We’re better off when we swipe right on public health

When Antón Castellanos Usigli was asked to help bring younger LGBTQ people into a Brooklyn clinic for sexual health services, he thought it would be a piece of cake. But after his first attempts failed, Antón turned to the one place where young people talk about sex every day: dating and hookup apps.

In this episode of “Better Off,” DrPH student Antón Castellanos Usigli talks about creating positive conversations about sexual health, and the parallels between sex education and the public health messaging during the COVID-19 pandemic.

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Episode Transcript

Anna Fisher-Pinkert: From the Harvard T.H. Chan School of Public Health – this is Better Off, a podcast about the biggest public health problems we face today . . .

Antón Castellanos Usigli: There’s so much shame and stigma around our sexuality.

Anna Fisher-Pinkert: . . . and the people innovating to create public health solutions.

Anton Castellanos Usigli: We have to develop public health programs that actually talk about the whole spectrum of what sexuality means.

Anna Fisher-Pinkert: I’m your host, Anna Fisher-Pinkert.

Imagine it’s a regular Friday night – before the pandemic. You’re thinking about going out, but none of your friends are around so you open your favorite hookup app. The first person you see isn’t your type, so you swipe left on that profile, and then you swipe left on the next profile, and the next one. And just when you’re about to give up, you see this hot nurse. And his profile is just one line: “Let’s talk about sexual health.”


So you start chatting – and you learn that the nurse is actually representing a local health clinic, just around the corner from where you’re sitting. You can get STD testing there, you can get pre-exposure prophylaxis, or PrEP, to prevent HIV.

This is not a scam or a catfishing scheme – it’s actually a public health program dreamt up by Harvard Chan School DrPH student Antón Castellanos Usigli. The story of how this program came to be says a lot about how public health messaging succeeds or fails in convincing us to do things for our health – and the health of those around us. It’s also a story that could help us untangle why so many people have resisted public health measures during the COVID-19 pandemic.

So don’t ghost us – because this week, we’re better off with Antón Castellanos Usigli, sexual health expert.

In 2015, a very idealistic Antón started working at the HIV services clinic of Wyckoff Hospital in Brooklyn. Wyckoff is located in a neighborhood full of young, Latinx LGBTQ people, but the people coming in for HIV treatment and prevention services were still mostly older adults. So, the clinic director approached Antón and asked him: could you get more of the community into the clinic?

Antón Castellanos Usigli:  And I was telling myself, how difficult could this be? You know, it’s gonna be a piece of cake. And then it turned out to be very complicated.

Anna Fisher-Pinkert: So, Antón started doing all the tried-and-true methods for community outreach.

Antón Castellanos Usigli: And so I started going to meetings with community based organizations, trying to build linkages of agreement for them to refer patients to us. Then we coordinated efforts to go out in the community to bars, clubs, talk to people about sexual health in the middle of the night, trying to convince them to come in to our clinic for services. And after all of those efforts, we saw zero clients going into the clinic for services. No one wanted to receive sexual health services with us.

Anna Fisher-Pinkert: And in the midst of this failure, he had an idea.

Antón Castellanos Usigli: And one day I, I just looked at myself and I thought, well, Antón, you have been doing this all wrong. You are young. You are gay. And so – and you’re Latino. You’re the target group that you’re looking for. So where do you talk to other men about sex? And then I had that realization that day that I didn’t talk about sex with them in bars or clubs. Well, I talked with them about sex through dating apps, through hookup apps. That’s the space where we have these conversations all the time – day, night, afternoons.

Anna Fisher-Pinkert: This is where Antón decided to ditch the tried-and-true methods and go out on a limb.

Antón Castellanos Usigli: And so I did something. I created a profile in one of these popular hookup apps. I put the image of a sexy male nurse and I just put a one line description that said, “Let’s talk about sexual health.”

Anna Fisher-Pinkert: And from there, Antón starts messaging guys who are located nearby.

Antón Castellanos Usigli: “Hey, man. Hey, bro. What’s up? What are you doing?” and starting very casually. And they would tell me something about how their day is going. And then I would get into the point in which I would tell them, “Well, I’m actually working in a clinic. And so, you know, I provide sexual health services. When was the last time you had an HIV test or when was the last time you had an STI test, or do you know what PrEP is?”

Anna Fisher-Pinkert: And guys responded to this!

Antón Castellanos Usigli: We had very interesting conversations about different sexual health issues and services. And people asked so many questions. So then, you know, we encountered these situations in which people told us, “That’s fantastic. That’s great. You know, I’m actually curious about this” or “Do you know something about this?” or “The other day something happened to me. And so can you help me?”

Anna Fisher-Pinkert: And once the conversation got going, Antón would take it to the next level – asking them to come, in person, to get sexual health services.

Antón Castellanos Usigli: But we always got to the point in which we made the invitation and we were emphatic in the sense that we needed to see them in person to keep talking about that and to provide them the services that they needed.

