A survey of members of the Gay and Lesbian Medical Association (GLMA) released this week listed 10 health care concerns men who have sex with men (MSM) should include in discussions with their physicians or other health care providers.

"Clinicians providing health care to gay and bisexual men may not be aware of all of the things that should be discussed during the visit," said GLMA President Christopher E. Harris, MD. "We are concerned that physicians and other health care providers who do not understand the health risks in the gay community cannot provide competent care. This is why we asked our members to help us define the health care concerns most relevant to MSM. Our purpose is to inform health providers and allow patients to be proactive in their relationship by knowing what questions to ask."

"Naturally, not everyone has the same set of risks," said educator and medical journal editor Vincent M. B. Silenzio, MD, MPH. "But after we look at gender (men in general are increased risk of heart disease, for example) age, family history, and other basic factors, we need to consider issues that relate to the culture or subculture. We know that gay men face greater discrimination than their heterosexual counterparts, for example. Family pressures, combined with social pressure, cause significant stress. It might be important to discuss depression or anxiety, and possibly substance use. If you know that someone is sexually active, it is important to talk about safe sex, the need for hepatitis immunization, or periodic tests for anal papiloma."

Both Harris and Silenzio stress that this list broadens previously held views about appropriate treatment for gay men. They indicated this doesn't represent special treatment for gay or bisexual men, but appropriate treatment. Patients often don't know what they should ask their health care provider. And worse, many providers don't know what to look for. To effectively provide the best in health care, knowledge and honesty are essential.

"Both the provider and the patient should be aware of these concerns and they should be addressed non-judgmentally as part of a patient's regular health care program," Harris said.

"Certainly, there are other health concerns that gay men and MSM face," Harris added. "And there are other cultural competence issues—gender identity, race, ethnicity, economic status, for example. But the 'Ten Things' list is a way to get the discussions started. Every physician and every health care professional—gay or straight—should know these things. And they should provide an open, comfortable environment in which these issues can be discussed."

The Ten Things List

1. HIV/AIDS, Safe Sex: That men who have sex with men are at an increased risk of HIV infection is well known, but the effectiveness of safe sex in reducing the rate of HIV infection is one of the gay community's great success stories. However, the last few years have seen the return of many unsafe sex practices. While effective HIV treatments may be on the horizon, there is no substitute for preventing infection. Safe sex is proven to reduce the risk of receiving or transmitting HIV. All health care professionals should be aware of how to counsel and support maintenance of safe sex practices.

2. Substance Use: Gay men use substances at a higher rate than the general population, and not just in larger communities such as New York, San Francisco, and Los Angeles. These include a number of substances ranging from amyl nitrate ("poppers"), to marijuana, Ecstasy, and amphetamines. The long-term effects of many of these substances are unknown; however current wisdom suggests potentially serious consequences as we age.

3. Depression/Anxiety: Depression and anxiety appear to affect gay men at a higher rate than in the general population. The likelihood of depression or anxiety may be greater, and the problem may be more severe for those men who remain in the closet or who do not have adequate social supports. Adolescents and young adults may be at particularly high risk of suicide because of these concerns. Culturally sensitive mental health services targeted specifically at gay men may be more effective in the prevention, early detection, and treatment of these conditions.

4. Hepatitis Immunization: Men who have sex with men are at an increased risk of sexually transmitted infection with the viruses that cause the serious condition of the liver known as hepatitis. These infections can be potentially fatal, and can lead to very serious long-term issues such as cirrhosis and liver cancer. Fortunately, immunizations are available to prevent two of the three most serious viruses. Universal immunization for Hepatitis A Virus and Hepatitis B Virus is recommended for all men who have sex with men. Safe sex is effective at reducing the risk of viral hepatitis, and is currently the only means of prevention for the very serious Hepatitis C Virus.

5. STDs: Sexually transmitted diseases (STDs) occur in sexually active gay men at a high rate. This includes STD infections for which effective treatment is available (syphilis, gonorrhea, chlamydia, public lice, and others), and for which no cure is available (HIV, Hepatitis A, B, or C virus, Human Papilloma Virus, etc.). There is absolutely no doubt that safe sex reduces the risk of sexually transmitted diseases, and prevention of these infections through safe sex is key.

6. Prostate, Testicular, and Colon Cancer: Gay men may be at risk for death by prostate, testicular, or colon cancer. Screening for these cancers occurs at different times across the life cycle, and access to screening services may be negatively impacted because of issues and challenges in receiving culturally sensitive care for gay men. All gay men should undergo these screenings routinely as recommended for the general population.

7. Alcohol: Although more recent studies have improved our understanding of alcohol use in the gay community, it is still thought that gay men have higher rates of alcohol dependence and abuse than straight men. One drink daily may not adversely affect health, however alcohol-related illnesses can occur with low levels of consumption. Culturally sensitive services targeted to gay men are important in successful prevention and treatment programs.

8. Tobacco: Recent studies seem to support the notion that gay men use tobacco at much higher rates than straight men, reaching nearly 50 percent in several studies. Tobacco-related health problems include lung disease and lung cancer, heart disease, high blood pressure, and a whole host of other serious problems. All gay men should be screened for and offered culturally sensitive prevention and cessation programs for tobacco use.

9. Fitness (Diet and Exercise): Problems with body image are more common among gay men than their straight counterparts, and gay men are much more likely to experience an eating disorder such as bulimia or anorexia nervosa. While regular exercise is very good for cardiovascular health and in other areas, too much of a good thing can be harmful. The use of substances such as anabolic steroids and certain supplements can adversely affect health. At the opposite end of the spectrum, overweight and obesity are problems that also affect a large subset of the gay community. This can cause a number of health problems, including diabetes, high blood pressure, and heart disease.

10. Anal Papilloma: Of all the sexually transmitted infections gay men are at risk for, human papilloma virus—which cause anal and genital warts—is often thought to be little more than an unsightly inconvenience. However, these infections may play a role in the increased rates of anal cancers in gay men. Some health professionals now recommend routine screening with anal Pap Smears, similar to the test done for women to detect early cancers. Safe sex should be emphasized. Treatments for HPV do exist, but recurrences of the warts are very common, and the rate at which the infection can be spread between partners is very high.