Category Archives: bottom

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.

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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).

Taking the “fe” out of the female condom for HIV protection

So recently I was reading my city’s gay newspaper, Metro Weekly, and the last page of the paper had a feature about the Washington, DC female condom campaign, and how the female condom can be used by MSM for anal sex (see article to the left). The condom, made of a synthetic rubber nitrile, contains two flexible rings, and can be inserted into the anus of a receptive partner prior to intercourse.

While initially I was confused why MSM would want to use the female condom when the male condom exists, I have come to understand that it provides another choice of prevention method.  And, the more choices that one has, the better.  Basically, there are times when an insertive “top” will not want to use a condom.  In these instances, the receptive partner can insert the female condom to protect himself and his partner.  Additionally, there are times when unfortunately it is next to impossible to negotiate condom use.   In the MSM community in North America, drugs like ecstasy and crystal meth increase sexual appetite, and decrease inhibitions, and thus condom use, fueling the HIV epidemic.    A receptive “bottom” can insert the female condom before going out to the club, drinking or partying, and stand a much better chance of protecting himself from HIV and other infections.

In case you wanted to see how to use the female condom is used I discovered this great video.  I’m not sure who produced it, or where it is from but I think it’s great. Unfortunately it says embedding has been disabled, but if you click on the “Watch on You Tube” link you should be brought the video!