ZONE:

A survey of 452 men who have sex with men (MSM) in New York City have revealed that four in 10 of those anonymously surveyed are not out to their doctors about their sexuality - a statistic that spells troubling implications for HIV prevention.

The Health Department last month launched the largest HIV testing initiative in New York City history with a goal to have all Bronx residents between the ages of 18 and 64 learn their HIV status within the next three years.

The Health Department survey found that men who have not disclosed their sexual activity with other men are far less likely to get tested for HIV. Some 63% who are out have got an HIV test, compared to 36% of those who aren't.

While the overall rate of disclosure was just 61% among MSM in New York City, the rate increased to 78% among those who identified themselves as homosexual.

Strikingly, none of the men who had sex with men but identified themselves as bisexual had told their doctors

The findings also indicate that the stigma of homosexuality as well as the individual's apprehension about how their homosexuality is perceived can be harmful to people's health, said Dr Monica Sweeney, Assistant Commissioner.

"Because of the fear and discrimination that still surround coming out, we are missing opportunities to stop the spread of HIV," said Dr Sweeney.

Certain other sub-groups were also less likely to disclose their sexual practices. Men who were 28 or older were more like than younger men (69% vs. 52%) to be out to their healthcare providers. Black (60%), Hispanic (48%) and Asian men (47%) are far less likely to tell their doc that they're gay than white men (19%).

"It's a combination of people being less comfortable with the term gay or homosexual, and discrimination they perceive they will experience if they are open about their sexual experiences and attractions," said Dr Elizabeth Begier, the city's director of HIV epidemiology.

The survey results, published this month in The Archives of Internal Medicine, examined data from the National H.I.V. Behavioral Survey conducted in 2004-5 by the Centers for Disease Control and Prevention.

Some Activities Are Riskier Than Others
According to the best available evidence:
- Receptive anal intercourse is the riskiest sexual act - it is 5 times riskier than receptive vaginal intercourse and 50 times riskier than receptive oral sex.
- Insertive anal or vaginal intercourse is 10 times riskier than insertive oral sex.
- Oral sex carries some risk for both partners, but is less risky than other penetrative sexual activities.
- Condoms greatly reduce the spread of HIV for both partners in anal, vaginal, and oral sex.

Know Your HIV Status - Get Tested
- If you have ever been sexually active or have injected drugs (even once) you should be tested for HIV.
- Rapid tests are now available that give results in less than an hour.
- If you're infected, you can get medical treatment that can help you feel better and live longer. You can also prevent others from becoming infected.

Protect Yourself and Others
- Not having sex is the surest way to avoid HIV and other STDs.
- If you are sexually active, you can reduce your risk of getting or spreading HIV by having sex only in a mutually monogamous relationship with a partner you are sure is not infected.
- Always use a latex condom if you have sex - vaginal, anal, or oral. NYC Condoms are available for free. Call 311 or visit nyc.gov/condoms.
- Limit the number of people you have sex with. The more people, the higher your risk. Sex with people you do not know also increases your risk.
- Avoid alcohol and other drugs when you have sex. Being intoxicated or high makes it much harder to remember to use condoms.

(Source: New York City Department of Health and Mental Hygiene)

The US Gay and Lesbian Medical Association (GLMA) has published three lists specifically highlighting what they think are the top 10 health issues of concern for gay men, lesbians and transgender persons. Click on to pages 2, 3 and 4 for the lists.

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Ten things gay men should discuss with their health care providers

Following are the health issues GLMA's healthcare providers have identified as most commonly of concern for gay men. While not all of these items apply to everyone, it's wise to be aware of these issues.

1. HIV/AIDS, Safe Sex
That men who have sex with men are at an increased risk of HIV infection is well known, but the effectiveness of safe sex in reducing the rate of HIV infection is one of the gay community's great success stories. However, the last few years have seen the return of many unsafe sex practices. While effective HIV treatments may be on the horizon, there is no substitute for preventing infection. Safe sex is proven to reduce the risk of receiving or transmitting HIV. All health care professionals should be aware of how to counsel and support maintenance of safe sex practices.

2. Substance Use
Gay men use substances at a higher rate than the general population, and not just in larger communities such as New York, San Francisco, and Los Angeles. These include a number of substances ranging from amyl nitrate ("poppers"), to marijuana, Ecstasy, and amphetamines. The long-term effects of many of these substances are unknown; however current wisdom suggests potentially serious consequences as we age.

3. Depression/Anxiety
Depression and anxiety appear to affect gay men at a higher rate than in the general population. The likelihood of depression or anxiety may be greater, and the problem may be more severe for those men who remain in the closet or who do not have adequate social supports. Adolescents and young adults may be at particularly high risk of suicide because of these concerns. Culturally sensitive mental health services targeted specifically at gay men may be more effective in the prevention, early detection, and treatment of these conditions.

4. Hepatitis Immunization
Men who have sex with men are at an increased risk of sexually transmitted infection with the viruses that cause the serious condition of the liver known as hepatitis. These infections can be potentially fatal, and can lead to very serious long-term issues such as cirrhosis and liver cancer. Fortunately, immunizations are available to prevent two of the three most serious viruses. Universal immunization for Hepatitis A Virus and Hepatitis B Virus is recommended for all men who have sex with men. Safe sex is effective at reducing the risk of viral hepatitis, and is currently the only means of prevention for the very serious Hepatitis C Virus.

