Caring for the Whole Person:
Comprehensive Health Services for MSM
Kenneth H Mayer, Linda-Gail Bekker,
Andrew Grulich, Ron Stall,
Grant Colfax, Javier R Lama
Fenway Health/Beth Israel Deaconess Medical Center, USA
Desmond Tutu AIDS Foundation, S Africa
Kirby Institute, UNSW, Australia
University of Pittsburgh, USA
San Francisco Dept of Health, USA
IMPACTA, Peru
2012
Structure of the Article
• Reviewed medical work published in English between
Jan, 1977 and Jan, 2012 related to MSM
• Searched PubMed and Google Scholar with the key
terms related to MSM and specific clinical issues
• Reviewed more than 1000 articles, preferentially
choosing systematic reviews, papers with new data,
or recently published work
• Life course perspective, focused on factors that can be
changed to decrease HIV risk
• Assessed structural issues influencing health disparities
Introduction
• Although MSM existed in societies throughout history,
AIDS created awareness of health concerns
• Programs that dealt with emergencies transitioned to
the provision of chronic care post-HAART
• Increased recognition of MSM and other LGBT
health disparities
• Recent research has increased recognition that
homophobia has health consequences
• Recent research has documented enhanced
health disparities for MSM living in LDCs
(Mayer, AJPH, 2008; Stall, AJPH, 2003; Safren, J Consult Clin Psych, 1999;
Almeida, J Youth Adolesc, 2009; Beyrer, STI, 2008)
MSM are heterogeneous
Growing Up and Coming Out
• Same sex behavior and gender non-comformity
remains stigmatized in most societies
• Societal messages remind MSM Youth they are
not accepted
(e.g. marriage pressure, exclusion from military)
• MSM Youth may encounter loss of friends,
non-support from families, religious
abandonment, and verbal or physical abuse,
resulting in adverse health outcomes
• External stigma may → internalized
homophobia → depression, substance use
• Sexual expression is happening earlier
(Harrison, J Sch Health, 2003; Drasin, J Homosex, 2008; D’Augelli,
Clin Child Pysch, 2002; Grov, J Sex Res, 2006)
Growing Up and Coming Out
• Self-acceptance can lead to early identity
integration, disclosure and adaptation of safer
practices; adverse experiences impair identity
formation and behavior
• In the U.S. Black and Latino Youth were less
comfortable with disclosing their MSM identity;
Role of dual stigma?
• Youth experiencing homophobic bullying may
withdraw from school
• In some countries, homophobic laws may impede
successful development
• Having supportive conversations with adults and
role models may lead to successful maturation
(Merighi, Jour Contemp Human Serv, 2000; Butler, J Homosex, 2008; Rosario, Cult Divers
Ethnic Minor Psych, 2004; Murdock, Psych in the School, 2005; Beyrer, Epidemiol Rev,
2010)
Life Course Development
• Some MSM experience syndemics,
i.e. increased risk for depression, substance
use, sexual risk and HIV
• Internalization of homophobic and domestic
violence plays a role in syndemic formation
• Despite the stressors MSM experience,
the majority are not depressed
and are not using substances
• Factors that enhance resilience need to be
better understood
(Stall, Addiction, 2001; Mills, Am J Psych, 2004; Greenwood, AJPH,
2002; Mustanski, Ann Behav Med, 2007; Friedman, AIDS and
Behavior, 2008)
Resilience in the Face of Stressors:
Majority of MSM are not infected or risk taking
No. of Psychosocial Health Problems*
0
(n = 1,392)
1
(n = 812)
2
(n = 341)
3 or 4
(n = 129)
Recent high
risk sex
7%
11%
16%
23%
HIV
prevalence
13%
21%
27%
22%
All associations have p’s < 0.001.
All p values are two-tailed.
