandemic has been provided by community based organisations such as Thorne Harbour Health (1), ACON (2), Scarlet Alliance, the Australian Sex Workers Association (3), the New Zealand AIDS Foundation (4), as well as the NSW Ministry of Health (5) and the New York Department of Health (6).
Casual sex plays a very important social function for many individuals and communities. Healthcare providers should be aware that being disconnected from social and sexual networks may have an impact upon individuals’ physical and mental health and wellbeing. For example, for some men who have sex with men (MSM), sexual networks may be their only connection to other MSM; for sex workers, social distancing restrictions may directly impact upon their connections to peer networks and source of income.
SARS-CoV-2 (which leads to COVID-19 disease) is a highly infectious respiratory virus and can be transmitted through close contact with a person who has the virus (7). Transmission can also occur as a result of contact with surfaces, or objects where infectious droplets from coughing, sneezing, speaking or breathing have landed (7).
People can protect themselves and others from the virus by practicing good hand hygiene, refraining from touching their face, covering their nose and mouth when coughing and sneezing with a tissue or a flexed elbow, practising physical distancing which includes not having sex with casual partners, or with regular partners if their partner has COVID-19, or has COVID-19 symptoms, staying at home if they are unwell, by following jurisdictional guidelines on limitations on private and public gatherings, accessing COVID-19 testing if they have symptoms of COVID-19 and isolating themselves if they are required to do so.
SARS-CoV-2 has been detected in saliva (8), faeces (9, 10), and in semen in some (11), but not all (12, 13), studies. A small study detected no SARS-CoV-2 in vaginal fluids (14), however angiotensin-converting enzyme2 (ACE 2), which is the receptor used by SARS-CoV-2 to enter host cells, is expressed in the vagina, uterus and ovaries (15). Currently there is no evidence that transmission of SARS-CoV-2 occurs via the faecal-oral route or via exposure to semen, or vaginal secretions.
There are no data currently available on whether different types of sexual practices have different levels of risk for transmission of SARS-CoV-2.
When discussing sex and sexual health with an individual, it is important to be non-judgemental and take a thorough sexual history. The Australian STI Management Guidelines for use in Primary Care recommend using normalising language and using a hook to engage individuals in a conversation about their sexual health. Guidance on how to take a sexual history can be found here.
During the COVID-19 pandemic, clinicians should continue to take sexual histories from patients and should be aware that patients may be reluctant to disclose that they have been having casual sex while social distancing restrictions are in place and may be afraid of being prosecuted or discriminated.
Telehealth and other remote consultations may offer both barriers and benefits to taking a sexual history from patients. In line with the results of ASHM’s provider survey on telehealth, patients engaging in a consultation from their own homes may be more comfortable to discuss their health. However, it may also be more difficult to establish the patient rapport required for sensitive topics such as sexual health via a telehealth consultation.
In addition, clinicians should recognise that individuals may experience stigma in both healthcare settings and in the broader community as a result of having casual sex during the pandemic. It is also important to be aware of the additional stigma attached to key populations such as gay, bisexual and other MSM, people living with HIV, hepatitis B, and hepatitis C, sex workers and people who inject drugs.
Clinicians should educate all patients about how SARS-CoV-2 is transmitted and that the close contact that occurs during sex is a key risk factor for infection with this virus.
There are a number of measures that clinicians can recommend to patients who are having casual sex that may help reduce their risk of COVID-19 transmission (1, 3, 6).
Clinicians should encourage their patients to remain on HIV pre-exposure prophylaxis (PrEP) or commence PrEP if they are planning to have casual sex with HIV acquisition risk during the COVID-19 pandemic. Patients who prefer to use condoms for HIV prevention should be encouraged to use condoms consistently if they are having casual sex with HIV and STI acquisition risk during the pandemic. PEP should be offered to patients who have had a possible exposure to HIV and who present within 72 hours of that exposure.
Clinicians in Australia are reporting that they are diagnosing recently acquired HIV infection in patients who had stopped PrEP during the early stages of the pandemic when social distancing requirements commenced. The ASHM PrEP Clinical Guidelines can be found here.
Clinicians should encourage people to use safe injecting practices, including during times when they are having casual sex.
It is important during the COVID-19 pandemic for healthcare workers to continue to encourage all sexually active individuals, and particularly those who identify as key populations, to engage in regular HIV and STI screening as per regular screening guidelines (15, 16).
The Australian STI Management Guidelines for use in Primary Care provide guidance on STI screening.
If an individual is identified as requiring STI screening during a Telehealth consultation they will need to attend the practice, or clinic for appropriate clinical follow-up and STI testing.