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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

THE EPIDEMIC BEFORE THE EPIDEMIC

Even before the first AIDS cases among homosexual men were diagnosed, the homosexual community was already in the midst of an epidemic of STDs. During the 1970s, infection with a STD carried no stigma within the homosexual community. The ritual of repeated infection and treatment had become part of the homosexual lifestyle:

Gay men were being washed by tide after tide of increasingly serious infections. First it was syphilis and gonorrhea. Gay men made up about 80 percent of the 70,000 annual patient visits to the city's VD clinic. Easy treatment had imbued them with such a cavalier attitude toward venereal diseases that many gay men saved their waiting-line numbers, like little tokens of desirability, and the clinic was considered an easy place to pick up both a shot and a date. Then came hepatitis A and the enteric parasites, followed by the proliferation of hepatitis B, a disease that had transformed itself, via the popularity of anal intercourse, from a blood-borne scourge into a venereal disease.(Shilts p.39)

SYPHILIS AND GONORRHEA

Sexually transmitted diseases (previously labeled venereal diseases) are those conditions which can be transmitted by sexual contact. Before 1970, the two most common STDs were syphilis and gonorrhea. Left untreated, syphilis can cause birth defects, insanity, and a number of other conditions. Gonorrhea can cause infertility in women and men, arthritis, and blindness in children born to an infected mother. After the efficacy of treatment of early syphilis and gonorrhea with antibiotics had been established in the 1940s, the number of cases decreased significantly, but in 1957 the number of cases began to rise sharply, particularly among those under 25 and among homosexuals.("Venereal" 1963)

According to J.L. Fluker, a British doctor with considerable experience treating homosexuals, "A myth was once held that venereal disease was not transmissible homosexually."(Fluker 1981) However, during WWII doctors saw a number of cases of homosexually transmitted gonorrhea and syphilis resulting from anal and oral sex. Gabriel Rotello, a homosexual author and activist, hypothesizes that before WWII, STDs were not a major problem among homosexuals in the United States because during that period homosexual men engaged mainly in oral sex, and homosexually identified men did not engage primarily in sex with one another but with non-homosexually identified men. Rotello contends that the homosexual life-style consisted in large part of effeminate "fairies" who performed oral sex on the "trade" — sailors and other masculine men who did not consider themselves homosexual. After World War II, non-homosexually identified men were less willing to engage in this kind of activity because they feared being stigmatized as homosexual, and men who experienced same-sex attractions began to engage in active and passive sex with one another. This created a core group of men among whom infections could be easily spread. The rise of the bathhouses and other sex clubs facilitated anal sex because anal sex requires more privacy than oral. Because individual homosexual men engaged in both receptive and insertive behaviors, infections spread quickly within a core group of extremely sexually active men. The first men to be diagnosed with AIDS reported an average of 1,000 sexual partners. Unfortunately, these men did not restrict their contacts to core group members. Any casual participant in male homosexual behavior was at risk. Given these behavioral changes, sexual acts between males became an extremely effective means for transmitting a number of infectious agents.(Rotello pp.40-49)

In the 1960s, homosexual men accounted for an increasing percentage of the increasing number of infections with syphilis and gonorrhea. A study published in the American Journal of Epidemiology compared 12,201 heterosexual men with 5,324 homosexual men. Both groups were interviewed during their initial visits to the Denver Metro Health Clinic during 1977/1978. The homosexual men were significantly more likely to have gonorrhea (30.31% vs. 19.83%) and early syphilis (1.08% vs. 0.34%). The authors speculated that "higher rates of gonorrhea and syphilis result from a larger mean number of sexual contacts, more potential sites of infection, and more hidden and asymptomatic disease" among homosexuals. When asked the number of different sexual partners within the previous 30 days, the homosexual men reported a mean of 5.5, the heterosexual men a mean of 2.3.(Judson 1980)

In 1977, Raymond Berger reported on the high incidence of asymptomatic gonorrhea infections at a venereal disease clinic organized by homosexual men for homosexual men. He advised the "screening of atypical sites in this population," since homosexual men might have gonorrhea infections of the throat and anus as well as the penis. Among the 1,156 tests given at the clinic for Neisseria gonorrhea, the organism that causes gonorrhea, 3.5% were positive for pharyngeal, 4.7% for urethral, and 3.9% for anal infection.(Berger 1977)

J.L. Fluker studied the male cases of homosexually acquired STDs at Charring Cross Hospital (West London Branch) between 1962 and 1971 and noted "an explosive increase in case load, particularly between 1968-1971."(Fluker 1976) According to clinic records, in 1962 there were 105 cases of STDs among homosexual men; by 1971 the number had climbed to 1,773 cases. Fluker reported that male homosexuals had a high repeat infection rate, "some patients having had 40-59 new infections over the years in the same clinic."(Fluker 1981) It should be noted that legislation legalizing homosexual practices between consenting adults took effect in England in 1968.
 
