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Dale's Web Pages ONE OUT OF TWO

AIDS and sexually transmitted diseases among men who have sex with men

Review of the literature, by Dale O'Leary

The material presented here was collected by members of the
National Association of Research and Therapy of Homosexuality, NARTH

Table of Contents


PUBLIC HEALTH

Once a test for HIV was developed, it was hoped that those at risk would undergo confidential testing and adjust their behavior accordingly. Early in the epidemic, Dr. Don Francis of the CDC tried to encourage homosexual men to restrict their sexual activity. He suggested to a largely homosexual audience that those who were HIV-positive should go to bed only with others who were positive and those who were negative only with those who were negative. All that was required was that everyone know to which group they belonged. Francis's call to for control on behavior outraged the mainly gay audience.(Shilts p.550)

Many gay opinion leaders actively dissuaded men from being tested.(Ostrow 1994) Ten years after the epidemic began, many homosexual men still didn't know their own or their sexual partners' HIV status. A 1991 study of 121 HIV-positive and 84 HIV-negative gay and bisexual men in New York City revealed that: "About one-third of the subjects do not know the HIV status of even their primary sex partner. A much higher rate must apply to the other partner categories especially one-time and extradomestic partners." In addition, one third of the HIV-positive men and one third of the HIV-negative men engaged in unprotected receptive anal intercourse on at least one occasion. When asked the number of lifetime male partners, the median response was 308.(Meyer-Bahlburg 1991)

Public health measures for controlling infectious diseases have traditionally included:
 

  • Locating the sources of infection – In the case of HIV, it has been established that the infection is spread through contact with the body fluids of infected persons. The testing of high risk groups and individuals has not always been voluntary. Knowing who is infected would help to control the epidemic. Not knowing can be dangerous. For example, 163 health care workers are suspected of having been infected through medical procedures.
  • Informing those at risk – partner identification and notification has been one of the most employed means of controlling STDs. Those infected were asked the names of all their sexual partners and so far as possible all sexual partners were notified and tested.
  • Closing places where infection is spread - During the polio epidemic of the 1950s, swimming pools were closed even though there was no firm evidence that infection was spread by swimming. When meat was contaminated with E. coli, an entire packing plant was closed and millions of pounds of meat recalled even though most was not affected. Bathhouses, adult bookstores, backrooms of bars, and public rest rooms have been identified as places where infection can spread.

In the battle against other contagious diseases, education and self-protection, while important, have never been seen as a substitute for more basic public health procedures. Work toward a cure or vaccine has not prevented basic epidemic control aimed at preventing new infections.
 

CONTACT TRACING

In 1992, more than a decade after the epidemic began, doctors were still trying to win acceptance for contact tracing. In a commentary piece in the New England Journal of Medicine, Willard Cates and Alan Hinman argued that notifying partners of those carrying HIV "can not only provide them with education in risk reduction, but also offer them medical and social referral services if they are HIV-sero positive." They were concerned that even this late into the epidemic "many persons with HIV infection apparently do not disclose their status to their sexual partners."(Cates 1992) Their plea went unheeded.

In 1977 Chandler Burr, in an article in The Atlantic Monthly entitled "The AIDS Exception," pointed out that the "standard public-health measures" used to control other infectious diseases such as typhoid, diphtheria, tuberculosis, and STDs have not been deployed against AIDS. These include: "routine testing for infection, often undertaken without explicit patient consent; reporting to local health authorities the names of those who test positive for infection; contact tracing, or the identification of any people who may have been exposed to the infection; and notification of those possibly infected people that they may have been exposed."

Ralph Frerichs, epidemiologist at the University of California at Los Angeles, expressed concerned that many public-health officials "have remained steadfast in their commitment to programs and approaches that have hidden the identity of HIV carriers but have failed to halt viral transmission." Frerichs says that the current policy grants "rights to the viruses and to the bacteria."(Burr 1997)

Although testing, contact tracing and notification would appear to be the absolute minimum required to stop the epidemic and save lives, homosexual organizations and AIDS groups such as the Gay Men's Health Crisis, the AIDS Action Council, and the National Association of People with AIDS have fought testing programs. For example, in order to monitor the epidemic's effect on children, newborns were tested for HIV but, at the insistence of the AIDS establishment, the mothers were not informed of the results. Wives were not informed when their dead husbands were HIV-positive.

