Sexual health outcomes and biomedical prevention behaviors among men who have sex with men engaging in fisting

Background: Anal fisting is understudied as a sexual practice despite being a popular activity in kink sexual communities that has potentially significant implications for the transmission of human immunodeficiency virus (HIV) and sexually transmitted infections (STIs). Aim: This study explores the sexual health outcomes and biomedical preventative health behaviors of men who have sex with men (MSM) who engage in fisting (MSMF), examining fisting role (top, bottom, or versatile) and considering HIV pre-exposure prophylaxis (PrEP) and doxycycline post exposure prophylaxis (DoxyPEP); and comparing these to MSM who engage in kink but who do not engage in fisting (MSMK). Methods: A total of 1012 users of a website for MSM seeking kink completed an online survey in July 2024. Alongside sociodemographic factors and health experiences, the survey assessed respondents’ experience with fisting and biomedical sexual health prevention practices. Bivariate analyses were conducted between MSMF and MSMK. Outcomes: Understanding the sexual health outcomes and biomedical preventative behaviors of MSMF and MSMK. Results: Within the sample, past-year fisting engagement was 33.5% (n = 339). Human immunodeficiency virus prevalence was higher among MSMF than MSMK (22.1% vs 8.5%); HIV incidence was 5.5% among MSMF compared to 2.7% among MSMK. Biomedical prevention utilization also varied: among HIV-negative participants, PrEP use in the past 12 months was 64.3% among MSMF vs 31.1% among MSMK. Past-year STI testing was more common among MSMF than MSMK (85.7% vs 65.2%, P < .01). MSMF were also more likely to use DoxyPEP (22.1% vs 7.1%, P < .01) and reported greater interest in future DoxyPEP utilization (70.2% vs 61.2%, P < .01). Clinical Translation: Public health prevention, education efforts, and clinical guidelines should recognize fisting as a high-impact activity that can influence the syndemics of HIV and other STIs. Strengths and Limitations: Fisting is an understudied activity and findings from this study are from the largest data set on MSMF, with data collected after the introduction of HIV pre-exposure prophylaxis and DoxyPEP. The study is cross-sectional, limiting the ability to establish causal relationships, and it is based on self-report data. Conclusion: This study highlights significant group differences in HIV prevalence and incidence, PrEP and DoxyPEP use, and STI testing, suggesting that MSMF may be at higher risk for HIV and other STI acquisition, yet are simultaneously more connected to prevention and care services.