Despite evidence that undetectable equals untransmittable (U=U), negative attitudes toward people living with HIV persist among men who have sex with men (MSM). We examined HIV-related knowledge, attitudes and relationship willingness among Swedish MSM and evaluated an anti-stigma campaign. Repeated cross-sectional online surveys of MSM aged ≥ 18 years were conducted in Sweden (2020–2021) before and after an anti-stigma campaign. Participants were recruited via LGBTQIA+ media and dating or cruising platforms. Multivariable logistic regression adjusted for sociodemographic and behavioral factors. We analyzed 3100 pooled responses and 1132 post-campaign responses. Knowledge gaps were substantial: 72% had not encountered U=U messaging and only 53% knew that treatment prevents transmission. Nearly half expressed unwillingness to consider relationships with people living with HIV. Negative attitudes decreased with higher knowledge (adjusted odds ratio [aOR] 0.38; 95% confidence interval [CI] 0.28–0.53) and increased with greater worry (aOR 3.66; CI 2.75–4.90). Greater relationship willingness was associated with higher HIV knowledge (aOR 3.79; CI 2.67–5.41). Less negative attitudes and greater relationship willingness were also linked to openness about sexual orientation. Campaign exposure was significantly associated with higher knowledge, less negative attitudes, lower worry, and greater relationship willingness. U=U awareness remains limited and stigma persists. The interrelations between knowledge, worry, and attitudes highlight cognitive and emotional dimensions of stigma. Observed links with campaign exposure suggest potential value of concise, context-specific U=U-centered communication in addressing stigma among MSM.

Oral pre-exposure prophylaxis (PrEP) is a highly effective and safe way to prevent HIV acquisition among men who have sex with men (MSM). PrEP became available to MSM in Sweden in 2018, but there have been challenges in its accessibility. The aim of this study was to gain an improved understanding of the lived experience of MSM enrolled in a PrEP program in Sweden. Data were collected through in-depth interviews with 16 MSM enrolled in the Uppsala PrEP program, which was the first PrEP program in Sweden. After being transcribed verbatim, data were analyzed using qualitative content analysis with an inductive approach to explore both the manifest and latent meanings of the interviews. The analysis resulted in an overarching theme: Transforming the sexual health landscape through PrEP, based on three descriptive sub-themes representing the perceptions and experiences among the participants: Constructing the “deserving” PrEP user, Being in the process of re-defining HIV, and Becoming a new sexual being. The results suggest that while several benefits, such as reduced HIV anxiety and sexual freedom, are experienced by PrEP users, continued HIV worry, risks of bacterial STIs and negative experiences of stigma and control are challenges that need to be addressed further.

This dissertation focuses on key conceptualizations of adolescent substance use that are used in science, policy, and prevention to calibrate societal responses to related problems. It examines how such conceptualizations and other ways of providing meaning to both legal and illegal substance use function in explaining who these users are and how their use develops over time. The ambition is also to study how adolescents, upon reaching young adulthood, provide meaning to substance use and to what extent dominant conceptualizations are reflected in their lay discourse. The conceptualizations addressed include the Risk Factor Model, the Normalization Thesis, the Gateway Theory, and the discourse of neoliberalism. The dissertation consists of four studies that are based on quantitative survey data and qualitative interview data from the Futura01 cohort; a representative sample from the normal population of adolescents. The data cover three time points: survey data from 2017 (participants’ age: 15/16) and 2019 (age: 17/18), and interview data from 2022-23 (age: 21/22). Study I use regression analysis to explore the association between risk factors and substance use at two time points. Study II employs latent transition analysis to identify clusters of adolescent substance users and how adolescents transition between these clusters over time. Study III uses the Logics of Critical Explanation framework to examine how substance use, risk factors, and future prospects are understood by young adults in qualitative interviews. Finally, Study IV uses a narrative approach to explore how young adults understand their own transition out of adolescent substance use and into responsible adulthood. The studies jointly found support in the Swedish normal population for some of the above-mentioned conceptualizations, while others fell short. The Risk Factor Model and the Normalization Thesis could partially explain adolescent substance use. For instance, some micro-level risk factors were stable predictors of substance use as they could predict use of both legal and illegal substances, both in 9th and 11th grade. Others could predict use of certain substances or use at specific time points, or fail to predict at all. However, this dissertation found little support for the Gateway Theory. Although these conceptualizations are primarily utilized in quantitative research, they were prominently reflected in the participants’ lay discourse, as expressed during the research interviews. Furthermore, the participants primarily conceptualized substance use through neoliberal ideals such as individualism, moderation, and health. The use of both legal and illegal substances was understood as something enjoyable and, in part, as a practice associated with adolescence. However, participants believed that substances should not be used to the extent that they would jeopardize a successful transition into adulthood. For them, this stance was associated with a process of maturing out of substance use during their early 20s, as well as maintaining a permanent state of vigilance if they choose to try or use legal or illegal substances after this period in life. In correspondence with the setup of substance use prevention and policy in Sweden, the participants seemed to favor conceptualizations whose point of departure was individualism. The dissertation closes with a discussion about whether this far-reaching focus on substance use as individual choice risks obscuring alternative conceptualizations and societal responses that highlight the influence of structural factors on deviant behavior such as adolescent substance use.

