Elsevier

Clinics in Dermatology

Volume 32, Issue 2, March–April 2014, Pages 181-188
Clinics in Dermatology

Sexually transmitted infections in men who have sex with men

https://doi.org/10.1016/j.clindermatol.2013.08.001Get rights and content

Abstract

Homosexuality is a global human phenomenon. Although the American Psychiatric Association removed homosexuality from its list of disorders more than 35 years ago, homophobia among physicians is still widely prevalent. Men who have sex with men (MSM) form a relatively new epidemiological risk group for STI. To perform correct management, clinicians evaluating men with male-male sex contacts for STI related complaints or STI screening must obtain a thorough sexual history. Emerging STI like lymphogranuloma venereum, hepatitis C, and multidrug resistant N. gonorrhea strains have been described first in MSM. STI related proctitis often occur in MSM. Within the MSM population, HIV positive patients form a special group affected by STI related diseases, such as anal carcinoma and neurosyphilis. The final part of this review concludes with recommendations to reduce the STI burden in MSM.

Introduction

Homosexual male-male activity is as old as mankind and a part of life for many men throughout society. A large sex survey conducted by Kinsey et al. in 1970 indicated that a minimum of 20.3% of adult men in the United States in 1970 had sexual contact to orgasm with another man at some time in life; 6.7% had such contact after age 19; and between 1.6% and 2.0% within the previous year.1 In a more recent report, approximately half the men estimated to have homosexual contacts were currently or previously married.2 These estimates incorporated adjustments for missing data and the likelihood of underreporting; yet, they still might reflect lower bounds on the prevalence of same-gender sex among men.

Although the American Psychiatric Association removed homosexuality from its list of disorders more than 35 years ago, homophobia among physicians is widely prevalent.3 Many specialists dealing with sexually transmitted infection (STI) patients are not immune to these feelings of aversion, even if they have experience with the larger spectrum of human sexual behavior and desire.4 Even today, homosexuality is considered aberrant and a danger to society in many parts of the world. Anti-homosexual feelings, prosecution, and exclusion of homosexuals have led to undeserved suffering and threaten the health and well-being of many individuals, as well as society at large. Health care workers should do all they can to alleviate the vehemence and take a stand against homophobic attitudes and practices in society.

In the first part of this contribution, I shall address MSM as an epidemiological risk group for relatively newly occurring STIs like lymphogranuloma venereum (LGV), hepatitis C, and multidrug resistant N gonorrhea strains. The second part is dedicated to STI related proctitis and STI-related diseases found often in HIV positive MSM, such as anal carcinoma and neurosyphilis. The final part concludes with recommendations to reduce the STI burden in MSM.

Section snippets

The acronym MSM (men who have sex with men)

Being homosexual can have different meanings. First it can describe someone’s behavior; that is, a person engaging in sexual contacts with persons of the same sex.4 To assess the risk of having an STI, health care providers prefer to use the term “men who have sex with men” (MSM) over terms like homosexuals or bisexuals. Today, few physicians know the true meaning of these names. The same vocabulary men who have sex with women (MSW), and women who have sex with men (WSM) are used nowadays in

Classical and new risk groups for STI

STIs are associated with risk groups that engage in sex with multiple partners. From a historical perspective, sailors, soldiers, and sex workers (prostitutes) were individuals with a polygamous life style and were thus often exposed to STI. Even today, travelling abroad, either for labor or leisure, is associated with risky contact and can be seen in countries where work related migration is on the rise.7., 8.

Homosexual male-male activity as a strong risk factor for STI is a relatively modern

Criminalization of homosexuality

Although homosexuality is becoming more and more accepted in many countries of the world, in large parts of society it is still considered as deviant, unnatural, and to be discouraged.11 Although considered a crime already in medieval Western Europe, homosexuals were not persecuted systematically until the 19th century under the ruling of Victorian/puritanistic influences in society.,12., 13. It was then that engaging in homosexual acts became considered illegal and punished with jail

MSM and the HIV/AIDS epidemic

It was already apparent in the 1970’s and 1980’s that gonorrhea and syphilis were especially affecting the gay community.10 When the HIV/AIDS epidemic was heralded in the beginning of the 1980’s, a downturn in the syphilis and gonorrhea epidemic curves started. The first case reports of AIDS patients described homosexual men with a history of multiple STIs and engaging in promiscuous sex.20 This led to further condemnation of promiscuity among gay men, but when a few years later it proved that

Emerging STI in MSM

In 2004, dermatologists in Rotterdam, The Netherlands diagnosed an HIV positive MSM with anorectal LGV infection.28 Detailed contact tracing revealed a network of men, the vast majority HIV seropositive that engaged in unprotected sex with multiple men during sex parties through out Europe.29 Until that time, LGV was seen only sporadically as imported STI among patients who got infected in tropical regions where LGV was known as endemic infection.30 Soon after the first reports from Rotterdam,

Distinct STI networks across MSM populations

Phylogenetic techniques have helped to unravel the network of HCV strains that spread via sexual intercourse among HIV positive MSM. “Fingerprint” typing and subsequent cluster analysis has recently opened the possibility to unravel other STI transmission networks in more detail and increased the insight into transmission mechanisms in MSM.38 Through molecular fingerprinting it was found that the LGV epidemic that had gone unnoticed until 2004 must have circulated in MSM at least from the

Proctitis in MSM

Anal sexual intercourse is widely practiced among heterosexuals and especially in MSM.44 As a consequence, rectal infections should be routinely excluded when MSM are screened for STI. Even when a man does not practice receptive anal intercourse, N gonorrhoea can be transmitted easily to the anal canal via fingering.45

Proctitis is defined as an inflammatory syndrome of the distal 10 to 12 cm of the anal canal, also called the rectum. The clinical manifestations of proctitis include itching,

Anal carcinoma in HIV infected MSM

HIV-related morbidity and mortality have considerably decreased since the introduction of highly active antiretroviral therapy (HAART).53 As a result of the significantly prolonged life span of HIV-positive patients in the HAART era, new causes of morbidity and mortality have become evident. Non-AIDS defining malignancies like anal carcinoma are observed in excess in HIV-positive MSM. Between the early 1990s and 2004, the incidence of anal cancer in HIV-positive individuals has risen from 11 to

Neurosyphilis in HIV infected MSM

With the reoccurrence of syphilis in MSM from the mid-1990s on, there were several reports on a rising incidence of neurosyphilis, especially associated with HIV co-infection.66 In HIV-infected individuals: 1) syphilis antibody responses were less reliable; 2) progression to the next stage of syphilis, including neurosyphilis, occurred earlier despite adequate therapy.67., 68. These publications date from before or during the introduction of ART and they predominantly included patients with low

Recommendations to reduce the burden of STI among MSM

In the recent past, MSM have proven to be a vulnerable group for STI throughout the world. Prevention, treatment, and care programs dedicated to high risk MSM are required. In large parts of Africa, Eastern Europe, and the Islamic World repression of homosexuals is increasing.13., 15. As a result, access to good health care for MSM is a challenge. Sub-Saharan countries mostly affected by the HIV epidemic should initiate and adequately fund evidence-based and targeted prevention programs for MSM.

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