Primary care of gay men and men who have sex with men

INTRODUCTION — Much of the care of gay, bisexual, and other men who have sex with men (MSM) reflects standards of recommended care of all men [1]. However, there are unique features regarding both medical and behavioral health of MSM of importance to practicing clinicians [2,3]. In addition, MSM may have specific concerns about access to care, insurance coverage, and the clinical office environment that should be considered as part of ensuring equitable and quality care [4,5].

Healthy People 2030, a document that outlines health goals in the United States, highlighted areas of concern regarding health care disparities impacting MSM and other sexual minorities [6]. In particular, MSM are disproportionately impacted by human immunodeficiency virus (HIV) and syphilis. The Centers for Disease Control and Prevention (CDC) reported that in 2019, close to 70 percent of new cases of HIV in the United States were in MSM [7]. Despite likely underreporting of sexually transmitted infections (STIs) due to the coronavirus disease 2019 (COVID-19) pandemic, nearly 2.4 million cases of syphilis, gonorrhea, and chlamydia were diagnosed in 2020 in the United States [8]. Though the number of primary and secondary syphilis cases in MSM slightly decreased in 2020, the majority of cases continue to be diagnosed in MSM [8]. In addition, gay men across a broad age spectrum are more likely to attempt suicide, experience homelessness, and have high rates of tobacco, alcohol, and other drug use [9]. All MSM, but especially older individuals, may face additional barriers to health due to isolation and lack of supportive services due to homophobia and stigma.

Despite ample evidence of these disparities, education about the medical care of MSM is sorely lacking in both undergraduate and graduate medical settings [10-12], leading to official calls for program revisions to include curricula about LGBTQ care [13].

TERMINOLOGY — The population that has come to be referred to as "gay" in the Western world is not a descriptive term that would be recognized by all men who have sex with men (MSM). While LGBTQ culture is increasingly open and discussed, MSM comprise a diverse population that may respond differently depending on how communications in clinical settings are framed [14]. MSM are a diverse group with respect to race, ethnicity, religion, education level, and socioeconomic status [15].

Sexual orientation is generally considered to encompass three components: identity, attraction, and behavior. “Gay” is generally used to describe how people identify themselves, while “men who have sex with men” (MSM) describes a behavior. It is important to recognize that “MSM” refers to a range of sexual behaviors and may not specifically reference anal sex. MSM may self-identify as gay, bisexual, queer, non-binary, same-sex loving, transgender, genderqueer, questioning, or heterosexual/straight. Additionally, some men who are beginning to explore their sexuality may experience a desire to be intimate with other men but may not identify as being gay or have yet to be sexually active with men.

Some persons may identify as belonging to a gender that differs from the sex they were assigned at birth. They may identify as transgender, using a term such as transwoman, or use a term such as "genderqueer", which blurs the gender male-female binary. Other terms are used around the world, but transgender is often used as an umbrella term to describe individuals whose gender varies from their assigned sex at birth. Transgender individuals challenge existing conceptions of “men who have sex with men,” as they may not identify as men or have traditionally “male” anatomy. Care of transgender individuals involves both general primary care as well as consideration of behavioral, hormonal, and gender-affirming surgical care. It is important that primary care clinicians know whether their patients are transgender so they can manage these issues as well as preventive and other care related to natal anatomy, such as screening for cancer. Transgender men and women may have unique behavior patterns related to HIV risk and their gender identity is entirely separate from their sexual orientation. For example, a transgender woman may identify as heterosexual because she partners with men, and a transgender man may identify as gay because he partners with men. (See "Primary care of transgender individuals" and "Transgender women: Evaluation and management" and "Transgender men: Evaluation and management" and "Sexual and gender minority women (lesbian, gay, bisexual, transgender, plus): Medical and reproductive care" and "Lesbian, gay, bisexual, and other sexual minoritized youth: Primary care".)

