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

INTRODUCTION — 

The care of gay, bisexual, and other men who have sex with men (MSM) includes both standards of recommended care of all men [1,2] and medical and behavioral health concerns specific to MSM [3,4]. MSM may also experience issues that require special considerations, including social stigma and discrimination in the health care environment that impact their access to equitable and quality care [5,6].

This topic will focus on the primary care health concerns that impact MSM, inclusive of transgender women. The primary care of transgender individuals, including transgender men, is discussed in detail separately (see "Primary care of transgender individuals"). The primary care of lesbian, gay, bisexual, and other sexual minoritized youth and adolescents is also discussed separately. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Primary care" and "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns".)

When discussing study results in this topic, we will use the terms "men," "women," "LGBTQ," "LGBTQ+," and other reference terms for gender identity, sexual orientation, and sexual identity as they are used in the studies presented. We encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive patients as they relate to the information presented in this topic.

TERMINOLOGY — 

Traditional terms used to describe various aspects of gender and sexuality relevant for the care of MSM are reviewed below and in the table (table 1).

●Sexual orientation – Sexual orientation or sexual identity encompasses an individual's assessment of their attraction. While some patients use sexual orientation to include or imply sexual behavior, this should not be assumed.

●Sexual behavior – Sexual behavior refers to specific sexual activities with both self and others. Sexual behavior includes anal sex and is sometimes implied by the term MSM, as below. Sexual behavior does not necessarily indicate sexual orientation, as it may represent exploration or experimentation.

●Gender identity – Some persons have a gender identity and/or expression that differs from the sex they were assigned at birth and the cultural expectations associated with that assignment. While other terms are also used, transgender is the generally accepted term to describe any individual whose gender varies from their assigned sex at birth. They may identify as transgender (and use a term such as transgender woman or man) or as "nonbinary" or "genderqueer"—identities that do not conform to a traditional male-female binary spectrum. The term transgender is used as an adjective or descriptor (eg, transgender person); using the term in isolation as a noun may be considered insensitive or offensive.

●MSM (men who have sex with men) – While MSM originated as a description of sexual behavior (eg, people who engage in anal intercourse), it has also evolved into an epidemiologic term used to describe a group of people who may participate in a range of same-sex emotional, romantic, and/or sexual behaviors inclusive of but not restricted to anal sex. MSM comprise a diverse population with respect to race, ethnicity, religion, education level, and socioeconomic status that may respond differently depending on how communications in clinical settings are framed [7-9].

MSM does not imply gender identity or sexual orientation, nor is it synonymous with gay and/or bisexual men. MSM may self-identify as gay, bisexual, queer, nonbinary, same-sex loving, transgender, genderqueer, questioning, or heterosexual/straight. Transgender individuals may not identify as men or have traditionally "male" anatomy but may still identify as MSM. Additionally, some men may experience a desire to be intimate with other men but may not identify as being gay and may not have engaged in sexual activity with men.

Knowledge of the patient's sexual behavior and gender identity facilitates comprehensive care of MSM, including screening tests and assessment of health risks.

EPIDEMIOLOGY AND SCOPE — 

Contemporary studies suggest that between 5.5 to 7.6 percent of the United States adult population identifies as lesbian, gay, bisexual, or transgender (LGBT) [10,11]. A 2021 survey conducted in 27 countries found that 3 to 4 percent of adults globally identify as gay or bisexual [12]. When asked about sexual attraction, 13 percent of adults in the United States reported at least some same-sex attraction compared with 11 percent of adults globally.

In Gallup polls, persons identifying as LGBT increased from 3.5 percent in 2012 to 7.6 percent in 2023 [13]. This equates to an estimated 25 million United States adults who identify as LGBT. Among the millennial (born between 1981 and 1996) and Generation Z (born 1997 to 2012) populations in 2023, 9.8 and 22.3 percent of adults, respectively, identified as LGBT [13]. Identities within gender and sexual minorities include genderqueer or questioning, intersex, asexual, and two-spirit, expanding LGBT to 2SLGBTQIA+.

