Month: December 2006

CDC, anal sex, and risk

Related to a couple of previous posts, I thought it would be helpful to review what The Centers for Disease Control (CDC) has to say about anal sex and risk.

Can I get HIV from anal sex?

Yes. In fact, unprotected (without a condom) anal sex (intercourse) is considered to be very risky behavior. It is possible for either sex partner to become infected with HIV during anal sex. HIV can be found in the blood, semen, pre-seminal fluid, or vaginal fluid of a person infected with the virus. In general, the person receiving the semen is at greater risk of getting HIV because the lining of the rectum is thin and may allow the virus to enter the body during anal sex. However, a person who inserts his penis into an infected partner also is at risk because HIV can enter through the urethra (the opening at the tip of the penis) or through small cuts, abrasions, or open sores on the penis.

Not having (abstaining from) sex is the most effective way to avoid HIV. If people choose to have anal sex, they should use a latex condom. Most of the time, condoms work well. However, condoms are more likely to break during anal sex than during vaginal sex. Thus, even with a condom, anal sex can be risky. A person should use generous amounts of water-based lubricant in addition to the condom to reduce the chances of the condom breaking.

Working with clients, I provide this information and accentuate the risks involved. This is true for men and women, no matter what their erotic orientation.

For information purposes, Laumann et al found that 25% of men and 20% of women reported anal sex. Among gay and bisexual men, 76% of the survey respondents had experienced insertive anal intercourse and 82% receptive. This was in 1994, I suspect the numbers are higher among straights now.

To me, this means that straights need the CDC information and some gays do not engage in anal sex (although they need the information as well). Assumptions that all gay males do this routinely, while often correct, are not always true. Frequency of such activities and with whom are important factors for health care professionals to ask about and they are the determinants of disease, not sexual attractions per se. My view is that sexual promiscuity in gay men owes more to being male than being attracted to the same sex. Of course, this is not proven but it fits my clinical experience and observations better than assuming the reverse.

There are people of both sexes and all sexual orientations who are at high risk for acquiring and spreading STDs. These individuals often have significant emotional needs and profit from interventions that are individually suited to their needs.

Take away point: People who do not manage their intimate lives well are at higher risk for disease and emotional distress than those who do.

NARTH article asking why homosexuality isn’t a disorder.

This article by Kathleen Melonakos from the NARTH website was recently reprinted by Lifesite News.

While I think it is important to advocate for healthy sexual conduct, I do question the sources and some of the conclusions of this article. I did not check everything but a few things seem important to note.

First, the article quotes the discredited work of Paul Cameron and relies on his conclusions based on questionable assumptions. One popular response to his work notes the problems with sampling and inference in his articles.

Also, Ms. Melonakos says: As far as I know, there is no other group of people in the United States that dies of infectious diseases in their mid-forties except practicing homosexuals. The evidence for this statement is in a footnote that leads to the 1997 article by Hogg et al that has been widely reported. The finding often quoted that is generalized to homosexuals as a group is:

In a major Canadian centre, life expectancy at age 20 years for gay and bisexual men is 8 to 20 years less than for all men. If the same pattern of mortality were to continue, we estimate that nearly half of gay and bisexual men currently aged 20 years will not reach their 65th birthday.

Rarely do sources that cite the Hogg et al study or that simply assume a mid-40s life expectancy then cite the follow up letter from Hogg et al where the authors provide context for their research. It is important to read this letter to understand the significance of their findings. In this note, they state:

In contrast, if we were to repeat this analysis today the life expectancy of gay and bisexual men would be greatly improved. Deaths from HIV infection have declined dramatically in this population since 1996. As we have previously reported there has been a threefold decrease in mortality in Vancouver as well as in other parts of British Columbia.

and

It is essential to note that the life expectancy of any population is a descriptive and not a prescriptive mesaure. Death is a product of the way a person lives and what physical and environmental hazards he or she faces everyday. It cannot be attributed solely to their sexual orientation or any other ethnic or social factor. If estimates of an individual gay and bisexual man’s risk of death is truly needed for legal or other purposes, then people making these estimates should use the same actuarial tables that are used for all other males in that population. Gay and bisexual men are included in the construction of official population-based tables and therefore these tables for all males are the appropriate ones to be used.

Ms. Melonakos then notes the psychiatric criteria for viewing a syndrome as a diagnosis. The behavior or syndrome must cause subjective distress and/or negative social/life consequences. She asserts that homosexuality satisfies these criteria because many gays are unhappy with their sexual orientation and being gay is a “lethal addiction.” First, the DSM does include a diagnosis for those who are in distress over their sexual orientation (302.90). Second, the evidence is not clear that simply having same-sex attraction or taking on a gay identity requires one to pursue practices that do indeed lead to shortened life or disabling disease. I have previously addressed this issue relating to mental health morbidity.

