Oct 122015
 
Human Papilloma Virus

Human Papilloma Virus

Little is known about reproductive cancer risks among cisgender lesbian and bisexual women. Cancer registries generally don’t ask about sexual orientation. Studies suggest so far that lesbian and bisexual women are less likely to get a pelvic exam and pap smear when it’s recommended. Pap smears help to detect cancer in its earlier, most easily treated and cured stages. Logically, lesbian and bisexual women may be at risk for having more developed (and potentially incurable) cancers. The data confirming that aren’t in yet, but it seems likely.

And now we have HPV vaccines. The human papilloma virus is a major cause of cervical cancer, along with anal cancer, penile cancer, and mouth/throat cancers. Human papilloma virus spreads by skin-to-skin sexual contact regardless of biological sex or gender. Along with pap smears, the HPV vaccine has been a great tool for preventing advanced cervical cancers.

This week I looked at a study of survey data from 15-25 year old women from the National Survey of Family Growth, from 2006-2010. They asked the questions: “Have you heard of the HPV vaccine?” and “Have you received the HPV vaccine?”

The results were rather spectacular. Lesbian, bisexual, and straight women had heard of the HPV vaccine. There was no difference there. However, 28% of straight women, 33% of bisexual women and 8.5% of lesbian women received the HPV vaccine.

That’s 8.5% of lesbians vs 28-33% of non-lesbian women.

Why?? Lesbians are at risk for HPV infection too!

Before looking at what the authors thought, I have some thoughts of my own.

2006, the earliest year this study had data on, isn’t too far off from when I graduated high school. I remember the sex ed class we had. We were lucky to have sex ed at all. It was a one-day class focused on the effectiveness of birth control options, how to put a condom on a banana (or maybe it was a cucumber?), and sexually transmitted diseases that can be passed between men and women in penis-in-vagina sex. There was no discussion of sexually transmitted diseases that are passed between men who have sex with men or women who have sex with women. I remember walking out of the class feeling confused and alone — what STDs were passable between women, and how can women protect themselves and their partners? Were there diseases that women could spread? Was protection warranted? I had no idea.

The study authors discuss similar problems and attributed the difference between lesbian HPV vaccine and bisexual/heterosexual HPV vaccine to misinformation. The idea that lesbian women who have never had sexual contact with men don’t need pap smears or HPV vaccines is old and incorrect, but still persists. I remember when pap smears were recommended starting at first sexual contact with men — if a woman never had sexual contact with a man then she didn’t ever need a pap, right? Wrong!

But it takes time to correct misinformation. As the authors correctly point out, important changes have happened since 2010. HPV vaccine is now recommended for all young people regardless of sex, sexual activity, sexual orientation, or gender identity. It’s not just a vaccine for a sexually transmitted disease — it’s a vaccine against some forms of cancer. Pap smears are now recommended for everyone with a cervix every 3-5 years or so.

So can you be part of the change? Help spread the word about HPV vaccine for *all* people, and pap smears for people cervixes!

The study was published in the Annals of Internal Medicine. The abstract is publicly available.

Sep 072015
 

In its August 27th issue, the New England Journal of Medicine (NEJM) published a paper reviewing primary health care needs of men who have sex with men. NEJM is one of the most prestigious American medical journals. It was home to the first paper detailing HIV infection in gay men. It’s one of the two major medical journals that my class has been urged to read weekly — part of our professional development as medical students.

What kinds of things does this review article recommend? And was it complete? Let’s take a look…

First is the recommendation to discuss a comprehensive and open sexual history. This should not stop at the classic “Are you sexually active?” question, but ask how the patient self identifies (gay, bisexual, etc), the kinds of sexual activity, the forms of protection used and the consistency with which they are used. Why? Because of HIV. Other sexually transmitted infections are a concern as well, but the big fear is HIV. Of all new infections in the United States each year, just under 2/3 are among men who have sex with men.

Other infections to be wary of include gonorrhea and chlamydia, Hepatitis A/B/C, and HPV. There has also been a rise in meningitis infections among gay men, caused by the bacterium Neisseria meningitidis. Of these infections, hepatitis A, hepatitis B, HPV, and meningitis all have vaccines. Where possible, men who have sex with men should be vaccinated against these diseases. HIV and hepatitis C have no vaccine. To prevent them, barriers such as condoms and gloves can be used in sexual encounters and screening tests should be performed. Pre-exposure prophylaxis and antiretroviral therapy for HIV+ individuals can also be helpful for preventing HIV spread, but cannot and should not replace barriers.

Thankfully, this article was not all about the sex lives of men who have sex with men. Too often the lives of gay and bisexual men are distilled down to just their sex lives, particularly because of HIV. The author points out that men who have sex with men should be screened for substance use, depression and anxiety. However, they stop there. While asking about tobacco, alcohol and illicit drugs is very important, there are other important aspects of the lives of gay and bisexual men that should be addressed. In particular, I would ask about…

  • Social support and living situation, particularly among young gay/bi men and older gay/bi men. Young men are at higher risk for being homeless because of family discrimination. Bullying also happens frequently among young gay/bi men. Older men may have lost their support group during the 1980s-1990s and may be facing the challenge of growing old alone. LGBT elders may face the prospect of going “back into the closet” to receive nursing home care.
  • Domestic violence. Same-sex domestic violence is under reported and specific resources are scarce.
  • History of assault or violence. Violence against men perceived to be gay/bi can have lifelong health consequences, including post traumatic stress disorder.
  • Attempts to self harm or suicide. These must never be ignored, no matter who one is talking to.
  • Diet and exercise. Eating disorders are known to occur in gay/bi men. Diet may be poor and exercise may be too low or too high, depending on the individual and his situation.

Yes, screening for HIV and other sexually transmitted diseases is important. And this article did bring some specific health issues to a large audience. However it’s important not to distill men who have sex with men down to a cluster of diseases. Let this article be a spark for discussion, and not the be-all and end-all of primary care for men who have sex with men.

What do you think? Did I miss anything important in the things I would add?

A preview of the paper is publicly available.