0
Brian C. Willoughby, MD, CCFP
Health Concerns (excluding AIDS)
for Male Homosexual Patients
SUMMARY RESUME
Since 1981, the Acquired Immune Depuis 1981, le syndrome d'immunod6ficience acquise
Deficiency Syndrome (AIDS) has emerged (SIDA) se revele l'infection 6pid6mique la plus importante
as the major infectious epidemic of our des temps modernes et a fait converger l'attention sur la
time and has focused much attention on communaut6 homosexuelle male. Malgr6 le fait que le
SIDA soit la preoccupation la plus importante concernant
the male homosexual community. While la sante des homosexuels, il ne represente en fait qu'une
AIDS is the most serious of gay-related des nombreuses maladies infectieuses touchant ce groupe
health concerns, it is only one of several de patients. Par ailleurs, le fait qu'un patient reconnaisse
infectious diseases that have particular son homosexualite souleve des inqui6tudes
relevance for this group of patients. In psychologiques speciales que le professionnel des soins
addition, the mere acknowledgement of de premiere ligne doit prendre en consid6ration.
L'auteur decrit un moyen d'aborder les homosexuels et
homosexuality by a male patient evokes passe en revue les infections specifiques (excluant le
unique psychosocial concerns that are SIDA) auxquelles ils sont expos6s.
important considerations for the primary
health-care provider. The author of this
article describes an approach to gay male
patients for those who provide health care
to such men and provides a review of
specific infectious diseases (excluding AIDS)
for which they are at risk. (Can Fam
Physician 1988; 34:1765-1769.)
Key words: homosexuals, primary health care, gay community
Dr. Brian Willoughby is a gine how the decade will be viewed by costs and complex ethics involved. In
primary-care practitioner in historians. Business recessions, inter- the latter, the issues are perhaps even
central Vancouver. He has a national and domestic terrorism, and a more complicated. There are the same
special interest in the health care trend toward conservative political and elements of cost, suffering, and pro-
of gay men, most notably those fiscal attitudes may all be cited as lega- gress, but these are further com-
with AIDS, and has been actively cies of the era. pounded by issues of infectivity and al-
involved in local, national, and In the medical sphere, the frontiers ternative lifestyles.
international organizations of immunology have been dominant, Although my intent in writing this ar-
dedicated to the provision of and the direction of society remains un-
ticle is to review aspects of health, ex-
appropriate health care to the gay clear, yet to be determined. The rapid
cluding AIDS, that are of particular rele-
community. Requests for reprints changes in both transplant procedures
to: Dr. Brian C. Willoughby, and Acquired Immune Deficiency Syn- vance to gay men, it is impossible to ex-
#404 - 1160 Burrard St., drome (AIDS) present unprecedented clude AIDS totally, and it is certainly not
Vancouver, B. C. V6Z 2E8 moral and ethical challenges. In the possible to ignore the effects it has had
former instance, we both welcome the on other areas of health concerns to gay
biotechnological progress that permits and bisexual men. In addition, this
A S THE TWILIGHT of the 1980s the resolution of much human suffering group of men is, of course, subject to
Aldeepens,
one can begin to ima- and debate agonizingly the enormous all ofthe same ills as is heterosexual so-
CAN. FAM. PHYSICIAN Vol. 34: AUGUST 1988 1 765
ciety, including hypertension, athletic As resources for, and advisors of, tion for action on otherwise-suppressed
injuries, and hyperacidity. our patients, we must appear approach- sexual issues.