 

GAY BOWEL SYNDROME

Syphilis and gonorrhea are not the only diseases affecting homosexual males. In the 1970s, doctors began grouping the large number of conditions affecting the lower intestinal tract of homosexual men under the classification "gay bowel syndrome." These included viral infections, infectious diarrheal diseases caused by bacteria and parasites, and injuries caused by anal sexual activity. Before physicians could treat the patients with gay bowel syndrome, they had to determine which infection their patient had contracted. The possibilities included: bacteria, such as Shigella sonnei, Shigella flexneri, Campylobacter enteritis, Campylobacter jejuni, or Salmonella enteritis; intestinal parasites such as Giardia lamblia, Entamoeba histolytica, and Entamoeba coli; herpes simplex and Chlamydia trachomatis. Most of these infections could be traced to exposure to fecal material either through oral/anal sexual acts, or through oral/genital sexual acts occurring after anal/genital sexual acts. At one point, health officials, uneducated as to homosexual practices, were so concerned about an unexpected outbreak of dysentery in the Greenwich Village section of New York City that they ordered an inspection of the water supply, fearing contamination with raw sewage.

A 1983 study of homosexual men attending a San Francisco Bay Area health fair found "strikingly higher prevalence rates of intestinal parasitic infections" among homosexual men when compared with rates in a control group of health plan members who had a routine multiphasic health examination. Of 105 homosexual men, 59.1% had intestinal protozoa, in contrast to 14.2% of the men in the control group.(Markell 1983) The number of homosexual men in the control group, if any, was not ascertained. According to Shilts:

In San Francisco, incidence of the "Gay Bowel Syndrome," as it was called in medical journals, had increased by 8,000 percent after 1973. Infection with these parasites was a likely effect of anal intercourse, which was apt to put a man in contact with his partner's fecal matter, and was virtually a certainty through the then-popular practice of rimming, which medical journals politely called oral-anal intercourse.(Shilts p.18)

Different gay communities were affected by different agents. English physicians found homosexual males infected with threadworms and Giardia lamblia.(Fluker 1981) US doctors were seeing enteric diseases caused by Shigella, Salmonella, Campylobacter, as well as Giardia. Doctors were warned to test regular sexual partners of clients to prevent ping-pong infections with asymptomatic partners.(Ketterer 1983)

Researchers found so many different agents in the bowels of homosexual men that they had difficulty determining which ones were causing the symptoms and which were harmless. Surawicz and associates, who studied spirochetes in the bowels of homosexual men, stated "The presence of frequent co-infection makes it difficult to know whether the treatment is specific for the spirochetes and whether the spirochetes alone can cause symptoms of proctitis."(Surawicz 1987)

A single patient often had a number of concurrent problems. For example, a 43-year-old homosexual male was diagnosed with amebic proctitis caused by Entamoeba histolytica and Entamoeba coli, secondary syphilis, and viral hepatitis. In another case a 38-year-old homosexual male with a previous history of hepatitis and gonococcal proctitis had to be hospitalized for 54 days. Doctors found "superficial ulceration, recent hemorrhage, chronic inflammatory cell reaction, depletion of goblet cells, and crypt abscesses. Shigellia flexneri was isolated from the stool. . . The patient's course was complicated by the development of toxic megacolon and Klebsiella bacteremia."(Kazal 1976)

Another study warned doctors that infection with Entamoeba histolytica could lead to amebic liver abscess in a "homosexual who engaged in oral-anal sexual practices." The physicians were concerned, "since amebiasis is epidemic in the gay community." According to the report, "the large increase in the incidence of intestinal amebiasis in the young male homosexual population in San Francisco is attributable primarily to oral modes of sexual transmission." The researchers warned that "50% of homosexual patients with intestinal amebiasis are completely asymptomatic carriers of cysts that escape detection, but these men are nevertheless less highly infectious and inadvertently infect many other individuals."(Thompson 1983)