Some MSM struggle with cognitive dissonance, stigma, and internalized homophobia related to their sexual behavior and may not identify as MSM or as any sexual minority. Some do not even consider same-sex or same-gender sexual activity to be sex at all. Stigma, oppression, and stress related to sexual desire, sexual activity, and sexual identity may affect the risk for sexually transmitted infections (STIs) and certain cancers. Understanding a patient's sexual orientation, including one's identity, behavior, and desires, all have a bearing on the ability to provide quality care.

PREVALENCE — Kinsey's 1948 study Sexual Behavior in the Human Male was the first report on same-sex sexual experiences among men in the United States (US) [16]. More contemporary studies suggest that about 3.5 percent of the United States adult population identifies as gay or bisexual, while higher percentages engage in same-sex sexual activity (8 percent) and an even greater number are attracted to people of the same sex (11 percent) [17]. The study, which also included surveys from other countries (Canada, Australia, United Kingdom, and Norway), demonstrated that 1.8 percent of adults in the United States identified as gay or lesbian, with similar rates in the other included countries, ranging from 0.7 to 1.1 percent.

In Gallup polls, persons identifying as lesbian, gay, bisexual, or transgender (LGBT) increased from 3.5 percent in 2012 to 7.1 percent in 2021 [18]. An estimated 10 million United States adults identify as LGBT. Among the millennial (born between 1981 and 1996) and generation Z (born 1997 to 2003) populations in 2021, 10.5 and 20.8 percent of adults, respectively, identified as LGBT [18]. Identities within gender and sexual minorities include genderqueer, intersex, asexual, and others, expanding LGBT to LGBTQIA+.

Regardless of the precise numbers, United States census figures confirm that "same sex"-headed households are widespread throughout the country. Such households were found in over 93 percent of counties in every state [19] and suggest MSM live across the United States. Thus, all clinicians, at least in the United States, should be familiar with the concepts of sexual orientation and identity and how to discuss sexual behaviors when seeing patients.

OBTAINING A HISTORY — Some trainees in United States medical schools are taught, when taking a sexual history, to ask whether someone is sexually active, and if so, how their partner/s describe their gender; how many sexual partners they have had in the past year; and whether they engage in anal, oral, and/or vaginal sex. Patients should be told that the information related to their sexual activity is asked of everyone and has relevance to their health care and prevention decisions.

Nonjudgmental questions about sexual behavior are valuable, although they may not identify those who have never engaged in same-sex behavior, but have the desire to do so. Unrealized sexual desires may be an important trigger for discussing issues such as related anxiety or depression, fear of "coming out," and concern about how this information in the medical record could affect potential insurance coverage or employment.

Additional questioning about concerns with sexuality or gender identity may help identify issues related to sexual health and concern about sexual function, as well as possible gender identity issues.

Providers should routinely ask the following questions to normalize sexual history taking for sexual minorities. Questions such as the following can be incorporated into routine screening questionnaires that may be completed by the patient prior to seeing a provider and can inform discussion and screening tests during a visit.

●"What is your current gender?"

●"What sex was recorded on your birth certificate?"

●"What is the gender of your sex partners?" or, alternatively, "Do you ever have sex with men, women, trans or non-binary partners?"

●"What type of sex do you have? Insertive anal (top), receptive anal (bottom), or versatile (both)? Oral? Vaginal?"

It is also important to ask about any history of sexually transmitted infections (STIs), including exposure to HIV (see 'HIV' below). For patients who identify as transgender, it is important to ask about plans or goals for medical transition (eg, hormonal therapy) and surgical history, which may affect sexual behavior and thus HIV/STI risk. For example, many transgender women report that maintaining an erection is often difficult after starting hormone replacement therapy. This may make them more likely to be a receptive anal sex partner. Additionally, for providers who feel more comfortable with obtaining a sexual history, it may be prudent to ask about other sex behaviors including anilingus ("rimming") or insertion of the entire hand into the anus and rectum ("fisting"), as these activities have also been associated with transmission of STIs including hepatitis C and shigellosis.

