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(:title Homosexuals/Bisexuals and Sexually Transmitted Infections:)
(:description This page describes the relation between homosexuality and sexually transmitted infections; some topics discussed include anal cancer, kaposi's sarcoma, hepatitis, tuberculosis, syphilis, HIV, gonorrhea, parasitic intestinal infections, amebic liver abscess, multidrug-resistant pathogens, anorectal symptoms, multidrug-resistant bacterial skin infections and STDs.:)
(:keywords anal cancer, MSM, kaposi's sarcoma, hepatitis, tuberculosis, syphilis, HIV, gonorrhea, parasitic intestinal infections, amebic liver abscess, multidrug-resistant pathogens, anorectal symptoms, bacterial skin infection, STD:)
Some STIs (sexually transmitted infections) are rare, which means that whereas the promiscuous will have a several-fold higher prevalence of these STIs, the absolute prevalence of STIs among the promiscuous will be low/very low.  Correspondingly, if an STI is relatively common, then the odds of the promiscuous being more likely to have it will not be considerably greater compared to the non-promiscuous.  These issues need to be kept in mind when looking at the medical literature since the general picture from the literature on STIs and HIV/AIDS is that homosexually behaving individuals are responsible for a disproportionately high share of the overall venereal diseases/HIV burden.  Whereas a number of studies documenting this observation are not based on random sampling, the find is generally consistent across studies and is in excellent agreement with population-representative studies.  The data are consistent with the greater promiscuity of homosexually behaving individuals and/or higher rates of anal sex among these individuals and/or a greater susceptibility to contracting STDs and HIV among these individuals.  An examination of the literature will easily show that both greater promiscuity and higher rates of anal sex are implicated.
!!Generic examples
%rfloat%(:thumb Origin-Updates.Chapter6/natsal.gif titlefmt="Promiscuity and venereal diseases in the 2000 British Natsal survey." px=200 supercache=1:)
See the right thumbnail for data from population-representative British surveys in 1990 and 2000.  Homosexually behaving men and women are clearly responsible for a disproportionately high STI burden.[^K. A. Fenton et al., J Infect Dis 191 Suppl 1, S127 (Feb 1, 2005).^]

Additional examples:

* In a 1996 national sample of 1,852 New Zealand MSM (men who have sex with men), 26.2% had been for a sexual health check-up/treatment in the previous 12 months, and the self-reported history of various infections was as follows: hepatitis-A (7%), hepatitis-B (8%), hepatitis-C (1.8%), any hepatitis infection (14.9%); an STD infection (37.1%) such as gonorrhea [anal (4.4%), oral (3.0%), penile (13.6%)], Chlamydia (17%), syphilis (3.6%), herpes [anal (1.9%), genital (6.9%)], and anal warts (11.7%); or any of the above (42.8%).[^P. J. Saxton, A. J. Hughes, E. M. Robinson, N Z Med J 115, U106 (Jul 26, 2002). ^]
*In the 1991 New Zealand Partner Relations Survey, a history of STDs was reported by 10.4% of men and 54% of MSM.[^P. Davis, R. Lay-Yee, Venereology 9, 226 (1996). ^] 
*A 1990 report from a Ft. Lauderdale, Florida clinic noted that up to 55% of homosexual men with anorectal symptoms had gonorrhea, 80% of the patients with syphilis were homosexual men, 15% of asymptomatic homosexual men had Chlamydia, and about 1 in 3 male homosexuals had active anorectal herpes simplex infection. Additionally, intestinal infections that normally result from eating food contaminated with human feces were rampant in the homosexual community.[^#wex^]
*In 1997, 17% of a random sample of MSM in New York, Los Angeles, San Francisco and Chicago were found to be HIV-positive.[^J. A. Catania et al., Am J Public Health 91, 907 (Jun, 2001).^]
!!Anal cancer
*  In the mid-20th century, male homosexuals constituted about 8% of men afflicted with anal cancer; by the mid-1980s, this figure had risen to 72%. [^#wex^] The transmission of certain types of human papilloma viruses explains the association of anal intercourse with anal cancer.[^Frisch M, Glimelius B, van den Brule AJ, et al. Sexually transmitted infection as a cause of anal cancer. N Engl J Med 1997;337(19):1350-8.^] Anal carcinomas among male homosexuals can approach 4-7 inches in diameter.[^Cobb JP, Schecter WP, Russell T. Giant malignant tumors of the anus. A strategy for management. Dis Colon Rectum 1990;33(2):135-7; discussion 137-8.^]
