More than just M in MSM

transSo I had an enlightening experience the other day.  As a public health professional for years I had been thrown into the throngs of using the “MSM” categorization when discussing HIV risk and sexual behavior.  For those of you that are unaware this refers to “men who have sex with men”.   I am not sure where the MSM moniker arose from, however if you have information, please feel free to leave as a comment.

What I do know, is that a more appropriate risk category would be termed “people that have anal or oral sex with men”.  While it is biologically true that receptive anal sex is one of the most risky sexual encounters in terms of HIV transmission, it is not just “male” homosexuals that engage in this activity.  This came to light yesterday when I was interviewing a transgender patient about restarting female hormones.   She reported having sex with men only, however does not necessarily fit the classification of “MSM”.  She is a male to female transgender and although at the moment biologically male, she identifies as female, and I’m sure would me scathing if I called her a “man who has sex with men”.  The “scientific” term MSM  refers to sex (i.e. biology – i.e. something with a penis) and not gender.  Gender is complex, a social construct, including social norms,  how one identifies with these norms, etc.

Providers must be cautious when using such terminology to assess HIV and STI risk.  For example saying to a transgender male to female “many men who have sex with men are at higher risk for HIV and STIs.  Let’s do a HIV test and a rectal and throat gonorrhea and chlamydia culture”” is completely inappropriate and will turn her away from ever receiving care.  She does not identify as man, and although she has receptive anal sex, she cannot be labeled as a MSM.  Additionally, many biological women who also identify as a female gender, especially in developing countries are also in this high risk receptive anal sex category, even though they are not “MSM” .

There are several other articles that I found that talk about this in more detail:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1470585/

http://www.med.unsw.edu.au/nchecrweb.nsf/resources/HeppReports/$file/The-term%27MSM%27demeans-us-all.pdf

So basically, I obviously never use this term with patients and am now cautious when throwing it around in scientific circles.  I just basically consider any person that takes a cock up their ass (more so with regular frequency and unprotected) at risk.

A celebration of life

A few weekends ago I had the privilege of visiting the NAMES project AIDS quilt on the national mall in Washington, DC.    Growing up as a child of the 1980s, just when the epidemic was beginning I had seen images of the quilt being displayed in DC and had heard about it.  However, I was given the amazing opportunity to see a portion of the quilt myself.

I am sure that I have different feelings about viewing the quilt, then do many of my friends.  Many of my friends are generations older than myself, and lost many friends and loved ones to AIDS in the late eighties/early nineties.  Many of the quilt panels on display were dedicated to individuals who died during this period.  I felt emotion for those lost, however did not have a personal connection to them, as I have been lucky to come of age in the era of HAART.  Many individuals I know who saw the quilt for the first time cried, recalling their loved ones.

It was amazing to see tributes to so many diverse individuals – men, women, children.  So many lives were taken so young.  I cringed when I saw a panel dedicated to someone who passed away in their twenties.

I am happy that the quilt is being displayed for a new generation to view – in many ways I was excited because I thought it was a step forward in eradicating the current complacence in my opinion that surrounds HIV/AIDS – many think that because there are retrovirals and pre-exposure prophylaxis, that HIV and AIDS no longer affects people.  It does, and as we know epidemics are still raging among many communities around the world, unfortunately with no hint of letting up.  I believe that displaying the quilt served as a reminder to remind generation Z+ (I just made this name up for them) the impact AIDS has had on our nation and our world.

The quilt will also be displayed in various locations in its entirety for the International AIDS Conference.  I am so excited that I will be attending this conference! Although I have to work for some of the days I will be privileged to attend the opening and some of the evening sessions.  Of course I will report on what I attend.

What would all of you like to talk about?

So I apologize for not updating this blog more frequently.  Part of the problem has been medical school is super time consuming.  But I have noticed that roughly about 30 people come to this blog daily.  I want to write about things and topics that are relevant to readers around the globe.  So what specific things would you like discussed/written about relating to MSM and HIV?  Please leave a comment on items that you would like to see discussed.

Bareback.com?

So perhaps these websites for men interested in bareback sex have been around for a while, but I have been unaware of them.  Recently, a friend informed me of one such site, barebackrt.com, however several more exist.   At first I wasn’t quite sure what to think.   Upon digesting this concept some more, I came to an initial conclusion that perhaps these sites could serve as an online forum for serosorting i.e. a place where HIV+ men could find other HIV+ to have bareback sex with, and where HIV- men could presumably find other HIV- men for bareback anal sex.

