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Dale's Web Pages ONE OUT OF TWO

AIDS and sexually transmitted diseases among men who have sex with men

Review of the literature, by Dale O'Leary

The material presented here was collected by members of the
National Association of Research and Therapy of Homosexuality, NARTH

Table of Contents


A REVIEW OF THE LITERATURE

INTRODUCTION

The world is in the midst of an epidemic caused by the Human Immunodeficiency Virus. HIV discriminates and the infections are concentrated in certain populations. Men who have sex with men constitute one half of all the cases in the United States. In spite of massive education and prevention programs, epidemiologists predict that for the foreseeable future one out of two men who have sex with men will eventually become HIV- positive.

HIV disease is not easily transmissible. It requires fluid to fluid contact. With the exception of infants who acquire the infection prenatally from an infected mother, HIV infections are acquired only by those who engage in a limited and identified number of behaviors. The risk for people who avoid these behaviors is almost nil. These behaviors include intravenous drug use, transfusion or a needle stick with contaminated blood, and various sexual practices.

Men who have sex with men are at extremely high risk because of:

1) the variety of their sexual practices, including receptive and insertive anal/genital, oral/genital, anal/oral, and anal/manual sex activity,

2) the large number of sexual partners with whom they engage in these sexual practices,

3) the high percentage of homosexual men who are already HIV- positive.
 

Even before the first case of AIDS was diagnosed, men who have sex with men were in midst of an epidemic of sexually transmitted diseases. Homosexual men are more likely to be diagnosed with sexually transmitted gonorrhea, syphilis, dysentery, hepatitis, and viral infections. In 1983, the year the HIV virus was identified as the cause of AIDS, 58% of the homosexually active men in San Francisco were already HIV-positive.

While homosexual men responded initially to the AIDS epidemic by reducing the number of their sexual partners or using condoms, these changes have not been sufficient to halt the spread of the disease. Even after intensive AIDS education, the average number of sexual partners per homosexual man is still substantially higher than that of the average single heterosexual man. Condoms offer some protection, but condoms fail and homosexual men frequently fail to use condoms, particularly when under the influence of recreational drugs or alcohol.

New drug therapies offer hope of controlling the disease, but the announcement of successful treatment has unfortunately been greeted by an increase in unsafe behaviors within the homosexual community. When these new drugs were introduced, physicians were concerned that the HIV virus would become resistant to the current drugs. This fear appears fully justified. Recent reports indicate that forms of the virus resistant to new drugs are spreading. There is also a real risk that one of the different forms of the virus may find its way from Asia or Africa into the homosexual community, one that might be transmitted by oral sex, thus starting the epidemic cycle all over again

Even if HIV disease is reduced from an almost certain killer to a treatable disease, if the homosexual male community continues its current levels of sexual activity, it will only be a matter of time before another deadly sexually transmitted disease takes advantage of the opportunity provided by homosexual behavior patterns.

There are already two candidates for the next epidemic: hepatitis-C and human papilloma virus. Hepatitis-C causes chronic liver disease, resulting in cirrhosis of the liver, liver failure, and liver cancer. It can be sexually transmitted through homosexual activity. The human papilloma virus causes venereal warts and has been linked to cervical cancer in women and anal and genital cancer in men. Venereal warts in the anal/rectal area are extremely difficult to detect. The cancer may appear decades after the initial infection.

The younger a man is when he enters the homosexual lifestyle, the greater his risk of contracting HIV disease. In one study of homosexually active males, aged 20 to 22, 9% were HIV-positive. The percentage infected is expected to increase to 30% by the time this group is 30 years old and 50% by the time they are 50 years old.

Intensive educational programs have failed to prevent the spread of infection, largely because they have failed to address the psychological problems which are at the root of the compulsive behavior associated with the homosexual lifestyle. AIDS educators, many of them active homosexuals, have showed themselves to be more interested in preserving that lifestyle than in protecting at-risk youth and adults. The homosexual community has resisted public health measures normally used for controlling epidemics, such as contact tracing and partner notification.