ISSUES TO TARGET — There are few population-based studies of health issues in gay men. Based on clinical experience and epidemiology, we identify several areas in which clinicians providing primary care to gay men should lend additional attention beyond what they might focus on in heterosexual men. A 2020 consensus report published by the National Academies that summarizes studies of disparities among lesbian, gay, bisexual, and transgender (LGBT) people in general and gay men specifically highlighted that important issues to target include: HIV; infectious diseases including sexually transmitted infections (STIs); cancer; immunizations; substance and tobacco use; behavioral health, mental disorders, and intimate partner violence [15].

HIV — In the United States, the overall incidence of HIV decreased in populations of men who have sex with men (MSM) between 2010 through 2019, with new infections decreasing in White MSM, and no change in new infections among African American or Latino MSM [20]. In 2020, 21 percent of the overall incident HIV diagnoses were among Latino MSM, while they represented 31 percent of all diagnoses among MSM. Black MSM accounted for 26 percent of all new HIV diagnoses and 39 percent of diagnoses among all MSM [21]. The high incidence among Black MSM is not due to increased unsafe sexual practices or drug use but is likely related to structural racial inequality, lack of access to prevention services and care [20], lack of awareness of HIV status, delayed recognition and treatment of STIs, and increased prevalence of HIV in Black MSM sexual networks, which all make the risk of any single sexual encounter greater [22]. Statistics from the Centers for Disease Control and Prevention (CDC) show that, of the 36,801 new HIV infections reported in 2019, 69 percent were among MSM, including MSM who inject drugs [7]. The highest prevalence of HIV (up to 42 percent in the United States) is found among transgender women [23-25], who also experience high rates of STIs, discrimination, violence, and poverty.

While a combination of prevention activities seems most effective, key interventions are universal screening, treatment as prevention, and post- and preexposure prophylaxis (PEP and PrEP) using a harm-reduction approach that empowers patients to make informed choices and manage their risks [26].

In the United States, the CDC recommends that for effective HIV prevention [27-30]:

●Sexually active MSM can take steps to reduce the risk of contracting HIV, such as serosorting (choosing sexual partners based on HIV status) or seropositioning (choosing sexual activities based on HIV status) with men who are known to be HIV positive, consistent condom use, and, if HIV positive, letting potential sex partners know their status. (See "HIV infection: Risk factors and prevention strategies", section on 'Clinical approach to HIV prevention'.)

●For MSM who are HIV-negative, are not taking PrEP, and have a significant exposure event, taking PEP can reduce HIV risk after an exposure. The CDC issued guidance on use of PEP for nonoccupational exposures in 2016. (See "HIV infection: Risk factors and prevention strategies", section on 'Pre-exposure prophylaxis'.)

●For sexually active MSM at risk, PrEP is recommended. PrEP guidelines were updated in 2021 [30]. (See "HIV pre-exposure prophylaxis".)

●Health care providers and public health officials should work to ensure that:

•Sexually active MSM are tested at least annually for HIV (providers may recommend more frequent testing, for example every three months for individuals using PrEP) (see "Screening and diagnostic testing for HIV infection", section on 'Routine screening' and "HIV pre-exposure prophylaxis", section on 'Patient monitoring')

•MSM who are HIV-negative and engage in condomless sex receive risk-reduction interventions

•MSM living with HIV receive HIV care, treatment, and STI prevention services

Universal screening — HIV screening has long been a core prevention strategy. Recommendations for universal screening are discussed separately. (See "Screening and diagnostic testing for HIV infection" and "Screening for sexually transmitted infections", section on 'HIV and hepatitis viruses'.)

Treatment to virologic suppression for all persons with HIV — One of the major preventive benefits of HIV testing is the identification of individuals who have HIV and are therefore candidates for antiretroviral therapy (ART). In the United States, ART is recommended for everyone with HIV, regardless of CD4 count, because it halts the progression of disease and prevents HIV transmission by lowering viral loads and making transmission to individuals without HIV much less likely. Studies have shown that the risk of HIV transmission from a virologically suppressed patient (ie, person with a HIV viral load <200 copies/mL) is zero [31], prompting the “U=U” campaign (ie, undetectable equals untransmittable). (See "When to initiate antiretroviral therapy in persons with HIV".)

