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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


GOOD NEWS, BAD NEWS

As it has become increasing clear that "safe sex" or "safer sex" is not stopping the epidemic, many in the field looked toward the possibility of a cure or a vaccine. New combination therapies involving protease inhibitors appear to be successful in reducing the viral count and eliminating the symptoms of AIDS in some patients. They appear less successful at restoring the T-cell level (the indicator of a healthy immune system) to normal. Researchers do not yet know if the virus can hide in nerve cells and reappear later. These combination drug therapy regimes are also extremely demanding. Some patients must swallow as many as 60 pills a day. Skipping just a few doses can be a fatal step because it can allow drug resistant strains of HIV to take over. Those treating AIDS worry:

Development of resistance to drugs does not make the virus more virulent but increases the difficulty of treating HIV. So a deep concern is that individuals who develop protease-resistant strains will transmit them to others. If this happens often enough, the resistant strains could create a significant public health problem. (Altman 1997)

It is important to understand why those who work on the AIDS problem are extremely concerned about drug resistant strains of HIV. They know that men who have AIDS, who are in these intensive drug therapy programs, and who have been just been saved from death, are probably going to go out and put other people's lives at risk either by engaging in unprotected sex or through a condom failure. There would be no danger from resistant strains if all those treated agreed to refrain from behavior which could spread the virus. There is no reason, however, to believe that they will do so voluntarily, and currently there are no follow-up programs to see if they have infected others with resistant strains of HIV.

From the beginning of the epidemic the homosexual community has been looking for a magic bullet which would cure AIDS the way antibiotics cured syphilis – a simple treatment that would make safe-sex practices unnecessary. A number of the studies reviewed here reveal that one of the reasons homosexual men have continued to engage in unsafe sex was because of their belief that by the time they contracted the disease there will be a cure.

President Clinton has called for increased funding for research to find a vaccine which will prevent AIDS. While some initial research is encouraging, a tested vaccine is years if not decades away, and even then, given past experience with the hepatitis-B vaccine, it is possible that the majority of at-risk homosexuals may not choose to be vaccinated.
 
 

AIDS ISN'T THE ONLY KILLER

While the HIV/AIDS risk dominates the media, physicians recognize the continued threat of STDs other than AIDS. AIDS victims are prone to opportunistic infections, including those which are sexually transmitted. An opportunistic infection is one which would be relatively harmless in a person with a normal immune system, but life-threatening in a person whose immune system as failed. All the diseases which were a problem before the epidemic are still out there. Their presence may cause complications for those infected with HIV. The gastrointestinal complaints, which were a common complaint among gay men before the AIDS epidemic, can cause a life-threatening diarrhea in a person whose immune system has failed. Herpes becomes a serious health concern in a HIV-positive person. The spectrum of possible infectious agents increased and now include Cryptosporidium, Mycobacterium, Avium-intracellularis, and Isopora belli. Doctors are also concerned that the various cancers seen in HIV-positive patients may be related to viral infections which can be transmitted.(Rompalo 1990) For these reasons, HIV-positive persons are warned against unsafe sexual practices, even with other HIV-positive persons.

At the beginning of the AIDS epidemic, behavioral changes by homosexual men had resulted in a 14.9% drop in reported cases of syphilis (1982 to 1984), and an even greater decline in incidence of gonorrhea (95% from 1982 to 1988). There was, therefore, concern when a "study from the Baltimore City Health Department STD clinics reported that homosexual men accounted for a high proportion of syphilis cases in 1988. In a more alarming report, these clinics also showed a high recidivism rate for STDs among patients who were diagnosed HIV-sero-positive and intensively counseled." If these clients were getting STDs from their sex partners, there is a strong possibility that they were giving their sex partners HIV infections. Dr. Rompalo, an expert in the field, has expressed concern that "despite safer sexual practices and profound changes in lifestyle, STDS remain a major health problem for some homosexual men."(Rompalo 1990) A study in Washington state found that, after an eight year decline (1980 to 1988), cases of sexual transmitted diseases among homosexual men were again increasing. Rectal gonorrhea cases had fallen from 955 in 1982 to 33 in 1988. In 1989, they rose to 102.(Handsfield 1990)

Syphilis is also a recurring problem. In 1999 an outbreak was linked to homosexual chatrooms:

Health officials tracking an outbreak of syphilis cases have followed the virus into cyberspace, identifying an Internet chat room as ground zero for infection. Jeffrey Klausner, director of the sexually transmitted disease unit at the San Francisco Department of Health, said investigators quizzing the last seven homosexual men reporting syphilis infections were surprised to find that all seven found their most recent sexual contacts through a chat room on America Online : SFM4M, or San Francisco Men-For-Men.