Anna Fisher-Pinkert: A lot of the men who engaged in these conversations said, “Yeah, ok, I’m in!”

Antón Castellanos Usigli: At the end of their day after receiving different services, it happened to me so many times, that they came to me, they shook my hand and they were saying things like, “Thank you so much for bringing me here. The way you’re talking with people about sexual health in these apps is really smart.”

Anna Fisher-Pinkert: Antón trained peer educators at the clinic on this new approach, using apps like Grindr that are popular with men who have sex with men. And the makeup of the patients at Wyckoff started to change.

Antón Castellanos Usigli: That particular clinic had been providing services for the most part to older adults, people in their late 40s, 50s, some of them in their 60s, who had been going there for years. And so suddenly the medical providers were telling me, we are seeing more young men coming into the clinic for services. So we shifted the whole demographic that the clinic was serving. And the other thing that we noticed as time went by was that people began talking about us to their friends, to their partners. And so our online outreach strategy was the number one source of patients that we have who are men who have sex with men. The number two source of patients were friends and partners. And that was, again, very powerful and another proof that what we were doing was having tremendous impact in the community.

Anna Fisher-Pinkert: I admit that I was pretty skeptical – I mean, didn’t guys feel like this was a bait-and-switch?

Antón Castellanos Usigli: It happened a couple of times. It was rare, I would say, maybe three percent of the times or five percent at most. And so, you know, again, coming from this place of understanding what dating apps are and hookup apps are, people are trying to have sex. People are trying to meet other people. And so not everyone is going to be receptive to a conversation that doesn’t lead into sex.

Anna Fisher-Pinkert: Antón says that any good public health campaign is going to have people who aren’t receptive to the message, and it’s on public health professionals to be patient and responsive to the communities they want to serve.

Antón Castellanos Usigli: You know, some people are going to like what you’re doing. Some people are going to be ready to get the service or to get what you’re trying to get to them. But some others are not going to be very receptive or it’s going to take them some time to process the information that you’re giving them and to think for themselves, “When is it that I’m ready?” Some people – for some people, it takes a few weeks, it takes a few month, and we saw that often as well in the apps. That our peer educators were having conversations with people. And they had been having a conversation with the same person over a period of weeks or months. And finally that day arrived in which the person reached out to the peer educator and they were like, “Hey, you know what? I actually decided that I will go to your clinic for services.” But it took them weeks. It took them months.

So we also have to realize that – that it’s a process. It’s not going to be immediate for everyone. Again, it’s a journey. Sexual health is – it’s a very personal part of who we are, our sexuality is a very personal part of who we are. So some people are going to be ready to just go have an open conversation with the providers. And some others are going to be scared. Some others are going to be ashamed. Some others, it’s going to take time for them to say, “Yes, I need those sexual health services.” You know, so it’s about understanding that as well.

Anna Fisher-Pinkert: I think that’s also really interesting because it is such a difference from meeting someone in the middle of the night and having maybe a five minute conversation about sexual health. You’re talking about building an ongoing relationship with someone and maybe it’s not the deepest relationship, but having that open channel where, you know, if they suddenly have an experience where they think that they have taken on an extra risk or something goes wrong, and then in a sexual experience, they can go back through their messages and find like what was the name of that clinic and send another message and reengage.

Antón Castellanos Usigli: Absolutely. Absolutely. And that was exactly what we saw. For some people, it’s a long process. And again, there are very negative feelings around sexuality that we all grew up listening to. “Oh, you shouldn’t be having sex in general. Oh, you shouldn’t be having sex with someone from your same gender.” Right? We are hearing all of these messages since we are children. And so I myself, I grew up in a very conservative environment. My family was not particularly conservative, but the environment around me was – the people in my school, my teachers . And so you didn’t hear very sex positive messages about sexuality in general and you didn’t hear anything about the gay sexuality or if you heard comments they were homophobic. And so we grew up with this fear, with these feelings of shame. And you grow up scared. And that is why a lot of people end up having issues when it comes to sexual health, because they didn’t have the confidence. They were not in a good position to negotiate sexual relations. And this goes back to the initial education, initial informal education that we all receive around sexuality and particularly gay men. There’s so much shame and stigma around our sexuality. It seems we are children. We hear so many negative, homophobic comments about our sexuality. So this has an impact in the long run. And then that’s why some people are not confident enough to negotiate protection or to have open conversations with their partners. They think that what they’re doing is dirty or things like that.

Anna Fisher-Pinkert: Antón says that we need to start dismantling this problem by changing the way we talk about sexual health.