Use of barrier methods — Although condom use has declined among MSM in the United States [32], for individuals without HIV, counseling about HIV risk reduction when condoms are used properly during vaginal or anal intercourse remains important. There is a minimal risk of HIV transmission with oral sex, which is highest when a man with HIV and a detectable viral load ejaculates into the mouth of a person with open mouth sores. While it makes sense to inform patients that routine use of condoms can decrease the risk of HIV transmission, it is also important to recognize that many patients prefer not to use condoms for sex on a regular basis and that, in the United States, there has been an increase in condomless anal intercourse [27,32]. This suggests the need to consider recommending use of HIV PEP or PrEP accompanied by ongoing counseling and monitoring for adherence.

Post-exposure prophylaxis — MSM should be educated about obtaining HIV PEP in the event of a substantial nonoccupational exposure, such as condomless receptive anal intercourse with a partner of unknown HIV status or with a partner known to be HIV-positive with a detectable viral load. Repeated exposures suggest the need for additional counseling about risk reduction and recommendation of HIV PrEP. (See "Management of nonoccupational exposures to HIV and hepatitis B and C in adults".)

Pre-exposure prophylaxis — HIV PrEP most commonly consists of using daily oral tenofovir-emtricitabine (TDF-FTC [generally preferred] or TAF-FTC), along with HIV and STI testing every three months and ongoing counseling and assessment of risk at follow-up visits. Long-acting injectable PrEP (cabotegravir LA), a newer formulation approved in 2022 for persons weighing at least 35 kg, can be administered intramuscularly every two months and may be an alternative for some populations. Education and monitoring for injectable PrEP are more complex than for oral PrEP. Irrespective of the formulation, PrEP has and continues to be evaluated in several large clinical trials in a range of populations at increased risk for HIV, including MSM, adolescents, cisgender women, transgender women, and serodiscordant heterosexual couples (ie, couples in which one partner has HIV and the other does not). Overall, these studies demonstrate that the effectiveness of oral PrEP is highly contingent upon medication adherence; when used consistently and correctly, effectiveness for HIV prevention is >99 percent. Additional information is reviewed elsewhere. (See "HIV pre-exposure prophylaxis".)

Other sexually transmitted infections

●Prevention – Clinicians can play an important role in prevention of STIs by discussing risk reduction and safe sexual practices with patients [29]. Individuals may need reassurance that close physical contact, kissing, and hugging are safe. While there is a minimal risk of HIV transmission associated with oral sex, the same is not true for other STIs like syphilis, herpes, and chlamydia. STIs are largely transmitted during oral, vaginal, or anal intercourse. Consistent and correct condom use can reduce the risk for these STIs, but pericoital antibiotic prophylaxis may be a preferred method for some people [33]. Clinicians should spend more time on such discussions when there is a concern that a patient may have multiple sexual partners, has not been using barrier methods, has been recently diagnosed with an STI, or engages in drug use, particularly stimulants, while having sex. (See "Prevention of sexually transmitted infections".)

●Antibiotic prophylaxis – PEP with doxycycline has proven to be effective in preventing bacterial STIs among MSM. This strategy is discussed elsewhere. (See "Prevention of sexually transmitted infections", section on 'Doxycycline post-exposure prophylaxis for selected individuals'.)

Although doxycycline PEP is now an evidence-based intervention for decreasing bacterial STIs in MSM, there are still several unknowns about long-term doxycycline use and implementation of doxycycline PEP that may preclude broad use. Specifically, more data are needed on the possible effect of antibiotic resistance on STI pathogens such as Neisseria gonorrhoeae, Chlamydia trachomatis, and Mycoplasma genitalium; the potential impact on non-target bacteria like Staphylococcus aureus and other organisms within the gut microbiome; effects of long-term use of doxycycline such as weight gain; and whether use of doxycycline PEP will more broadly affect community-level transmission of STIs. Additionally, which subgroups of MSM (eg, those with >1 STI in the prior year or those with a history of syphilis) should be offered or recommended doxycycline PEP has yet to be defined. The San Francisco Department of Public Health released interim local guidelines for doxycycline PEP in October 2022 [34]; however, no national guidelines yet exist. Interim CDC guidance for doxycycline PEP is expected soon.