The outbreak rang alarm bells for Klausner, who noted that venereal diseases like syphilis can boost a person's vulnerability to HIV, the virus which causes AIDS. Clearly, the remaining visitors in the SFM4M needed to be warned – but how to fight a cyberspace health threat in a chat room where anonymity is prized and people are known only by their on-line nicknames?

"The challenge for us has been to contact, notify and inform individuals (when) we only have their Internet screen handles," Klausner said Monday. America Online declined to alter its privacy policy and reveal the identities of the chat room regulars, but it did put Klausner in touch with PlanetOut, an online gay and lesbian community.

"The health department did contact us looking for advice on how to use the online medium to deal with this public health issue," said Rich D'Amato, an AOL spokesman.

PlanetOut staff spent two weeks visiting the chat room and warning users about the outbreak, urging them to take syphilis tests and to practice safe sex.

While the chatters' anonymity has been protected, officials hope they have got the message. Klausner said the experience has been an eye-opener, and that future public health campaigns would certainly take into account the growing role that the Internet plays in human relationships.

"We've learned that Internet contacts are an important sexual network," he told the San Francisco Examiner Monday.
 

In the Netherlands, once considered to be the model for successful AIDS education, disturbing trends have also been noted:

After several years of decrease, the number of cases of (anorectal) gonorrhea among homosexual and bisexual visitors to sexually transmitted disease clinics in Amsterdam was found to rise. In addition, in 1990 an unexpected increase was noted in the incidence of human immunodeficiency virus (HIV) infection among generally well-informed participants in the Amsterdam Cohort Study.(de Wit 1993)

RATIONALIZATIONS

Why are some homosexual men acting with such careless disregard for their own lives? Annick Prieur sought to answer that question by interviewing 17 Norwegian men who had unprotected anal intercourse with at least two different partners during the last year without knowing their own or their partners' HIV status. According to her report for these 17, sexuality was the main way they achieved close contact with other people. For them, safer sex is experienced as "emotionally colder, as expressions of distrust, and as a reminder of death." These men believed that a condom sends "a negative message."(Prieur 1990) Of the 17 men, 6 said that they had sex with over 1,000 partners. These high-risk men "use rationalizations to overcome anxiety" convincing themselves that what they are doing is not dangerous or that a cure will soon be found. Prieur attributes some of this risk-taking to a passivity toward sexuality. She cites the case of a 19-year-old, who began experimenting with gay sex when he was 15. He said: '"I've never brought a condom when I've been with somebody. But it's happened that my partners had one used one. But I don't think too much about it."

Prieur feels that homosexual sex is a language of communication and that lack of language leads to contempt for homosexual sex which is a particular problem for homosexuals because, according to Prieur: "All gay men have had to fight feelings of contempt for the sex that they participate in." She points out how difficult it is to have "your entire sex life labeled as something dangerous."

She concludes her report:

When we started this research, some of us were surprised that gay men still had unsafe sex. Why can't they change their sex life, it must be more important to survive than to keep on having sex in the same way as before... We hope that this has served to show that unsafe sex is also rational behavior, and also that a wider understanding of rationality is needed.(Prieur 1990)

The more that one understands the motivations for unsafe behavior, the more unlikely it appears that education can stop the epidemic; for it is not ignorance that drives the epidemic, but the inherent dynamics of homosexual sexuality.

In their book After the Ball, homosexuals Marshall Kirk and Hunter Madsen explain the addictive nature of male homosexual activity. As with the alcoholic and drug addict, the homosexual must increase the stimulus to achieve the same high:

As one gains experience, vanilla sex with one partner becomes familiar, tame, and boring and loses it capacity to arouse. At first the increasingly jaded man seeks novelty in partners, rather than practices, and becomes massively promiscuous; eventually, all bodies become boring, and only new practices will thrill. Two major avenues diverge in this yellow wood, two nerves upon which to press: that of raunch and that of aggression. (Kirk p.304)

Kirk and Madsen go on to describe behaviors which are to say the least unsanitary. They appear to be speaking from experience.
 
