Optimizing primary care for men who have sex with men.

OVER THE PAST 2 DECADES, THE LITERATURE ON THE health care needs of gay men and those who may not identify themselves as such, but are men who have sex with men (MSM), has been dominated by issues related to human immunodeficiency virus (HIV) prevention and care. This focus on HIV remains critically important; at least a quarter million MSM are living with HIV in the United States and approximately 20 000 more will likely become infected this year. Nevertheless, the vast majority of MSM are not HIV-infected but still require high-quality medical care that is culturally competent and targeted to their needs. Unfortunately, the most comprehensive articles about the medical care of MSM who are not HIV-infected date from the dawn of the AIDS epidemic more than 20 years ago. Current standard sources of practical medical information for primary care practitioners do not sufficiently address the routine care of MSM. This is true even though the Department of Health and Human Services’ Healthy People 2010, a document produced each decade to outline national health goals for the years ahead, identifies gay men and lesbians as 1 of the 6 most underserved groups. Although it is difficult to quantify precisely how many gay-identified men and other MSM live in the United States, it is clear that they are present in virtually all communities and likely, every primary health care practice. For instance, the US Census in 2000 found same-sex households in more than 99% of counties throughout the country with the highest densities ranging from 5% to 7% of households in many urban centers. Studies that describe the prevalence of male homosexual behavior and sexual identity often vary based on demographic and geographical variables, as well as the fluidity of sexual behavior, desire, and identity in the course of a lifetime. In 1994, Laumann et al found that 2.8% of men identified themselves as gay, whereas 9.1% described having had same-sex sexual activity at some point in their lives. In several urban centers, the prevalence of men with a gay identity was as high as 9.2%, with 15.8% of men reporting some sexual contact with other men since puberty. There have been no population-based studies of non– gay identified MSM; however, while some men will eventually identify as gay, many, particularly individuals from ethnic minority communities, do not choose to identify with gay culture for a variety of reasons, ranging from subcultural tolerance of bisexuality to internalized homophobia or the perception that gay identity is conflated with being white. Outside of the United States and Europe it is even more common for MSM to not identify as gay. Given the range and fluidity of sexual behavior and identity among MSM, it is important for clinicians to recognize the medical implications of sexual behavior, as well as to identify patients whose sexuality may be evolving and who may want help identifying themselves as gay to friends, family, and society, ie, “coming out.” At the same time, physicians and other clinicians must appreciate the need to provide care and support for MSM for whom social and cultural reality may preclude coming out or the desire to do so.