In short, I do not believe the article makes the case for considering homosexual attraction per se to be a psychiatric disorder. Disordered sexuality of any sort (many partners, risky behavior, comcommitant drug usage, etc.) can be treated under several diagnostic headings, whether the person is gay, straight or bisexual.

More on this article. In it, Ms. Melonakos asks: “Can anyone refute that increased morbidity and mortality is an unavoidable result of male-with-male sex–not to mention the increased rates of alcoholism, drug abuse, depression, suicide and other maladies that so often accompany a homosexual lifestyle?[v] People with this whole cluster of behavior patterns are somehow “normal”?”

This is pretty easily refuted by observing people who engage in male-to-male sex but do not have these disorders. Even in studies showing an increased risk of the disorders cited here, the majority of people studied do not have them. Somewhat, and in some cases, very minor, elevated risk, yes, but “unavoidable” incidence? No. Research does not show that increased morbidity and mortality is an unavoidable result of male-with-male sex.

To better understand the issues in anal cancer, see this National Cancer Institute article. HPV (against which condoms do not protect well) seems to be the major culprit. Men and women who engage in anal sex are at risk as are those who have had other STDs. The 4000% number quoted in the NARTH article seems pretty amazing until you consider that anal cancer is about unheard of in the general population. So instead of less than 1 case per 100,000, the rate is 35 per 100,000 in men who engage in anal sex. The risk is substantially elevated but the cancer is pretty rare. Even though the incidence is rare, I do think health professionals should provide this information to patients and in schools as well.

UPDATE (12/19/06) – NARTH Board member Dave Pruden tells me that the NARTH Scientific Advisory Committee is reviewing this article for accuracy.

1/4/07 -This article has been pulled from both the NARTH and Lifesite News websites.

Rick Warren’s AIDS conference dust up

The last several days, a fuss has erupted about an AIDS conference at Rick Warren’s (Purpose Driven Life) Saddleback church hosting an AIDS conference. Pro-life groups are upset that Barack Obama is speaking (he favors partial-birth abortion) and the new AIDS Truth Coalition wants more time at the conference on gay promiscuity. Saddleback has responded and the conference goes on.

Given our discussion of gay culture, is there something to the idea that gay leaders should be more vocal about promiscuity? That sounds provocative but I mean it to be a serious question. Feel free to comment on any aspect of this controversy.

NARTH article reviews Danish study on childhood correlates of gay and straight marriage

Lifesite News ran an article by Linda Ames Nicolosi summarizing a research report by Morten Frisch and Anders Hviid. I covered this research last month.

While I believe the research points to the potential influence of environmental factors broadly speaking, I think the Lifesite article overstates some of the findings.

Mrs. Nicolosi correctly notes the population size – 2,000,355 native-born Danes between the ages of 18 and 49 but does not clarify that the research did not examine childhood correlates for the unmarried Danes. For gays that would mean that the study examined social factors for the married gays or about 1-5% of the gay population in Denmark (n=1890 men; n=1573 women). The study is still quite large but conclusions cannot be generalized with certainty to unpartnered gay people.

In reading the Lifesite article, one could get the impression that gays and straight were directly compared and interrelated. In other words, if homosexual rates of marriage go up then heterosexual rates go down. Not necessarily so. The childhood correlates were independently compared to gay and straight marriage decisions. People with unknown fathers were indeed less likely to marry heterosexually (“Men and women with “unknown fathers” were significantly less likely to marry a person of the opposite sex than were their peers with known fathers”) but there was no significant relationship between unknown fathers and elevated homosexual marriage. Reduced heterosexual marriage rates do not necessarily mean increased same-sex marriage. I do not think Mrs. Nicolosi’s article is clear on this point.

Another point that is misleading from the Lifesite article is this bullet point: “Men whose parents divorced before their 6th birthday were 39% more likely to marry homosexually than peers from intact parental marriages.” While this is a true finding, Mrs. Nicolosi does not report that there were only 35 men in this category and that the difference in marriage rates between this group and the comparison group was not statistically significant. Thus, although true, one cannot attach much importance to it.

It is also relevant to point out that nearly 83% of the gay men in the study did not experience parental divorce prior to their 18th birthday. Thus, the vast majority of these men enjoyed intact families through their childhood.

As I read the study, there are several provocative findings, including:

1. The fraternal birth order effect did not show up, 2. Cohabitation is correlated with higher probability of marrying homosexually, 3. Divorce has negative impacts on marriage rates for staights, and 4. Elevated rates of homosexual marriage are associated with being born in a metropolitan area versus lowered rates if you live in a rural area.

UPDATE: 1/3/06 – Warner Huston has posted an article about this study on several conservative websites. He draws heavily from the NARTH article I reference above. My comment about his piece is here.