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 The Geography of Sex
www.geographyofsex.ca

Dionne Gesink, PhD DISCLAIMER: (NOT PHO)

Dalla Lana School of Public Health This presentation was created by its author.
It will be published on the Public Health Ontario (PHO) website for
University of Toronto public use as outlined in the Website Terms of Use.
PHO is not the owner of this content. Any application or use of the
information in this document is the responsibility of the user.
Funded by CIHR PHO assumes no liability resulting from any such application or use.
2
Moyo Health and Community Services
Jillian Watkins Ho Yan (Winson) Wong
Executive Director 2SLGBTQ+ Training and Capacity Building Coordinator

3
Disclosures

Conflict of Interest Funding

• Dionne Gesink: None • Canadian Institutes of Health
• Jillian Watkins: None Research (CIHR Funds: 174889
and 169645)
• Winson Wong: None

4
 Explain Explain how suburban MSM are connecting with urban, suburban,
rural and sexual health care settings in the Greater Toronto Area.

Discuss Discuss concepts such as convection mixing and activity space and
describe how these concepts might inform interventions.

Objectives
Identify Identify factors that affect positive and negative sexual health care
experiences.

Discuss Discuss “outness” and how it might influence health care seeking
decisions for MSM.

5
 Background: Social Geography of STIs

The Geography of Sex, Urban Edition – Toronto

Flow of the The Geography of Sex, Suburban Edition – Peel
Talk: Preliminary Recommendations

Discussion

6
Background:
Social
Geography
of Sexually
Transmitted
Infections
(STIs)

7
Yorke JA, Hethcote HW, Nold A. Dynamics and control of the transmission of gonorrhea. Sex Transm Dis. 1978;5(2):51–56
8
Rothenberg RB. The geography of gonorrhea. Empirical demonstration of core group transmission. Am J Epidemiol 1983; 117: 688-694
Thomas JC, Tucker MJ. The development and use of the concept of a sexually transmitted disease core. J Infect Dis. 1996;174(suppl 2):S134–S1439
Partner selection is
local
phenomenon…

but the role of apps

is unclear

• Zenilman JM, Ellish N, Fresia A, et al. The

geography of sexual partnerships in Baltimore:
Applications of core theory dynamics using a
• geographic information system. Sex Transm Dis
1999; 26:75-81
• Gindi RM, Sifakis F, Sherman SG, et al. The
geography of heterosexual partnerships in
Baltimore City adults. Sex Transm Dis
2011;38:260Y266 10
Law DCG, Serre ML, Christakos G, Leone PA, Miller WC. Spatial Analysis and Mapping of Sexually Transmitted Diseases to Optimize
Intervention and Prevention Strategies. Sexually Transmitted Infections. 2004. 80: 294-299 11
Partners move around to each other for sex

12
13
14
15
16
17
18
19
20
After the Epidemic

Gesink Law DC, Bernstein KT, Serre ML, et al. Modeling a syphilis outbreak through space and time using the
Bayesian maximum entropy approach. Ann Epidemiol. 2006;16(11): 797–804
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The Geography of
Sex
The social process of partner
selection
in the context of
the spatial relationships
between
individuals
and
their natural and built
environments.
22
Local Environment Combined Environment

The
Village

City
Space

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24
25
Gesink D, Wang S, Norwood T, Sullivan A, Al-Bargash D,
Shahin R. Spatial Epidemiology of the Syphilis Epidemic
in Toronto Canada. STDs. 2014 Nov;41(11):637-48 26
 Wang S, Widener W, Burchell AN, Grace D, Gesink D. Spatial access to sexual health clinics
measured through a novel accessibility score in Toronto, Canada. STDs. 2022 Jul 1;49(7):484-489 27
The Geography of Sex
- Toronto

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Purpose
• Study the spatial relationships
between sexual partners, and
their environments, for gay,
Individual bisexual, and other men who
have sex with men (gbMSM) in
Toronto, Canada

Partner(s) Environment • Use results to inform response

to the ongoing syphilis epidemic

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 Interviews with 31
Sexual Minority Men
(June-July, 2016)

30
How Did Guys Find Partners?
Top Three External
Partner
Characteristics: INTENTION:
- Attractiveness Sex
- Geographic
Relatio
proximity nship
Dating