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 [14] and suggest MSM live across the United States.

Healthy People 2030, a document that outlines health goals in the United States, highlights areas of concern regarding health care disparities impacting MSM and other sexual minorities [15]. In particular, MSM are disproportionately impacted by human immunodeficiency virus (HIV) and syphilis. The Centers for Disease Control and Prevention reported that, in 2022, close to 70 percent of new cases of HIV in the United States were in MSM [16]. Bacterial sexually transmitted infections remain a significant public health issue, with over 2.5 million cases of syphilis, gonorrhea, and chlamydia being diagnosed in 2022 in the United States [17]. While the number of primary and secondary syphilis cases in MSM only slightly increased by 4 percent in 2022, the majority of cases continue to be diagnosed in MSM [17]. 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 substance use [18,19]. 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 lacking in both undergraduate and graduate medical settings [20-22], leading to official calls for program revisions to include curricula about lesbian, gay, bisexual, transgender, and queer care [23,24].

THE PRIMARY CARE VISIT

Inclusive best practices — We strive to provide and model respect, support, and open acceptance of patients of all sexual orientations and gender identities. Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) patients often experience discrimination in the health care setting and lack access to medical personnel who are sensitive to LGBTQ+ issues, resulting in psychologic barriers to care [25,26]. 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.

Attention to the general office environment, including educational materials that include images of LGBTQ+ partners and families, offers nonverbal signs that the health care team is sensitive to LGBTQ+ issues [27,28]. Intake forms asking for gender identity and pronouns, sexual orientation, and marital status should use inclusive language supportive of domestic partnerships and same-sex marriages [29].

Taking a sexual history — Our approach to taking a sexual history is generally consistent with Centers for Disease Control and Prevention guidance [30]. Gender identity, sexual orientation, and sexual behavior should be viewed as independent of each other; while some patients may classify their sexual behavior based on their sexual orientation, it is best to ask the patient about each of these categories specifically rather than assume or extrapolate their responses. For example, a transgender woman may identify as heterosexual because she partners with men, a transgender man may identify as gay because he partners with men, and not all MSM who practice anal sex identify as LGBTQ+. Understanding a patient's gender identity and sexual behaviors facilitates the establishment of a respectful, supportive clinician-patient relationship in addition to informing the assessment of patient risk, necessary testing, and opportunities for risk reduction. (See 'Specific health concerns' below.)

Providers should routinely ask the following questions to normalize sexual history-taking for sexual minorities. Patients should be reassured that the information related to their sexual activity is asked of everyone and the relevance to their health care and prevention decisions should be explained. Using a "two-step" method, some questions 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 [30-32]:

●Intake questions:

•"What is your current gender?"

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

●Questions to discuss during the visit:

•"Are you currently having sex of any kind? Oral, vaginal, anal, or other?" If no, "Have you ever had sex of any kind with another person?"

•"What is/are the gender(s) of your sex partner(s)?" or, alternatively, "Do you ever have/have you ever had sex with men, women, or trans or nonbinary partners?"

•"What type of sex do you have or have you had? What parts of your body are involved when you have sex? Are you a top (insertive anal), bottom (receptive anal), or both (versatile)? Oral? Vaginal?"

Providers should also ask about current use of protection from sexually transmitted infections (STIs) and frequency of use (eg, sometimes, most of the time, every time) as well as any history of STIs and STI treatment. For patients who identify as transgender or nonbinary, clinicians should inquire about plans or goals for gender-affirming care (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 therapy. This may make them more likely to be a receptive anal sex partner. Additionally, providers who feel more comfortable with obtaining a sexual history may also 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.

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 concerns.

SPECIFIC HEALTH CONCERNS — 

A 2020 consensus report published by the National Academies of Sciences, Engineering, and Medicine identified several key areas in which clinicians providing primary care to gay men and MSM should lend additional attention beyond the focus of a typical clinic visit [9].