Indeed, this is what bareback.com, the “original bareback only site” envisions:

“Now at BareBack.com you know that we are not AIDS Nazis, condom wrappers or fearful fools! What we are is a community of gay men who like the feel of raw nasty sex and want the whole world to be able to spray our holes!

That’s why we embrace a policy of containment. What does that mean – It’s simple. If poz boys stick to poz boys and neg boys stick to neg boys AIDS will be over. It’s just that simple.”

Or is it?  So although the same site site intro states that “The only drugs you should use should come from your doctor! Nothing makes you more likely to fuck up, get sick or be an asshole than poppers, meth or other party drugs.” So, I can say that I have heard negative men, who know they are negative, fucked up by drugs, tell me that they have used this site to search for men, and HIV status was irrelevant – the bottom line was the negative men just wanted bareback sex and such sites were the easiest place to find it.   Then of course there are the men who don’t really know if they are negative since they haven’t been tested (the site encourages people to know their status), but just like to assume that they are negative even though they have had unprotected sex with everyone under the sun, because it is easier for them to personally accept.  Such “negative” men will go onto to have sex with men who truly are negative who utilize the site.  Also, positive men may not always sero sort, and may have sex with negative men who agree to take the risk of having bareback sex with a positive man, simply because they like bareback sex.

While I am not judging anyone’s sexual preferences (I can not with a clear conscience say that plastic up one’s ass is sensual or comfortable), I guess the thing that irks me about such sites as a physician and public health practitioner, is that there are no sites (at least that I know of) promoting dirty needle use  for IV drugs or unsafe blood transfusions.  While I acknowledge men who want to have bareback sex will, and will find any avenue to do so, why must we create an avenue to directly promote this behavior? Why can we not have a “safe only” site? Upon googling I have found nothing.  While mainstream sites such as Grindr and Manhunt allow users to state their safe/bareback preference, are there sites dedicated exclusively to safe sex?

As bareback.com notes, users need to be made aware that not only can HIV be contracted by bareback sex, but other STDs such as gonorrhea and herpes can also be shared between bareback partners.   I just still can’t see the value of such sites from a HIV eradication/prevention standpoint.  Perhaps someone can comment to offer me some insight?  I know the mainstream porn movement has sought to not glamorize bareback pornography, and this is a battle that is still being fought as one can find bareback porn as easily as they can a hookup on Grindr.  In my ideal corner of the earth, I would hope that everyone using such sites was already aware of their HIV status, understood the risks that bareback sex poses, and made an educated choice which would put both them and their partner at the least risk possible.

Why men who have sex with men commemorate World AIDS Day

So as busy as I am (I have an exam tomorrow) I could not let today slip by (although its actually already Dec. 2 here 12:15 am) without taking a few moments to write about why as a community of men who have sex with men we (and I ) commemorate World AIDS day.   I at first wanted to write “celebrate”  but didn’t know if this was an appropriate term – however I do know that many of us are indeed celebrating the lives of many we have lost over the past thirty years.  Why we as a global community of men who have sex with men we commemorate World AIDS Day December 1:

1) There is still no cure: We must make policy makers aware that further funding needs to be dedicated to a cure for this virus – and current developments such as vaccines and rectal microbicides should be funded at a maximum level.  Infection rates continue to rise among men who have sex with men, and research into current and future developments need to continue to be funded until a cure is found.

2) To fight stigma: Millions of individuals are living with this virus and although there is global attention paid to the cause of HIV, tremendous stigma still exists against HIV+ individuals all over the world, especially HIV+ men who have sex with men. The truth is when we think of HIV, even on World AIDS day, one prefers to think about the pregnant mother acquiring the virus and transmitting it to her baby, rather than the thousands of MSM who contract the disease annually.

3) To remember those we have lost: Although I was born just at the beginning of the epidemic so many of my friends have lost loved ones – friends, relatives neighbors.  Today is a day to remember and honor the memories of these individuals.

4) To instill hope in a new generation of young men who have sex with men: HIV is still on the rise in our community, and young individuals who have not grown up in a generation of fear and loss must be educated and made aware of HIV, to prevent future epidemics and loss.  The generation who knows “a pill a day” must fully understand what it is like to live with HIV on a daily basis, and how to protect themselves from the virus.

