OPTIMIZING PRIMARY CARE FOR MEN WHO HAVE SEX WITH MEN

OVER THE PAST 2 DECADES, THE LITERATURE ON THE health care needs of
gay men and those who may not identify themselves as such, but are
men who have sex with men (MSM), has been dominated by issues related
to human immunodeficiency virus (HIV) prevention and care. This focus
on HIV remains critically important; at least a quarter million MSM
are living with HIV in the United States and approximately 20 000
more will likely become infected this year.1 Nevertheless, the vast
majority of MSM are not HIV-infected but still require high-quality
medical care that is culturally competent and targeted to their
needs. Unfortunately, the most comprehensive articles about the
medical care ofMSMwho are not HIV-infected date from the dawn of the
AIDS epidemic more than 20 years ago.2 Current standard sources of
practical medical information for primary care practitioners do not
sufficiently address the routine care of MSM.3 This is true even
though the Department of Health and Human Services' Healthy People
2010, a document produced each decade to outline national health
goals for the years ahead, identifies gay men and lesbians as 1 of
the 6 most underserved groups.4

Although it is difficult to quantify precisely how many
gay-identified men and other MSM live in the United States,5 it is
clear that they are present in virtually all communities and likely,
every primary health care practice.

For instance, the US Census in 2000 found same-sex households in more
than 99% of counties throughout the country with the highest
densities ranging from 5% to 7% of households in many urban centers.6
Studies that describe the prevalence of male homosexual behavior and
sexual identity often vary based on demographic and geographical
variables, as well as the fluidity of sexual behavior, desire, and
identity in the course of a lifetime.

In 1994, Laumann et al7 found that 2.8% of men identified themselves
as gay, whereas 9.1% described having had same-sex sexual activity at
some point in their lives.

In several urban centers, the prevalence of men with a gay identity
was as high as 9.2%, with 15.8% of men reporting some sexual contact
with other men since puberty. There have been no population-based
studies of non- gay identified MSM; however, while some men will
eventually identify as gay, many, particularly individuals from
ethnic minority communities, do not choose to identify with gay
culture for a variety of reasons, ranging from subcultural tolerance
of bisexuality to internalized homophobia or the perception that gay
identity is conflated with being white.8,9 Outside of the United
States and Europe it is even more common for MSM to not identify as gay.10

Given the range and fluidity of sexual behavior and identity among
MSM, it is important for clinicians to recognize the medical
implications of sexual behavior, as well as to identify patients
whose sexuality may be evolving and who may want help identifying
themselves as gay to friends, family, and society, ie, "coming out."
At the same time, physicians and other clinicians must appreciate the
need to provide care and support forMSMfor whom social and cultural
reality may preclude coming out or the desire to do so. Specific
Health Care Needs of MSM Even though most major health care issues
forMSMare similar to the routine health recommendations for all men,
independent of sexual orientation or sexual behavior, there are
unique issues to consider, including screening for and immunizing
against hepatitis A and B virus; routine screening for sexually
transmitted diseases (STDs); routine screening for certain cancers
(ie, anal human papillomavirus [HPV]-related neoplasia); assessing
drug, alcohol, and tobacco use; screening for psychological health
and mental health disorders, domestic violence, hate crimes, and
posttraumatic stress; and helping patients deal with stigma
associated with being a sexual minority as well as the social and
psychological issues of coming out.11 The Centers for Disease Control
and Prevention (CDC) provides updated, basic guidelines for health
promotion and prevention of STDs among MSM.12 Some MSM are at high
risk for HIV infection and other viral and bacterial STDs. Younger
men and men of color have been particularly affected.

Black MSM are experiencing a disproportionate increase in the number
of new cases of HIV.13 Although the frequency of unsafe sexual
practices and STDs had declined substantially among MSM after the
recognition of AIDS, more recently, increased rates of syphilis,
gonorrhea, and chlamydia among MSM, and, in particular,
HIVinfectedMSMhave been reported in many cities in the United States
and other industrialized nations.

These data suggest that despite on-going educational efforts, some
MSM continue to engage in high-risk sexual behaviors placing them at
risk for HIV and other STDs.14,15 Adherence to safer sexual practices
that were inculcated in the early days of the AIDS epidemic appear to
be waning, perhaps related to "safer sex burnout," beliefs that
improved treatment reduces infectiousness or makes HIV a less serious
disease (therapeutic optimism), increases in substance abuse, or the
coming of age of young MSM in an era in which AIDS seems remote and
HIV treatment seems manageable.16

Therefore, all MSM, independent of HIV status, should routinely
undergo straightforward, nonjudgmental STD/ HIV risk assessments and
patient-centered prevention counseling to reduce the likelihood of
acquisition or transmission of HIV and other STDs. Routine screening
for STDs should be considered for MSM even in the absence of physical
complaints or symptoms.