Use of doxycycline as PrEP for bacterial STIs among MSM will be evaluated in a multisite Canadian trial [35]; at present, empiric data to support this strategy are limited. Additional studies are needed to confirm and clarify the potential impact of meningococcal vaccine on gonorrhea incidence; currently, cost and limited availability of the vaccine may impede widespread use for gonorrhea prophylaxis.

●Screening – Clinicians should perform at least annual HIV and STI screening for all sexually active MSM and transgender persons who have sex with men, except those in long-term (>1 year), mutually monogamous, HIV-concordant relationships [29]. Sexually active MSM and transgender persons include those engaging in any anal, vaginal, and/or oral sex. In addition to HIV, we screen annually for syphilis, genital chlamydia and gonorrhea, rectal chlamydia and gonorrhea (in those who have had receptive anal intercourse in the prior year), and oropharyngeal gonorrhea (in those who have had receptive oral intercourse in the prior year). More frequent screening every three months is warranted for MSM at particularly high risk for STIs, including those with multiple or anonymous partners and persons taking HIV PrEP. We perform one-time screening for hepatitis A virus (HAV) and HBV (with vaccination if susceptible), and at least one-time screening for HCV (table 1), with annual HCV testing recommended for MSM on PrEP. This is reviewed in detail elsewhere. (See "Screening for sexually transmitted infections", section on 'Men who have sex with men'.)

Other infections — Other infectious diseases outbreaks have affected populations of MSM.

●Monkeypox – A new outbreak of nonendemic monkeypox (mpox) was first reported in Europe in May 2022 [36]. Cases related to this outbreak have continued to be reported globally, providing evidence of community spread. In July 2022, the World Health Organization (WHO) declared this outbreak a public health emergency of international concern [37], and the United States similarly declared mpox a national public health emergency in early August 2022 [38]. Nearly all cases within this outbreak have been identified in gay, bisexual, and other MSM, while prior outbreaks were likely zoonotic and affected other non-MSM populations [39]. Transmission of mpox occurs via close or other intimate physical contact, including sexual activity. The management of patients with mpox and those at risk for mpox is reviewed in detail elsewhere. (See "Treatment and prevention of mpox (monkeypox)", section on 'Infection prevention and control'.)

●Meningococcal meningitis – Outbreaks and clusters of meningococcal meningitis have been reported among MSM in the United States (eg, New York City and Los Angeles) and Europe [40-43], and the Advisory Committee on Immunization Practices (ACIP) recommends that MSM receive meningococcal vaccination in the setting of such an outbreak.

Immunizations — In addition to routine adult immunizations, we recommend that MSM who are sexually active receive these additional vaccines (figure 1):

●Hepatitis A and B vaccines because both viruses are sexually transmissible [44,45]. (See "Standard immunizations for nonpregnant adults" and "Hepatitis A virus infection: Treatment and prevention" and "Hepatitis B virus immunization in adults".)

●For all individuals, including MSM, routine human papillomavirus (HPV) vaccination is recommended through age 26 to prevent HPV-associated malignancies. Vaccination of some MSM up to age 45 may be considered through shared decision-making, though the overall benefit may be limited given that HPV prevalence from sexual exposures is higher in this group. Use of the HPV vaccine is discussed elsewhere. (See "Human papillomavirus vaccination", section on 'Indications and age range'.)

●Mpox vaccination may be indicated for some MSM based upon risk criteria set forth by CDC and local health jurisdictions [46]. (See "Treatment and prevention of mpox (monkeypox)", section on 'Pre-exposure prophylaxis with orthopoxvirus vaccines' and "Vaccines to prevent smallpox, mpox (monkeypox), and other orthopoxviruses".)

●Meningococcal vaccination is recommended for all adults with HIV. Additional vaccination recommendations for adults with HIV are found in the table (figure 1). (See "Immunizations in persons with HIV".)

