Gay, Lesbian, Bisexual and Transgender Health

Sexually transmitted diseases (STD) have been among the most significant health problems (along with high rates of alcohol, tobacco and other drug use) for gay & bisexual men (G/BM) since at least the time of the sexual revolution and the Stonewall rebellion (June, 1969). Rates of STD were extremely high in G/BM for a number of years before AIDS, but even after that when our STD rates dropped to their lowest levels in recorded history (1987-96), we remained at higher risk for STD than straight men. This article provides a basic overview about STD rates, what's known and speculated about the reasons for these high rates of STD and numbers of sexual partners among G/BM, and provides the latest risk data being seen among local G/BM.

Not all G/BM are the same: there are very wide and important variations in our sexual behaviors. Some for example, are pretty much monogamous with only one partner for long periods of time. Others report hundreds or even thousands of partners, in apparent pursuit of the slogan "So many men; so little time". For still others - perhaps a majority - the level of risk varies from time to time; these G/BM who are usually monogamous go through periods of higher risk. Variation in numbers of partners is also seen among heterosexual men; while more heterosexual men may be in relatively monogamous relationships, some have had very many partners. And some men who call themselves "heterosexual" have also had male sexual partners, even in the recent past. (A study we did at the HIV counseling and testing sites of Public Health - Seattle & King County showed that of all the men who reported recent sex with men, about 1 in 25 said they were "straight".) But when all these factors are averaged, the number of partner over time is much higher for most G/BM than for most straight men, straight women, or lesbians.

In this article I describe STD rates and risks averaged across the general G/BM population, because we don't know a lot about the variations in rates from one "segment" of the G/BM population to another. By "segments" I mean any natural groupings of G/BM, such as young versus older men, black vs. white, urban vs. rural, etc. Readers should be aware that these averaged rates mask the fact that in some segments of the community, the rates may be lower while in others they could be higher. Studies of many communicable diseases (such as tuberculosis, or measles) have shown that usually small segments of an at-risk population, e.g., perhaps only 20% of the larger G/BM group, often account for most infections.

Few STD clinics and US cities in the 1960s and 70s consistently obtained data on client sexual orientation or behavior; even today many don't collect this information. Also, regions generally have not tried to estimate the sizes of local populations of sexual minority persons like G/BM. Thus, rates of STD in G/BM (e.g., numbers of cases typically calculated among 1,000 or 100,000 persons in a set period of time, such as a year) were not often measured or tracked over time. Finally, rates can be questionable because some G/BM, worried about STD symptoms or disease, would not readily tell their providers about their homosexuality or other personal information, and many providers don't even ask.

So, the study of STD and specific behaviors in G/BM got off to a slow start. Many problems and needs went unrecognized by the medical and public health providers and the rates reported are generally minimal estimates. That is, real rates are likely to be higher. However, by the late 1970s, STD clinicians and researchers in Seattle were among the first in the country to systematically study, and increase awareness, of these higher risks in G/BM. Many of the Seattle studies were taken to the field, and included gay venues like bars and bathhouses. Thus, local findings didn't just describe men who presented to STD clinics, but provided a broader view of the sexual health of G/BM.

There is now clear consensus and solid data (which I show below) that G/BM are at very high risk not just for HIV, but for many STD. Not only do the same behaviors and sexual practices transmit both kinds of infection, but the presence of STD makes it easier to transmit or catch HIV if either partner is infected. But, before I go on to describe the actual rates of these diseases in G/BM, let's explore some of the interesting reasons offered for why some G/BM have large numbers of partners and a higher risk for STD and HIV.

This question has two basic answers: 1) on average, we have more sex partners, some of us very large numbers of partners; and 2) most of our partners tend to be other G/BM who also may have many partners. Even if some of us have pretty small numbers of partners (more like many straight men), we're at much greater risk for STD and HIV because of whom we have sex with. Since our partners tend to be G/BM, it's much more likely that one or more of our partners might be other men who have a large number of partners.