Doctors also warned that the bowel could be injured during anal-rectal sex or anal-manual sex (fisting). These behaviors can result in abscesses, fistulas, and hemorrhoids at a young age (15 to 25). Anal fissures and ulcers can be severe enough to require surgery.(Ketterer 1983)

Foreign bodies inserted into the anus during sex play may have to be removed by surgery. Some injuries have been serious enough to require a colostomy. In one study, surgeons reported 112 patients with "trauma of the rectum or with retained foreign bodies, or both, resulting from homosexual or autoerotic practices." Rubber phalluses and plastic vibrators were the most common objects retained. "Two patients were injured twice." In addition one of these patients died, "a 23 year old man who presented in a state of shock 12 hours after fist insertion. In this patient, Fournier's gangrene developed."(Barone 1983)

In another study, 51 patients were treated for "55 retained foreign bodies in the rectum and colon, during a nine-year period from 1976 through 1984." The objects recovered included: rubber phalluses, vibrators, spray cans, corn cobs, glass bottles, light bulbs, and a sugar dispenser.(Kingsley 1985)

Venereal warts around and inside the genital and anorectal areas are caused by the human papilloma virus (HPV), which is sexually transmitted. HPV has been linked to cancer of the cervix in women and to cancer of the anus and penis in men. A study of homosexual men found that 18.1% of homosexual men self-reported infections with venereal warts.(Darrow 1981) However, many infections may be missed because it is more difficult to detect the internal warts and the cell abnormalities (dysplasia), which are a symptom of this disease, in the rectum and colon.(Surawicz 1995) Because those infected may not develop anal cancer until their late 50s or early 60s, this may be an epidemic waiting to happen.

Anal cancer can be fatal, particularly if the patient does not seek early treatment. Four homosexual male patients with giant anal carcinomas (tumors ranging from 10 to 17 cm in diameter) delayed seeking treatment in spite of what must have extreme discomfort. According to the report of their cases, "These patients suffered from social and psychological problems that contributed to their late presentation (4 to 8 months after the appearance of symptoms). Three of the four patients died within 12 months of diagnosis.(Cobb 1990)

Rectal inflammation caused by herpes is also a problem for homosexual men. An article in the New England Journal of Medicine reported, "Acute herpes simplex virus (HSV) infection was detected in 23 of 102 consecutively examined, sexually active male homosexuals who presented with anorectal pain." The doctors noted that "herpes simplex virus (HSV) was the most common cause of nongonococcal proctitis in sexually active male homosexuals." Herpes simplex is a chronic condition, although outbreaks can be controlled. The mean age of the patients in this study was 28 (range 15-55). All reported engaging in receptive anal sex.(Goodell 1983)
 
 

HEPATITIS

Viral hepatitis is a contagious disease attacking the liver. There are at least 8 different types of viral hepatitis, perhaps more. It wasn't until 1966 that doctors in England began to suspect that hepatitis might be sexually transmitted.(Fluker 1976) The three most common types of hepatitis – A, B, and C – are transmitted by male homosexual activity.

Hepatitis-A (HAV) is transmitted through feces and other secretions. Oral-anal contact is thought to be the most common route of transmission among homosexual men.(Ketterer 1983) It is normally a self-limiting disease, which creates an immunity to future infections.

In a report published in the New England Journal of Medicinein 1980, Corey and associates conducted a series of monthly examinations and tests for the hepatitis virus A on 57 heterosexual and 102 homosexual men from a clinic for sexually transmitted diseases in Seattle. Initially, 30% of homosexual men and 12% of heterosexual men tested positive for HAV. After one year, among those who had been hepatitis-free at the beginning, 22% of the homosexual men had became infected with HAV, while none of the heterosexual men had acquired HAV. According to the authors: "acquisition of hepatitis-A infection was correlated with frequent oral-anal sexual contact. Hepatitis-A should be considered one of the enteric infections that appear to be sexually transmitted among homosexual men."(Corey 1980) The risk is substantial since in a study of 612 homosexually active Canadian men, 42.2% reported engaging in oral/anal sex during the previous three months.(Myers 1992b)

