More than just M in MSM

So 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/

Click to access 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.

What is a bathhouse? Do people actually bathe?

So as I made a comment the other day, “Our library is like a bathhouse…all of these little rooms where people can walk around the hall..” it occurred to me that the majority of my class mates probably had no idea what a bath house really was like.  Sure, they have probably heard of it  in the context of HIV probably referenced to the ones that shut down in San Francisco decades ago, but I don’t think they know the true reality of the current state of bath houses, or that they currently still exist all around the world and contribute to the spread of HIV.

Much to my chagrin, the Spartacus Gay Guide still exists.  This was the same guide I used when I was 20 backpacking around Europe almost a decade ago.  Basically, anywhere in the world you go, you can use either the book (or apparently a iPhone app) to locate gay establishments such as bars, restaurants, and of course “saunas”. Most urban meccas in both the US an abroad (including, Europe and Asia) have at least one such bathhouse.  Houston, where I formally came from boasts 2.  One is part of the “Club Baths” franchise.  The Clubs is generally an upscale franchise, consisting of newly renovated saunas, steam rooms, pools and small rooms (I’ll get to this later). Generally such cities that have two bathhouse will usually have a nicer “upper echelon” one that is clean and somewhat hygienic and contains somewhat more upscale clientele, and a gross one that is filthy, skeezy, where you stick to the floor and it’s not advisable to not wear footwear.

Not all bathhouses are gross.  Some are QUITE deluxe.  The one I went to in Bangkok called “Babylon” was probably one of the nicest in the world with 3 bars, a full service restaurant, gardens, outdoor pools.  So the establishment can range from crab infestations to four star service.

So what exactly is a bathhouse? Wikipedia does a good job explaining to the novice in its article “gay bathhouse” (OOOOH and they even have a photo of the Crew Club in DC right near my house on 14th street. Did you really think the nation’s capital wouldn’t have a bathhouse?) especially in the “etiquette” and “layout” sections.  But for those of you that don’t have the patience to sift through such a gem I’ll get down to it briefly.  Basically most bathhouse operate on a “membership only” basis.  They call themselves “health clubs” and many do have a small (some extremely will equipped) weight area that they purport can be used for exercise (although I’ve generally only ever seen one person working out).  Even if a bathhouse boasts exercise equipment, most people come to a bathhouse to fuck.  There are usually also lockers (see below) communal showers, steam areas, sometimes an indoor or outdoor pool, and usually always small individual rooms, varying from simple with one small bed in a corner and minimal other room, to more deluxe, with a bigger bed, and TV playing porn.

Upon entering, you usually have to pay the “membership fee”.  Such fees can be one time only or you can usually get a 6 month membership if you plan on coming back and “working out” a lot.  You then have the option of purchasing either a “locker” or a “room”.   Both are assigned on an hourly basis, and you usually have about 12 hours or so (varies) in your room or locker.   With either option you are given a towel to change into.  Some more upscale places will also give you temporary footwear. If you buy a “locker” the only place to put your items is in your locker.  You will generally wander the hall, looking for someone to have sex with, either in their room, or in the sauna or some other communal place.  If you have a room you will proceed to your room and can leave your items there. See the photo to the left from the Crew Club for a typical price list.

Generally, paying the extra money for the room allows a client a little more privacy and flexibility with their evening.  They can decide who they want to invite in for sex, how they want to attract people for sex, who they want to have sex with etc.  The cheaper locker option, in my opinion limits flexibility.

Many bathhouses have also been places where gay men go to “party and play” or do drugs such as crystal meth and ecstasy and have sex.  Bathhouses have been known for their association with drugs and drug fueled sex, and still are venues where gay men may go to both seek and use drugs and to have sex.  Of course, such activity can lead to unprotected sex.  I know that any ads that the crew club has advertised in DC gay magazines have featured the phrase “No PNP” meaning “no party and play” i.e. no drug use tolerated.  I know they have also been doing much to crack down on bath house drug use.    However, its next to impossible to enforce these rules, as most bath houses have lax security, and given the nature of the establishments, unless you stick an undercover in the scene, its next to impossible to have someone patrolling private small rooms that patrons have sex in.

Then there’s the question of condom use.  Much like in any other sexual encounter,  condom use is up to the two partners involved.  Of course, drug use will lower inhibitions, and perhaps decrease condom use.  Also, since most of the time sex is anonymous it is likely that HIV status will not be discussed or disclosed during bath house encounters, and partners won’t know their true risk.  However, as a gesture, many bath houses provide condoms in common areas, and do all they can to encourage condom use.  However, what goes on between two consenting adults is something beyond their control.

So yes, technically one can bathe at a bathhouse, but more or less its a euphemism.

Salaam to HIV – MSM HIV Epidemic in the Middle East

Salaam alakoom friends (hello in Arabic).   In the first study of its kind, researchers from Cornell University in Qatar have concluded that concentrated epidemics (infection rates above 5 percent in a certain group) among men who have sec with men exist in Egypt, Sudan, Pakistan and Tunisia.  There is little data on this region where homosexuality is considered taboo.  According to one researcher quoted in the article, the region is like a “black hole” in the global HIV data since such little data is available.  The research has found “considerable and increasing epidemiological evidence on HIV and risk behavior among men who have sex with men” in the region.

The findings are not surprising  – in  2008 researchers found that  HIV transmission via anal sex among men was responsible for more than a quarter of notified cases of HIV in several countries in the region.  This is not surprising given the fact that sex, let alone homosexuality is rarely if ever discussed in the region.  Men who have sex with men have no resources to turn to for sexual health services, and like in many societies must have underground sex.  In such scenarios without education and intervention and acknowledgement from NGOs and the government HIV spreads outside of the MSM population to the general public – although the article states that in Lebanon and Pakistan NGOs have emerged to deliver services to this highly hidden population.  Education, education, education – remove the stigma of homosexuality and the barriers to service that prevail.  It won’t happen overnight – but neither did the spread of HIV. Oh yeah – I forgot its also illegal for men to have sex with men in 18 out of 21 countries in this region.

“Yes SIR Give me HIV SIR”: Leather and HIV

So on a whim, I recently googled “Leather and HIV”.  For those readers not aware of what leather has to do with homosexuality or MSM, in the gay (and heterosexual) community, there exists a subset of individuals who gather pleasure from dressing in erotic leather (i.e. chaps, harnesses) and having consensual sex with other leatherphiles.  Usually the sex will consist of individuals taking either a dominant or passive role playing “master” and “slave”.   In many large gay cities there is usually a “leather bar” where people with such interests can meet like minded people.  Here in DC, there is the DC Eagle.

The first hit was a recent study entitled HIV in the Leather Community: Rates and Risk-Related Behaviors The link to this article has the full text.   Interestingly, according to this study leathermen were 61% more likely to be HIV positive than non-leathermen.    The study also found that combined, HIV-negative and HIVpositive Leathermen were less likely to use condoms during receptive anal intercourse than non-Leathermen.  The same trend was found for insertive anal intercourse.   Additionally, role seemed to matter.  Combined, HIV-negative and HIV-positive leathermen who self labeled as “submissive” were less likely than those who self labeled as non-submissives to use condoms.

So next time you are hanging out at the leather bar, some food for thought.  I’d be interested to see some future studies.

HIV in the Leather Community: Rates and Risk-Related
Behaviors