Despite growing understanding and acceptance of the concept of Undetectable = Untransmittable (U = U) among gay men, HIV stigma remains a burden for people living with HIV. This study explored perceptions of HIV among HIV seronegative gay men in Sweden in this new context. Using snowball sampling, 15 gay men born between 1980 and 2000 were recruited to the study. Semi-structured interviews were conducted and data were subjected to reflexive thematic analysis. Men grew up experiencing gay stigma and were repeatedly informed by parents, schools, communities, peers, and popular culture about the dangers of HIV, and that gay men were a high-risk group. As men grew older, and the premise of HIV shifted dramatically due to U = U, some remained emotionally anchored to the pre-U = U era, while others realigned their perceptions, often after a process of reconciling emotional responses (e.g. HIV = death) with the logical-rational claims made about U = U. The study highlights key areas for future efforts, namely establishing a balance between HIV education strategies and stigma reduction initiatives. Study findings underscore the need to care for the memory of those lost during the crisis years, while also addressing the stigma faced by those currently living with HIV.

Objectives: There is a lack of in-depth studies on men's personal experiences of having hypospadias across different aspects of their lives. We therefore aimed to explore the experience of having hypospadias in relation to identity and interpersonal relationships.

Subjects and methods: Using purposive sampling, we included 17 adult men aged 20–49 with variation in hypospadias phenotype. The informants further represented variation in sexuality, relationship status, parental status, and familial cultural context. In-depth interviews were conducted with each informant and the data was analysed using qualitative content analysis.

Results: We identified four categories. Firstly, The internal experience of hypospadias in relation to being different, being impacted, and being masculine. The remaining three categories related to interpersonal spaces: Intimate spaces, comprising personal relationship with sex, having sex, and being in a relationship; Familial spaces, comprising being a son, and becoming a father; and Public spaces, comprising being hidden, being naked, and peeing. We identified the latent theme varying impact and coping, highlighting differences in experiences relating to both the internal and interpersonal.

Discussion: Issues related to hypospadias included struggles with identity and confidence, as well as recurring patterns of social and sexual avoidance. While informants generally related to certain shared experiences, there is large variation in how much hypospadias impacts life, ranging from hardly at all to extensively. This could also fluctuate over time, with puberty and adolescence being an especially sensitive period. Functional and aesthetic outcomes are potentially important for well-being, especially in the case of more severe complications, while personal and interpersonal circumstances play a role in coping and the overall experience of the individual.

Conclusion: Healthcare, research, and other channels such as patient groups may be able to offer support to those who need it to help more boys and men with hypospadias live unhindered lives.

Sweden has a long tradition of restrictive policies regarding both legal (such as alcohol and cigarettes) and illegal substances (such as cannabis and amphetamine). However, research is needed on how regulatory frameworks and cultural understandings of substance use play out in the lives of young adults. Utilizing the logics of critical explanation framework, I explore the different logics that young Swedes draw upon when they conceptualize legal and illegal substance use. The data included 30 interviews with 21/22-year-olds who had previously participated in a prospective cohort study. The analysis shows that substance use played a minor role in the participants’ lives. Overall, it represented an obstacle to becoming an adult with a good life. They drew on social logics related to responsibility, ambition, and health to make sense of substance use, regardless of its legal status. These social logics have been used to explain previous years’ decreased use of cigarettes and alcohol among young people, and this study shows that they may also elucidate why illegal substance use is still rare in this group in Sweden. The analysis further suggests that these social logics were naturalized through the political logics of risk and choice, which emphasize the ideal of always being vigilant and safe. To dig deeper into this discourse, I uncover the emotional and ideological dimensions of the participants’ conceptualizations by discussing how they articulate beatific or horrific futures. The beatific future holds a promise of a bright, independent, and productive life, which includes abstaining from substances or using them moderately and responsibly. The horrific, in turn, holds that careless substance use will lead to social exclusion, addiction, and death. The participants’ hopes and fears strengthened the neoliberal idea that a good life is achieved through choice, vigilance, and by avoiding risk.

Objectives: There is a lack of studies on men's individual experiences of living with hypospadias. We aimed to explore the personal experiences of having hypospadias in relation to healthcare and surgery.

Subjects and methods: Purposive sampling was used to include men (aged 18 and over) with hypospadias representing different phenotypes (from distal to proximal) and ages in order to maximise the variation and richness of our data. Seventeen informants, aged 20–49, were included in the study. In-depth semi-structured interviews were conducted between 2019 and 2021. Inductive qualitative content analysis was used to analyse the data.