5. STDs
Sexually transmitted diseases (STDs) occur in sexually active gay men at a high rate. This includes STD infections for which effective treatment is available (syphilis, gonorrhea, chlamydia, pubic lice, and others), and for which no cure is available (HIV, Hepatitis A, B, or C virus, Human Papilloma Virus, etc.). There is absolutely no doubt that safe sex reduces the risk of sexually transmitted diseases, and prevention of these infections through safe sex is key.

6. Prostate, Testicular, and Colon Cancer
Gay men may be at risk for death by prostate, testicular, or colon cancer. Screening for these cancers occurs at different times across the life cycle, and access to screening services may be negatively impacted because of issues and challenges in receiving culturally sensitive care for gay men. All gay men should undergo these screenings routinely as recommended for the general population.

7. Alcohol
Although more recent studies have improved our understanding of alcohol use in the gay community, it is still thought that gay men have higher rates of alcohol dependence and abuse than straight men. One drink daily may not adversely affect health, however alcohol-related illnesses can occur with low levels of consumption. Culturally sensitive services targeted to gay men are important in successful prevention and treatment programs.

8. Tobacco
Recent studies seem to support the notion that gay men use tobacco at much higher rates than straight men, reaching nearly 50 percent in several studies. Tobacco-related health problems include lung disease and lung cancer, heart disease, high blood pressure, and a whole host of other serious problems. All gay men should be screened for and offered culturally sensitive prevention and cessation programs for tobacco use.

9. Fitness (Diet and Exercise)
Problems with body image are more common among gay men than their straight counterparts, and gay men are much more likely to experience an eating disorder such as bulimia or anorexia nervosa. While regular exercise is very good for cardiovascular health and in other areas, too much of a good thing can be harmful. The use of substances such as anabolic steroids and certain supplements can adversely affect health. At the opposite end of the spectrum, overweight and obesity are problems that also affect a large subset of the gay community. This can cause a number of health problems, including diabetes, high blood pressure, and heart disease.

10. Anal Papilloma
Of all the sexually transmitted infections gay men are at risk for, human papilloma virus —which cause anal and genital warts — is often thought to be little more than an unsightly inconvenience. However, these infections may play a role in the increased rates of anal cancers in gay men. Some health professionals now recommend routine screening with anal Pap Smears, similar to the test done for women to detect early cancers. Safe sex should be emphasized. Treatments for HPV do exist, but recurrences of the warts are very common, and the rate at which the infection can be spread between partners is very high.

Author: Vincent M. B. Silenzio, MD, MPH, Former Member Board of Directors, GLMA and Former Co-Editor, Journal of the Gay and Lesbian Medical Association

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Ten things lesbians should discuss with their health care providers

Following are the health issues GLMA's healthcare providers have identified as most commonly of concern for lesbians. While not all of these items apply to everyone, it's wise to be aware of these issues.

1. Breast Cancer
Lesbians have the richest concentration of risk factors for breast cancer than any subset of women in the world. Combine this with the fact that many lesbians over 40 do not get routine mammograms, do breast self-exams, or have a clinical breast exam, and this cancer may elude early diagnosis, when it is most curable.

2. Depression/Anxiety
Lesbians have been shown to experience chronic stress from homophobic discrimination. This stress is compounded by the need that some still have to hide their orientation from family and colleagues at work, and by the fact that many lesbians have lost the important emotional support most others get from their families due to alienation stemming from their sexual orientation.

3. Heart Health Smoking and obesity are the most prevalent risk factors for heart disease among lesbians; but all lesbians need to also get an annual clinical exam because this is when blood pressure is checked, cholesterol is measured, diabetes is diagnosed, and exercise is discussed. Preventing heart disease, which kills 45 percent of women, should be paramount to every clinical visit.

4. Gynecological Cancer
Lesbians have higher risks for many of the gynecologic cancers. What they may not know is that having a yearly exam by a gynecologist can significantly facilitate early diagnosis and a better chance of cure.

5. Fitness
Research confirms that lesbians have higher body mass than heterosexual women. Obesity is associated with higher rates of heart disease, cancers, and premature death. What lesbians need is competent and supportive advice about healthy living and healthy eating, as well as healthy exercise.

6. Tobacco
Research also indicates that lesbians may use tobacco and smoking products more often than heterosexual women use them. Whether smoking is used as a tension reducer or for social interactions, addiction frequently follows and is associated with higher rates of cancers, heart disease, and emphysema — the three major causes of death among all women.

7. Alcohol
Alcohol use and abuse may be higher among lesbians. While one drink daily may be good for the heart, more than that can be a risk factor for cancer or osteoporosis.

8. Substance Use
Research indicates that lesbians may use illicit drugs more often than heterosexual women. This may be due to added stressors in lesbian lives from discrimination. Lesbians need support from each other and from health care providers to find healthy releases, quality recreation, stress reduction, and coping techniques.