* In an examination of 3,391 Danish men in registered homosexual partnerships, followed for an average of 4.6 years, the incidence of anal cancer (0.12%) was 31-fold higher compared to Danish men in general.[^#fris^]
!!Kaposi's sarcoma
In an examination of 3,391 Danish men in registered homosexual partnerships, followed for an average of 4.6 years, the incidence of Kaposi’s sarcoma (1.12%) was 136-fold higher compared to Danish men in general.[^#fris^] Whereas 0-9% of heterosexuals are infected with Kaposi’s sarcoma-associated herpes virus (KSHV), 15-60% of male homosexuals are infected with KSHV.[^S. J. Gao et al., N Engl J Med 335, 233 (Jul 25, 1996).^]'^,^' [^D. H. Kedes et al., Nat Med 2, 918 (Aug, 1996).^]'^,^' [^G. R. Simpson et al., Lancet 348, 1133 (Oct 26, 1996).^]'^,^' [^B. Chandran et al., Virology 243, 208 (Mar 30, 1998).^]'^,^' [^D. H. Osmond et al., Jama 287, 221 (Jan 9, 2002).^]
!!Hepatitis
*  During 1982-1989, MSM constituted less than 10% of individuals with hepatitis-A, but during the first 6 months of 1991, 29% of the hepatitis-A cases in Denver, 66% in New York City, 50% in San Francisco, 56% in Toronto, 42% in Montreal, and 26% in Melbourne consisted of homosexuals.[^Hepatitis A among homosexual men--United States, Canada, and Australia. MMWR Morb Mortal Wkly Rep 1992;41(9):155, 161-4.^] Between Nov 1998 and May 1999, among the reported cases of hepatitis-A in Columbus, Ohio, 66% of the men were MSM.[^Cotter SM, Sansom S, Long T, et al. Outbreak of hepatitis A among men who have sex with men: implications for hepatitis A vaccination strategies. J Infect Dis 2003;187(8):1235-40.^]
* In a sample of 735 MSM in San Francisco, 4.6% had hepatitis-C infection and 81% had hepatitis-B infection; 89% among the HIV-positive and 68% among the HIV-negative had hepatitis-B infection.[^Osmond DH, Charlebois E, Sheppard HW, et al. Comparison of risk factors for hepatitis C and hepatitis B virus infection in homosexual men. J Infect Dis 1993;167(1):66-71.^] Hepatitis-B appears to be transmitted 8.6-fold more efficiently than HIV-1 among homosexual men, according to a study.[^Kingsley LA, Rinaldo CR, Jr., Lyter DW, et al. Sexual transmission efficiency of hepatitis B virus and human immunodeficiency virus among homosexual men. Jama 1990;264(2):230-4.^]
* The hepatitis-C virus used to be mainly transmitted via sharing needles for intravenous drug use and blood or plasma transfusions. However, a 2003 reported that male homosexuals have started to make a significant contribution to the spread of the hepatitis-C virus via risky sexual behaviors.[^Fletcher S. Sexual transmission of hepatitis C and early intervention. J Assoc Nurses AIDS Care 2003;14(5 Suppl):87S-94S.^]
!!Syphilis
*   During the 1990s, syphilis occurred predominantly among African-American heterosexuals in the South and in large cities. In Seattle, syphilis declined from 1987 to 1996, but a syphilis outbreak occurred around 1997. The outbreak was traced to a cluster of homosexuals. 68% of syphilis patients were MSM, among whom 66% were also HIV-positive. Most MSM were 30 years or older (i.e., old enough to know what they were doing) and had recruited many anonymous partners.[^Williams LA, Klausner JD, Whittington WL, et al. Elimination and reintroduction of primary and secondary syphilis. Am J Public Health 1999;89(7):1093-7.^]
* As above, a syphilis outbreak occurred among MSM during January-July, 2000 in Southern California.[^Outbreak of syphilis among men who have sex with men ---Southern California, 2000. MMWR Morb Mortal Wkly Rep 2001;50(07):117-20.^] 57 among 66 syphilis-afflicted homosexuals knew their HIV status; 34 (60%) of the 57 reported that they were HIV-positive. The year of HIV diagnosis was known for 27 of the 34 HIV-positive homosexuals; the median time since diagnosis of HIV infection was 4 years (range: 0-19 years). Once again, homosexuals who knew that they were HIV-positive still went on to have unprotected sex.