 

PATHOLOGY

Urvashi Vaid, former executive director of the National Gay and Lesbian Task Force, looks forward to a time when the world accepts "homosexuality as morally, politically and socially equal to heterosexuality."(Vaid p.3) If the homosexual rights movement's goal is to create a society in which homosexuality is regarded as healthy, natural and normal, then the AIDS epidemic clearly undermines that objective. As Rotello points out:

Who wants to encourage their kids to engage in a life that exposes them to a 50 percent chance of HIV infection? Who even wants to be neutral about such a possibility? If the rationale behind social tolerance of homosexuality is that it allows gay kids an equal shot at the pursuit of happiness, that rationale is hopelessly undermined by an endless epidemic that negates happiness. . . an endless AIDS epidemic would essentially hand anti-gay forces their greatest gift: seeming proof that liberated homosexuality inevitably leads to disease and self-destruction. (Rotello p.286)

Rotello argues that the homosexual community must face the facts and make behavioral changes which will reduce the risk of infection. The homosexual community has not only rejected this kind of advice in the past, but has condemned those who suggested change as anti-sex and homophobic. Homosexual playwright Larry Kramer made the same suggestion before the epidemic began and was roundly criticized for his efforts.
 
 

SEXUAL LIBERATION MORE IMPORTANT THAN LIFE

Walt Odets has been an outspoken critic of those who call on homosexuals to make radical changes in their sexual behavior. For Odets, if it is a choice between anal sex (and other high risk practices) and life, homosexual men should feel free to choose anal sex and take their chances. [He] holds that the efforts to control the epidemic should be directed toward "harm reduction." Odets does not expect harm reduction to eliminate transmission completely. He writes, "the epidemic is not an aberration in our lives, but a permanent form of life." According to Odets the reduction of HIV transmission should "only be the secondary task because it must be built on the foundation of lives experienced as worth the trouble." He condemns those who "are not addressing the human needs of the gay community by offering or insisting upon biological survival as an exclusive and adequate purpose for human life."

While Odets insists that he wants to reduce the harm caused by epidemic, he also insists that the values of the homosexual community cannot be sacrificed so that individuals can live what he regards as meaningless lives:

Survival must include the idea of meaningful, human survival for a community that has traditionally been scorned or punished for the way it makes love, communicates intimacy, and creates human bonds." (Odets 1994)

According to Odets:

If biological survival is considered the essential purpose of human life, then motivations to engage in unprotected sex – which assuredly offers the possibility of shortened life – will be understood as pathological. If the possibility of other essential values and purposes are accepted, values that are not about longevity but about the content or quality of life, then unprotected sex might not be considered pathological. (Odets 1995, p.205)

Odets points out that the model for prevention, which has not changed since the beginning of the epidemic, is a "social-marketing model that espouses information and education as the foundation of behavioral change, and the establishment of 'social norm' or 'community standards of behavior' to motivate implementation of new behaviors." Odets condemns this model as "simplistic," "incompetent," and "responsible for a considerable psychological damage to gay men." (Odets 1994)

Odets criticizes AIDS education advocates for holding on to the illusion that education had "worked at one time and should work again." He does not believe that this approach has ever really been successful. (Odets 1994)

Odets' writings reflect his own internal conflicts. He sees the suffering, he doesn't want to see homosexuals die, but he appears willing to accept a certain number of deaths if that is what it takes to defend the homosexual lifestyle. He acknowledges the psychological dynamics that drive homosexual men to dangerous behavior, but blames society for making homosexual men feel bad about themselves. For Odets, "people are not having unprotected sex because they have been drinking, they have been drinking in order to have unprotected sex." When one of his clients confesses to being "addicted to sex," Odets tries to convince the client that he is mistaken.
 