HIV — In the United States, the overall incidence of HIV decreased in populations of MSM between 2018 through 2022, with new infections decreasing in White and Black/African American MSM but no change in new infections among Hispanic/Latino MSM [16]. In 2022, 25 percent of the overall incident HIV diagnoses were among Latino MSM, while they represented 37 percent of all diagnoses among MSM [33]. Black MSM accounted for 23 percent of all new HIV diagnoses and 35 percent of diagnoses among all MSM. The high incidence among Black and Hispanic/Latino MSM is largely due to intersecting social, political, and structural determinants of health, including poverty, stigma, discrimination, and other barriers impeding access to care, rather than disproportionately higher levels of drug use or "unsafe" sexual practices [16]. Statistics from the Centers for Disease Control and Prevention (CDC) show that of the 38,043 new HIV infections reported in 2022, 67 percent were among MSM, including MSM who inject drugs [33]. The highest prevalence of HIV (up to 40 percent in the United States) is found among transgender women [34,35], who also experience high rates of sexually transmitted infections (STIs), discrimination, violence, and poverty.

While a combination of prevention activities seems most effective, key interventions are universal screening, treatment as prevention (TasP), and post- and pre-exposure prophylaxis (PEP and PrEP) using a harm-reduction approach that empowers patients to make informed choices and manage their risks [36].

In the United States, the CDC recommends the following for effective HIV prevention [37-39]:

●MSM be screened and treated for STIs, given that the presence of STIs can increase the risk for HIV acquisition in people at risk for HIV and transmission from people with HIV who are not virally suppressed. (See "HIV infection: Risk factors and prevention strategies", section on 'Clinical approach to HIV prevention'.)

●For MSM at risk for HIV acquisition from current or anticipated sexual activity, PrEP is recommended. PrEP guidelines were updated in 2021 [38]. (See "HIV pre-exposure prophylaxis".)

●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 the use of PEP for nonoccupational exposures in 2016. (See "HIV infection: Risk factors and prevention strategies", section on 'Pre-exposure prophylaxis'.)

●For MSM who inject drugs or use methamphetamine, PrEP should be offered [38]. Additional harm reduction strategies, such as the use of clean needles and other equipment, should be discussed, and persons should be offered naloxone and linkage to medication-assisted treatment as appropriate. (See "HIV infection: Risk factors and prevention strategies", section on 'Clinical approach to HIV prevention'.)

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

•Sexually active MSM know their status and 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 in adults", section on 'Routine screening' and "HIV pre-exposure prophylaxis", section on 'Patient monitoring'.)

•MSM who are HIV negative and engage in condomless sex receive counseling on risk-reduction interventions (eg, condoms, STI prophylaxis). (See "Prevention of sexually transmitted infections", section on 'Doxycycline post-exposure prophylaxis for selected individuals'.)

•MSM living with HIV receive HIV care, treatment to achieve a suppressed viral load (TasP), and STI prevention services.

Universal screening — HIV screening is an established core prevention strategy. Recommendations for universal screening are discussed separately. (See "Screening and diagnostic testing for HIV infection in adults" 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, a person with an HIV viral load <200 copies/mL) is zero [40], 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 [41], for individuals without HIV, counseling about HIV risk reduction when condoms are used properly and consistently 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 remains advisable to inform patients that correct and consistent 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 and other countries, there has been an increase in condomless sex among MSM [41,42]. This reinforces the need to recommend the use of HIV PEP or PrEP to appropriate candidates and provide ongoing counseling and monitoring for adherence, as below.

Postexposure 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 have HIV and 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. On-demand (also known as "2-1-1," event-driven, or intermittent) PrEP is the strategy of taking two pills of TDF-FTC 2 to 24 hours prior to sex, followed by one pill 24 hours after the initial dose and a final pill 48 hours after the initial dose; this option may be preferred for MSM who have sex infrequently (eg, once a week or less) and are able to plan around sex. Long-acting, injectable PrEP (cabotegravir LA) is a newer formulation that can be administered intramuscularly every two months. Lenacapavir, another long-acting agent that is administered subcutaneously every six months, is currently under evaluation in clinical trials involving sexual- and gender-minority persons [43].