Hepatitis-B (HBV) can be spread by saliva, semen, or urine, through mouth-to-mouth contact, or anal-genital sexual contact. About 10% of those infected with hepatitis-B become carriers and can pass the infection on to others. Carriers risk liver failure or liver cancer. In a 1977 study, J.C. Coleman confirmed previous reports that hepatitis-B may "be sexually transmitted" and warned that:

the male homosexual population represents a pool of individuals within which the hepatitis-B virus is readily transmitted, particularly subclinical infections. Clinical hepatitis does occur in some patients.(Coleman 1977)

Hepatitis-B infection can result in serious liver damage. Of the 2,612 homosexual males attending genitourinary clinics, 5% were found to be hepatitis-B positive. The researchers were not surprised at this finding since the rate of infection with hepatitis-B is 50 times greater among homosexual males in the United Kingdom than among unpaid blood donors; however, they were surprised by "the large number of subjects with serious liver disease." When a liver biopsy was done on 25 who had abnormal liver-function tests but no other signs of liver disease, 56% had chronic active hepatitis or active cirrhosis of the liver. The researchers were concerned that these men might be symptomless carriers of the disease:

We have not only confirmed the presence of a large pool of symptomless hepatitis-B virus infection but we have also identified a group of individuals in whom that infection is associated with severe, and possibly, progressive, histopathological changes in the liver.(Ellis 1979)

In 1990, JAMA published the results of a study of 1,062 homosexual and bisexual men which sought to determine how many men would become infected with the hepatitis-B Virus or become HIV positive over a 30 month period. The authors reported that initially 7% of the men were HBV positive and 22% were HIV positive. After 30 months, 19.8% of those who initially HBV-negative became positive and 7.8% of the initially HIV-negative became positive. (Kingsley 1990)

The authors discovered that "insertive, not receptive, anal intercourse was the major risk factor identified for HBV seroconversion, suggesting that transurethral exposure is an important mode of transmission."

Homosexual men account for a high percentage of reported hepatitis cases, according to one report: "At least 44 (43 per cent) of 102 reported cases of hepatitis-B and 48 (22 per cent) of 217 reported cases of hepatitis-A in Seattle-King County in 1980 occurred in gay men."(Handsfield 1981)

Hepatitis-C (HCV) kills between 8,000 and 10,000 Americans each year; 30% of those infected develop cirrhosis of the liver and others die from liver cancer.(Melani 1997) Experts predict that the death toll from hepatitis-C will triple in the next 10 to 20 years. Four million people are believed to be infected currently. The prevalence of hepatitis-C far exceeds that of HIV disease.(Greenberg 1997) Hepatitis-C is a blood-born virus and those who practice unprotected anal sex are at risk. Many people who have the disease are asymptomatic, but infectious. There is no vaccine and no sure cure. While patients with hepatitis-A and most of those with hepatitis-B have an acute infection from which they recover completely and to which they develop antibodies that protect them from ever acquiring the disease again, the antibodies for hepatitis-C are not protective and therefore there is a high rate of chronic cases. A small number of the carriers rid themselves of the disease without medical intervention, but chronic hepatitis develops in at least 50% of those infected and at least 10% will die of associated complications. Complications of hepatitis-C are the leading reason for liver transplants. Those with chronic hepatitis can pass the disease on to others.

Homosexual men appear to be particularly at risk. Test results from 2,523 patients in an inner city emergency room found that, of the 24 patients who admitted to engaging in homosexual sex, 21% were HCV-positive; in addition, 17% were HBV-positive and 67% were HIV-positive.(Kelen 1992)
 
 

WAITING FOR A MAGIC BULLET

In addition, homosexual men often had infections of the urethra, which were not caused by gonorrhea. In these cases, doctors check for Chlamydiatrachomatis, streptococcus b, or herpes simplex. Other sex-related diseases occurring among homosexuals include chancrodie, lymphogranuloma vereum, granuloma inguinale, pediculosis (pubic lice), pinworms, scabies, and flea bites.