- Availability
COMMUNITY:

Online Offline

PARTNER
CHARACTERISTICS:

External
Preferences

Interaction Internal
Experience Preferences Gesink D, Salway T, Kimura L*, Connell J*, Widener
M, Ferlatte O. The Social Geography of Partner
Selection in Toronto, Canada: A Qualitative
Description of “Convection Mixing”. Archives of Sexual
Behavior. 2020 Jul;49(5):1839-1851 31
32
Geosexual Archetypes

33
Geosexual Archetypes

34
Geosexual Archetypes

35
Geosexual Archetypes

36
Geosexual Archetypes

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 Geosexual Archetypes

Gesink D, Wang S, Guimond T, Kimura L, Connell J, Salway T, Gilbert M, Mishra S, Tan D, Burchell A, Brennan D, Logie C, Grace D. Conceptualizing Geosexual Archetypes:
Mapping the sexual travels and ego-centric sexual networks of gay and bisexual men in Toronto, Canada. Sexually Transmitted Diseases. 2018 Jun. 45(6) 368-373 38
 Characteristics ALL HOSTERS HOUSE-CALLERS PRIVATES ROVERS TRAVELLERS GEO-FLEXIBLES

Number of participants 31 3 8 4 3 5 8
Range of partners, preceding 3 1 to 10+ 10+ 1 to 10+ 2 to 10+ 4 to 5 4 to 10+ 5 to 10+
months
Average # of partners, preceding 6 10+ 4 5 4 5 7
3 months
Median # of partners, preceding 5 10+ 3 4 4 4 7
3 months
% Of partners met online 70.1% 93.3% 78.8% 65.0% 0.0% 92.3% 60.0%
Range of distance travelled* 0 to 25.1km 0 to 7.5km 0 to 20.6km 0 to 5.7km 0.8 to 6.5km 0.6 to 25.1km 0 to 17.1km
Average distance travelled* 3.2km 0.4km 3.7km 0.9km 3.8km 7.6km 3.2km
Median distance travelled* 1.2km 0km 1.8km 0km 4.2km 5.1km 1.0km
Out of town (OOT) travels 9 0 3 2 0 2 2
Minimum OOT distance travelled 31.2km -- 44.6km 31.7km -- 36.5km 112.2km
Maximum OOT distance 5991.7km -- 508.7km 70.8km -- 5991.7km 3392.0km
travelled
Average OOT distance travelled 1028.2km -- 215.6km 51.3km -- 3014.1km 1752.1km
Average age (years) 37 48** 42 31 45 26 36
% White 52% 100% 50% 75% 33% 40% 37%
% Tested for STIs, preceding year 87% 100% 50% 75% 100% 100% 100%

% Syphilis, ever 23% 100% 0% 0% 100% 0% 12%

% HIV 13% 33% 0% 0% 66% 0% 12%
% Gonorrhea, ever 32% 67% 25% 25% 33% 20% 37%
% Chlamydia, ever 29% 33% 37% 0% 33% 0% 50%
% Herpes 13% 0% 0% 25% 33% 20% 12%
% HPV 13% 0% 25% 0% 0% 20% 12%
Gesink D, Wang S, Guimond T, Kimura L, Connell J, Salway T, Gilbert M, Mishra S, Tan D, Burchell A, Brennan D, Logie C, Grace D. Conceptualizing Geosexual Archetypes:
Mapping the sexual travels and ego-centric sexual networks of gay and bisexual men in Toronto, Canada. Sexually Transmitted Diseases. 2018 Jun. 45(6) 368-373 39
 Rover

Hypothesis: Sirens?