Results: We identified three categories: (1) Having surgery, which comprised the decision to operate, the experience of having surgery, and the outcomes of surgery; (2) Going to the doctor, which focused on follow-up care, re-entering care in adolescence or adulthood, and the experience of healthcare interactions; (3) Being informed, both about hypospadias in general, as well as about your specific body and medical history. There was overall a large variation in experiences. The latent theme across the data was the importance of owning your own narrative.

Conclusion: The experience of men with hypospadias in healthcare is complex and varied, highlighting the difficulty of fully standardised care. Based on our results, we suggest that follow-up should be offered in adolescence, and that ways of accessing care for late onset complications be made clear. We further suggest clearer consideration for the psychological and sexual aspects of hypospadias. Consent and integrity in all aspects and all ages of hypospadias care should be adapted to the maturity of the individual. Access to trustworthy information is key, both directly from educated healthcare staff and if possible, from websites or patient-led forums. Healthcare can play a key role in providing the growing individual with tools to understand and address concerns that may develop relating to their hypospadias through life, giving them ownership over their own narrative.

Background: Research is needed on how substance use patterns develop over time in the general adolescent population. This knowledge is crucial in calibrating prevention and other interventions. Method: The study concerns use of cigarettes, alcohol, and cannabis in a nationally representative cohort of Swedish adolescents (n = 3999). Two waves (9th and 11th school grade) from the Futura01 study were analyzed using latent transition analysis (LTA) and multinomial regression analysis. Results: Four substance use patterns, were identified, ranging from Non-user, Alcohol experienced, Alcohol User to Co-user of cigarettes, alcohol, and cannabis. Statuses thus conveyed a continuum from no use to more advanced use. Half of the individuals remained in their original status between time-points, and half transitioned, most often one step on the continuum. Alcohol user was the most stable status over time (0.78), and the Non-user status the least (0.36). The probability of remaining in the Alcohol experienced status was 0.57, and 0.45 for the Co-user status. There was a low probability of transitioning from alcohol to cannabis use. Females were more likely to belong to Alcohol experienced and males to Co-user statuses, but these associations weakened over time. Conclusions: The study identified transitions across substance use statuses between time-points. These usually concerned different levels of alcohol use, and not into more advanced substance use that included the illegal substance cannabis. The study corroborates that young Swedes belong to a “sober” generation and usually do not transition from legal into illegal substance use during late adolescence, though with some gender differences.

Background

Men who have sex with men (MSM) are at the epicenter of the HIV epidemic. Efforts to prevent sexually transmitted infections (STIs) and HIV transmission have traditionally focused on condoms and abstinence from high risk sexual practices. Recently, additional methods such as pre-exposure prophylaxis (PrEP) and viral load sorting have been introduced. The aim of this study was to gain understanding about risk management and risk perception strategies for HIV among highly sexually active Swedish MSM with men in Berlin.

Methods

Eighteen sexually active Swedish MSM who travelled to or lived in Berlin were recruited and interviewed in this study. The data were analyzed using content analysis.

Results and discussion

These men represent a group of knowledgeable MSM in terms of HIV. They acknowledged that having sex with men in Berlin was linked to high sexual risk taking due to the higher prevalence of HIV/STIs than in Sweden, but reported that they nevertheless did not alter their risk management strategies. The analysis resulted in a conceptual model of risk assessment that allows for a deeper understanding of the complexity of the risk reduction decision-making process. Three ontological perceptions of risk were identified: accepting, minimizing and rejecting risk. Seven practiced risk reduction methods were described. Some informants applied their preferred method or set of methods to all settings and partners, while others faced complex decision-making processes.

Conclusion

HIV is integrated into the core of MSM’s sexuality, independently of how they ontologically related to the idea of risk. A constant navigation between pleasure, risk and safety, alongside having to relate to risk created a complex process. Efforts were made to remove HIV from their lives by rejecting the idea of risk, and thereby reject the idea of the homosexual body being a possible vessel for a virus and an epidemic.

Aim: The public health model for prevention of disease and disorder has been influential in informing interventions regarding substance use. While a number of risk factors within this model have been found to predict substance use, few studies have explored the associations across substances, at different time points and in the same individuals. The aim of this study was to test this model across legal and illegal substance use among adolescents, and to identify potential changes in associations over time. Methods: Data from two waves of a nationally representative cohort study among Swedish adolescents were used. Baseline data were collected in 2017 (9th grade) with a follow-up in 2019 (11th grade). Using modified Poisson regression analyses, we explored cross-sectional associations between factors from different domains and prevalence of cigarette use, binge-drinking and illegal drug use at both baseline and follow-up. Results: The results in part supported the public health model. Substance use was predicted by factors within the family, school and the individual/peer domain, but several associations were not statistically significant. The only consistent risk factors across substances and time points were lack of parental monitoring, truancy and minor criminal activities. Conclusion: Despite widely different prevalence rates across substances, some risk factors were consistently associated with adolescent substance use. Nonetheless, the findings challenge the assumption that risk factors are stable over adolescence. They suggest a need for flexible prevention interventions spanning across substances and legal boundaries of substances, but also over domains to reflect the heterogenous needs of adolescents.