Cancer screening — MSM experience increased rates of anal carcinoma. Anal carcinoma is more common in men with HIV, but it has also been found in those without HIV infection (table 2). (See "Classification and epidemiology of anal cancer", section on 'Sexual activity and sexually transmitted infections' and "Classification and epidemiology of anal cancer", section on 'HIV infection'.)

The putative cause is infection with HPV, which appears to progress through stages of anal dysplasia to anal carcinoma in much the same way as cervical HPV infection progresses to cervical carcinoma in women and other persons with a cervix [47]. Certain subtypes of HPV appear to predispose more to this progression. A 2012 systematic review showed that there is a higher prevalence of anal HPV infection in MSM, regardless of HIV status [48].

Among MSM without HIV or other immunocompromising conditions, screening to look for precancerous lesions or cancer related to HPV infection is not universally recommended by any clinical guidelines [29,49,50]. However, based upon the increased risk among this population, we advise screening all MSM for squamous intraepithelial lesions (SIL) every two to three years beginning at age 40 if feasible and resources allow. Screening for precancerous anal lesions is discussed in detail separately. (See "Anal squamous intraepithelial lesions: Epidemiology, clinical presentation, diagnosis, screening, prevention, and treatment", section on 'Our suggested approach'.)

HPV is also associated with oropharyngeal cancer (see "Epidemiology, staging, and clinical presentation of human papillomavirus associated head and neck cancer"). However, no special screening beyond that which occurs with routine medical examinations and dental care is recommended at this time.

Substance and tobacco use — Stigma and discrimination are commonly reported by LGBTQ persons and have been shown to induce physiologic changes such as dysregulated metabolism and cortisol function and impaired cardiovascular health. Minority stress is also associated with greater prevalence of substance use, including tobacco and alcohol; these effects are compounded for Black, Native American, and other LGBTQ persons of color who, in addition, often report lived experiences of racism and trauma [15].

Tobacco use — Smoking is more common among gay men than heterosexual men in the United States [51]. Younger gay men also report heavier tobacco use than their heterosexual counterparts, in large part due to targeted advertising for tobacco and vaping and lack of knowledge and access to smoking cessation programs [15,52]. Clinicians should counsel and assist all patients with smoking cessation. (See "Overview of smoking cessation management in adults".)

Alcohol use — Alcohol use is common among MSM in the United States, with alcohol use disorders being more prevalent in men who identify as bisexual [15,51]. Heavy alcohol use is not more prevalent among MSM than other men but is associated with behaviors that can increase risk for HIV acquisition (eg, condomless receptive anal intercourse) [51,53]. Clinicians may be the first to discover evidence of this issue through discussion. A multidisciplinary approach to stopping or reducing alcohol use is necessary. (See "Screening for unhealthy use of alcohol and other drugs in primary care" and "Alcohol use disorder: Treatment overview" and "Brief intervention for unhealthy alcohol and other drug use: Efficacy, adverse effects, and administration" and "Alcohol use disorder: Psychosocial management".)

Drug use — In the United States, use of illicit and recreational drugs is not different among gay populations than among others. There are, however, trends of drug use that do predominate in the gay community. According to a 2017 to 2019 survey, reported use of alcohol, marijuana, and hallucinogens were the most common among MSM; use of cocaine, prescription medications (ie, opioids, stimulants, and sedatives) and methamphetamine were less common but still increased relative to the United States general population [51,54].

Depending on what drugs are being used, these may lead to significant short- and long-term morbidity. Substance use during sex (ie, "chemsex"), particularly binge drinking and methamphetamine use, is associated with increased likelihood of condomless sex and sex with serodiscordant partners, which may in part explain sustained rates of HIV/STIs among MSM [55-58].

Screening for substance use disorder is discussed in detail separately. (See "Screening for unhealthy use of alcohol and other drugs in primary care", section on 'Unhealthy use of other drugs'.)

