A Perspective on Gay Men’s Health
Cavanaugh, Timothy
A patient meets his doctor for the first time. Taking a history, the doctor jocularly asks, “You don’t have sex with other men or nasty stufflike that, do you?” The patient, who is gay, leaves the office without revealing his sexual orientation and never returns. True story. And not an uncommon one.
Studying gay men’s health is not about developing new diagnostic strategies or learning unusual therapeutic modalities, but about recognizing how we wittingly and unwittingly alienate some patients, depriving them of much-needed healthcare. We all are subject to culturally ingrained attitudes and often presume a heterosexual orientation. These attitudes and presumptions leave gay and lesbian patients struggling between suffering in silence or (once again) risking disapproval and rejection from a caregiver. The key to good health care for MSM (men who have sex with men), as with all patients, is frank and trusting communication, in a safe and tolerant environment.
Studies in the 1990s found 2.8% of the male population identified as gay or bisexual – over 30,000 people in Rhode Island. An additional 7.7% of men admitted to same-gender desire and 9.8% reported some history of same-gender sexual behavior.19,22 Yet the medical community remains largely untrained in and uncomfortable with gay men’s health. Half of US medical school Family Medicine departments offered no training in LGBT issues, and in those programs that did offer training, the average time dedicated to the subject was only 2.5 hours in the four-year curriculum.32 In a 1989 survey, 35% of Internal Medicine and Family Practice residents agreed or were “unsure” that homosexuality was a mental disorder (25 years after the American Psychiatric Association removed homosexuality from the DSM); 20% weren’t comfortable with homosexuals.16 Nursing students revealed similar attitudes in a 1998 study: 8-12% “despised” LGBT people; 40-43% felt “that they should keep their sexuality private.”17 Understandably, many gay men are reluctant to reveal their sexual orientation to their providers. In 1992 the Gay and Lesbian Medical Association found 44% of gay men had not “come out” to their PCP; this number dropped to 23% in 2003.12 LGBT and questioning youth were less forthcoming; in 1998, two-thirds had not discussed sexual orientation with their provider.1
Providers face a two-fold challenge: first, to familiarize and educate ourselves on the health issues that are particularly pertinent to this population, without pathologizing the patient and his lifestyle; second, to foster enlightened attitudes among staff.
Few medical topics are peculiar to gay men alone. Gay men share the same health concerns and present with problems similar to heterosexual men. However, we providers should be aware of specific issues; i.e., sexually transmitted infections, anal cancer, substance abuse and mental health.
Little accurate data are available concerning the incidences, but MSM probably have disproportionately high rates of sexually transmitted infections. Recent increases in primary and secondary syphilis in the US have been attributed almost exclusively to MSM.5 Many communities have seen increasing rates of gonorrhea in MSM, compounded by flouroquinolone-resistant strains in areas with large gay populations.3 MSM are at higher risk of Hepatitis A and B: the 1993 San Francisco Young Men’s survey showed 20% had been infected with Hepatitis B.20 In our own hepatitis vaccination program at a Rhode Island bathhouse, nearly 1/3 of men had been previously infected with hepatitis B.
HIV is a major concern for this population. According to the CDC, in 2004, 48% of all persons diagnosed with HIV were MSM, and MSM represented 67% of all persons living with HIV.4 Providers need to educate their patients on the implications of co-infection, how infection with one organism can affect the transmission of other organisms and the course of other infections.