Those areas of health that are espe- able if the gay male patient is to disclose Most primary-care physicians who
cially relevant to male homosexuality this infomation. And indeed, the very know their patients well would suspect
include two major categories: psycho- act of disclosure, "coming out", is some form of anxiety or stress in such a
social concerns and infectious diseases. often a source of both anxiety and de- patient who abruptly develops a sub-
pression for many men. Assisting a pa- stance abuse disorder. However, some
Psychosocial Concerns tient through that process is not infre- may not include questions about sexual
Interactions between patient and quently a role for primary-care physi- orientation in attempts to understand
physician produce a relationship that is cians. To assist both physician and pa- the source of the anxiety. Again, the
unlike most others within our society. tient, there are some excellent books, physician can and should give this anx-
As physicians we experience intimate including Loving Someone Gay by Dr. ious man permission to divulge what
glimpses into our patients' lives and Don Clark, Family Matter: A Parent's the patient may perceive as a most un-
loves, as well as into their livers and la- Guide to Homosexuality by Dr. Charles desirable problem. Non-judgmental
rynges. However, precisely because Silverstein, and Now That You Know: listening and support are the best ther-
we are physicians, we rarely experi- What Every Parent Should KnowAbout apy. Reassurance that the "problem"
ence the other side of that relationship, Homosexuality by Betty Fairchild and is actually a common variant within our
for even though we do consult our col- Nancy Hayward. Most regions of the society, and that the disclosure is com-
leagues for concerns about our own country also have homosexual and les- pletely confidential, will generally
health, we are far from typical patients. bian organizations that are often helpful serve as adequate "treatment" in the
Through years of experiencing the to the newly aware gay man. In most initial disclosure interaction. Follow-
physician's side of the relationship, we larger urban centres, there are psy- ing this, there may or may not exist a
may lose sight, at least temporarily, of chologists, psychiatrists, and social need for treatment of substance abuse.
the patient's experience of visiting the workers whose area of expertise is There are, of course, as many spe-
doctor. So-called "doctor-bashing" helping the man through any crises of cial circumstances as there are individ-
and malpractice suits notwithstanding, adjustment. ual gay men. However, mention should
physicians retain a high level of public The adjustment may include divorce be made of gay youth, ethnic gays, and
esteem. As such positive societal repre- and disclosure to family and co-work- men emerging from heterosexual rela-
sentatives, physicians' opinions and ac- ers; it invariably includes lesser or tionships.
tions in areas of controversy, such as greater degrees of difficulty in accept- Adolescents face an especially diffi-
homosexuality, may be presumed to ing self-worth as a gay man. The many cult situation, as peer pressures to con-
have a not insignificant influence. And myths and stereotypes of the male ho- form are particularly onerous; and
with the inextricable connections be- mosexual that pervade our society while many confreres may be seeking
tween homosexuality and the present serve to produce a sense that homo- to experiment sexually with women,
epidemic of AIDS, we physicians often sexuals are inferior or second-class the gay adolescent is usually at great
appear as divided as society does as a citizens, worthy of, at best, tolerance pains to hide his sexual orientation for
whole. Split as we are between "fam- or pity. Indeed, some readers may sup- fear of ostracism, ridicule, or even vio-
ily-value traditionalists" and "liber- port this view. However, such a view, lence. Schoolyard and locker-room
als", between the mandatory testers in ourselves as physicians or within so- jokes are often most pejorative in deni-
(some of whom have a true plague men- ciety as a whole, does little to facilitate grating homosexuals. Consequently,
tality) and those who seek to alleviate a sense of "health" in the anxious man the youth may present as a behaviour
human suffering even though, in cer- who has discovered that his true sexual problem in school or with failing
tain circumstances, it may produce an preference is for other males. Inevita- grades and other depressive symptoms.
insignificant risk to themselves, we bly, all physicians who would seek to The young man may not view the fam-
present mixed messages as a profes- provide appropriate and useful health ily doctor, who usually attends the en-
sion. Thus it is not surprising that the care to gay male patients need to exam- tire family, as a suitable confidante for
gay male patient often perceives a need ine deeply their own feelings about fear that his secret may be divulged to
to conceal his sexual orientation from male homosexuality, and to resolve any his family. Again, non-judgmental ac-
his physician for fear of censure. misgivings they may have before they tive listening and gentle probing, par-
Consequently, we must all be aware assume such a role. ticularly combined with assurances that
of cues that we may provide during the The "coming-out" period is often a the youth's confidence will be main-
patient encounter not only to give the time of high sexual activity, and the tained, is the best tack. An emotional
patient permission to disclose such a physician should gently inquire about encounter might then be expected in
highly pertinent piece of history, but in- this possibility in a sexually active male which the secret is divulged, generally
deed to encourage such disclosure. who presents frequently with concerns with a plea for help and occasionally
Neutral enquiries about "regular sex- about sexually transmitted diseases with one for a "cure for this disease".
ual partner(s)" reassure the man that (STDs), or with such diseases them- Knowledge of local support groups and
you are not presuming exclusive het- selves. Some individuals may also have gay-positive therapists would be par-
erosexuality (even with married pa- problems with substance abuse. Such ticularly helpful in guiding the young
tients) and serve as a springboard to substances, particularly alcohol, pro- man to a successful resolution of his
permit the more intimate question, duce cortical disinhibition and some- fears and anxieties.