The controversy over testing, tracing, and notification continues. In an editorial in the New England Journal of Medicine, Robert Steinbrook urged mandatory confidential reporting of HIV infection and contract tracing. The AIDS Establishment continued to object. Dr. Kenneth Mayer, director of Brown University's AIDS program warned that mandatory testing would frighten people away from taking blood tests. Marc Paige, an HIV positive AIDS educator, criticized testing and notification, saying that it would discourage people from getting tested.(Carbone 1997)

It appears that Mayer and Paige believe that homosexuals who know they have engaged in high risk activity, know that they may be infected, know that therapy would prolong their lives, and know that they could be infecting others with a serious disease will refuse testing rather than have to reveal their sexual partners.

One of the most disturbing aspects of the epidemic is that from the beginning, men who knew they were carrying the HIV virus and knew that they could infect others continued to engage in unsafe practices without concern for the health of their partners. The most well-known example of this was Patient Zero, the Canadian airline steward who, in spite of repeated warnings from medical professionals, continued to engage in unsafe sex.

AIDS educators have not insisted that those who are HIV-positive have a moral responsibility to inform sexual partners of their HIV status. According to a pamphlet from the Gay Men's Health Crisis, "Safer Sex for HIV Positives":

If you follow [the guideline to use condoms], you don't need to worry about whether your partners know that you're positive. You've already protected them from infection and yourself from reinfection. Just use your judgment about who to tell – there's still discrimination out there.

Rotello criticizes this approach because "implicit in this advice (aside from the assumption that HIV-positive men will continue to have multiple partners) is the idea that the risk of discrimination to the infected person is as serious, or even more serious, than the risk of infecting one's partners."(Rotello p. 107)

In the 1997 session of the US Congress, Tom Coburn of Oklahoma introduced a bill which would require states to inform anyone who has been exposed to HIV that they are at risk. It would require that all people accused of sexual offenses be tested for HIV. And it would allow health-care providers to test a patient for HIV before performing a risky invasive medical procedure. The AIDS Action Council denounced the bill as an attempt to "stigmatize and punish people living with HIV/AIDS."

Those opposing contact tracing have been supported by some of the government officials assigned the task of controlling the epidemic. In a response to the Burr article, Dr. Helene Gayle of the CDC wrote:

The CDC actively supports community-based decision-making about HIV-prevention programs. Our experience has shown that HIV prevention works best if it is designed and implemented in cooperation with the communities affected, rather than being mandated from the federal level.(Gayle 1997)

A CDC official may receive less grief from the activist groups by surrendering to activists' demands, but the evidence suggests that the HIV prevention programs designed by the homosexual community have not stopped HIV transmission in the past. There is no reason to hope these programs will work in the future.

Local public health officials, whose main concern is controlling a deadly virus, were frustrated when every strategy they suggested met with fierce resistance. In the beginning of the epidemic, they had to fight to close bathhouses which catered to an exclusively homosexual clientele even though these were clearly a place where the infection was being spread. The homosexual community claimed that the effort to close these establishments was potentially discriminatory. They defended the bathhouses as places where AIDS education would go on and condoms would be available.

Eventually, many commercial sex establishments were closed. But recently there has been a resurgence of commercial sex businesses. In 1997, when a bill that would finally close bathhouses in California was under consideration in the state legislature, the Executive Director of California's Lesbian/Gay and AIDS Lobby resurrected the argument that closing the bathhouses was counterproductive, arguing in a post on the internet that:

Bathhouses provide access to a population that needs HIV prevention education. We should be putting our efforts toward prevention and education, and not grandstanding on issues that would drive at-risk individuals underground.

There is no evidence that the bathhouses serve an essential educational function and ample evidence that, by providing a venue where homosexual men can engage in multiple sexual acts with different partners on the same evening, they were the crucial element in creating the AIDS epidemic:

According to the CDC interviews, the first several hundred gay men with the disease had an average of 1,100 lifetime partners, which means that some had far more. For most, this level of activity was possible only because of commercial sex institutions.(Rotello p.62)

There is also no evidence that homosexual men who are denied this opportunity would be able to engage in the same behavior with the same numbers of partners in non-commercial settings.
 
