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 565 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 statistical significance 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).
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).
Table 2
Type of abnormalities felt during ASE, ease of performing the examination and likelihood of recommending it to other MSM.
Experience related to ASE | | |
Felt something during ASE | N = 173 | Percentage (%) |
Yes | 81 | 47 |
No | 92 | 53 |
Description of abnormalities | N = 79 | |
Lumps | 50 | 63 |
Ulcers or sores | 22 | 28 |
Bleeding | 30 | 38 |
Others * | 12 | 15 |
(Haemorrhoids x7, warts x2, tearx1, lump, varicose vein, tenderness) | | |
Ease of performing ASE | N = 172 | |
Very easy | 43 | 25 |
Easy | 72 | 42 |
Neutral | 44 | 26 |
Difficult | 11 | 6 |
Very difficult | 2 | 1 |
Likelihood of recommending ASE to other men by men who had ever performed ASE | N = 167 | (%) |
Very likely | 74 | 44 |
Likely | 60 | 36 |
Maybe | 21 | 13 |
Unlikely | 9 | 5 |
Very unlikely | 3 | 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 (e.g. www.anal.org.au), 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 showed the responses from the participants.
Table 3
ASE positions, locations, resources, information among men, stratified by ever and never performing ASE
| Ever performed* ASE (N,%) | Never performed ASE* (N,%) |
ASE positions | N = 176 | % | N = 227 | % |
Standing | 88 | 50 | 88 | 39 |
Squatting | 80 | 45 | 61 | 27 |
Lying on the side | 35 | 20 | 47 | 21 |
Lying on the back | 36 | 20 | 31 | 14 |
Others | 6 | 3 | N/A | |
Locations for performing ASE | N = 173 | | N = 232 | |
Shower | 106 | 61 | 151 | 65 |
Bed | 40 | 23 | 66 | 28 |
Bathroom/toilet | 85 | 49 | 105 | 45 |
Others | 4 | 2 | 3 | 1 |
Resources relating to ASE technique^ | N = 171 | | N = 328 | |
Instructional graphics on poster or website | 113 | 66 | 222 | 68 |
In-person explanation from doctor/nurse | 82 | 48 | 172 | 52 |
In-person demonstration by a doctor/nurse using a training model/manikin | 31 | 18 | 85 | 26 |
Videos of a doctor/nurse using a training model or a live person | 64 | 37 | 162 | 49 |
Online videos from a trusted source (i.e. existing and available to general public) (e.g., www.anal.org.au) | 81 | 47 | 182 | 55 |
Explanation from partners or friends | 23 | 13 | 17 | 5 |
Do not need any resources | 4 | 2 | 13 | 4 |
Information relating to ASE and anal syphilis | N = 168 | | N = 325 | |
How to do the examination | 44 | 26 | 105 | 32 |
Where to do the examination | 11 | 7 | 21 | 6 |
What a healthy anus should look like | 43 | 26 | 106 | 33 |
What a syphilis lesion looks like | 42 | 25 | 101 | 31 |
What a syphilis lesion feels like | 42 | 25 | 105 | 32 |
What other sexually transmitted infections (STI) symptoms would look or feel like on the anus, including warts and herpes | 0 | 0 | 80 | 25 |
Other non-STI symptoms of the anus (e.g., haemorrhoids) | 31 | 18 | 75 | 23 |
Symptoms of anal cancer | 32 | 19 | 80 | 25 |
All of the above | 106 | 63 | 193 | 59 |
% Percentage |
*The two groups were not comparable as they were presented with different scenarios such as positions already used by men who had performed ASE vs positions likely to be used by men who had never performed ASE. |
^ allowed multiple options |
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 for an abnormality, 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.
Most men (68%, n = 222) out of 328 men answering questions about information about ASE and resources, would like at least some information about ASE (how to perform ASE, locations to perform ASE, and how to distinguish between normal and abnormal findings) and anorectal syphilis with 59% (n = 193) wanting all the information about ASE, syphilis lesions, other non-STI symptoms of anus and symptoms of anal cancer (Table 2). 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 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.