"Is/Are your partner(s) male, female, times serve an almost ritualistic func- In some instances, the concerns may
or both?" tion in the anxious male as a rationaliza- be based on a single homosexual en-
1766 CAN. FAM. PHYSICIAN Vol. 34: AUGUST 1988
counter in an otherwise heterosexually lationship to the heavy load he drags Persons who develop acute hepatitis
oriented youth, and reassurance that with him daily on his path toward reso- B require rest, good nutrition, and ad-
this experience is of no grave conse- lution of his conflict. Any or all of indi-
vice on transmissibility during their
quence and is common to a large per- vidual, couple, and family counselling convalescence. Repeat serology six
centage of men in their sexually active may be indicated to help resolve feel- months later is necessary to determine
years may be all that is necessary. On ings; appropriate legal counsel is re- the presence or absence of persistent
the other hand, for the young man quired to effect property and/or cus- antigenemia.
whose true orientation is homosexual, tody agreements. Again, exposure to For the patient with persistent hepa-
longer-term supportive therapy, in- others who have endured and grown titis B surface antigenemia, hepatitis e-
cluding referral to some of the reading from such life crises can be very help- antigen status becomes important, as
materials mentioned above, will be ful. those who are also positive for this anti-
necessary. Careful consideration gen are simultaneously both more in-
should be given to the youth's family, Infectious Diseases fectious and at greater risk of chronic
who are both an obvious source of sup- It has been recognized for many dec- hepatitis than are e-antigen-negative
port and the greatest source of anxiety, ades that many illnesses follow the chronic carriers. Opinions vary among
should they react badly and deny that epidemiologic pattern of sexual trans- hepatologists as to whether minimal or
support. The importance of local com- mission. Because sexual acts between zero alcohol is the appropriate regime
munity support cannot be over-empha- two male partners are inherently differ- in attempts to limit further hepatic dam-
sized, as the real or perceived lack of ent from heterosexual vaginal inter- age in the chronic carrier. There are
such support is one of the major deter- course, it is no surprise that some or- concerns, also, about interactions be-
minants in gay youths' leaving small ganisms present clinical pictures that tween HBV and human immunode-
communities, often to end up prostitut- are unlike those seen in the heterosex- ficiency virus (HIV), whereby either vi-
ing themselves on the street corners of ual patient. Additionally, some organ- rus may potentiate the effects of the
larger cities. isms that are rarely encountered in the other, resulting in either profound he-
Gay men of non-European back- general population assume great rele- patic disease or potentiated im-
grounds may also experience additional vance in the gay patient. munosuppression.
barriers because of their communities' Some 10% of chronic carriers of
view of homosexuality. Providing Viruses HBsAg develop chronic active hepatitis,
health care to members of any ethnic Hepatitis B Virus (HBV). HBV is a with relapsing fatigue, arthralgias,
group is frequently challenging and re- DNA virus widely distributed through- myalgias, and fevers. These individu-
warding as one deals with translation of out the world. Although endemic in als are at even greater risk than are
both words and concepts, and the much of Asia, it is relatively uncom- chronic asymptomatic carriers for
thoughtful practitioner takes time to de- mon in the industrialized West. Much hepatocellular carcinoma, cirrhosis,
velop an understanding of the patient's has been learned about HBV since its ascites, varices, and premature death.