There are other approaches which offer real hope of preventing infection, namely the prevention and treatment of same-sex attraction. Therapists and support groups who work with homosexual men who wish to come out of homosexuality have had remarkable success with clients willing to make a commitment to change. Therapists have also found that treating Gender Identity Disorders in pre-adolescent boys can prevent the development of same-sex attraction during adolescence in at least some of these boys. Even though all the adult clients who enter treatment do not become fully heterosexual, many experience a life-saving freedom from compulsive homosexual activity. Since it is predicted that one out of two men who have sex with men will become HIV-positive, preventing same-sex attraction and behavior can prevent HIV infection.

While not all men who have sex with men are interested in pursuing this option, in the interests of public health they should at least know that the option exists. Public health agencies should support those men who do wish to receive treatment. Parents should be informed as to the signs of Gender Identity Disorder and know where to find treatment for boys with symptoms of the disorder. Treating Gender Identity Disorder in boys before adolescence has other benefits – boys who are not comfortable with their masculine identity are often unhappy, fearful, lonely, and angry and experience rejection, teasing, drug and alcohol abuse, and other problems.

Those who read the following report should do so with compassion. For the last fifteen years, homosexual men have been living in the midst of a terrifying epidemic, knowing that they have a one in two chance of becoming infected, seeing friends and loved ones die painful deaths at a young age, struggling to care for the dying, fighting for treatment and research, and trying to find a way to go on living. But compassion for their suffering should be a motivation for a exploring every possible means of preventing HIV infection. They will be the primary beneficiaries of an honest review of the available research.

There is substantial evidence that homosexual men do not choose to be attracted sexually to other men and that same-sex attraction is, in many cases, the end result of a development disorder which begins in early childhood. While the disorder is amenable to treatment, no one should think that such treatment is easy or quick or always successful. Sexual behaviors are potentially addictive and overcoming addiction is rarely easy or quick.

Dr. Jeffrey Satinover, author of Homosexuality and the Politics of Truth, in a speech to the Jewish conservative group Toward Tradition, admonished his audience to remember that both homosexual and heterosexual persons struggle with human weaknesses. He praised the courage of those homosexuals who have come through that struggle. At the end of his book he writes:

I have been extraordinarily fortunate to have met many people who have emerged from the gay life. When I see the personal difficulties they have squarely faced, the sheer courage they have displayed not only in facing these difficulties but also in confronting a culture that uses every possible means to deny the validity of their values, goals, and experiences, I truly stand back in wonder. Certainly they have forced me by the simple testimony of their lives to return again and again to my own self-examination. It is these people – former homosexuals and those still struggling, all across America and abroad – who stand for me as a model of everything good and possible in a world that takes the human heart, and the God of that heart seriously.(Satinover p.249)

HIV AND HOMOSEXUAL MALES

Homosexual males, who make up less than 2% of the US population, account for 56% of the adult AIDS cases. As of January 1, 1997, 324,728 men who have sex with men have been diagnosed with AIDS.("HIV" 1997)

AIDS is the end stage of infection with the human immunodeficiency virus (HIV). In spite of massive educational efforts, the number of HIV-positive persons in the US continues to increase. The risk to men who have sex with men continues to remain as high as it was at the beginning of the epidemic. According to a study published in 1991, ten years after the epidemic began: "The overall probability of seroconversion [for a homosexual male] prior to age fifty-five is about 50 percent, with seroconversion still continuing at and after age fifty-five."(Hoover 1991) And this is the best case scenario because according to the authors of the study: "Given that this cohort consists of volunteers receiving extensive anti-HIV-1 transmission education, the future seroconversion rates of the general homosexual population may be even higher than those observed here."[Seroconversion in this context means that a person who previously tested HIV-negative, subsequently tested HIV-positive]

The news that protease inhibitors in combination with other drugs appear to control HIV may make the situation worse, since history demonstrates that when at-risk individuals believe that treatment for a sexually transmitted disease is available, they frequently relapse into behaviors guaranteed to spread infections. And what is worse, HIV disease is not the only sexually transmitted disease (STD) threatening the lives and health of homosexual men.

The relationship between HIV disease and homosexual behavior concerns not only homosexual men, but the entire community. Legislators struggle with how to pay for treatment and protect the public health. Medical professionals need to know how to counsel patients. Educators in many states are required to provide accurate AIDS education. Parents need to know what to tell their children. The media need to know the facts before communicating them to the general public.
 