 

UNIVERSAL PRECAUTIONS

Those in the AIDS education movement had their own ethic of prevention: those who were clearly at high risk had no obligation to be tested, to discover their test results if they were tested or, if they discovered they were positive, to inform their past, present or future sexual partners. The AIDS establishment defended the right of infected persons to remain ignorant of their condition and the right of infected persons to conceal their contagious condition from others, including sexual partners and health care personnel. AIDS educators insisted that universal precautions woul d control the epidemic. Everyone was to assume that everyone else was HIV positive and use barriers during all sexual contact and medical procedures involving the possibility of fluid exchange.

Any suggestion that the infected might have a duty toward others was greeted with scorn. For example:

To mark the occasion of the city's [N.Y.] 50,000th AIDS case, efforts were made to launch a prevention campaign that would focus on protecting others as well as oneself. Those efforts were aborted when AIDS specialists inside the health department denounced the proposal as "victim blaming."(Bayer 1996)

In an opinion piece in the New England Journal of Medicine, Ronald Bayer explains why prevention efforts have focused on self-protection rather than the duty to protect others:

It was considered crucial to articulate an ideology of solidarity, one that rejected as divisive all efforts to distinguish the infected from the uninfected. Such distinctions, it was feared, would lead to "viral apartheid." Solidarity was endangered to the extent that the infected were held to have special duties... Cohesiveness could best be grounded in the concepts of universal vulnerability to HIV and the universal importance of safe sexual practices.(Bayer 1996)

Bayer called for a re-examination of the self-protection ethic and a reconsideration of the ethic of personal and moral responsibility toward others.

The strategic decision to ignore proven public-health methods for controlling an epidemic has been more than amply documented by homosexual writers Randy Shilts and Gabriel Rotello. Some homosexuals have even complained that the ethic of universal precautions is excessive. Dr. Walt Odets criticizes AIDS education programs for being too concerned with physical survival, too sex-negative, and homophobic.

Among homosexual activists preserving the gains of the sexual liberation movement took priority over preventing HIV infection. According to Rotello, many of the homosexual men involved in AIDS education believe: "the proper of goal of AIDS prevention is 'to defend the gay sexual revolution.'" For these men, "Gay liberation was founded on a 'sexual brotherhood of promiscuity'," and "any abandonment of that promiscuity would amount to a 'communal betrayal of gargantuan proportions'." Edward King, author of Safety in Numbers, called on AIDS educators "to encourage condom use rather than attempt to persuade them to abandon anal intercourse." He argued that: "AIDS educators have a responsibility to aim only for the minimum necessary changes in individuals' lives which are needed to reduce the risk of getting AIDS."(Rotello p.109)

The fear of a long, painful illness and almost certain death should have motivated homosexual men to refrain from risky sexual activity, but the homosexual community reacted to the crisis by concealing the horror of the final stages of the disease and romanticizing HIV infection:

A stranger to gay culture, unaware of the reality of AIDS, might believe from much of the gay press that HIV infection was a sort of elixir that produced high self-esteem, solved long-standing psychological and substance abuse problems, and enhanced physical appearance...creating the subconscious impression that infection – the "penalty" of unsafe sex – is really not so bad after all.(Rotello p.241)

HIV-positive status was portrayed in some homosexual publications as more fun. An editorial in Steam, a magazine for homosexuals, quotes a man who has been positive since the early years of the epidemic: "I'm so sick and tired of these Negatives whining about how difficult it is to stay safe. Why don't they just get over it and get Positive." According to Scott O'Hara, Steam's HIV-positive editor: "One of my primary goals is the Maximization of Pleasure, and just as I believe that Gay Men Have More Fun, so too do I believe that Positives have learned to have much more fun than Negatives. I'm delighted to be Positive. . .The Negative world is defined by fear, ours by pleasure." (Rotello, p. 242)

Those who have died of AIDS have been memorialized as martyrs. Rather than calling for changes in the behaviors which led to these deaths, the AIDS establishment blamed the general public for not finding a cure, or funding education, or for causing homosexuals' low self-esteem.
 