Human papilloma virus poses particular risks for MSM. In a 1998 study, 61% of HIV-negative men and 93% of HIV-positive men showed evidence of HPV infection.2” As with cervical cancer, HPV infection has been strongly associated with anal cancer. Thus, although the risk of anal cancer in the general population of men is 7 per million, the risk is 35 per 100,000 in MSM (rivaling the rate of cervical cancer in women prior to the introduction of routine Pap smears).7 The rate of anal cancer in HIV-positive men is twice as high as in HIV-negative men.21 Although it has not become standard of care, experts now recommend anal Pap smears for high-risk men. Abnormal Pap smears would be evaluated by referral for anoscoopy. Data on outcomes are limited, but the sensitivity of anal Pap smears has approached 98%, although the specificity for predicting severe dysplastic changes is much lower.2 Surgical treatment of anal HSIL has shown excellent results in small numbers of HIV-negative men; unfortunately, HIV-positive men have had high rates of recurrence.6
Without stereotyping gay men as promiscuous, providers need to address the role that sexual activity may play in their patients’ lives. In a recent behavioral survey of gay men, 75% had more than one partner in the past year; 27% had 10 or more.24 Some gay men find their sex partners at bars, bathhouses, private sex parties, public “cruising” areas like parks and rest stops, and, increasingly, on the internet. Others have traditional dating experiences, and many gay men have been happily partnered for years, despite their inability to legally marry. A longstanding relationship does not ensure sexual monogamy: many gay men have sex outside dieir relationships, often with the consent of their primary partners. There is growing concern for a perceived rise in the rates of unsafe sexual practices. Several surveys show that 10 to 50% of gay men are having unprotected anal intercourse;10,13,15,18,34 the surveys do not probe how or why men decide to engage in such behavior.
In our experience, while most MSM are aware of “safe sex” messages, these somewhat simplistic guidelines do not always address the complexities of their social and erotic lives. Providers must assist men in negotiating their individual strategies of harm reduction, through realistic discussions of sexual health that respect the sense of eroticism and the role that sexuality plays in their patients’ lives. In practical terms, patients need accurate information regarding symptoms and transmission of STIs in relation to different sexual practices. Men who report multiple or casual partners should be offered regular (every 6 to 12 month) testing for STIs from urethral, oral and anal specimens. And these men should be tested for and vaccinated against Hepatitis A and B; surveys of Hepatitis vaccination rates amongst MSM show vaccination rates of only 35 to 50%.11,20,23,28
Data about substance abuse in MSM are hampered by severe methodological flaws. Studies in the 70s to early 90s reported rates of alcohol abuse around 30%.8 However, a 1998 study showed no significant differences in alcohol consumption overall when compared to the general population; interestingly, the data were skewed by the findings that gay men were twice as likely to be heavy drinkers and also twice as likely to be abstainers.30 The study did find that drinking rates do not decrease with increasing age as quickly as in heterosexual populations. Tobacco abuse was also more prevalent in gay men – 41.5% versus 28% of the general population.31 Rates of abuse of other substances were not clearly documented; the scant data showed rates of use, but not rates of addiction, that were higher than in hetero populations.30
Providers need to ask about use of “club drugs; ” e.g., Ecstasy, ketamine, GHB, “poppers”, and methamphetamine. Their use has become popular among some groups in the gay (as well as the non-gay) community. The popular and the professional media have highlighted methamphetamine (or “crystal meth”) because of its strong addiction potential and its association with high-risk sexual behavior and HIV transmission. Users may take one or more drugs within a short time frame to enhance or counteract the effects of other drugs; e.g., Viagra and similar medications can counteract the sexual side effects of methamphetamine. Providers should familiarize themselves with the physiologic effects of these substances. An interesting perspective with advice on harm reduction for users can be found at www.DanceSafe.org.
One shouldn’t assume that every gay man abuses alcohol or drugs, but their use has permeated the fabric of gay culture. Many gay men “come out” and find community within gay bars and clubs. Many may rely on bars and parties for socialization. In a recent survey of gay men in southern New England, only 22% reported discussing substance abuse with their providers, (personal correspondence)
Providers should be cognizant of mental health. Although studies on depression lend mixed results, many find higher rates of affective and adjustment disorders, often linked to high-risk sexual behavior.8 Body-image disorders may be more prevalent in gay men. A 2001 Harvard study showed 20% of gay men suffered from anorexia and 14% from bulimia.29 Gay men may be more likely to have been sexually abused. In a 1992 study of 1001 gay men, 37% reported sexual encounters with an older or stronger male before the age of 17; of these episodes, 93% met the investigator’s definition of abuse.9 Several studies from the late 1990s demonstrated rates of suicidal ideation and attempts that were 3 to 7 times higher in gay and lesbian youth.8 In a 2002 survey of young MSM, 4.7% had attempted suicide in the past year and a third reported at least one suicide attempt at some time in their lives.26 Being able to discuss issues of sexuality with MSM, especially young men, may open the door to identifying those with mental disorders.