9. Domestic Violence
Domestic violence is reported to occur in about 11 percent of lesbian homes, about half the rate of 20 percent reported by heterosexual women. But the question is where do lesbians go when they are battered? Shelters need to welcome and include battered lesbians, and offer counseling to the offending partners.

10. Osteoporosis
The rates and risks of osteoporosis among lesbians have not been well characterized yet. Calcium and weight-bearing exercise as well as the avoidance of tobacco and alcohol are the mainstays of prevention. It is also important to get bone density tests every few years to see if medication is needed to prevent fracture.

Author: Katherine A. O'Hanlan, MD, Former President, GLMA, Co-Founder, Lesbian Health Fund, Gynecologist, Portola Valley, CA

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Ten things transgender persons should discuss with their health care providers

Following are the health issues GLMA's healthcare providers have identified as most commonly of concern for transgender persons. While not all of these items apply to everyone, it's wise to be aware of these issues.

1. Access to Health Care
Transgender persons are often reluctant to seek medical care through a traditional provider-patient relationship. Some are even turned away by providers. A doctor who refuses to treat a trans person may be acting out of fear and transphobia, or may have a religious bias against GLBT patients. It's also possible that the doctor simply doesn't have the knowledge or experience he needs. Furthermore, health care related to transgender issues is usually not covered by insurance, so it is more expensive. Whatever the reasons, transgender people have sometimes become very ill because they were afraid to visit their providers.

2. Health History
Trans persons may hide important details of their health history from their doctors. Perhaps they fear being denied care if their history is known. Even many years after surgery, they may omit the history of their transition when seeing a new provider. Patients should see their provider as an equal partner in their health care, not as a gatekeeper or an obstacle to be overcome.

3. Hormones
Cross-gender hormone therapy gives desirable feminizing (or masculinizing) effects, but carries its own unique risks. Estrogen has the potential to increase the risk of blood clotting, high blood pressure, elevated blood sugar and water retention. Anti-androgens such as spironolactone can produce dehydration, low blood pressure, and electrolyte disturbances. Testosterone, especially when given orally or in high doses, carries the risk of liver damage. Hormone use should be appropriately monitored by the patient and provider. Some trans people tend to obtain hormones and other treatment through indirect means, bypassing the health care system. Taking hormones without supervision can result in doses too high or too low, with undesired results.

4. Cardiovascular Health
Trans persons may be at increased risk for heart attack or stroke, not only from hormone use but from cigarette smoking, obesity, hypertension, and failure to monitor cardiovascular risks. Trans women may fear that a provider who finds them at risk for cardiovascular disease will instruct them to stop their hormones, and so they do not seek medical attention even when they have early warning signs of heart disease or stroke.

5. Cancer
Hormone-related cancer (breast in trans women, liver in women or men) is very rare but should be included in health screening. A greater worry is cancer of the reproductive organs. Trans men who have not had removal of the uterus, ovaries, or breasts are still at risk to develop cancer of these organs. Trans women remain at risk, although low, for cancer of the prostate. Furthermore, some providers are uncomfortable with treating such cancers in trans people. Some cases have been reported in which persons delay seeking treatment, or are refused treatment, until the cancer has spread.

6. STDs and Safe Sex
Trans people, especially youth, may be rejected by their families and find themselves homeless. They may be forced into sex work to make a living, and therefore at high risk for STDs including HIV. Other trans people may practice unsafe sex when they are beginning to experience sexuality in their desired gender. Safe sex is still possible even in transgender relationships.

7. Alcohol and Tobacco
Alcohol abuse is common in transgender people who experience family and social rejection, and the depression which accompanies such rejection. Alcohol combined with sex hormone administration increases the risk of liver damage. Tobacco use is high among all trans persons, especially those who use tobacco to maintain weight loss. Risks of heart attack and stroke are increased in persons who smoke tobacco and take estrogen or testosterone.

8. Depression/Anxiety
For many reasons, trans people are particularly prone to depression and anxiety. In addition to loss of family and friends, they face job stress and the risk of unemployment. Trans people who have not transitioned and remain in their birth gender are very prone to depression and anxiety. Suicide is a risk, both prior to transition and afterward. One of the most important aspects of the transgender therapy relationship is management of depression and/or anxiety.

9. Injectable Silicone
Some trans women want physical feminization without having to wait for the effects of estrogen. They expect injectable silicone to give them "instant curves." The silicone, often administered at "pumping parties" by non-medical persons, may migrate in the tissues and cause disfigurement years later. It is usually not medical grade, may contain many contaminants, and is often injected using a shared needle. Hepatitis may be spread through use of such needles.

10. Fitness (Diet & Exercise)
Many trans people are sedentary and overweight. Exercise is not a priority, and they may be working long hours to support their transitions. A healthy diet and a frequent exercise routine are just as important for trans persons as for the public. Exercise prior to sex reassignment surgery will reduce a person's operative risk and promote faster recovery.

Author: Rebecca A. Allison, MD
Board of Directors, Gay and Lesbian Medical Association
American Medical Association, Advisory Committee on GLBT Issues
Interventional Cardiologist, Phoenix, Arizona