 

MONOGAMY UNLIKELY

While many studies focus upon the percentage of homosexual men engaging in unprotected anal intercourse, several studies show that the number of sexual partners was a better predictor of AIDS status.(Winklestein 1987, Moss 1987, Goedert 1984, Kingsley 1987) The more sexual partners, the more likely a man will be HIV-positive. The first AIDS victims averaged over 1,000 partners; some victims admitted that they had over 2,500. One study found that 16% of those who said that they always used a condom during receptive anal intercourse were HIV-positive. The authors blamed this on the fact that:

The potential benefit of condom use was lessened by the tendency of condom users to be those men with the highest number of partners and the greatest frequency of receptive anal intercourse. In accord with most previous studies of risk factors for HIV, number of receptive anal intercourse partners, even without accounting for condom use, was the strongest risk factor for infection.(Osmond 1994)

The relationship between number of partners and HIV infection has led many to encourage homosexual men to enter into monogamous relationships. Rotello proposes providing an inducement to monogamy by allowing homosexual marriage and adoption of children. This, he argues, would provide an incentive for homosexual men to give up the promiscuous life style.

Unfortunately there is no evidence that those most at risk are interested in adopting a faithful, monogamous lifestyle. In a study of 601 men visiting an STD clinic, Doll and associates found that although 50% had primary relationships, only 22% had sex with just one partner, and only 10% were in relationships concordant for HIV-antibody status. The authors concluded:

Like previous studies, we found that partners in steady relationships... continued to engage in unprotected anal contacts...the majority of these steady relationships were not monogamous or between partners concordant for HIV-antibody status. Furthermore, results showing that persons with more steady partners engage in higher levels of high-risk behavior suggest that familiarity with a partner may lead an individual to assign a lower level of risk to sexual contacts without factoring in previous level of sexual activity.(Doll 1991)

In a study of 310 homosexual men, one third of the participants reporting unprotected intercourse in the previous year said that they had done so only in the context of a relationship in which they believed neither they nor their partner had had unprotected sex with anyone else. However, only a minority of these men (15%) also knew their partners' HIV status.(McLean 1994)

In 1990, Raymond Berger published a study in which he queried 92 males couples who were highly committed to monogamy. When asked about condom use, 4% said they used them sometimes and 69% said they did not use condoms. The author concluded:

These figures are not comforting. Almost half these couples were not using safe sex. AIDS education experts caution even those in monogamous relationships to practice safe sex. Repeated exposure to a single partner increased risk because the greater the number of contacts (particularly those involving receptive anal intercourse) the greater the likelihood of infection. In addition, an infected but asymptomatic partner may become more ineffective with time. Monogamy then is no guarantee of safety from AIDS.(Berger 1990)

Most homosexual men in relationships do not choose complete sexual exclusivity. David McWhirter and Andrew Mattison studied 156 homosexual males couples and reported the results in The Male Couple: How Relationships Develop. They found that none achieved long-term sexual exclusivity:

Ninety-five percent of the couples have an arrangement whereby the partners may have sexual activity with others at some time under certain conditions. Only seven couples have a totally exclusive sexual relationship, and these men all have been together for less than five years. Stated in another way, all couples with a relationship lasting more than five years have incorporated some provision for outside sexual activity in their relationships. (McWhirter p.252)

McWhirter and Mattison found that sexual exclusivity is something which is most male couples eventually dispense with:

Our culture has defined faithfulness in couples always to include or be synonymous with sexual fidelity, so it is little wonder that relationships begin with that assumption. It is only through time that the symbolic nature of sexual exclusivity translated into the real issues of faithfulness. When that happens, the substantive, emotional dependability of the partner, not sex, becomes the real measure of faithfulness. (McWhirter p.253)

A number of other homosexual writers have defended sexual infidelity among homosexual men as a positive aspect of their relationships, including homosexual marriage advocate Andrew Sullivan:

Same-sex unions often incorporate the virtues of friendship more effectively than traditional marriages; and at times, among gay male relationships, the openness of the contract makes it more likely to survive than many heterosexual bonds...there is more likely to be greater understanding of the need for extramarital outlets between two men than between a man and a woman. But something of the gay relationship's necessary honesty, its flexibility, and its equality could undoubtedly help strengthen and inform many heterosexual bonds. (Sullivan p.202)

Since homosexual men in committed relationships don't always have the same HIV status, don't always ask a partners his HIV status, are less likely to use condoms, but highly likely not to be sexually exclusive, and not always completely honest about the lapses, the risks are substantial.