 

SUICIDE-BY-AIDS

While Odets does not explicitly endorse risk taking, he identifies "intelligible reasons" for what amounts to suicide-by-AIDS:

Because AIDS is such an available and psychologically meaningful way for a gay man to not survive, it is surprising how difficult it has been for us to acknowledge that some men engage in unprotected sex for precisely that purpose. There are many psychologically intelligible reasons men might not wish to survive the AIDS epidemic. They include depression, anxiety, guilt, including guilt about surviving; lives emptied by loss, isolation, and loneliness; the loss of social affiliation and psychological identity; and the anticipation of a future that holds more of the same. (Odets 1995, p.206)

Odets equates the homosexuals' suicide-by-AIDS with the heroic sacrifices of doctors and nurses who risk their lives in a plague, captains who go down with their ships, and soldiers who run headlong into enemy fire:

The death need not, aside from its personal and social meanings, contribute anything. That the gay man, profoundly identified with his community, often feels such allegiance and identification is understandable...for some gay men a death by AIDS will continue to serve as an important and meaningful expression of identity and allegiance. (Odets 1995, p.207)

He quotes a homosexual man who was disappointed to discover he was HIV-negative as saying, "I'd rather be alive today and really living my life, and dead next month than be dead and walking around for the next forty years.(Odets 1995, p.218) Odets insists that a line can be drawn between what is medically pathological and what is psychologically pathological, "Tumor growth in the brain is pathological in all cultures, while suicidal feelings, as an example, are not." (Odets 1995, p.204)

Odets promotes utilizing therapy groups to help HIV-negative men deal with their feelings of being left out. These groups focus on affirming homosexuality as positive and overcoming the men's own negative feelings toward their homosexuality (internalized homophobia). The assumption on which this therapy is based is that the negative feelings are irrational, caused by society's oppression of homosexuality, and need to be changed. But there is another equally plausible conclusion: the men are correct in feeling uncomfortable with their homosexual behavior. They are correct in wanting to be free from the internal psychological forces which drive them to compulsive and dangerous behaviors. It is possible that this so-called "internalized homophobia" is the sign that the homosexual wants to find a way out of homosexuality.

Engaging in sexual activity known to spread disease with a large number of different partners, with partners whose name one doesn't know, while under the influence of drugs and alcohol, without knowing one's own or one's partners' HIV status can hardly be considered well-reasoned. Therapists, like Odets, who justify this behavior are doing their clients no service

There are a large number of rational reasons why a man might want to be free from same-sex attraction and behavior, not the least of which is the constant threat of disease.
 
 

SOLUTIONS

Over 100 journal articles were reviewed for this report. It is clear from these studies that as long as boys continue to become part of the homosexual community, the epidemic will continue and probably at the current rates. Unless a radically new approach is adopted, one out of two men who have sex with men will become HIV-positive and/or infected with other serious STDs.
 

The Possibility of Change

There is another answer which should at least be explored – the prevention of same-sex attraction and therapy for same-sex attraction. There are experienced therapists who are convinced that same-sex attraction is a symptom of a developmental disorder which is treatable and preventable. (Satinover 1996, Nicolosi 1991, Socarides 1995) The National Association for Research and Therapy of Homosexuality recently completed a study of 850 individuals struggling with homosexuality. Before treatment, 68% perceived themselves to be exclusively or almost entirely homosexual. Another 22% said they were more homosexual than heterosexual while only 2% perceived themselves as exclusively or almost entirely heterosexual. After treatment only 13% perceived themselves as exclusively or almost entirely homosexual and 33% perceived themselves as exclusively or almost entirely heterosexual. Ninety-nine percent of the respondents felt that therapy could be valuable and effective. (NARTH 1997)

From a public health standpoint, there are undeniable advantages to making therapy for homosexuality readily available for every man who want to explore that option. Even if therapy is not totally successful in allowing the man to establish a fully heterosexual life, therapy and support groups can help men experiencing same sex attraction to resist the sexual compulsions and overcome the addictive behaviors which can lead to infection. Therapy can also assist a man in developing healthy, intimate, non-erotic male friendships which can sharply reduce the desire to seek out male/male sexual encounters.

Unfortunately, professional organizations such as the American Psychological Association are under increasing pressure from homosexual groups to declare therapy for homosexuals unethical. Various homosexual groups have mounted a massive public relations campaign aimed at convincing the public, in general, and homosexuals, in particular, that homosexuality is a permanent, unchangeable condition. They go so far as to challenge the experience of the many individuals report changing. Groups which assist men who wish to leave the homosexual life are continually under attack.

