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  • • 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

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