* As of 2003, the incidence of syphilis was on the rise in San Francisco, mostly occurring among MSM, and two-thirds of the new cases were occurring in individuals already infected with HIV.[^Rise in syphilis for San Francisco. AIDS Patient Care STDS 2003;17(12):669-70.^]
* A syphilis outbreak occurred during 1999-2000, in Oslo, Norway; of 60 cases examined at a hospital, 55 were men, and 43/55 men were MSM.[^Halsos AM, Edgardh K. An outbreak of syphilis in Oslo. Int J STD AIDS 2002;13(6):370-2.^]
* From 1990 to 2001, early infectious syphilis and (ano)genital gonorrhea among those attending an outpatient STD clinic of the Amsterdam municipal health service sharply increased; homosexual men were almost entirely responsible for this increase. Syphilis increased mostly among men aged 35 years or older and gonorrhea increased mostly among younger men.[^Fennema JS, Cairo I, Spaargaren J, et al. [Syphilis epidemic and an increase of the number of HIV infections among homosexual men attending the Amsterdam venereal disease clinic]. Ned Tijdschr Geneeskd 2002;146(13):633-5.^]
* A July 2004 report mentioned the emergence of a drug-resistant (azithromycin-resistant) mutant syphilis strain, disproportionately among [often HIV-positive] MSM. (24)
!!Gonorrhea
*  It hardly needs mentioning who gets rectal gonorrhea. Homosexuals also get gonorrhea in the penis (urethral gonorrhea) and mouth (pharyngeal gonorrhea).[^McMillan A, Young H, Moyes A. Rectal gonorrhoea in homosexual men: source of infection. Int J STD AIDS 2000;11(5):284-7.^] Rectal gonorrhea and pharyngeal gonorrhea are often symptomless;[^Janda WM, Bohnoff M, Morello JA, et al. Prevalence and site-pathogen studies of Neisseria meningitidis and N gonorrhoeae in homosexual men. Jama 1980;244(18):2060-4.^] besides, a visual examination of the perianal region of male homosexuals will often misdiagnose rectal gonorrhea as trauma due to a variety of homosexual practices, i.e., the male homosexual community is ideally poised to function as a reservoir of the gonorrhea pathogen.