The management of substance use disorders are also discussed in detail separately. (See "Alcohol use disorder: Treatment overview" and "Substance use disorders: Clinical assessment" and "Stimulant use disorder: Treatment overview".)

Behavioral health and mental disorders — It was only in 1973 that homosexuality was declassified as a mental disorder. In 1986, the term "ego-dystonic homosexuality" was removed from the Diagnostic and Statistical Manual of Mental Disorders (DSM-III). Several studies have identified higher rates of depression in gay men [59-64]. There also appears to be an increased prevalence of anxiety disorders, particularly in relation to a man's growing consciousness of being gay and navigating societal pressures to come out [65] and coping with minority stress [15,66]. LGBTQ veterans also experience increased rates of posttraumatic stress disorder (PTSD), anxiety disorders, and suicidality [67,68].

Although there has been debate about whether MSM at large are at higher risk for suicide, many studies show increased suicidal ideation and suicide attempts among sexual minority men and transgender people [15,69]. Rates are particularly high among gay youth who may experience stigma, discrimination, and violence during vulnerable periods of biopsychological development; suicidal ideation and attempts are three to seven times higher among gay youth than among heterosexuals. Gay adolescents and men also experience increased incidence of body dysphoria and eating disorders [70].

The environment in which many LBGTQ adolescents and adults were raised, the violence and victimization faced by many at times in their lives, and the anxiety and fear about coming out can leave emotional scars that often need to be addressed. As a result, discussion of these and related issues is important and referral for counseling and/or psychopharmacologic intervention is often warranted. Many continue to struggle with the pressure of coming out, integrating their identity, and finding a sense of community or belonging. Nevertheless, many men demonstrate great resilience and are able to embrace their identity with no substantial adverse impacts to their mental health [71].

Intimate partner violence, sexual assault, and hate crimes — Studies suggest that the pooled prevalence of intimate partner violence among MSM is over 30 percent [72] and likely approaches similar rates as for heterosexual partners [73,74]; however, LGBTQ youth are at increased risk for dating violence compared with heterosexual youth [15]. (See "Intimate partner violence: Epidemiology and health consequences".)

Two striking differences are that informal discussions with survivors suggest that there is little screening done for intimate partner violence among gay individuals, and facilities designed to accommodate survivors of partner violence are rarely able to accommodate men [75].

A related and significant issue is that sexual assault among gay men is often underreported due to victim shaming and bias among some law enforcement officers. One study showed that only a small percentage of violent incidents were reported due to fear that open discussion would lead to further injury and that some victims had been victimized by police [76]. For gay men, finding a safe and supportive place to seek aid can be difficult as rape crisis programs are often unprepared to deal with male (and especially gay male) victims of sexual assault and rape. Furthermore, some legal definitions of rape exclude male victims. (See "Evaluation and management of adult and adolescent sexual assault victims in the emergency department".)

Primary care clinicians in the United States should be aware of the relatively high prevalence of violence and hate crimes against gay men. Although, as with heterosexual intimate partner violence and violence in general, there is little evidence about the benefits of screening or intervention, we believe that it is important to discuss with patients whether they have ever been physically or emotionally assaulted so that appropriate interventions can be deployed.

MAKING CARE ACCESSIBLE — Gay men, like all patients, must be made to feel welcome to increase the likelihood that they will be transparent with their providers and accept advice for preventive care. Perhaps the most important feature of care is the application of an open and nonjudgmental approach to finding out about each patient, their individual circumstances, concerns, and needs.

The same applies to the general office environment. Educational materials in waiting areas can give subtle signs that a practice may not be sensitive to same-sex issues, particularly if they do not include images of lesbian, gay, bisexual, transgender, and queer (LGBTQ) partners and families.

Some centers are now routinely asking patients for information on sexual orientation and gender identity at the time of registration. Forms asking for this information in language seeming to promote only traditional heteronormative family structures can be off-putting to gender and sexual minorities. Rather than just asking if a patient is married, single, or divorced, there should also be an option to indicate if a patient has a significant other or domestic partner. In countries and states where same-sex marriages are recognized, medical staff should acknowledge these relationships as they would with any heterosexual marriage, and they must recognize the legal status of these relationships for the purposes of hospital visitation [77,78].

