The Spatial Architecture of Egocentric Sexual Networks: A New Framework or Just New Terms for Old Ideas?

In their recent mixed-methods study of the egocentric sexual networks of gay, bisexual, and other men who have sex with men (gbMSM), Gesink et al.1 integrate multiple concepts of location (including the space where sex occurred, the residences of the egos and alters, the meeting place—online or in-person—where sexual partners were first in contact, and the distance traveled for sex) with more routine data elements, including the timing of sexual interactions and the age, race, and sexually transmitted infection (STI) history of the participants. Qualitative research is lamentably underrepresented in epidemiologic research, and this investigation demonstrates how qualitative data can provide depth and context to concepts not reducible to numerical codes.2 The primary contribution of the research is continued development of the concept of the spatial architecture of egocentric sexual networks. The authors classify 7 geosexual archetypes: hosters generally host sex at their homes; house-callers generally travel to their partners' homes for sex; privates generally either host or travel to their partners' homes for sex (part hoster, part house-caller); rovers generally have sex in public venues; travelers generally travel to their partners' homes or to a public venue for sex (part house-caller, part rover); and geoflexibles have sex in a variety of locations. A seventh archetype, siren, was not observed, but would include gbMSM who generally host sex or travel to public venues (part hoster, part rover). Although the study was conducted in Toronto, the authors posit that their findings are robust to the setting, with the caveat that the proportion of each archetype could vary by location depending on population size and density, public transportation, availability of private and public venues, and other factors. The spatial mapping of sexual networks is not new. What is the public health relevance of categorizing gbMSM according to where they have sex—and applying clever names to each group? One answer is that the exploration of geosexual archetypes by Gesink et al. suggests that conventional understanding of STI risk within gbMSM sexual networks, which informs how STI control programs respond to outbreaks, may be incomplete. A key assumption of many STI programs is that high-transmission (“core”) areas—with such areas defined by the residence of the identified cases—exist and that they can be effectively targeted for prevention efforts.3–5 In the current study, geosexual archetype was defined based on the physical location where sex occurred, but it was also correlated with STI history. (All hosters and rovers, and some geoflexibles had a history of syphilis; a history of gonorrhea, as well as HIV prevalence, was also highest in these 3 groups.) However, geosexual archetypes did not cluster geographically. Members of each archetype lived in core and noncore areas for syphilis, meaning that interventions focused on areas with high case rates would fail to reach some hosters, rovers, and geoflexibles in the syphilis transmission chain. Understanding the spatial architecture of egocentric sexual networks can provide other clues critical for STI control. Given the structural definitions of geosexual archetypes by Gesink et al., some gbMSM—for example, hosters and rovers—will rarely or never have sex with one another (hosters have sex in their own homes, rovers have sex in public venues). This observation, together with the fact that 100% of men from these 2 archetypes reported a history of syphilis, suggests that Toronto's gbMSM syphilis epidemic is likely occurring in (at least) 2 separate but geographically overlapping populations, with certain groups (perhaps geoflexibles) acting as a bridge between them. The study also confirms existing knowledge about sexual risk among gbMSM, even if the nomenclature is new. For example, rovers have long been identified as a high-risk group.6Geoflexibles, one of the subgroups with the highest numbers of partners in the preceding 3 months, are similarly recognizable using more traditional parameters of sexual risk.7 The most surprising subgroup is the hosters, who had the highest number of partners and the highest proportion of partners recruited online. Sexually transmitted infection control campaigns have not typically focused on people who have sex primarily in their own homes, yet provocatively, this group emerges as among the highest risk in the current research. Interestingly, the complementary group, house-callers, do not exhibit parallel risk behavior in terms of numbers of recent partners or STI history. The authors note that apps for dating, sex-seeking, and geosocial networking were used by most participants. These technologies have likely changed how gbMSM connect with partners both very close by and when far from home, and necessarily inform the parameters of “sexual travel,” including the distance between partners and who travels to whom in the spatial architecture of sexual networks. A key unanswered question, however, is whether the availability or use of STI prevention tools (e.g., condoms, serosorting, preexposure prophylaxis) differ systematically according to sexual travel, or whether any identified differences are meaningful compared with other variables not assessed in the current article, such as alcohol or drug use, or partner type (e.g., steady, casual, and anonymous)? When considering the potential STI risk associated with condomless anonymous sex in a public park, is the location of the sex (the geosexual archetype) a more critical factor than the lack of prevention modality (condomless) and the partner type (anonymous)? A related question is whether specific sexual archetypes should, or could, be targeted for STI prevention. How would groups be identified prospectively, and how would prevention messages be targeted to them? Would identified groups be receptive to existing STI prevention interventions? Extensive implementation research would be needed to examine the logistical, scientific, and ethical challenges of using sexual archetypes to inform future STI prevention efforts, as well as the cost/benefit ratio of such nuanced targeting in comparison to other, broader interventions. The limitations of the project—not disputed by the authors—caution against broad generalization of its findings before further study. For example, the small, purposively recruited sample of n = 31 gbMSM is appropriate for qualitative research,8 but 2 of the riskiest archetypes, hosters and rovers, were characterized based on only 3 people in each category. Going forward, the concept of geosexual archetypes to conceptualize the geography of a sexual network and the STI risk of its members must be explored in larger, more diverse settings and populations. The authors also captured data about only the first time participants had sex with a given partner; therefore, by definition, their data refer only to new partners. People may seek new sex partners in different physical and virtual spaces from those in which they encounter longtime partners,9,10 and whether patterns of sex with new partners are the most relevant for understanding STI transmission dynamics within sexual networks is not known. Similarly, the authors did not have an adequate sample size to stratify encounters by partner type (e.g., long-term vs. hookup), another variable correlated with both risk and prevention behaviors.11 Most importantly, the links between the spatial architecture of the sexual network and biological confirmation of STI transmission within that network are unknown. Gesink et al. captured participants' self-reported STI history, which is common in sexual health research, but it is also known to be an unreliable measure.12 Even if accurately reported, it captures STIs experienced over the lifetime, so may not correspond temporally with a participant's current geosexual archetype. The STI history variable may be further biased if health-seeking behavior—which is correlated with STI testing and treatment, and therefore knowledge of past infections—also differs by geosexual archetype. Finally, Gesink et al. write that further work is needed to “assess how well the archetypes resonate with participants themselves.” We fully agree. A primary consideration in all sexual health research is preventing stigmatization of people's sexual choices. Stigmatization itself is morally problematic. In addition, if findings are presented in a way that offends members of the community being studied, they may be less likely to participate in subsequent investigations, and the quality of future research will likely decline. To some, “rover” may bring to mind a household pet; a “siren” is a dangerous mythical creature who sexually tempts men to their deaths. If participants themselves have not yet had an opportunity to weigh in on the terms selected to describe them, a respectful alternative is to call the categories simply by what they are (e.g., men who have sex in public venues, men who have sex in their own homes or in public venues, etc). Incidence of many STIs in gbMSM and other populations is increasing.13 Reduced susceptibility of gonorrhea to antibiotic treatment has added urgency to calls for development of new approaches to complement current STI control efforts, for example, point-of-care tests to determine antibiotic susceptibility.14,15 The work by Gesink et al. can be seen in similar light. After further validation and considerable implementation research, perhaps the concept of geosexual archetypes can be incorporated into sensitive STI prevention messaging: expanding beyond the behavioral, clinical, and epidemiologic characteristics that establish who is at risk, to illuminate more clearly how those characteristics interface with the virtual and physical environments where STI transmission is occurring.

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