Why some G/BM have so many partners is a topic about which I could write a book. Some people have blamed the sexual oppression under which G/BM have existed for centuries for some of this highly sexual behavior. I recall reading, for example, John Rechy's book, Sexual Outlaw, back in the late 1970s. Rechy argued that the long history of prohibition against sex between men had caused at least some G/BM to act out against society's oppression. Society's just saying 'no', he argued, sparks a "we'll show you" response from G/BM. Rechy's book alternates chapters, one describing the prevailing and problematic social approaches to G/BM and homosexuality, while the next presents vivid descriptions of intense sex with muscle-bound strangers met in parks, tearooms, and under boardwalks. These anonymous encounters seemed never to materialize into long-term relationships, leaving Rechy to seek partner after partner.

Some people have theorized that many G/BM, internalize the societal homophobia, making us feel bad about ourselves, and causing us to seek partners (or also mind-numbing drugs) to satisfy our longings to feel better, or perhaps to reassure ourselves about our own desirability and attractiveness.

Other persons have claimed, and cited scientific evidence, that men were, by their very nature, just more sexually active creatures than women. Thus, it simply makes sense that when men are sexual with each other they'd engage in many more activities, with more partners, and for those reasons be more likely to acquire and spread disease. Men, gay and straight, were believed to be intrinsically less naturally monogamous and more likely to stray in relationships. It was women who attempted to hold men's tendencies to stray in check, demanding faithfulness and monogamy.

In my teaching about homosexuality and it's medical consequences over the years at the UW, I've argued that G/BM have few or often none of the social forces which help to hold straight people in monogamous relationships - especially, marriage and children. Gay unions are not legally (or religiously) sanctioned. Even in liberal countries like Denmark, Holland, and Sweden where gay men are encouraged to form societally-sanctioned partnerships, their relationships aren't called or truly equated with "marriage". Certainly, permitting or formalizing G/BM relationships seems to be regarded by many in the US as a major social threat, one that somehow weakens the institution of marriage. In Vermont, gay men and lesbians can now get their relationships legally sanctioned, but these bonds are not "marriage," and many of the other states have taken actions to assure that Vermont or European sanctioned relationships are not recognized within their own jurisdictions.

Although increasing numbers of lesbians and to a lesser extent gay couples are producing and adopting children, fewer gay and lesbian relationships involve children than straight ones. Yet, the presence of kids in a relationship can be a strong force to keep people together and relatively monogamous. Indeed, my parents told me some years ago that if they hadn't had three boys whom they felt obliged to nourish, mentor, and put through school, they wouldn't have stayed together - a conclusion I've heard many times from other parenting couples in my career in medicine. Unplanned pregnancies have pressured many couples to marry when their initial urges had no long-term consequences in mind. (Of course, the benefit to children, if any, for parents to remain together despite their loss of love for each other, is open to question.)

Gay and bisexual men also lack role models for healthy long term relationships. Instead, the media feed us images of attractive, muscular, and often very sexually active G/BM, smoking and using drugs, and (in recent decades) coming down with HIV/AIDS. We are shown in party scenes and clubs, engaged in frenzied late night dancing, using drugs and cigarettes, and even in orgies. Scattered throughout many gay magazines and newspapers are ads more often seeking sex partners and "escorts" than for longer-term relationships. What's a gay boy to do but try to fit in with what seems to be the order of the day, and to meet and sleep with as many men as possible, lest he be considered unattractive or undesirable?

Gay role models - even those whose behaviors and relationships might be the most healthy in a public and personal health sense - were rarely shown in most main-stream radio and TV shows in years past, because society has not only sought to deny, but has actively worked to suppress and discredit gay and bisexual behavior. And, now that we're more visible, what seems to sell best are depictions that meet the stereotypes and spark the emotional and sexual senses. Initially, the media controllers apparently didn't want the existence of G/BM, let along their behaviors, shown to the public. Since Stonewall, as G/BM have come out of the closet and opened society's eyes, there have been more media depictions; however, we're still mostly portrayed as highly sexual creatures (see Home Box Office's Queer as Folk), and only rarely are we shown in healthy long-term relationships. The net result leaves gay men with the impression that, to fit in, we must have lots of partners, use drugs, and join the gay party.