particular beliefs and practices as a pre- isolation in the 1960s, including its po- Herpes simplex virus (HSV). Herpes
requisite to developing the doctor-pa- tential presence in all body fluids. simplex is commonly encountered in
tient relationship and, ultimately, to ef- Epidemiologic evidence for spread, gay men. Acute herpes proctitis, fortu-
fecting meaningful treatment plans. though, is confined largely to blood- nately now seen much less frequently,
Because many peoples hold views of borne and sexual spread. HBV is spread as a result of safer sexual practices in
homosexuality different from that of effectively by anal-receptive inter- the face of AIDS, is intensely painful.
the European majority, some knowl- course. Unlike AIDS, there is evidence There is tenesmus and mucoid dis-
edge of such views would be helpful to for the spread of HBv by oral-receptive charge, often with blood, and the anal
the physician providing effective health intercourse. sphincter tone is often such that neither
care. In addition, exposure to these di- Because up to 50% of episodes of digital nor anoscopic examination is
verse views will help to provide the acute HBV infection produce minimal or possible. (Neither gonorrhea nor trau-
physician with a broader view of homo- no symptoms, many men are unaware matic lesions produce this degree of
sexuality itself. that they have been exposed to HBV. All pain.) Frequently, urinary frequency,
Special concerns are noteworthy for gay men should be screened for HBV dysuria, and posterior thigh pain may
men leaving heterosexual relation- markers, including hepatitis B surface occur, and prostatitis must be consid-
ships, especially marriages with chil- antigen (HBsAg), anti-core antibody, ered. Occasionally fever and, rarely,
dren. There is often, though not inevi- and anti-surface antibody. Some pa- urinary retention may cccur. Acyclovir
tably, the tragedy of divorce. For the tients prove to be chronic carriers of orally at 200 mg five times daily, as
woman and those who support her, HBv and have been unaware oftheir po- well as sitz baths and oral analgesics, is
there is frequently the perception ofbe- tential infectivity for sexual partners. effective therapy. Relapses generally
ing a victim. While in general she is, in- Others have one or both antibodies and are less severe, and may occur as ve-
deed, an innocent party, care must be are hence immune to the illness. Those sicular eruptions on the buttocks or in
taken not to present the man as there- who have neither antigen nor antibody the gluteal fold.
fore guilty. The family physician espe- should be urged to have prophylactic HIv-seropositive individuals have a
cially, who may see both parties, must immunization with one of the available more serious difficulty with HSV, and
recognize that each needs his/her care vaccines. This virus, which has been a suppressive therapy with lower doses
and support. Generally, the man has al- scourge of the gay male community- of acyclovir is often effective pro-
ready added the burden of guilt and and the health-care worker-is now ef- phylaxis, although long-term effects of
shame from ending the heterosexual re- fectively preventable. acyclovir are not known.
CAN. FAM. PHYSICIAN Vol. 34: AUGUST 1988 1767
Cytomegalovirus (CMV). Over one- later with a repeat dose, than to tetracy- sents with mild to moderate diarrheal
half of the adult North American popu- cline or aqueous procaine penicillin in- illness, and is frequently seen in gay
lation shows serologic evidence of pre- jections. Those patients with penicillin- men following travel to tropical climes,
vious CMV exposure. In gay men, this resistant strains, or those with rectal as in heterosexuals. In HIV-positive pa-
figure is 95%. Athough gay men, like gonorrhea who are penicillin allergic, tients, salmonella bacteremia may oc-
heterosexuals, are rarely ill with an should receive injectable spectino- cur, often necessitating prolonged ther-
acute CMV illness, this virus can often mycin. apy. Therapy with ampicillin is usually
produce retinitis with blindness, pneu- In all instances, follow-up test of effective, but sensitivities should be ob-
monitis, or colitis in HV-positive indi- cure is mandatory, as well as reporting tained, as well as post-therapy stool
viduals. Therapy with fosfonoformic to local health officials to facilitate con- specimens. Co-trimoxazole (Septra/
acid or gancyclovir is occasionally ef- tact notification and treatment. Bactrim) is also effective, but should be
fective. used cautiously in the HV-seropositive
Epstein-Barr Virus (EBV). This vi- Treponema pallidum. Syphilis, the man because of the high frequency of
rus, the agent of acute mononucleosis, great masquerader, is a disease that has adverse reaction to this drug.
is a DNA virus of the herpes family and traditionally been somewhat more Shigellosis also presents with diar-
as such causes chronic infection. It is common among gay men than among rheal illness, but is generally more se-
thought to have a function, interac- heterosexuals. This circumstance, too, vere and produces more constitutional
tively with HIV, in producing AIDS-re- is changing with the dramatic shift in illness, often with high fever, nausea,
lated lymphomas. behaviours since AIDS descended upon and myalgia. Again, therapy is guided
North America. by sensitivities.
