- • A thorough sexual history is requisite to identifying
sexual risk behaviors and the subsequent risk for sexually transmitted
diseases (STDs) in men who have sex with men (MSM).
- • Epidemiology of STDs and individual risk behavior
guide prevention, screening, and clinical management practices.
MSM are a diverse population defined by their sex and sexual
behavior. They include men who identify as gay, bisexual, or heterosexual
in their sexual orientation.
The epidemiology of STDs in MSM has changed considerably since
the mid-1980s. Declines in the incidence of STDs that occurred in
the late 1980s through mid-1990s have been followed by recent increases
in the incidence of syphilis, gonorrhea, and HIV among MSM in the
United States and Europe. These documented increases in STDs parallel
the reversal in AIDS morbidity and mortality with the advent of
highly active antiretroviral therapy (HAART).
Paradoxically, the success of HAART may have contributed to higher
risk sexual behaviors as a result of reduced fears of HIV transmission
among MSM who are infected with the virus and of HIV acquisition
among MSM who are not infected. Decreases in condom use, increases
in the number of sex partners, and changes in sex practices (from
oral sex to anal intercourse) have been reported in MSM in major
urban areas throughout the United States since the mid-1990s.
Changes in community norms resulting from HIV treatment optimism
and the improved physical well-being of HIV-infected persons are
some associated factors that may have contributed to these increases.
Social factors that may have contributed to recent changes in sexual
behaviors include the advent of the Internet as a means of meeting
new sex partners, increased availability and use of methamphetamine
and other drugs, and the use of the mass media for direct-to-consumer
HIV medication advertising, mitigating the severity of HIV and AIDS.
Because some MSM are not gay-identified, it is essential that
clinicians ask open-ended questions in a behavioral risk assessment
and not make assumptions about the sex of a patient’s sex
partners. Building trust and rapport with patients will facilitate
the disclosure of sexual behaviors. Every patient evaluation should
include a risk assessment for STDs that includes a nonjudgmental and
direct ascertainment of sexual behaviors. A thorough sexual history
includes the delineation of anal, digital, oral, and vaginal sexual
contact exposures (see Table 24–1; see also Chapter 31). The
following sexual behaviors are associated with STD transmission
in MSM: anal sex (insertive or receptive), oral sex (insertive or
receptive), vaginal sex (insertive or receptive), oral-anal or anal-oral
sex, and anal-digital or digital-anal sex. Sexually transmissible
pathogens and associated syndromes that are most frequently identified
in MSM are listed in Table 24–2.
Table 24–1. Principles of Sexual History Taking in Men Who Have Sex with Men.a