In Seattle by 1981, before AIDS was seen as a problem in Seattle and King County, public health counted 807 cases of rectal gonorrhea in men who reported having sex with other men. Even this was an undercount, because it included only G/BM seen at the STD Clinic or other public health clinics, plus some men seen by other providers. As noted above, many G/BM with gonorrhea didn't tell their providers that their partners were other men, and some providers - especially in those days - didn't report cases to Public Health, as the law says they must. (Today, that's less of an issue, because Public Health monitors all positive tests for gonorrhea, chlamycia, and syphilis at all King County laboratories.) This 807 cases, then, is a minimal estimate of the real 1981 number of cases among the local population of G/BM - a population that we estimate to number about 40,000. But even this minimal estimated rate of gonorrhea, equivalent to about 2000 cases for every 100,000 G/BM is a very high rate; it means that about 2% of King County G/BM were reported to have gonorrhea that year, and the true rate may be twice as high. By contrast, the reported gonorrhea rate in heterosexual mena nd women in 1981 was about 400 cases per 100,000, less than half a percent year year.

Although rectal gonorrhea in males is a clear sign of male homosexual behavior, the rectum is not the only place gonorrhea occurs in G/BM. Gonorrhea of the urethra (urine passage) is at least as common as rectal infection, and lots of other cases involve the throat. However, many (maybe most) of the cases of gonorrhea at these other body sites are not recognized by care providers as being spread among men.

Of course, gonorrhea is also not the only STD seen at high rates among G/BM. Syphilis, non-gonococcal urethritis (NGU), herpes, genital and anal warts, hepatitis A and B, and many other STD are also occurring at very high rates among G/BM. And, by the late 1970s a number of diseases which cause diarrhea (such as Shigella about which I recently wrote in January, giardiasis, and amebiasis) were added to the list of diseases to which G/BM were highly susceptible. Like gonorrhea and syphilis, the rates of these other STD have also been much higher than in the heterosexual population. For example, the rate of syphilis in G/BM in 1981 was about 200 cases per 100,000, compared with about 2 cases per 100,000 in the rest of the population. And when G/BM have blood tests for genital herpes - i.e., tests to detect infection with herpes simplex virus type 2 - 50% to 80% typically are positive, compared with 15% to 30% of the heterosexual men and women.

In the AIDS era, the STD list has grown even larger, to include a number of infections that generally don't cause much disease unless the person's immune system is seriously damaged, say by HIV and especially AIDS. Examples here include cytomegalovirus (which can cause widespread disease and blindness in persons with AIDS), and Kaposi's Sarcoma herpesvirus (likely spread by saliva and French kissing and which can cause KS lesions on the skin and in other organs of persons with AIDS).

Following the appearance of AIDS, rates of STD fell steeply in the late 80s (see the graph below). Yet, even at these low levels, STD rates in G/BM remained several times higher than in the non-gay population in our region. For example in 1997 - just before the resurgence of STD in G/BM, which is discussed below - the rate of reported gonorrhea in G/BM in King county was 175 cases per 100,000, compared with 53 reported cases per 100,000 women and heterosexual men. So at the high point of sexual safety among G/BM, our STD risk remained more than 3 times higher than in King County's straight residents.

The graph shows numbers of reported cases of gonorrhea, syphilis, and chlamydia rates per year for G/BM from 1981 through 2001. (Chlamydia testing didn't start until 1982.) It has been widely assumed that this steep fall in STD in G/BM resulted from efforts to educate the community about (and test gay and bisexual men for) HIV and AIDS. But, the fall in these rates actually began before HIV was determined to be the cause of AIDS (1984) and before funds for much education and testing first became available (1985). By that time, STD rates had already been cut in half among G/BM. It is likely that we spontaneously began to modify our high risk behavior as news of AIDS began to spread, before the cause was known and before formal education efforts began.