Irrespective of the formulation, in studies of PrEP in a range of populations at increased risk for HIV, including MSM, transgender and gender-diverse people, and serodiscordant heterosexual couples, effectiveness for HIV prevention is >99 percent when used consistently and correctly. Additional information on PrEP is reviewed separately. (See "HIV pre-exposure prophylaxis".)

Other sexually transmitted infections

●Prevention – Clinicians can play an important role in the prevention of STIs by discussing risk reduction and safe sexual practices with patients [37]. 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 [44]. Individuals may need reassurance that close physical contact, kissing, and hugging are generally safe; however, some STIs, such as herpes, monkeypox (mpox), and syphilis, may be transmitted through close physical contact or exchange of saliva through kissing. Clinicians should spend more time on such discussions if a patient has multiple sexual partners, has not been using barrier methods, has been recently diagnosed with an STI, or uses alcohol and/or drugs around sex. (See "Prevention of sexually transmitted infections".)

●Antibiotic prophylaxis – PEP with doxycycline is effective in decreasing bacterial STIs among MSM and transgender women with a history of bacterial STI in the past year [45-48]. CDC guidelines released in June 2024 recommend doxycycline PEP for MSM and transgender women using a shared decision-making approach [45]. Further details, including dosing and monitoring, are discussed separately. (See "Prevention of sexually transmitted infections", section on 'Doxycycline post-exposure prophylaxis for selected individuals'.)

PrEP to reduce bacterial STI among MSM is also under evaluation with doxycycline and meningococcal group B vaccine [48-51]. At present, empirical data to support these interventions are limited. In one randomized trial, meningococcal group B vaccine did not reduce the incidence of gonorrhea among MSM [48]. The use of meningococcal group B vaccine for gonorrhea prophylaxis is not recommended due to its limited efficacy data, availability, and high cost.

●Screening – Clinicians should perform at least annual STI screening (table 2) 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 [37]. 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, and rectal chlamydia and gonorrhea in those who have had receptive anal intercourse in the prior year (table 2). We also screen for 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 and hepatitis B virus (with vaccination if susceptible) and at least one-time screening for hepatitis C virus (HCV), with annual HCV testing recommended for MSM on PrEP. This is reviewed in detail separately. (See "Screening for sexually transmitted infections", section on 'Men who have sex with men'.)

Other infections — Other infectious outbreaks have disproportionately affected populations of MSM:

●Mpox – An outbreak of nonendemic clade II mpox (formerly monkeypox) was first reported in Europe in May 2022 [52]. In July 2022, the World Health Organization declared this outbreak a public health emergency of international concern [53], and the United States similarly declared mpox a national public health emergency in early August 2022 [54]. Nearly all cases within this outbreak have been identified in gay, bisexual, and other MSM [55], while prior outbreaks were likely zoonotic and affected non-MSM populations as well [56].

The diagnosis and management of patients with mpox are reviewed in detail separately. (See "Epidemiology, clinical manifestations, and diagnosis of mpox (formerly monkeypox)" and "Treatment and prevention of mpox (formerly monkeypox)", section on 'Infection prevention and control in health care and community settings'.)

●Meningococcal meningitis – Outbreaks and clusters of meningococcal meningitis have been reported among MSM in the United States (eg, Florida, New York City, and Los Angeles) and Europe [57-60], and the Advisory Committee on Immunization Practices 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 – Because both viruses are sexually transmissible, hepatitis A and B vaccines are recommended [61,62]. (See "Standard immunizations for nonpregnant adults" and "Hepatitis A virus infection: Treatment and prevention" and "Hepatitis B virus immunization in adults".)

●HPV – For all individuals, including MSM, routine human papillomavirus (HPV) vaccination is recommended through age 26 to prevent HPV-associated malignancies. Incident HPV infection is high among unvaccinated men, especially at anogenital sites in MSM, and can lead to increased risk for anal condyloma and other preventable HPV-related disease [63]. 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. The use of the HPV vaccine is discussed elsewhere. (See "Human papillomavirus vaccination", section on 'Indications and age range'.)