Cytomegalovirus (HCMV) and Epstein-Barr virus have both been linked to mononucleosis; both cause transient immunosupression; both have been cited as possible causes of cancer; and both are extremely prevalent among homosexual men. A 1982 study of 161 homosexual and 77 heterosexual males at an STD clinic found that: "A significantly higher percentage of homosexual men had serum antibodies to HCMV than did the heterosexual controls (98% vs. 43%)."(Greenberg 1984) A study of men who visited a venereal disease clinic found that 94% of homosexual men but only 54% of heterosexual men were HCMV positive.(Mintz 1983) A person infected with HCMV continues to be infectious and capable of spreading the virus even asymptomatic. The researchers were concerned because they found that "asymptomatic homosexual men have evidence of immune dysfunction."(Collier 1987)

Doctors treating homosexual men warned their colleagues that what might appear to be a treatment failure could be reinfection with the same condition.(Ketterer 1983)

In 1977, William Darrow and associates conducted survey of 4,329 gay men. In a self-administered questionnaire, "66.8 percent reported previous infection with pediculosis[lice]; 38.4 percent, gonorrhea; 24.1 percent, nonspecific urethritis; 18.1 percent, venereal warts; 13.5 percent, syphilis; 9.7 percent, hepatitis; and 9.4 percent, herpes." The authors admit that self-administered questionnaires may underreport the number of infections since, in another study, 21% of clinic patients said they had been infected with hepatitis, but a blood test revealed that 61% had actually been infected.(Darrow 1981)

Many of the men reported multiple infections with the same disease. The researchers compared infections with behavior patterns and concluded: "the number of different lifetime sexual partners was the very best predictor of previous infections with syphilis, gonorrhea, and other sex-related infections."

In an editorial in the American Journal of Public Health, H. Hunter Handsfield reviewed the results of the Darrow study:

The major risk factors – greater numbers of sexual partners and anonymous or 'furtive' sexual encounters – were expected. Significantly, the practice of anilingus also was an important risk factor.(Handsfield 1981)

Handsfield concluded pessimistically: "Education of gay men to limit the nature and numbers of their sexual partners is unlikely to be productive on a large scale. . . traditional contact tracing is not productive in populations with large numbers of anonymous sexual contacts."

During the 1970s, doctors such as David Ostrow of the Howard Brown Memorial Clinic in Chicago and Dan Williams of the New York City Department of Public Health, who were involved with the treatment of STDs among homosexual men, recognized the problem, but there was little they could do to halt the STD epidemic in the homosexual community. The general public was uninterested in the problem and there was no support for behavior change in the gay community. According to Randy Shilts, "Promiscuity. . . was central to the raucous gay movement of the 1970s." By 1980 the situation was clearly out of hand:

The fight against venereal disease was proving a Sysiphean task. . .The screening in Ostrow's clinic had revealed that one in ten patients had walked in the door with hepatitis-B. At least one-half of the gay men tested at the clinic showed evidence of a past episode of hepatitis-B. In San Francisco, two-thirds of gay men had suffered from the debilitating disease. It was now proven statistically that gay men had a one in five chance of being infected with the hepatitis-B virus within twelve months of stepping off the bus into a typical urban gay scene. Within five years, infection was a virtual certainty.(Shilts p.18)

In spite of the number of infections, no one seemed alarmed:

What was so troubling was that nobody in the gay community seemed to care about these waves of infection. Ever since he had worked at the New York City Department of Public Health, Dan Williams had delivered his lecture about the dangers of undiagnosed venereal diseases and, in particular, such practices as rimming. But he had his "regulars" who came in with infection after infection, waiting for the magic bullet that could put them back in the sack again. Williams began to feel like a parent as he admonished the boys: "I have to tell you that you're being very unhealthy." (Shilts p.19)

Dr. Ostrow had been involved in the development of a vaccine against hepatitis-B and was pleased that the homosexual community had played a part in its development. He announced the results at the CDC's annual sexually transmitted disease conference in May 30, 1981.(Shilts p.67) But this success was clouded over by Dr. Ostrow's growing concern that some heretofore unknown disease might break out in the homosexual community. Ostrow realized that given the high level of sexual activity among homosexuals, particularly in San Francisco's notorious bathhouses, there would be no stopping a new disease once it was introduced into this population. (Shilts p.20)

Dr. Selma Dritz, the infectious disease specialist for the San Francisco Department of Public Health, was also concerned. She knew the statistics. In the fall of 1980, she gave a speech at the monthly meeting of STD experts, where she presented the grim statistics: Hepatitis-B, shigella, and amebiasis had all increased dramatically during the 1970s among single men in their 30s. She warned, "Too much is being transmitted. . . We've got all these diseases going unchecked. There are so many opportunities for transmission that, if something new gets loose here, we're going to have hell to pay."(Shilts p.40)

Original text on Dale's Disk — aids2.rtf - Oct.14, 1999
Reformatted to HTML — 2000 10 21, —WHS