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Understanding the duration of tongue kissing among female sex workers for potential oropharyngeal–oropharyngeal gonorrhoea transmission

Several studies have proposed that oropharyngeal gonorrhoea can be transmitted via tongue kissing (hereafter ‘kissing’) in gay, bisexual and other men who have sex with men (MSM). 2 Female sex workers (FSWs) also have a high prevalence of oropharyngeal gonorrhoea. 4 A previous study has shown that FSWs had a median of 10 male clients in an average working week and 84% of FSWs kiss at least one client in an average working week. Kissing has been considered a low risk for HIV and STI transmission and hence has been neglected in research. This study aimed to examine the duration of kissing among FSWs. We performed a crosssectional survey between 1 May 2019 and 13 March 2020 at the Melbourne Sexual Health Centre (MSHC), Australia. Women aged 18 years or above who selfreported working as a sex worker and attending the MSHC during the study period were invited to participate in the survey via computerassisted selfinterviewing. This survey collected information on kissing practice and the duration of kissing. This study was terminated early due to the COVID19 pandemic as all brothels were closed during the lockdown. Of the 1104 eligible FSWs, 22% (n=247) consented to participate and completed the survey. The median age was 28 years (IQR 23–33) and 52% (n=128) were born outside Australia. Of the FSWs, 91% (n=226) reported kissing a man in the past 3 months. The median duration of kissing with the most recent man was 5 min (IQR 3–15) (figure 1). Furthermore, most (87%, 197 of 226) FSWs had sex with the man they most recently kissed. Of the FSWs, 38% (n=94) reported kissing a woman in the past 3 months and the median duration of kissing with the most recent woman was 5 min (IQR 3–10). Of the FSWs, 29% (n=72) reported having sex with another woman in the past 3 months, with a median of one (IQR 1–2) female sex partner. The test positivity was 1.3% (3 of 223) for oropharyngeal chlamydia and 1.8% (4 of 224) for oropharyngeal gonorrhoea. There were some limitations to this study. First, due to the small number of cases, we were unable to examine the association between oropharyngeal STI test positivity and the duration of kissing. However, a previous study found that there was no association between oropharyngeal gonorrhoea test positivity and the duration of kissing in MSM. Second, we were unable to stratify the data by type of partner (ie, paid clients vs private nonpaid partner) as this information was not collected. Third, our response rate was low. It is possible that there might be some differences in kissing duration and STI positivity between those who participated and those who did not, although there was no significant difference in demographic characteristics (ie, age, country of birth, injecting drug use in the past 3 months) between the two groups. Despite previous studies showing that there was no correlation between low response rate and validity, 9 further studies are required to investigate novel approaches to increase participation rate in sexual health research. This is the first study to estimate the duration of kissing in FSWs, and we found the duration of kissing in FSWs (ie, 5 min) to be substantial and not a transient ‘peck’, but the duration was half that of MSM (ie, 10 min), who are the other risk group with a high prevalence of oropharyngeal gonorrhoea. Like MSM, FSWs have a substantial number of partners; however, unlike MSM, FSWs report condoms frequently (79%) for fellatio with clients. Of interest, a study in Sydney has shown that condomless fellatio was not associated with oropharyngeal gonorrhoea in FSWs, raising the possibility that infection may be acquired from the client’s mouth. To date, there has been no study examining the association between kissing and oropharyngeal STIs among FSWs. With the rise of oropharyngeal gonorrhoea in FSWs, future research is required to examine the association between kissing and oropharyngeal gonorrhoea. This research will help reinforce safe sex messages for gonorrhoea control. Research Letter