* Between 1997-1999, among Swedish men who contracted gonorrhea, 28.9% were homosexual. Among Swedish men who contracted gonorrhea from overseas travel, 11.4% were homosexual; among men who contracted the STD domestically, 41.1% were homosexual.[^Berglund T, Fredlund H, Giesecke J. Epidemiology of the reemergence of gonorrhea in Sweden. Sex Transm Dis 2001;28(2):111-4.^]
* During the period 1994-1999, in Denmark, the incidence of gonorrhea among MSM was 30 times that among heterosexual men.[^Johansen JD, Smith E. Gonorrhoea in Denmark: high incidence among HIV-infected men who have sex with men. Acta Derm Venereol 2002;82(5):365-8.^]
* A 2004 U.S. report mentioned increasing drug-resistant gonorrhea among MSM; the prevalence of this drug-resistant form of gonorrhea was 12-fold higher in MSM compared to the general population.[^Increases in fluoroquinolone-resistant Neisseria gonorrhoeae among men who have sex with men--United States, 2003, and revised recommendations for gonorrhea treatment, 2004. MMWR Morb Mortal Wkly Rep 2004;53(16):335-8.^]
!!Parasitic intestinal infections
*  [[Sexuality/AnalEroticism|Parasitic intestinal infections are common among male homosexuals]]; they result from the consumption of fecal material via rimming and other sexual practices. A sexual transmission of typhoid, and a first of its kind in the U.S., occurred among a group of male homosexuals in 2000.[^Reller ME, Olsen SJ, Kressel AB, et al. Sexual transmission of typhoid fever: a multistate outbreak among men who have sex with men. Clin Infect Dis 2003;37(1):141-4.^]
* Amebic liver abscess, a disease usually found in developing tropical countries is found elsewhere among individuals who have visited these countries and also among MSM.[^Torre A, Kershenobich D. Amebic liver abscess. Ann Hepatol 2002;1(1):45-7.^]
* Between December 1999 and November 2001, multidrug-resistant C. jejuni jejuni was found in the intestines of some male homosexuals in Montreal, Canada, and appeared to have been acquired via sexual activity.[^Gaudreau C, Michaud S. Cluster of erythromycin- and ciprofloxacin-resistant Campylobacter jejuni subsp. jejuni from 1999 to 2001 in men who have sex with men, Quebec, Canada. Clin Infect Dis 2003;37(1):131-6.^]
!!Other infections
*  Not only did homosexuals bring about the AIDS epidemic in America, the weakened immune system of AIDS patients brought a resurgence of tuberculosis, too. Health care workers that deal with AIDS patients risk getting tuberculosis.[^Dooley SW, Villarino ME, Lawrence M, et al. Nosocomial transmission of tuberculosis in a hospital unit for HIV-infected patients. Jama 1992;267(19):2632-4.^]
* A 2003 U.S. report mentioned the emergence of a multidrug-resistant bacterial skin infection among homosexual men in some cities and also some prisons. Previously, this infection was mainly limited to hospitals.[^James JS. Antibiotic-resistant skin infections spreading among gay men, also in prisons. AIDS Treat News 2003(388):2-3.^]
!!Repeated infections
A study examined STD patients most likely to re-infect themselves soon after treatment. Among 17,466 patients attending 3 STD clinics in England between 1994 and 1998, 14% re-infected themselves within 1 year.[^Hughes G, Brady AR, Catchpole MA, et al. Characteristics of those who repeatedly acquire sexually transmitted infections: a retrospective cohort study of attendees at three urban sexually transmitted disease clinics in England. Sex Transm Dis 2001;28(7):379-86.^] Groups that were the most likely to get re-infected were:

* 17% of individuals reporting three or more partners in the recent past %green%[Adjusted OR = 1.53; 95% CI = 1.34-1.73, compared to those with a single partner in the recent past.].
* 20% of 12- to 15-year-old women %green%[Adjusted OR = 1.90; 95% CI = 1.13-3.18, compared to women, ages 20-24 years.].
* 25% of Caribbean attendees of African origin %green%[Adjusted OR = 1.87; 95% CI = 1.63-2.13, compared to whites.].
* And, of course, 22% of homosexual men %green%[Adjusted OR = 1.30; 95% CI = 1.07-1.58, compared to heterosexual men.].

Clearly, not all risky sexual behaviors follow from a lack of knowledge of risks. An STD infection is the ultimate form of safe-sex education with respect to definitively convincing the afflicted that they need to practice safe sex; however, such education fails to convince some individuals. Can classroom education for such individuals be expected to fare better? Besides, sometimes the only way to avoid the risks associated with some risky activity is to avoid the activity altogether, which is asking too much of homosexuals and bisexuals in general.
[^#wex Wexner SD, Milsom JW, Dailey TH. The demographics of anal cancers are changing. Identification of a high-risk population. Dis Colon Rectum 1987;30(12):942-6.^]
[^#fris Frisch M, Smith E, Grulich A, et al. Cancer in a population-based cohort of men and women in registered homosexual partnerships. Am J Epidemiol 2003;157(11):966-72.^]
!!References
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