Current CDC guidelines17 recommend that the following studies should
be performed at least annually for sexually active MSM: HIV serology,
if HIVnegative or not previously tested; syphilis serology; urethral
culture or urine nucleic acid amplification test for gonorrhea; a
urethral or urine test (nucleic acid amplification) for chlamydia;
pharyngeal specimen collection to test for gonorrhea in men with
oral-genital exposure; and rectal gonorrhea and chlamydia screening
in men having receptive anal intercourse.17

In addition, the CDC guidelines13,17 recommend immunization of
sexually active MSM for hepatitis A and B virus. More frequent STD
screening, eg, at 3- or 6-month intervals, may be indicated for MSM
at highest risk, eg, those having multiple partners, those having sex
in conjunction with recreational drug use, or patients whose sex
partners participate in these activities. Screening is indicated
regardless of a patient's stated history of consistent use of condoms
for insertive or receptive anal intercourse because some STDs, like
syphilis, may be transmitted by oral sex and condom protection is not
100% effective.

Clinicians should also be knowledgeable about common manifestations
of symptomatic STDs in MSM (ie, genitourinary and anorectal
abnormalities). If these symptoms are present, other specific
diagnostic tests are indicated.

It is also important for clinicians to educate MSM that STDs may be
asymptomatic and can spread without the presence of any abnormalities.

Counseling MSM to avoid STD risk may require careful and nuanced
discussions.18 Although syphilis, gonorrhea, and chlamydia are
commonly spread by oral-genital concontact, many patients may be
unaware of this and may be resistant to using condoms for oral sex.
Clinicians can play an important role in motivating patients to
reduce risky behaviors by discussing the recent increase in STDs
among gay men, by explaining the transmission synergy between HIV and
STD infections, and by helping them understand how STDs are contracted.

Human papillomaviruses are also sexually transmitted and common in
MSM.19 Human papillomavirus is most commonly associated with the
development of anal and genital warts. Unfortunately, the same
strains of HPV that are associated with cervical cancer (usually
types 16 and 18) can also develop into anal carcinoma.19 Anal
carcinoma is increasingly common among men infected with HIV and
other gay men who engage in high-risk activity, so it is important to
consider screening on a regular basis.19 Anal Papanicolaou smears are
recommended yearly for men who are infected with HIV due to growing
evidence that HIVinfected individuals are at increased risk for
HPV-related neoplasms. Screening of HIV-uninfectedMSMshould likely
occur every 2 to 3 years.19 The recent licensure of a safe and
effective vaccine to prevent oncogenic HPV infection is being studied
in MSM and may become another useful preventive health intervention
for MSM who engage in anal intercourse.

Beyond STDs and HIV, there are very few specific recommendations for
routine medical risk assessment of MSM. However, MSM smoke more on
average than the general population, making risk assessment and
counseling in this area important.11 The prevalence of alcohol and
drug abuse problems in this population also exceeds rates found in
the general population.11 Although particular drugs of choice change
over time, crystal methamphetamine is currently popular, particularly
among urban MSM. In addition to the cumulative effects of the drug,
which can lead to significant physical and psychological impairment,
methamphetamine has been associated with increased sexual risk
taking, resulting in the acquisition of HIV infection and other
STDs.20 Risk assessment, frank discussion about the shortterm and
long-term effects of these drugs, and referrals for prevention
options including harm reduction are critical in helping patients
avoid serious sequelae from substance abuse. Other behavioral issues
are also common.

For example, intimate partner violence occurs at the same rate in
same-sex relationships as it does in opposite-sex relationships,
making discussing with patients whether they feel physically safe in
their relationships an important part of the care of MSM.21

Challenges for Clinicians

Clinicians should take an active role in determining who among their
male patients are having sex with other men as well as who are having
sex with both men and women. This information will help guide
discussions of preventive sexual health and assist in identifying
those who may need additional supportive services.

When MSM feel comfortable disclosing their sexual behavior,
clinicians can provide effective health promotion and risk reduction
counseling. 22

Clinicians should elicit their patients' sexual history and, for
some, their sexual desires.