From Stall et al., 2003
* Childhood sexual abuse, depression, substance use, intimate partner violence
Sexual Health
• Not just absence of disease, but also safe and pleasurable
experiences
• Specific practices put MSM at risk for diverse STDs
• Anal sex: HIV, rectal GC/CT, HBV, HPV, HSV
Anal trauma may →HCV
Oral sex: Syphilis; Penile sex: HPV, HSV
Saliva: CMV, EBV, HBV, HHV-8
Oral-anal: enteric pathogens, HAV,HBV
Abraded skin: MRSA
• Some MSM may not be individually risky, but select partners
from high prevalence pools (e.g. Black MSM in the US)
(Wolitski, AIDS Behav, 2011; Hart, Current Op Infect Dis, 2009; Grulich, Austral NZ J Public Health,
2003; Jin, AIDS, 2010; Abdolrasouli, Sex Health, 2009; Cohen, STI, 2004; Tohme, Hepatology, 2010;
Jin, STI, 2007)
Infectious Diseases
• Syphilis: ↑ associated with HIV+ serosorting and SU
• GC and CT: Need to test with NAAT in order to detect
frequently asymptomatic rectal infections
• Increasing MDR GC, including quinolone resistance
• HSV2: More common among MSM and facilitates HIV
transmission. Acyclovir prophylaxis was not effective
• Hepatitis A/B, HPV vaccination should be standard of care,
Hepatitis C screening also indicated
• HPV: Vaccine preventable neoplasia; Frequency of anal
cytology screening needs further clarification
(Heffelfinger, AJPH, 2007; Kalichman, STI, 2011; Buchacz, AIDS, 2004; Kent, Clin Inf Dis,
2003; Annan, STI, 2009; Gunn, STD, 2007; Taylor, Clin Inf Dis, 2011; Szumowski, Clin Inf
Dis, 2009; Chin-Hong, J National Cancer Inst, 2005; Workowski, MMWR, 2010; Moreira,
Hum Vaccin, 2011; Cranston, STI, 2008; Kaplan, MMWR, 2009)
Mental Health Issues
• 40% of MSM become depressed,
2X the lifetime rate of heterosexual men
• Predictors of major depression are:
not having a partner, experiencing
anti-gay threats or violence, non-identification as gay
• Panic disorder, social phobia, generalized anxiety
disorder are more common among MSM
(20% lifetime incidence)
• Culturally-tailored treatment may involve groups that
enhance community identification
(Sandfort, Arch Gen Psych, 2001; Gilman, AJPH, 2001; Lewis, Health Place, 2010;
Safren, Health Psychology, 2012)
Substance Use
• Many studies suggest that substance use
is common among MSM
• Reasons for SU include: coping with
homophobia, depression/anxiety
• Among SU MSM, poly-drug use is common
• Rates of MSM cigarette smoking
range from 27 to 66%, higher than matched controls
• Heavy alcohol use (14-39%) tends to be lower than general
population
• Episodic recreational use is common;
drug addiction is uncommon
(Stall, AJPH, 1999; Ryan, Am J Prev Med, 2001; Greenwood, Drug Alcohol Dep, 2001; Ostrow, JAIDS,
2010; Mimiaga, AIDS Pt Care STDs, 2008)
Substance Use
• Substance use during sex is associated with HIV SC
• SU may ↑ libido, sense of invulnerability; impair
negotiation skills, select high risk network partners
• For HIV+ MSM, SU may decrease medication adherence
• For HIV- MSM, SU facilitates transmission by lowering
pain thresholds, allowing for more traumatic sex, and
possibly impairing host immunity
• Culturally-tailored programs that include groups and/or
support MSM identity, have been successful in
decreasing cigarette and crystal methamphetamine use
(Colfax, Lancet, 2010; van Griensven, J Int AIDS Soc, 2010; Johnston, Int J Drug Pol, 2010; Bautista, STI, 2004; Parry,
Drug Alcohol Dep, 2008; Koblin, AIDS, 2006; Cochran, Sub Use Misuse, 2007; Shoptaw, J Sub Abuse Treat, 2008;
Mausbach, Drug Alcohol Depend, 2007; Mansergh, PL0S Med, 2010)
Non-Communicable Medical
Conditions
• Body image and weight: some MSM may attempt to
conform to cultural ideals by increased exercise, others
may “self-medicate” depression by over-eating
• Medical complications of substance use: Cardiovascular
and pulmonary complications of cigarettes, inhaled
stimulants; alcohol potentiating liver disease
• Aging issues: Many MSM age alone, partially due to
social rejection of non-traditional families
(Sandfort, Arch Gen Psych, 2001; Greenwood, AJPH, 2005; Mansergh, STI, 2008)
Structural Changes
and MSM Health
• Will ↑ civil rights improve health outcomes?
• ↑LGBT teen suicide in non-supportive Oregon counties
compared to those with Gay-Straight student alliances
• MSM at Fenway Health had ↓ medical and mental
health costs after marriage equality
• But HIV and STD rates are not down in Europe/U.S.
Could lag be due to ↑ prevalence
antedating changes in social norms?
Or therapeutic optimism, or……
More data are needed
(Hatzenbuehler, Pediatrics, 2011; Hatzenbuehler, AJPH, 2012)
Culturally Competent Care
• MSM have often received suboptimal care and
have been reticent to disclose to providers because
of fears of stigmatization
• Many health care providers are unaware of the
diversity of MSM and their different health
conditions
• Ironically, health care providers may be uniquely
able to assist MSM in their coming out process
because of their social role
• Culturally-competent care is a basic human right,
and is essential for optimal clinical management
(Gonser, J Cult Divers, 2000; Meyer, AJPH, 2001; Mayer, AJPH, 2008;
Bettancourt, Cultural Competence in Health Care, 2002)
Caring for the Whole Person
• MSM and other LGBT people have similar health concerns as
others, as well as some additional concerns
• Important to engage the whole person,
not a collection of risk factors
• Important to understand that LGBT life issues are similar to others,
but also unique:
– Families, Coming Out
– Long Term Relationships
– Reproduction, Parenting
– Mental Health
– Chronic Diseases
– Communicable Diseases
Thank You
Steven A. Safren
Conall O’Cleirigh
Matthew Mimiaga
Rodney Vanderwarker
Harvey Makadon
Judy Bradford
Steve Boswell
Sean Cahill
Tom Mills
Amy Herrick
Chris Beyrer
NIAID, NIMH, NIDA, NICHD,
CDC, HRSA, Mass DPH