 

SOURCES

In the sixteen years since the beginning of the AIDS epidemic, substantial research has been published on the relationship between HIV infection and homosexuality. Entire journals are devoted to AIDS and related subjects. While it is not possible to review everything that has been published, the following is a systematic survey of the key literature from various professional journals and others sources.

Although many books have been written about the AIDS epidemic and related subjects, most originate with established AIDS activists and educators. They have promoted the following: AIDS just happened to hit homosexual men first, but now everyone is at risk; everyone needs to use precautions when engaging in sex; tolerance for homosexuals and elimination of discrimination against those with AIDS are essential to stopping the epidemic. Some call this agenda the "Condom Code," because it is based on the theory being that if everyone uses a condom every time the epidemic will end.

Three gay writers, however, have challenged this analysis: Randy Shilts, And the Band Played On; Walt Odets, In the Shadow of the Epidemic; and Gabriel Rotello, Sexual Ecology. These three men have had the opportunity to observe the epidemic close up and have a personal interest in the subject. Shilts was assigned to cover the epidemic from its beginning by the San Francisco Chronicle. He interviewed many of those involved in the battle to find a cure and died of AIDS in 1994. Odets is a homosexual psychologist who treats homosexual patients in Los Angeles, and is an open advocate of complete sexual liberation. His book and other writings provide insight into the psychological process which drives some of the risky behavior seen in homosexual men. Rotello was the editor of Outweek magazine and has written for The Advocate, The Nation, Out, New York Newsday, the Village Voice, and The New York Times. All three have written on the epidemic with an unflinching candor for which they have received substantial criticism from the AIDS establishment.

Because these three men have special insight into the epidemic and the thinking of the homosexual men whose lives are at risk, their own words have been used whenever possible to explain homosexual behaviors and attitudes which may seem incomprehensible to those outside their world.
 
 

UNDERSTANDING THE NUMBERS

Readers must be cautioned about the interpretation of statistics. Many people place undue emphasis on statistical studies without understanding their limitations. Even the best studies are only snapshots; they can only show what things looked like at a particular moment, at a particular place, from a particular angle, in a particular light. In order to evaluate a statistic, we need to know: How many people were in the study? How were they selected? Was this a representative sample? Did the researchers measure actual behaviors or ask their subjects to self-report their own behavior? Were the subjects asked to recall what they did last week, or what they did ten years ago? Is there reason to believe that the subjects might be less than candid? How were the questions asked? When was the study done? A study done in Peoria in 1950 would be expected to have very different results from one done in San Francisco in 1990. For all these reasons, percentages will vary from study to study.

If 100 homosexual men are asked the number of times they engaged in a particular sexual behavior in the last year, these men are being asked to guess. Furthermore, before one can apply the percentage obtained from such a survey to all homosexuals, it must be determined that the 100 homosexuals surveyed are truly representative of homosexuals in general, otherwise the percentage derived would be a guess about a guess. If, on the other hand, the Centers for Disease Control report that 573,800 adults have been diagnosed with AIDS as of January 1, 1997 and 357,598 have died, they aren't guessing; they are counting every adult whose diagnosis was, as required by law, reported to their office. And even then, in a footnote, they explain the reasons why their count may have missed a few people.("HIV" 1997)

In 1987, Saltzman and associates conducted a test to determine the reliability of self-reported sexual behavior by asking 116 asymptomatic homosexual men to complete two questionnaires six weeks apart. They found that self reporting of information on sexual behavior was not as reliable as demographic information, and that the social desirability of the answers appears to effect recall. (Saltzman 1987) Other researchers have suggested that the reliability of sexual behavior information decreases as the frequency of behaviors increases. A person is more likely to be accurate about one or two partners, less so about 50 or 100.(Martin 1984)

Psychologist Dr. Walt Odets believes self reports of sexual behavior may not be accurate:

About one-third of gay men would self-report the practice of unprotected anal sex, a behavior in itself always heavily stigmatized and now also bearing the considerable onus of HIV transmission. We know from considerable psychological experience with the anonymous self-reporting of severely stigmatized behaviors, that they are underreported by as much as 30 to 50 percent, regardless of how information is collected. Thus the real figures about unprotected anal sex are certainly higher than reported, and are likely to be about 44 to 53 percent.(Odets 1995, p.185)