5) People still die from HIV and AIDS related complications: While it is true excellent medications currently exist, the truth is some individuals, including long terms survivors will eventually loose their battle with HIV.  Because there is no cure (see #1) we must continue to acknowledge, that although a chronic treatable disease,  HIV does have the potential to kill men who have sex with men, especially in settings where treatments are not available.  For this reason we must continue to educate others and lobby our policymakers to make HIV/AIDS a top priority of the areas where they govern.

6) HIV truly does affect the world: Men who have sex with men are getting HIV in every nation.  Men of every socioeconomic level from every country will continue to acquire HIV from having sex with other men unless increased attention is paid to education, stigma against homosexuality is removed,  barriers to healthcare that exist in the MSM population are torn away, and laws that criminalize homosexuality are made a thing of the past.

7) Hope. Looking back and seeing the progress we have made as a world, and as a MSM community against HIV gives me renewed hope.  I am always optimistic on Dec. 1, despite the horrible toll that HIV has had on our community.

Until there is a cure we will continue to observe World AIDS Day.  It is my hope that in my lifetime, that all individuals, including my MSM brothers will be able to list HIV as one of the eradicated viruses of our time.

Dear Secretary Clinton…,

I thought I would post a letter that I would write to Hillary Clinton about her recent remarks at NIH this week, the video of which can be found below. I love the woman, but I am sad about her lack of any reference to MSM.  The speech was discussing how the US can lead the world in establishing an “AIDS Free generation”.   Sorry Secretary Clinton, but in most areas, even in areas with generalized epidemics like subSaharan Africa, MSM transmission and infection  rates are on the rise, and an AIDS free generation won’t magically appear without targeted aid and prevention efforts directed towards these groups.

Dear Secretary Clinton,

While I applaud the United States’ efforts in leading the world to fight AIDS, and its strong commitment to ensuring an AIDS free generation through programs such as PEPFAR, I am extremely  disappointed by your complete lack of any mention of men who have sex with men in your global prevention strategies.

You mention microbicides which “give women the power to protect themselves.”  Yes this is true, but there is also a robust (and largely underfunded and underpublicized) movement to develop a rectal microbicide to give MSM (and heterosexuals) the opportunity to protect themselves.    You talk about “combination prevention” that the US will lead including: ending mother to child transmission, expanding voluntary medical male circumcision and scaling up medical treatment for people living with HIV/AIDS.  There is no mention in this three pronged “AIDS Free generation plan” of addressing the prevention needs among vulnerable communities such as men who have sex with men, intravenous drug users and transgendered populations.   While I applaud the State Department’s efforts, targeting male circumcision and mother to child transmission, while not addressing prevention among men who have sex with men will not lead to an AIDS Free Generation.

Dr. Frits van Griesvan of the CDC, in his article , along with numerous other studies, detail the balooning rates of HIV among men who have sex with men with India, China,  and several areas of Latin America and subSaharan Africa.  PEPFAR II, has a specific directive targeting HIV prevention at MSM, and it is time for our government and your department to take action and put this plan into action – studies show that current prevention efforts only reach 10% of MSM around the world who would benefit from prevention education and programs.   You discuss a story about the Tanzanian mother infected with HIV concerned about passing it to her child.  What about the man in Botswana who has anal intercourse with another man without condoms because homosexuality is illegal in his country, and he has no education on how to maintain his health since the subject is never spoken about?  You briefly mention the presence of such laws making homosexuality illegal, but never further discuss this topic in the 30 minute speech.

You do mention “embracing treatment as prevention.”  While this prong is not directed toward MSM specifically, it obviously can help MSM currently living with HIV and prevent the spread of the virus among their communities.  For this I applaud you.  However, be aware that many MSM who present at clinic for such treatment will be stigmatized due to their sexual orientation  if it is disclosed, and may not feel comfortable obtaining treatment at traditional treatment clinics due to barriers to care that exist for MSM populations including providers who are homophobic, stigma against MSM and laws criminalizing homosexuality.

I have worked closely with the State Department in my past work before attending medical school, as I was employed by several USAID contractors.  In my capacity working towards improving the life of women and children around the world, I have seen the impact the the US, the State Department and its subsidiary USAID can have on the lives of individuals through improving health.  Why not give men who have sex with men the same fighting chance to protect themselves against HIV that you state you are giving to heterosexual men and women through promotion of male circumcision?