Rates of STD in G/BM Have Risen These Past 5 Years

The graph above also shows that the rates for gonorrhea, Chlamydia, and Syphilis have risen again, starting in the early to mid-1990s and continuing through 2001. Syphilis, in fact, is back to 1981 levels; these higher rates are continuing so far into 2002. Although there have been a few syphilis cases among heterosexuals, almost all (90%) of the syphilis cases we've been seeing in these years have been in G/BM.

For 1998-2001 the rates for syphilis in G/BM are 30-50 times higher than for the entire KC population, and for G/BM with HIV infection (estimated to number over 5,000 locally) rates are 200-400 times higher: an astounding 1% of G/BM with HIV acquired syphilis each year from 1999 to 2001. To the best of our knowledge, such rates of syphilis have never before bveen reported for any population anywhere in the world. Again, these data are averages and don't reflect risk behaviors of all G/BM or all HIV-infected G/BM. It is most likely that some group of G/BM are much more sexually active and account for most syphilis transmission; certainly, a sizeable proportion of the G/BM population is not acquiring syphilis at all. But that means that the rates in these higher risk segments of the population must be even higher!

The final graph of this article shows (in more detail than in the first graph) the rising rates of gonorrhea and chlamydia in recent years among G/BM who attended Public Health's STD Clinic at Harborview Medical Center. Again, these rates are much higher than in the general population and are creeping back up to rates seen before AIDS.

Seattle is not the only city reporting increased STD in G/BM. This development is also being reported in urban areas across the North America (including San Francisco, Portland, Los Angeles, Chicago, New York, Vancouver BC) and in Europe and Australia. Explanations include that the G/BM population seems "burned out" on HIV/AIDS information, and the continued recommendations to consistently use condoms. And, not just gay men, but the whole of the developed world appears to consider HIV/AIDS less of a threat than it used to be, now that effective treatments exist in countries able to afford treatment. Our own local HIV counseling and testing data on risk behaviors in G/BM show that many of us are increasing our numbers of partners and decreasing the use of condoms in recent years. In the my next article for 2002 I will write more about the reasons for these increasing rates of STD in G/BM.

What's a Gay Community to do?

We seem stuck in a self-fulfilling prophecy. We're finally coming out of the closet, speaking out to insist on our rights, trying to resist society's condemnation of us, and initially working hard to quell AIDS. But as we become more visible, many of us appear to be embracing the unhealthy stereotypes society paints on us, partying-on, picking up and transmitting diseases, and giving some people more and more justification to point their fingers at us. By internalizing societal homophobia, or for whatever reason, the result is that we're killing ourselves with HIV and AIDS more effectively than the homophobes could have dreamed possible.

In the next of this series of 2002 Dr. Bob articles, I will describe the considerable efforts public health together with community partner agencies, like Lifelong AIDS Alliance, People of Color Against AIDS Network (POCAAN), and Gay City have undertaken to try to combat this rise in sexually transmitted diseases and the growing complacency among G/BM in recent years. For example, on World AIDS Day (December 1st) of 2000 a G/BM Community "Summit" meeting on STD was held by public health and nearly 80 representatives of community HIV/AIDS agencies. In response to the recommendations of that meeting, we revised guidelines for STD screening in G/BM, specifically including those with HIV infection, and we have distributed these recommendations to practically every care provider in King County, and though their publication, to STD providers nationally and world-wide. We've also provided funding to Lifelong and some of our own staff to support a new community-based Task Force focusing on HIV and STD prevention for G/BM; and that group is developing new prevention messages, leadership, and resource support. Last spring we hosted investigators from the US Centers for Disease Control and Prevention (CDC) who interviewed a number of G/BM community members - to better describe the local gay and bisexual community situation, especially regarding HIV prevention. And, we've conducted research including surveys and blood samples to better understand and address the problem. More about all this and other steps we've undertaken next month.

In the meantime, responses to my articles by SGN readers are encouraged. Please write me (by snail-mail at HIV/AIDS Program, 400 Yesler Way, Suite #300, Seattle, WA. 98104 or by email at bob.wood@kingcounty.gov) or write the SGN directly. For more information on HIV or STD testing and treatment, call the HIV/STD Information line at 206-205-7837, that's 206-205-STDS.