Antón Castellanos Usigli: We can no longer be teaching and informing people about sexual health from the standpoint of risks of just talking about the negative consequences associated to sexual relationships. We have to go deeper than that. We have to talk about the positive aspects of sexuality and that, again, that starts by recognizing that the main motivation that people have for having sexual relations is not reproduction. It’s pleasure, period. And so that’s the reason why people have sex. It’s because it feels good. They feel pleasure. And so we have to acknowledge that reality. And we have to develop public health programs based on that that are sex positive, that do not only talk about the risks associated to sexual relationships, but public health programs that actually talk about the whole spectrum of what sexuality means. Public health programs where medical providers are trained to have conversations beyond just STI infection. And they know how to talk a little bit about consent. They know how to talk a little bit about confidence. They know how to talk a little bit about pleasure. So thinking about the linkages between sexual health, sexual rights and sexual pleasure. And how does that come off in the conversations that we have with patients in clinics, in hospitals around the country and around the world?

if we keep, you know, developing programs that are only based on sexual risks because we are afraid that by talking about the whole spectrum of sexuality, we are going to be doing something wrong? That’s a problem. That’s where public health programs fail. And this is why I would say we have such a deep epidemic among men who have sex with men, particularly black and Latinos in the U.S. when it comes to HIV and sexually transmitted infections. I think that public health has failed my community, which is delivering traditional risk based programs where people really don’t feel comfortable to talk, where people feel scared, where people feel more stigmatized. And so we really have to change the whole paradigm. But it’s a difficult process. Believe me, it’s very difficult.

Anna Fisher-Pinkert: It’s not easy to convince someone to do something they don’t want to do – particularly when it comes to health. No matter how many chipper postcards my dentist sends me, I always wait until the last minute to make my dental cleaning appointment.

The COVID-19 pandemic has only raised the stakes. Public health officials have had to convince people to wear masks, even though they’re uncomfortable, and to stay distant, even though people are hungry for human contact. So I asked Antón whether there were parallels between sex education, and COVID-19 education.

Antón Castellanos Usigli: The other day I was thinking about that, actually. I was thinking, why is it that we haven’t seen great campaigns about the use of masks where personal stories are portrayed and stories of solidarity, positive stories where we listen to people and understand that wearing a mask comes from a place of love, of protecting your grandparents, your fathers, of protecting your friend who might have an underlying condition that you might not be even aware of. And so I think that the messaging throughout this pandemic has been very much based on the negative, of course, and the risks and very much I think people have felt that the finger has been pointed at them many, many times and that it’s been very paternalistic. You should wear a mask, you should do this, you should do that.

And that’s where resistance grows. “I’m not going to do this. Why are they telling me this? I don’t trust that doctor. I don’t trust that expert.” But if it comes from someone from your own community and speaks to your emotions in that way, the outcome might be different.

Anna Fisher-Pinkert: Antón says that the way people talk about not wanting to wear a mask is kind of familiar.

Antón Castellanos Usigli: People think of them as inconvenient and they don’t want to wear them because they think that they will disrupt their day or their activities. It’s exactly the same thing with condoms. When you hear those stories about why people don’t want to wear them, “It will disrupt the passion. It will break the moment. It’s boring. It doesn’t feel as good. And so I don’t want to use it.” It’s the same with masks. And it’s so simple to just put a mask, just remove it when you have to eat and then put it back on and continue with your day. And that’s it. Like there’s not major science to it. But because this message has come from a place of finger pointing and I think very paternalistic of what people should be doing. And if they don’t do it, then people become resistant to that. And I think we could have done it in so much better ways, and being more far more creative than what the messaging has been and taking on that lesson from the world of HIV prevention and condoms.

Anna Fisher-Pinkert: Once Antón’s success with Wyckoff hit the media, he got calls from public health departments asking how to replicate the program. Scaling up this online outreach strategy has become Antón’s next project – and what he’s working on now as a Cheng Fellow at the Social Innovation and Change Initiative at Harvard Kennedy School. But Antón knows that our sexual culture is constantly changing – and that means public health professionals have to keep changing, too.

Antón Castellanos Usigli: I didn’t have an iPhone when I was 15, when I was 16, when I was 17. And so now for many people, their first sexual experiences happen in the digital world. They either happen through one of these apps or they happen through social media, through Snapchat, video dating, sending videos and pictures of yourself to other people. And so we have to recognize that this is a world that we’re living in. And we have to think how public health will respond to that. And I think with anything, there are risks and there are opportunities. And so I think what’s important is for us to not get stuck in the risks and adopt this, again, this paternalistic approach of telling adolescents or telling younger folks, “You shouldn’t be doing that. You shouldn’t be doing that. It’s not right for you to do that.” We have to go deeper than that. We really have to see that as an opportunity to provide services, to provide education. And the possibilities, I think are just infinite.

Anna Fisher-Pinkert: Thanks for listening to this episode. If you want to learn more about Harvard Chan School, and what some of our other students are up to – visit hsph.harvard.edu/news. There are some great stories you can read.

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I’m Anna Fisher-Pinkert, host and producer of Better Off a podcast of the Harvard T.H. Chan School of Public Health.