Thank you,

SR

Yes, Virginia, there is a gay health clinic in Indonesia!

Bali Medika Clinic, Bali, Indonesia

So just when I didn’t think my day could get any better I stumbled across some news that Indonesia has opened its first clinic for LGBT patients this past October.  As a medical student, it has been my pipe dream to open similar gay health clinics all over the world, especially in areas where homosexuality is denounced, and there is the most need.  Knowing that this has been done in Indonesia, gives me extreme optimism, hope and happiness. One of the main reasons I am studying medicine is so I can be equipped to meet the special needs of GLBT individuals, wherever the need arises.

The clinic is called  is called the Bali Medika Clinic, and is located in the city of Denpasar, and is the first of its kind in the country.  Since opening in October, the clinic has treated more than 100 patients.  The HIV rates in Indonesia are definitely on the increase, and in a predominately Muslim country where strict traditional values shun homosexuality and related sex acts, many men remain closeted and have unprotected MSM sex in the dark.   The mission of the clinic is to provide a safe place for gays, seen as sexual and social deviants by some members of society, to come for sexual health care and HIV and other sexually transmitted infection screenings.  The clinic offers counseling on safe sex practices and HIV prevention, and provides condoms and antiretroviral drugs for HIV patients.

I did find a website for a Bali Medika Clinic, but I am not convinced that it is the same one.  If anyone has any information about this clinic, I would love to receive it, as I would love to do some sort of medical work with them.

So for all all GLBT who feel stigmatized when seeking healthcare, and feel that huge barriers still exist in receiving equitable high quality care, hope does exist.

Here is the link to the AP article I found about the clinic.

Has anal sex gone out of vogue? What does this mean for HIV prevention?

Note: Since posting this article I was able to look at the full text of the study, which does ask participants questions about condom use at last encounter.  Roughly about 33% of respondents state that they used a condom at some point during their last sexual encounter, with almost half of those that have had intercourse stating a condom was used.  However, the article does not go onto the provide more specific analysis on condom use, since it is difficult to extrapolate generalities regarding condom use, based on information about singular encounters

So the Advocate recently reported the findings of a large-scale survey on sexual behaviors.  Apparently, only 37.2% of over 24,000 gay and bisexually identified men indicated that their last sexual encounter consisted of anal sex.   The most practiced activities were kissing (almost 75%) and mutual masturbation (73%).

The survey, entitled  ‘The Gay and Bisexual Men’s National Sex Survey’ was sponsored by Manhunt,  its sexual health affiliate Manhunt Cares (see my past post here about them) and  its research partners,  present the findings in a cutesy interactive graphical form which can be accessed from clicking on the picture on the left (i.e. I found out that 80.8 % of surveyed men have eaten cum at some point in their lives!) The abstract of the study, which appears in the Journal of Sexual Medicine can be found here.

Now before we give up our lube and condoms and other devices we find makes our anal sex experience more comfortable, there a few things to keep in mind.  For some reason, the majority of respondents in this latest conducted by researchers from Indiana University and George Mason University were Caucasian males.  Perhaps results would be changed if there was some diversity in the subject pool.  Also, one should note that the respondents were “self identified” gay or bisexual.  Perhaps if behaviors of non-identified men who have sex with men, (i.e. heterosexual identifying men) were recorded the results would also show a higher indication of anal sex.  However, I like the point that one of the commentators made:   Anal sex does require a lot of effort (much like vaginal penile sex as well) and perhaps people don’t want to go through such effort simply to get off.

First, usually the receptive bottom has to be sure that they have maintained proper ass hygiene – for some folks this means just a thorough cleaning in the shower, however for others this means anal douching (see my past insightful entry on this issue).  Then, both inserter and receptive partner both need to be properly lubricated.  Any condom needs to be applied, towels need to be made readily available to absorb the lube and any other pre and post-fucking products,  and finally one may fuck.  For some individuals this ceremonial ritual just may not be worth it.  I am not one of these people, but I can see the non appeal.  Additionally this survey stated that 40% of men surveyed said that their sexual encounter was with someone who they were in some way committed to.  For many couples anal sex is a special sex act, that does not have to be performed during every sexual encounter.  In my opinion, I seem to see anal sex as the final act in the play of random hooking up (especially bar sex) but I personally tend to think couples in a relationship have generally been with each other so long they have other ways of turning each other on and understand that anal sex is not a necessity.