In the United States, the Joint Commission and other agencies continue to collect data, looking at ways to improve the care environment for gay men in clinical settings [15,79]. The Joint Commission has implemented policies allowing patient choice of visitors in hospitals, prohibiting discrimination based on sexual orientation, gender identity, and gender expression.

Same-sex couples and families with same-sex parents may look to clinicians for guidance on issues of family commitment, marriage, adoption, parenting, foster parenting, and gestational carrier/surrogate pregnancy in the same ways that other partners and families do. Facilities for families must recognize that increasing numbers of children will now register with two same-sex parents or caregivers. Clinicians must be culturally sensitive and ensure that none of our patients experience psychological barriers to care.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: HIV screening and diagnostic testing" and "Society guideline links: HIV prevention" and "Society guideline links: Health care for lesbian, gay, and other sexual minority populations" and "Society guideline links: Sexually transmitted infections".)

SUMMARY AND RECOMMENDATIONS

●Considerations for care of MSM – While much of the care of gay, bisexual, and other men who have sex with men (MSM) reflect standards of recommended care for all men, there are unique features regarding both medical and behavioral health of MSM of importance to practicing clinicians. (See 'Introduction' above and "Overview of preventive care in adults".)

●Obtaining a sexual history – Not all MSM may identify as gay; thus, it is important to ask patients about the gender and anatomy of sexual partners rather than sexual orientation, as well as behavior and desire. Providers should routinely ask the following questions to normalize sexually history taking for sexual minorities (see 'Terminology' above and 'Obtaining a history' above):

•"What is your current gender?"

•"What sex was recorded on your birth certificate?"

•"What is the gender of your sex partners?"

•"What type of sex do you have? Insertive anal (top), receptive anal (bottom), or versatile (both)? Oral? Vaginal?"

●Screening and counseling for STIs and HIV

•Screening – Clinicians should perform at least annual HIV and sexually transmitted infection (STI) screening for all sexually active MSM and transgender persons who have sex with men, except those in long-term (>1 year), mutually monogamous, HIV-concordant relationships (table 1). (See 'Universal screening' above and 'Other sexually transmitted infections' above.)

In addition to HIV, we screen annually for syphilis, genital chlamydia and gonorrhea, rectal chlamydia and gonorrhea (in those who have had receptive anal intercourse in the prior year), and oropharyngeal gonorrhea (in those who have had receptive oral intercourse in the prior year). More frequent screening every three months is warranted for MSM at particularly high risk for STIs, including those with multiple or anonymous partners and persons taking HIV preexposure prophylaxis (PrEP) (table 1).

•Counseling – Additionally, MSM should be counseled about safer sex, risk reduction, and the availability of HIV postexposure prophylaxis (PEP) for sporadic exposures to HIV and PrEP for ongoing protection. Antibiotic PEP for other STIs is also an important option. (See 'Use of barrier methods' above and 'Post-exposure prophylaxis' above and 'Pre-exposure prophylaxis' above and 'Other sexually transmitted infections' above.)

●Viral hepatitis immunization and screening – All MSM should be immunized for hepatitis A and hepatitis B, and be screened at least once for hepatitis C (table 1). (See 'Immunizations' above and "Screening and diagnosis of chronic hepatitis C virus infection".)

●Screening for anal SIL – Anogenital human papillomavirus (HPV) infection is highly prevalent among MSM (table 2). Men with perianal warts should be carefully evaluated for dysplastic lesions as part of management of those warts. When feasible, we screen all MSM for squamous intraepithelial lesions (SIL) every two to three years beginning at age 40. Screening for precancerous anal lesions with anal cytology is discussed separately. (See 'Cancer screening' above and "Anal squamous intraepithelial lesions: Epidemiology, clinical presentation, diagnosis, screening, prevention, and treatment", section on 'Our suggested approach'.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Harvey Makadon, MD, and Shireesha Dhanireddy, MD, who contributed to earlier versions of this topic review.