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

●Mpox – Mpox (formerly monkeypox) vaccination is indicated for many MSM based upon risk criteria set forth by CDC and local health jurisdictions [64]. (See "Treatment and prevention of mpox (formerly monkeypox)", section on 'Pre-exposure prophylaxis with orthopoxvirus vaccines' and "Vaccines to prevent smallpox, mpox (monkeypox), and other orthopoxviruses".)

Cancer screening

Anal cancer — MSM experience increased rates of anal cancer. Anal cancer is more common in men with HIV, but it has also been found in those without HIV infection (table 3) (see "Anatomy, pathology, epidemiology, and risk factors of anal cancer", section on 'Sexual activity and sexually transmitted infections'). The putative cause is infection with HPV, which progresses through stages of anal dysplasia to anal carcinoma in much the same way as cervical HPV infection progresses to cervical carcinoma [65,66]. Certain subtypes of HPV appear to predispose more to this progression. In a meta-analysis of eight studies, MSM were associated with an increased prevalence of anal HPV infection, independent of HIV status [66,67].

The 2023 International Anal Neoplasia Society consensus guidelines recommend that anal cancer screening to look for precancerous lesions or cancer related to HPV infection be initiated for MSM and transgender women with HIV starting at age 35 and without HIV starting at age 45 [68,69]. The United States Department of Health and Human Services and the National Institutes of Health Office of AIDS Research recommend all adults with HIV receive annual assessment for anal abnormalities and digital anorectal examination, followed by standard anoscopy if abnormalities are detected [70]. Screening for anal cancer should only be undertaken if resources allow for linkage to a specialist with the capability to perform high-resolution anoscopy and other treatments if squamous intraepithelial lesions are detected. 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 'Screening for anal SIL'.)

Oropharyngeal cancer — 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 — The United States Preventive Services Task Force has recommended universal screening for unhealthy use of alcohol and other drugs [71,72]. An association between minority stress and increased prevalence of substance use has been reported; these effects are compounded for Black individuals; Native American individuals; and other lesbian, gay, bisexual, transgender, and queer (LGBTQ+) persons of color [9].

Tobacco use — Smoking is more common among gay men than heterosexual men in the United States [73]. 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 [9,74]. 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 [9,73]; however, heavy alcohol use is not necessarily more prevalent among MSM than other men. Data are mixed regarding the association between heavy alcohol use and risk for HIV acquisition via condomless receptive anal intercourse [73,75-78]. Clinicians may be the first to discover evidence of at-risk or unhealthy alcohol use 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".)

Unhealthy use of other drugs — Epidemiologic data from many countries, including the United States, suggest that substance use is higher among MSM compared with heterosexual men [73,79]. According to a survey conducted between 2017 to 2019, reported use of alcohol, marijuana, and hallucinogens was the most common among MSM; use of cocaine, prescription medications (ie, opioids, stimulants, and sedatives), and methamphetamine was less common but still increased relative to the United States general population [73,80]. Cannabis use has been associated with condomless anal intercourse and less planning for condom use with sex [81].

Substance use is associated with both significant short- and long-term morbidity. For example, substance use immediately before or during sex (ie, "chemsex"), particularly binge drinking and methamphetamine use, is associated with underlying compulsive sexual behavior and an increased likelihood of condomless sex and sex with serodiscordant partners. This may, in part, explain sustained rates of HIV/STIs among some MSM [76,78,82-85].

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 is 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 — Rates of depression are approximately three times higher in gay men when compared with the general population [86-91]. In addition to depression, there is an increased prevalence of anxiety disorders, particularly in relation to navigating societal pressures around having a gay identity, responses by family or other loved ones to coming out [92,93], and coping with minority stress [9,94]. LGBTQ+ veterans also experience increased rates of posttraumatic stress disorder, anxiety disorders, and suicidality [95,96].