Human papilloma virus (HPI). The Primary syphilis presents with a In most instances of diarrheal illness,
papilloma virus produces warts on painless firm-edged chancre at the site therapy will await laboratory isolation
faces, hands, feet, and genitals of peo- of entry of the spirochete, usually on of organisms, either bacterial or para-
ple of any sexual persuasion. In gay the genitals or in the mouth. This chan- sitic (see below). However, one can
men, again especially those who are cre disappears, to be followed many usually effect symptomatic relief with
HIV-seropositive, anal condylomata are weeks later by a widely-distributed use of bismuth-containing compounds.
a serious source of morbidity. Treat- macular rash. Palmar and plantar le- Narcotic agents such as diphenoxylate
ments of variable efficacy include topi- sions are uncommon in other der- (Lomotil) should be avoided because
cal podophylline, 5-fluorouracil or liq- matoses, and should make the physi- they may inhibit the passage of organ-
uid nitrogen, and local electrocautery. cian highly suspicious of secondary isms through their anti-peristaltic activ-
More recently, intralesional interferon syphilis. Other infrequent presenta- ity.
injections have offered some benefit. tions may include iritis and con- In some jurisdictions, food-handlers
Bacteria dylomata lata, exuberantly prolifera- with intestinal infections may be re-
tive growths particularly of the anal re- quired to complete a course of therapy
Gonococcus. Gonorrhea of the ure- gion. Again, routine serologic screen- and produce organism-free specimens
thra presents in the same fashion in both ing of non-monogamous homosexual before they may return to work. Con-
gay and heterosexual men, with dysuria men is to be recommended, as rectal sultation with local public health
and discharge in the majority of cases. chancres will rarely be diagnosed, and authorities is again encouraged.
The sizeable minority of asymptomatic the patient may ascribe transient, non-
cases, however, make periodic routine Other bacterial infections. Urethritis
irritative skin problems to other causes, and prostatitis are relatively commonly
urethral swabs in non-monogamous and so seek no medical attention.
men advisable. Because of the effects seen in the gay male patient. Isolation
Following diagnosis, treatment is of chlamydia is uncommon, and the
of HIV on gay male sexual practices, problematic and must be tempered in
the frequency of gonorrhea, particu- cost of such cultures may make them
those who test seropositive for HIY. In uneconomical in the majority of cir-
larly rectal, has greatly decreased in re- general, intramuscular injection of 2.4
cent years. cumstances. Therapy with tetracy-
million units of benzathine penicillin as cline, erythromycin, norfloxacin, or
Rectal gonorrhea may be asympto- a single dose is adequate for primary or
matic or may present with rectal ur- co-trimoxazole may be used.
early secondary syphilis. However, in Parasites. Parasitic infestations are
gency (though rarely severe tenesmus), patients who are HIV-positive, three
mucus- or blood-coated stool, and mild doses at weekly intervals are more ap- frequent in gay men. The high inci-
increase in stool frequency. Pharyn- propriate. Erythromycin or tetracy- dence ofboth parasitic and bacterial in-
geal gonorrhea is rare, but is also rarely cline regimes are used in penicillin-al- testinal disease has led to the term "gay
symptomatic, and, again, routine lergic persons. A full discussion of bowel syndrome". While some attrib-
screening is advised. treatment regimes for later forms ofthe ute this to a high frequency of oral-anal
Urethral gonorrhea can generally be disease is beyond the scope of this arti- sexual contacts, it is the author's expe-
treated with a witnessed one-time dose cle, and consultation with local public rience that most patients with parasitic
of 3.5 gm of ampicillin combined with health personnel is recommended in the disease at least are not practitioners of
1 gm of probenecid. Penicillin-allergic majority of cases. what is often called "rimming". It
patients or those with pharyngeal gon- seems not unreasonable to speculate
orrhea should receive tetracycline 500 Enteric bacteria. Both salmonella that oral contact with posterior scrotal
mg four times daily for one week. Rec- and shigella infections are not uncom- skin may also lead to the ingestion of
tal gonorrhea will respond more reli- mon in gay men, and may prove life- parasites or cysts.