Geoflexible

House-caller Private Hoster

Gesink D, Wang S, Guimond T, Kimura L, Connell J, Salway T, Gilbert M, Mishra S, Tan D, Burchell A, Brennan D, Logie C, Grace D. Conceptualizing Geosexual Archetypes:
Mapping the sexual travels and ego-centric sexual networks of gay and bisexual men in Toronto, Canada. Sexually Transmitted Diseases. 2018 Jun. 45(6) 368-373 40
 Prevalence of STIs by Archetype
using Sex Now! 2019 Data

Dharma C, Guimond T, Salway T, Lachowsky N, Card K, Gesink D. Geosexual Archetype, Preventive Behaviours, and Sexually Transmitted Infections
Among Men who Have Sex with Men. Sexually Transmitted Diseases. 2023 Apr 17 online 41
 Sex Now! 2019: Prevention Strategies

Dharma C, Guimond T, Salway T, Lachowsky N, Card K, Gesink D. Geosexual Archetype, Preventive Behaviours, and Sexually Transmitted Infections
Among Men who Have Sex with Men. Sexually Transmitted Diseases. 2023 Apr 17 online 42
 What Guys New About
STIs and Syphilis
• Guys knew nothing about the syphilis epidemic in
Toronto
• No knowledge of syphilis symptoms
• Even if previously infected
• Little concern for syphilis, lots still for HIV
• STI prevention centred around methods to
prevent HIV transmission
• Asking about STI testing better than asking about STI
status
Gesink D, Salway T, Connell J,
• Mixed attitudes towards condoms: Kimura L. STI Knowledge and
Attitudes Among Sexual Minority Men
• Condom code During Ongoing STI Epidemics in
• PrEP Toronto, Ontario: A Qualitative Study.
Sexually Transmitted Diseases. 2020
• No one used condoms for oral sex Oct; 47(10):658-662 43
44
Geography and Sex
I work near [major intersection downtown], I’m
mobile on a bike only, I don’t drive. So basically,
if you were within 2 or 3 subway stops of where I
am at work, or 5- or 10-minute bike ride, I could
engage with you. If you were 7 or 10 [subway]
stops away, or in the suburbs, or somewhere
that I couldn’t bike to easily, I would not engage
with you.

JC01, age 52, downtown-outbreak north

45
I would say about 90% of the time
I’m travelling. … I would say I’m
travelling downtown, ‘cause there’s
not really anyone in North York that
I’ve come to know in that way. I
think there’s been like one or two
guys um… and it was great but one
of them moved to Oshawa so… that
was out of the question [chuckles].
And then most of the other people
that I do, if I see regularly, they’re
downtown so. I usually come
downtown and then… go with them.

(JC16, 28, peripheral suburban)

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Social and
Sexual Isolation
• …when I was living
downtown I was very
sexually active and now that
I’m in North York again it’s
kind of slowed down…

• (JC16, age 28, peripheral

suburb)

47
Where Participants Travelled for Sex

Where Participants Had Sex with Partners

Participant Core Outbreak Suburb Small City Out of
Residence
Province

Core (n=13)
57 (72%) 15 (19%) 3 (4%) 0 3 (4%)

Outbreak
7 (11%) 50 (78%) 1 (2%) 2 (3%) 4 (6%)
(n=10)

Suburb (n=7)
20 (44%) 15 (33%) 8 (18%) 1 (2%) 1 (2%)
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 (Oshawa)

CONVECTION MIXING

(Hamilton)
49
 Guys are traveling from peripheral suburban areas…
What Does Into the downtown STI core area looking for sex…

The Not realizing, or caring, that there are ongoing STI

epidemics…

Geography Using HIV safer sex practices that do not necessarily

protect them from bacterial STIs…

of Sex Tell Returning home possibly with an infection…

Where they may conceal their sexual identity and

Us? sexual health resource are limited…

Returning to the core area later.

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What Does • Peripheral/suburban areas may be important
reservoirs of STIs, re-inoculating urban core areas
This Mean • Core theory of STI transmission is not going to
prevent STI transmission to peripheral areas or
About STI reduce the burden of STIs in peripheral reservoirs
• We need to pay more attention to what is
Transmission? happening in peripheral/suburban areas

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52
The Geography of Sex - Peel
www.geographyofsex.ca

53
 Dionne (U of T) Michael (Moyo) Laura (PHO)
Hope (Moyo) Winson (U of T/Moyo)

The Research
Team
Chris (U of T) Manny (Moyo)
Yoshi (Moyo) Jodh (Moyo)

Joseph (U of T) Ruchit (Moyo) Sean (Moyo) Sarah (U of T)

Jillian (Moyo)

54
Explore how peripheral
MSM navigate their sexual
lives and sexual health
• How peripheral MSM connect with
social (including cultural, racial,
ethnic, religious), sexual, and
health service communities, and
navigate sexual stigma
• Sexual health care practices and
preferences of peripheral MSM