Sexual minority men are also more likely to experience suicidality compared with the general population [9,97]. Rates are particularly high among gay youth who may experience stigma, discrimination, and violence during vulnerable periods of biopsychologic development; suicidal ideation and attempts are three to seven times higher among gay youth than among heterosexuals. Gay adolescents and men also experience an increased incidence of body dysphoria and eating disorders [98].

The environment in which many LGBTQ+ 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. Discussion of these and related issues in a psychologically safe environment is important; referral for counseling and/or psychopharmacologic intervention is often warranted. Nevertheless, it is equally important to recognize that many men demonstrate great resilience and embrace their identity with no substantial adverse impacts on their mental health [99]. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'Potential psychosocial and health concerns'.)

Intimate partner violence, sexual assault, and hate crimes — Studies suggest that the pooled prevalence of intimate partner violence among MSM is over 30 percent, approaching or exceeding similar rates for heterosexual partners, and may be higher in men who use methamphetamine or engage in sexualized drug use [100-105]. LGBTQ+ youth are also at increased risk for dating violence compared with heterosexual youth [9]. (See "Intimate partner violence: Epidemiology and health consequences".)

Studies of survivors suggest that there is little screening done for intimate partner violence among gay individuals, and facilities designed to accommodate male survivors of partner violence are rare [106].

Sexual assault among gay men is also frequently underreported due to victim shaming, bias, and inappropriate response (eg, mocking or blaming the victim) by law enforcement [107,108]. Fear of homophobia, racism, misinterpretation that abuse is mutual, and the prevalence of anti-LGBTQ+ laws are also significant barriers [108]. 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.

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

●Inclusive best practices – While much of the care of gay, bisexual, and other men who have sex with men (MSM) reflects 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".)

Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) patients often experience discrimination in the health care setting and lack access to medical personnel who are sensitive to LGBTQ+ issues. We strive to provide and model respect and open acceptance of patients of all sexual orientations and gender identities through attendance to the general office environment and inclusive intake forms. (See 'Inclusive best practices' above.)

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

•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 relationships (table 2). (See 'Universal screening' above.)

In addition to HIV, we screen annually for syphilis, genital chlamydia and gonorrhea, and rectal chlamydia and gonorrhea in those who have had receptive anal intercourse in the prior year. We also screen for oropharyngeal gonorrhea in those who have had receptive oral intercourse in the prior year. More frequent screening is warranted for MSM at particularly high risk for STIs, including every three months for those with multiple or anonymous partners and persons taking HIV pre-exposure prophylaxis (PrEP) (table 2) and every three to six months for persons using doxycycline postexposure prophylaxis (PEP). We perform one-time screening for hepatitis A virus and hepatitis B virus (with vaccination if susceptible) and at least one-time screening for hepatitis C virus. (See 'Other sexually transmitted infections' above.)

•Counseling – Additionally, MSM should be counseled about ways to reduce sexual risk for HIV/STIs, including condoms, frequent screening, decreasing numbers of sexual partners, vaccination for preventable infections, the availability of doxycycline PEP, HIV PEP for sporadic exposures to HIV, and PrEP for ongoing protection. (See 'HIV' above and 'Other sexually transmitted infections' above.)

●Immunizations – All MSM should be immunized for hepatitis A, hepatitis B, and human papillomavirus (HPV). Some men may qualify for meningococcal vaccination based on HIV or immunologic status and in outbreak settings. (See 'Immunizations' above.)

●Screening for anal cancer – Anogenital HPV infection and anal cancer are highly prevalent among MSM (table 3). Guidelines recommend screening all MSM and transgender women with HIV for precancerous lesions or cancer related to HPV infection starting at age 35 and in MSM and transgender women without HIV at age 45. (See 'Cancer screening' above and "Anal squamous intraepithelial lesions: Epidemiology, clinical presentation, diagnosis, screening, prevention, and treatment", section on 'Screening for anal SIL'.)

ACKNOWLEDGMENTS — 

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