ably to the above ampicillin and pro- threatening in immunocompromised Parasites commonly encountered in-
benecid regime, followed 24 hours individuals. Salmonella usually pre- clude entamoeba histolytica, giardia
1 768 CAN. FAM. PHYSICIAN Vol. 34: AUGUST 1988
lamblia, and a host of "non-patho- the investigating laboratory. Rectal men's health care is appropriate. This
genic" parasites. Some experts in the swabs will rarely be effective for diag- article has been written to review those
field of AIDS question whether these nosis. Treatment is with diodohydroxy- aspects of health care, excluding AIDS,
other organisms should be considered quin 650 mg three times daily for 20 which are of especial concern to physi-
non-pathogenic, as one may certainly days. Alternate regimes with metro- cians caring for gay or bisexual male
find that symptoms of intestinal gas, nidazole or emetine are used in those patients. U
mild diarrhea, and vague malaise re- rare instances of extraintestinal dis-
gress with eradication of these organ- ease.
isms. There is further the question of For Further Reading
Giardiasis is not uncommonly seen
whether these organisms may produce in both gay and heterosexual patients, 1. Bredfeldt JE. Hepatitis-B virus: update
some degree of stimulation of the im- on the spectrum of clinical manifestations
especially in rural areas where con- and on prophylaxis. Postgrad Med 1985;
mune system that could prove detri- tamination of water supply may occur. 78(6):71-83
mental in the presence of HIV. Suffi- Symptoms are similar to those de-
cient data from which to draw conclu- 2. Gerety RJ, Tabor E. Newly licensed
sions about whether or not to treat these scribed for amebiasis. Therapy with hepatitis-B vaccine: known safety and un-
metronidazole or quinacrine is effec- known risks. JAMA 1983; 249(6): 745-6.
organisms are not yet available.
Entamoeba histolytica occurs world- tive. In all instances, follow-up stool 3. Jaczek KH. Screening homosexual men
wide. In tropical climes it may produce examination is recommended. for hepatitis-B. Can Fam Physician 1986;
Since 1981, the AIDS epidemic has 32:855-8
dysentery, although in North American
gay men, more frequent symptoms in- emerged as the major health concern 4. Schreeder MT, Thompson SE, Hadler
clude mild bowel disturbance, occa- for gay men. It has also brought some SC, et al. Hepatitise-B in homosexual men:
sionally with blood, often with mucus, practitioners of health care to focus on prevalence of infection and factors related
to transmission. J Inf Dis 1982;
both flatulence and belching, and vague sexual orientation of patients, espe- 146(1):7-14.
upper abdominal discomfort. Diagno- cially men; multiple partners and anal
sis is made by isolation of the organism intercourse are features of sexual be- 5. Szmuness W, Much MI, Prince AM, et
al. Role of sexual behaviour in the spread of
or its cysts from stool samples collected haviour known to increase risk of HIV hepatitis-B infection. Ann Int Med 1975;
at home and then promptly returned to exposure. Such focus on homosexual 83;489-95
A ROUNDWORM
41DROUJND UP A PINWORM.I
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\YJ hen common worms families-too
find
VY accommodating, recommend Combantrin.
pleasant caramelfiavoured It's the anthelmintic that offers families
a choice.
susp,sion (50 mL) Tablets or suspension. Two formulations to pin
down roundworms and round up pinworms. In just
one convenient dose.
12ALETS . i
Easy-to-swallow taiiet
(bhisterpackoflZ)
12*ABET mbantnT
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-_ Leeming Division,
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Product monograph available on request. CCPP
CAN. FAM. PHYSICIAN Vol. 34: AUGUST 1988 1769