A provider must consider sexual identity. “In addition to examining normative, age-specific developmental tasks, it is also important to look at stages in the development of lesbian/gay identity… Where is the individual along the continuum of integration and consolidation of his gay identity versus internalized homophobia and conflict about being gay?”33 Sexual identity may be a source of shame and self-loathing, or may have engendered great strength and resiliency, sense of humor, and dedication to community. These issues are not just crucial to the younger patient. A body of recent literature dedicated to aging and end-of-life issues in gay men has replaced “the stereotypes of lonely, alienated and despondent older gay men” with a more accurate picture of “successful” aging related to the process of coming out and adapting to a largely homophobic culture.27 Providers can help patients tap into these special strengths.
Harrison and Silenzio outlined four steps to appropriate care for gay and lesbian patients: 1) maintaining a non-homophobic attitude, 2) distinguishing sexual behavior from identity, 3) communicating clearly and sensitively using gender-neutral terms, and 4) recognizing how our attitudes affect clinical judgments.14 The first requires us to acknowledge and step outside our prejudices. We may need to put aside personal feelings of uncertainty, discomfort, even disgust, to provide appropriate care. As health professionals we like to think that our decisions are based on a dispassionate synthesis of clinical knowledge and fine-tuned diagnostic skills. But our emotional responses can color our perceptions and distort our conclusions.
Providers need to become comfortable taking a sexual history, treating it as a routine part of a patient encounter. Use gender-neutral terms such as “partner” or “significant other” and remain open to the possibility of non-traditional relationships. Distinguish between sexual identity and behavior; asking a patent if he is “gay, straight or bisexual” is different from asking if he “has sex with men, women or both.” The patient who identifies as “straight” may be having sex with other men. Conversely, not every man who identifies as gay has multiple partners and needs immediate referral for HIV testing. In adolescents who are not yet sexually active, ask whether they think about men or women when they fantasize about sex; acknowledging that it may be “normal” to be attracted to the same sex and that you are open to discussing such issues may open the door to future discussion for teens who are not yet able or willing to address their sexuality. Take care in using medicalized terms (like “anal receptive”), and acknowledge unfamiliarity with certain sexual practices without appearing shocked.
Ensure that staff use appropriate language and are familiar with LGBT issues. The Gay and Lesbian Medical Association’s website includes links to other sites and access to the “Healthy people 2010 Companion Document for LGBT Health.” Consider scheduling an in-service for staff on LGBT health. Have an informal discussion with a gay patient on how the practice works for him. The provider may want to consult with a physician or mental health professional who is knowledgeable about the gay community.
Make the office environment more welcoming. Post a non-discrimination policy that includes sexual orientation. Distribute written intake materials that use culturally inclusive, gender-neutral terms; ask about “relationship” status rather than “marital” status and include non-traditional responses. Consider displaying pamphlets and posters with gayfriendly and gay-positive images. Include gay-oriented publications in the waiting room, like the Advocate, a national magazine written for the LGBT community, and Options, a Rhode Island bimonthly newspaper.
When a provider assists a patient through a major life experience, like pregnancy or bereavement, the insight that the provider gains into that patients life and the enduring influence on that patients health often reach beyond the presenting problem. Addressing sexuality with a patient can provide the same impact, especially for the gay, lesbian, or bisexual patient who has been culturally defined by his sexuality. The medical provider’s open attitude can help to create a strong therapeutic relationship with every patient.
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Timothy Cavanaugh, MD, and David Abbott
Timothy Cavanaugh, MD, is a physician with the Family Health Services/Comprehensive Community Action Program, Medical Director for The Men’s Health Collabarative, and Associate Clinical Professor, Department of Family Medicine, Brown Medical School.
David. Abbott is Director of the Men’s Health Collaborative, AIDS Project RI.
CORRESPONDENCE:
Timothy Cavanaugh, MD
Family Health Services
1090 Cranston St.
Cranston, RI 02920
Phone: (401) 943-1981
e-mail: cav79@msn.com
Copyright Rhode Island Medical Society Jun 2006
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