Men who have sex with men (MSM): how much to assume and what to ask?

What does it matter that the patient, whatever his sense of identity, has anal sex with men, and perhaps also has penetrative sex with women? The international medical literature on MSM builds a picture of a risk-taking and at-risk group. They are particularly, if not exclusively, considered in the context of HIV risk, and to a much lesser extent are known to be at risk of other sexually transmitted infections (STIs).

We recently completed a study of the knowledge and attitudes of gay men towards anal cancer and human papilloma virus (HPV).2 We know that anal sex carries a high risk of HPV transmission, particularly for men who are HIV-positive, but our study showed that very few gay men had even heard of HPV, and most were not aware of its association with sexual practices. In this regard, they differ little from women, who are at similarly high risk — of cervical cancer — through HPV exposure.

MSM are at greater risk of gonorrhoea or syphilis than are other men. However, most consultations with MSM are for issues other than STIs and reflect the profile of health conditions experienced by Australian men.

Certainly, if a category or group is defined only in terms of sexual activity, it is unsurprising that STIs feature large. However, there is some evidence of health risks other than sexual health risks in MSM, which nevertheless derives from HIV studies. These indicate a higher than expected rate among some MSM subcultures of alcohol use, and injecting and other illegal drug use. Men in the Australian Study of Health and Relationships who identified as bisexual were eight times more likely to report a history of injecting drug use, and gay men were twice as likely, as those who identified as heterosexual.3 However, they were no more or less likely than other men reporting a history of injecting drug use to report sharing needles or injecting paraphernalia.

In Private lives, our national online survey of health and wellbeing among gay, lesbian, bisexual, transgender and intersex Australians, we found that 38.3% of gay-identifying men reported tobacco use on more than five occasions in the previous month,4 which compares with 26% for Australian men in general.5

Findings about MSM are mixed in the area of mental health. Numerous studies have indicated higher rates of depression and anxiety in gay men. A 5-year study in South Australia reported 30% of homosexually active men met the criteria for a major depressive episode, as measured by the Primary Care Evaluation of Mental Disorders screening tool.6 Twenty-seven per cent of the men in the survey were diagnosed with dysthymic disorder on enrolment, while the survey indicated a lifetime prevalence of a depressive disorder of 48%. This is five times the rate for all men reported from primary health care clinics in the United States where the survey instrument was validated.7

In Private lives, which involved 3429 gay men from all Australian states and territories, we found that the prevalence of depressive disorders was high, with 48.7% of men scoring on at least one of the two criteria for a major depressive episode. Nearly a quarter of respondents (23.8%) met the criteria for a major depressive episode, with a similar proportion reporting experiencing depression (24.2%). It is of particular concern that 15.7% of gay men indicated suicidal ideation in the 2 weeks before completing the survey. While the causes are not easily identified, it is probable that living in a society characterised by homophobia is a contributing factor.4

How does one recognise MSM? Would the behavioural question be: “Have you ever had sex with a man?” or “Have you had sex with a man in the past year?” and/or “Have you also had sex with a woman?” And how would the word “sex” be interpreted?

Presumably, the narrowest definition of MSM would be a man who has experienced anal sex (insertive or receptive) on at least one occasion in his life. However, it is not surprising that publications on MSM almost never offer a definition or, if they do, proceed to bundle MSM with gay, bisexual and other homosexually active men into a single analysis.

MSM and their health needs are most likely to evade recognition because of the heteronormative nature of most clinical practice — based on the assumptions that, until proven otherwise, all people have a simple sexual identity, and that it is heterosexual. A gay man who is “out” about his sexuality to his doctor (67.2% of men in the Private lives survey had told their doctors) may find his general health concerns sometimes overshadowed by concerns about sexual health. This may be understandable, given the relatively high rates of HIV and other STIs among these men. However, STIs or any other single issue should not become an overriding focus of any clinician–patient relationship.

Simply put, when and if you consider it matters, avoiding a default assumption that the man is heterosexual, even if he is married, partnered with a woman or has children. MSM have wives and children too! In most cases, the need to ask is determined by the presenting condition, and it may not matter so much to whom a man is attracted, or what he identifies as his sexual identity, as what his recent sexual practices have been. So, ask questions about the sex he does, rather than about what he is. Of course, if the presenting problem has to do with a complicated life course perhaps including mental health issues, then questions about sexual attraction and identity could well be the important ones. The case scenarios (Box) show the differing process and outcomes when a doctor recognises, or fails to recognise, the possibilities.

For new patients, it may be easy to indicate that a full sexual history is a usual part of an initial consultation, whatever the presentation. For existing patients, sexual history may be best approached indirectly. A statement that hepatitis B vaccination is freely available and recommended for all men who have had sex with another man can be mentioned in the context of reminding all male patients of vaccination schedules. If a clinician (or a practice) takes a “no default assumptions” approach to sex, then the move into questions of sexual attraction, identity and practice will happen when, and if, they matter.

Finally, we are confident that it is rare that health articles define the population in terms of a single behavioural characteristic. To think analogously, would we not shrink from referring to WWR (women who reproduce), PWJ (people who jog), or indeed MSW (men who have sex with women)? Is it so surprising that we would prefer the term “male-to-male sexual practices” or MMSP?