These are areas of inquiry often overlooked by clinicians compared
with other issues more frequently discussed during routine assessment
of health, such as smoking or alcohol use.23 Answers to questions
regarding sexual behavior, such as "Do you have sex with men, women,
or both?" have clear implications for medical care. However,
questions about sexual desire can be particularly important for men
not comfortable discussing issues related to their sexual identities.
Physicians may encounter patients who may initially appear
uncomfortable but express relief when given an opportunity to talk
about their desires and possible conflicts regarding wanting to be
with another man or about wanting to come out. Exactly how to begin
such a conversation is difficult to prescribe, and questioning
patients along these lines can be challenging to fit in a 15- or
20-minute clinical session.

Listening is a good start, in addition to asking open-ended,
nonjudgmental questions. For example, asking, "Do you ever have any
attraction to members of the same sex?" can be a useful way to begin
this discussion. Such inquiry may yield productive conversation with
some patients.

Many patients who have come out or who are struggling to do so
express having lingering demons regarding work or their family, which
keep them from being completely comfortable with themselves and their
evolving sexuality.

Displaying empathy and making referrals for counseling can help those
experiencing conflicting feelings.

Having a list of mental health professionals in the community who are
open and accepting of patients in need of this type of counseling may
be helpful.

Clinicians should keep in mind that patients may come out at all
ages, even those who are middle-aged or older and may have been in
heterosexual marriages or other long-term relationships. Coming out
at any age can be complex; however, more has been studied about
adolescents and young adults.

Among all adolescents, including male youth who identify as gay or
bisexual, identity formation is an important developmental task that
is not unidimensional, but rather encompasses a mosaic of multiple
identities within various realms of life (eg, occupation, gender,
sexuality, religion).24 Understanding the emergence of a gay or
bisexual orientation and integrating this into an overall personal
identity can be a challenging and distressing task for many
adolescents. For some gay and bisexual male youth, this process can
be long, painstaking, and complicated by experiences of heterosexism,
stigma, homophobia, and prejudice.24 This process can be particularly
difficult for MSM who are from communities of color who may
experience a dual stigma associated with being both a sexual and
racial/ethnic minority.

As with adult MSM, a knowledgeable and caring physician can be an
important resource helping gay youth overcome the challenges
associated with a sexual minority identity and to lead happy,
healthy, and productive lives.

Conclusions

Much work remains to determine how to help gay men and
non-gay-identified MSM engage in healthy lives that include embracing
a positive image and minimizing sexual risk. Despite the complexities
involved and the need for further research, clinicians can listen to
these patients openly and without judgment and become better educated
about current recommendations for the care of gay men or other MSM.3

It is also important to consider the environments in the practice
setting and whether they are welcoming to MSM and those from other
diverse backgrounds. Are there inviting pictures, relevant
educational materials, and inclusive forms that make all patients,
including MSM, feel as though they are desired as patients?

Office personnel who or documents that simply ask if the patient is
single, married, or divorced are still too common and give patients
who may not think in these terms an unwelcoming message, as do forms
or policies that do not accept names of partners or close friends as
opposed to blood relatives for notification purposes. These may not
seem like large issues but are essential for helping patients feel
safe and welcomed when seeking health care. The Gay and Lesbian
Medical Association has developed helpful guidelines for practice
environments (http://www.glma.org).

Although clinicians may face challenges to complete required tasks in
increasingly short patient visits, they may consider referring
patients to self-learning resources, such as those that are also on
the Gay and Lesbian Medical Association Web site. Also, it is
possible that some physicians and practices might not be able to
provide welcoming and nonjudgmental care for gay men or other MSM; in
those cases, referral of the patient to another physician who can
provide such care is imperative.

Primary care clinicians should never underestimate their importance
in their patients' lives and how they can help promote healthful
behavior by appearing open to discussing sexuality and making this as
normative as reviewing smoking, diet, or exercise in the primary care
clinical encounter. With adequate education and training, clinicians
not only will provide appropriate routine care for their sexual
minority patients but also will help patients avoid internalizing
stigma associated with homosexuality, access the optimum health care
they need and deserve, and lead more satisfying and healthy lives.

Financial Disclosures: None reported.

Acknowledgment: We deeply appreciate all the critical advice and
editorial assistance given to us by our colleague Hilary Goldhammer,
MS, an associate at Fenway Community Health, who was compensated for
her assistance. We are also indebted to the Horace W. Goldsmith
Foundation for its support of the education program at the Fenway
Institute, Fenway Community Health, Boston, Mass.