THE 10% MYTH

Statistics are often misinterpreted and misused. In May of 1997, advice columnist Ann Landers responded to a 15-year-old boy who was suicidal because he was experiencing same-sex desires. She wrote: "According to some studies, an estimated 10 percent of individuals worldwide are homosexual."(Landers 1997) Ann Landers is only one in a long list of people promoting the myth that 10% of the population is homosexual. "One in Ten" educational campaigns have been launched in public schools. Students are told, "Look around your classroom; if there are 30 other students, 3 are homosexuals."

This 10% figure is a prime example of the misuse of a statistic. The figure comes from an analysis of interviews conducted from 1938 to 1948 under the supervision of Alfred Kinsey and published as Sexual Behavior of the Human Male (Kinsey, 1949). In this study, 10% of men interviewed reported being more or less exclusively homosexual for at least three years between the ages of 16 and 55.

The study considered only male behavior and thus the 10% figure cannot be applied to the half of the population who are women. Furthermore, the Kinsey study itself did not claim that these 10% were exclusively homosexual for life. Many boys engage in same-sex behavior in adolescence only to become completely heterosexual later in life. In fact, the Kinsey study itself claims that only "4% of white males are exclusively homosexual throughout their lives after the onset of adolescence."(Kinsey, 1949)

And, based on other studies, even this lower figure is probably a gross overestimate. At the time the study was published, it was acknowledged that because of inadequacies of the sample design and the unrepresentative nature of the sample interviewed (prisoners, college students, and people who volunteered to talk about their sex lives), the figures collected by Kinsey could not be used to predict behavior rates in the general population. According to an article published in Science magazine:

Even 40 years ago, Kinsey's data were regarded as unsuitable for making such estimates . . .Since the Kinsey sample was not a probability sample, the data do not allow estimation of the characteristics of the national population with knowable margins of error. It is this point that is made most trenchantly in the major statistical reviews of Kinsey's research."(Fay 1989)

Fay et al analyzed a number of studies and concluded that only 1.4% of adult men engaged in same-sex behavior "fairly often." After the AIDS epidemic began, the debate over the percentage of men who have sex with men was no longer merely an academic question. Once a test for the HIV virus had been developed, researchers were able to estimate the percentage of homosexuals infected with HIV who would eventually need treatment for full-blown AIDS. In order to plan for future treatment needs, they needed to know the total number of men engaging in same-sex behavior. Initially, those making projections relied on the Kinsey figures. The warnings that Kinsey's numbers were not based on a statistically valid sample appear to have been forgotten. The 10%-of-the-population-are-homosexual myth had achieved the status of "it's a widely accepted fact that. . ." by dint of constant repetition.

In 1986, the US Public Health Service published its estimate that 1.5 million people in the United States were already infected with HIV. They based their estimate on the Kinsey figures. When the predicted numbers of infected homosexual men manifesting AIDS symptoms did not appear, researchers recognized the flaws in the Kinsey research, and the numbers were revised sharply downward. Homosexual activists continue to defend the higher percentage since it allows them to claim that they represent a significant constituency. When New York City Health Commissioner Stephen Joseph revised the estimate of the number of people in the city infected with HIV from 400,000 to 200,000, he faced a storm of criticism even though his second estimate may also have been too high. He later concluded that the number infected in New York at the time was probably closer to 100,000..(Joseph 1992)

The fact that the actual number of homosexual men developing AIDS was smaller than predicted by the Kinsey-based numbers proved that the Kinsey estimates were not projectable. Even though the Kinsey percentage has been discredited, the myth that 10% of the population is homosexual remains part of many school curricula and the figure is still widely quoted.

It should be noted that a number of the articles reviewed for this report used Kinsey percentages or studies based on Kinsey percentages. It is therefore important when reviewing articles to check referenced material since the presence of footnotes does not guarantee that information in the source is accurate.


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Original text on Dale's Disk — aids1.rtf - Oct.14, 1999
Reformatted to HTML — 2000 10 21, —WHS