55
Interviews with 44
Sexual Minority Men
(June-Sept 2021)

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 Gender:
• 7 non-binary, trans, fem-boy
• 37 cis-male
Age:
• Range: 21-63 years,
• Average: 28-29 years

Who Did Geography:

• Brampton, Mississauga, Toronto, Milton, Hamilton, Guelph,
We Talk Cambridge
Race:
To? • Black (N=5)
• East Asian (N=2)
• Latino (N=4)
• Middle Eastern (N=2)
• Mixed (N=4)
• South Asian (N=14)
• South-East Asian (N=1)
• White/Caucasian (N=12)
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 Connectedness
Sex Life
and Belonging
What Did We
Ask Them
About?
Sexual Health Activity Space

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59
60
61
 Connectedness
Sex Life
and Belonging
What Did We
Ask Them
About?
Sexual Health Activity Space

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 What Were We Told?
No one size fits all

Health care deserts

Health care access

Outness

Impact of COVID

63
 Geography of services:

• Some seek nearby services in Peel

• Others travel to Toronto
• Others seek services when traveling out of country
No "One size Motivations when selecting services
fits all" • Level of outness
approach to • Desire for high quality care (well-informed providers)
• Friendly, non-judgmental
meeting • Some prefer shared cultural/religious background, others do not
sexual health Accessing a wide variety of services
needs • STI clinics, HIV or PrEP clinics
• Family doctors
• LGBT-specific clinics
• Breastfeeding clinics
• Private labs (I.e., Lifelabs)
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Outness as a driver of provider selection
Varying rationale when weighing outness and choice of
provider
• Services that are "under the radar" (I.e., family
doctor) perceived as safer
• Fear of judgement from family doctor (especially if
shared with parents or from same cultural
background)
• Some seek LGBTQ specific clinics; prefer to travel far
(I.e., from Peel to downtown Toronto) for
discretion, anonymity, geographic buffer
• Others would like LGBTQ friendly clinics close to
home.

65
 What makes a negative experience?
Difficulty scheduling an appointment

Long wait times in the clinic

Perceive that provider has low knowledge on STI transmission, symptoms, PrEP

Difficulty finding family doctor who is affirming

Confidentiality fears

Referrals leading to dead ends

Cost of PrEP

66
What Makes a Positive Experience?
Information readily available on website

Symbols to demonstrate LGBTQ-friendly space*

Friendly and affirming staff

Ease of scheduling

Fast – no long wait times to schedule appointment, while in clinic, etc.

Confidentiality

Provider is knowledgeable about LGBTQ sexual health (STIs, PrEP)

Physician from shared cultural / religious community desirable to some (if LGBT friendly)

67
Impact of Covid-19 on
sexual health access
Pandemic had mixed impact on access to sexual
health care:
• For some, faster and easier than usual (I.e.,
scheduled for specific appointment window, in and
out of clinic quickly, increased remote access to
testing or telehealth.)
• For others, COVID resulted in local clinics reducing
capacity, impossible to schedule appointment, etc.

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Stigma & COVID-19

• Fear of judgment for

needing an STI test during
time of lockdown or social
distancing.
• Fear COVID-19 exposure
while seeking services.

69
 Increase Urgent need for more permanent LGBTQ
access friendly sexual health resources in Peel

Improve baseline level of LGBTQ friendliness and

Preliminary Broad
sexual health competency across all healthcare
Recommendations approach
providers

Innovation
Explore innovations in services to improve
at STI/PrEP
accessibility, efficiency, and patient experience
clinics

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“…hook gay people up with gay medical support…”
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Increase sexual health resources
in non-urban areas

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END SHAME

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Questions and Discussion

DOES ANY OF THIS RESONATE WHAT SHOULD WE DO NEXT 

WITH OTHER PARTS OF ONTARIO? PRIORITIES FOR PHO?

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Questions? www.geographyofsex.ca

75
Participants: How Did They Find Us?

Instagram 17
Meds Expert 1
Maple Leaf PrEP Clinic 13
Friend 7
Hookup Partner 1
Meetup.com 1
Pornhub 2
Woodys 3
Peel Service Provider 4 76