I don’t think this study can necessarily tell us too much about HIV prevention strategies, or where they should be aimed.  As some may know, receptive anal intercourse without a condom is the most risky sexual activity one can perform in terms of HIV acquisition.  And although we know that only 40% of these Caucasian gay identified men admit to having anal sex, we don’t know anything about condom use (I couldn’t find anything about condom use at last anal sex in any of these graphics).  So, it can be assumed that a portion of those having anal sex (or oral sex) are having unprotected sex.  Additionally, we can assume that many of these surveyed men did either not know their own or their partners HIV status (which is likely given that 60% of the sex acts were recorded to be with people whom the respondent was not intimately partnered with.) So this our crusade most likely should continue.  Even if anal sex is supposedly  not the most common sex act, it is the most risky, and deserved to still receive, in my opinion, the bulk of prevention attention directed toward MSM.  However, additionally since oral sex almost seems to be universally practiced, individuals should also understand the risks of such behavior, especially with an individual one does not know, including herpes and other sexually transmitted infections.

So in my opinion, while interesting, and while it sheds light on the sexually behavior of a self selected group of gay and bisexual individuals, this survey does little to give us insight into HIV prevention. But I guess that was not its intention.  However, I would expect that a survey carried out by Manhunt and partners would include information on condom use. (see note above: it does).

Pedro Zamora – an example for us all

So being almost 30, I remember watching the original episodes of the Real World on MTV.  Now they are on something like Real World XXV.  Only a young adolescent I remember being amazed and inspired by Pedro Zamora, the housemate on Real World II: San Francisco who was living with HIV.  I was just starting to begin to discover my own sexuality at that point, and seeing an openly gay man on TV gave me hope and encouragement.  My heart would cringe every time Puck would ridicule or mock the man who was trying to bring such an important message to the world: HIV is preventable and we can do something about it.  I grew up as a teenager during Pedro’s brief time on TV, and his message still resonates with me today man years later.

While pursuing the web, I came across the Equality Forum’s wonderful web site for GLBT HIstory Month (I must admit that being in medical school has completely encased me in a bubble and I did not even know that October was GLBT HIstory month) which features a “GLBT” icon for each day of the month.  Today’s was Pedro Zamora.  He was the first TV personality to be open about his HIV status.  Although he was gay, and contracted HIV through having sex with a man, his story is a universal one of hope and he has inspired a generation of individuals.  He has been recognized by President Clinton for his outstanding contributions to society.

I only hope that in my advocacy I can continue to fight for what Pedro thought it was important and to ensure that we all have the proper education and tools we need to combat HIV in all communities.

Gaddafi: “Only homosexuals contract AIDS”

So as many of us know, the rebel movement in Libya has killed Muammar Gaddafi, and I have been trying to wrap my head around what this means for HIV and MSM in this Arab North African state.  It has been stated that Gaddafi has been quoted as saying that only homosexuals get AIDS, and has jailed homosexuals and made sex among two consenting males a crime.  According to the New Civil Rights Movement, Gaddafi is quoted as saying that he believed it was “impossible” for one to contract HIV through unprotected heterosexual intercourse.

As I have stated many times before, lack of political support for gay rights may cause MSM to be uneducated about HIV and sexual risk taking, and may cause MSM to engage in risky sexual behavior and fuel the spread of HIV.

However, as I have heard on the news that the new Libya wishes to embrace Islamic law, I am left wondering if anything will change in this arena.  As we know, past Arab regimes and current ones such as Iran are intolerant of gays or MSM, and I don’t know if a new strict Islamic rule will take the same stance, making homosexuality and its associated behaviors illegal.  Under strict Islamic law, even a democracy, I do not foresee an environment where Libyan MSM (or any Libyan) will be adequately educated in HIV prevention.   The country is just starting to understand and investigate what happened to cause hundreds of children to become infected with HIV in the late 1990s.  The incident was blamed on the foreign Bulgarian nurses working in the hospitals, who were kidnapped and released for ransom.  It is suspected that the infections came about from poor hospital hygiene.  There is obviously much to be learned in this nation about HIV, both for MSM and Libyan citizens.

I can only hope that freedom will bring education for men who have sex with men on the risks of unprotected sex. Hopefully the “new Libya” will embrace the ideas of education and equality for all to ensure that Libyans do not die needless deaths.