In August of 1997, the CNN's newsmagazine Impact ran a segment on the homosexual party scene called "Sexual Roulette. A 21-year-old homosexual male was interviewed. He had been in what he thought was a faithful relationship. After he and his partner had tested HIV-negative, they engaged in unprotected anal intercourse. Although he had done everything according to rules, a few days after his 21st birthday the young man tested HIV-positive. His partner had been cheating on him, acquired HIV, and infected him.
 
 

ORAL SEX

Safe sex education has concentrated on promoting condom use during anal intercourse. This has led many homosexual men to conclude that oral sex is safe and to adjust their behavior accordingly. There are a number of forms of the human immunodeficiency virus, (A, B, C, etc.), but only one, HIV-B, has been detected in the US. There is evidence that HIV of the B variety prefers the tissues of the anorectal area to the mouth or genitals, but there are numerous cases of oral and genital transmission of HIV-B. In 1997, a case of transmission by deep kissing was reported. Both partners reported having bleeding gums at the time transmission was suspected.

A number of studies report HIV infection in the homosexual men who denied engaging in anal intercourse. (Lifson 1990; Rozenbaum 1988; Murray 1991; Lane 1991; Keet 1992). The problem with all these studies is that they all begin with the assumption that if an HIV-positive man ever engaged in receptive anal sex, he acquired the infection through that activity. Keet and associates admit that they began with the premise that HIV infection was transmitted through anal sex: "Orogenital transmission was considered to be the possible transmission route if receptive anogential intercourse was consistently denied." Even then, Keet et al seem unwilling to definitively accept the findings of their own study: "We conclude that orogenital transmission of HIV does appear to occur, but a psychological barrier in reporting the practice of anogenital receptive intercourse may lead to an overestimation of the transmission rate." (Keet 1992) It could also be argued, that classifying all cases of HIV infection in which the person engaged in both oral and anal sex as always due to anal sex could lead to an underestimation of the oral transmission rate.

There is ample evidence that dangerous incurable infections can be acquired through oral sex:. These include oral gonorrhea, herpes, cytomegalovirus, Epstein-Barr virus, and hepatitis:

The common wisdom then and now has been that these diseases are insignificant, mild and easy to cure, and that they didn't have much to do with AIDS. But the common wisdom is largely wrong. Herpes remains incurable in all its forms, as do Epstein-Barr Virus and CMV. Gonorrhea has mutated into a deadly and incurable antibiotic-resistant strains. Hepatitis remains a killer and although a highly effective vaccine is now available, very few gay men have taken it.(Rotello p.105)

While unprotected oral sexual activity is a less efficient means of transmitting HIV, oral-genital transmission is possible and therefore calling oral-genital sex "low risk" may lead some homosexual men to believe that it is "no risk" which is certainly not the case. Martin and Hasin, in a study of the sexual behavior of 604 homosexual men, compared "high risk versus low risk sexual behaviors." Unprotected receptive anal sex was considered high risk. "In contrast, receptive or insertive oral-genital sex, with or without a condom, has not been shown to carry a high degree of risk of HIV infection, and thus is considered by many gay men to be low risk." Given this perception it is not surprising that Martin and Hasin found that the men in the group studied reported engaging in receptive oral sex a average of 36.7 times during the last year of the study. According to the report: "Although we inquired about oral-genital sex with or without a condom, the use of condoms during oral sex was too rare to generate stable estimates." (Martin 1991) Non-condom use would substantially increase the risk.

In one of their studies, Kelly and associates found over a two-month period "35 percent of the sample reported unprotected insertive, and 29 percent in receptive, oral intercourse with fluid exchange." (Kelly 1990a)

In a study of sexual risk behavior of 121 HIV positive and 84 HIV negative homosexual and bisexual men in the New York City area, approximately 75% engaged in oral sex without a condom. 15.3% of the HIV negative men reported oral contact with semen. (Meyer-Bahlburg 1991)

In the Canadian study of 612 homosexual men, 88.4% reported engaging in oral sex, 26.8% said that they engaged in receptive oral sex which included exposure to their partner's semen. (Myers 1992a )

HIV, type E, is found primarily in southeast Asia. It appears to be more easily transmitted by genital sex and transmissible from women to men. It is possible that HIV, type E might be transmissible through oral sex or that another variety of HIV might appear which is adapted to transmission through oral sex, in which case those who practice oral sex would be at substantial risk.


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Original text on Dale's Disk — aids4.rtf - Oct.14, 1999
Reformatted to HTML — 2000 10 21, —WHS