Not all homosexual adults want therapy, but many adolescents experiencing same-sex attraction initially react negatively to the idea that they may become homosexual. According to one study, for about 27% this regret continues in to adulthood and 29% at one time considered discontinuing homosexual activity. (Bell 1978)

In many cases, the symptoms of future problems can be identified before a boy reaches puberty and appropriate interventions can reduce the probability that he will engage in same-sex behavior as an adult. (Newman 1976) While not all adult homosexual men had identifiable gender identity problems in childhood, in one study about 80% of boys who were diagnosed with Gender Identity Disorder (GID) in childhood were later classified as bisexual/homosexual. (Bradley 1997) According to Bradley and Zucker, who have worked extensively with GID children, while treatment of GID may prevent future homosexuality and parents may choose it for that reason, it offers immediate benefits – increasing the boy's self-esteem and comfort with his own maleness. Zucker and Bradley have expressed concern about the pressure put on therapists not to treat GID children:

Despite political pressures that come largely from outside the domain of child psychiatry, it is important that efforts continue to explore the best ways to assist individuals with GID to resolve their acute sense of unhappiness and to develop the skills to live with comfort in their families and amidst their peers. (Bradley 1997)

Currently, parents, school counselors and therapists are told that the best thing they can do for a boy struggling with his sexual identity and orientation is to encourage him to "accept" his homosexuality as inevitable and "come out as a homosexual," but these boys "come out" into a community where illness and early death are the norm. In the face of the overwhelming evidence that one out of two of these of the young men will eventually become HIV positive or infected with other dangerous, incurable or drug resistance diseases, such advice is indefensibly negligent.

They have a right to know that they have another choice.


Postscript: Since this report was completed it is clear that the Second Wave of infection is sweeping through the homosexual community. These new infections are the result of out of control drug use, wild parties, and the belief that a cure is just around the corner. The following is taken from an article which appeared in the New York Times:

In a report released Thursday, the Centers for Disease Control and Prevention said complacency caused by medical advances and improved H.I.V. drugs were at least partly responsible for an increase in risky sexual behavior among gay men, and particularly among young gay men.

The report said the number of gay men in San Francisco who reported having unprotected anal sex increased to 39 percent in 1997 from 30 percent in 1994. Those who said they had unprotected sex with multiple partners grew to 33 percent from 24 percent, with men 25 and under accounting for the largest increase.

Those who are using recreational drugs, typically young men in their 20's and 30's, often are also those most susceptible to complacency, said Helene D. Gayle, director of the National Center for H.I.V., S.T.D. and TB Prevention, an arm of the disease control agency in Atlanta.

That age group tends to use alcohol and recreational drugs most aggressively, often to escape the stigma and confusion associated with their newly embraced homosexuality, Dr. Gayle said. Because they have come of age at a time when the death and debilitation caused by AIDS is less visible in the United States than it once was, young gay men are also more likely to ignore warnings about the perils of unsafe sex, she said.

And last week, AID Atlanta kicked off an aggressive new educational campaign on the nexus between drug use and unsafe sex. The group grew concerned after seeing a 50 percent increase last year in H.I.V. tests that yielded positive results, to 2.7 percent of 4,144 tests in 1998 from 1.8 percent of 4,290 tests in 1997.

AID Atlanta has produced a series of seven advertisements that will appear in gay publications and as posters in gay bars and clubs. "Taking risks with drugs or alcohol means your sex could be risky too," one typical ad says.

The group kicked off its educational effort last Wednesday night with a forum called "Buzzed: A Gay Men's Forum on Party Drugs," which was held in the auditorium of an Atlanta high school. Some 70 people attended, and the discussion clearly illuminated the severity of the problem. All of the questions asked by audience members concerned the pharmacology of various drugs. None concerned H.I.V.

"Can you take ecstasy and anti-depressants at the same time?" one person asked.

"Is it possible to have a chemical dependence on ketamine?" another asked.

Although the speakers at the forum made a point of not moralizing about drug use, they said after the event that they were disturbed by the cavalier attitudes of the questioners.

"The crowd was thinking about what they could use to cause the least amount of damage and get the best high," said Charles R. Dickey, an Atlanta psychotherapist who served as a panelist. "Today's young folks did not grow up in the trenches of watching people die," said Dickey, whose clientele is predominantly gay. "They don't see Kaposi's sarcoma. They don't see people wasting away. Back in the old days, when people were dropping like flies, there was real fear. Now people think H.I.V. is no big deal, that it's like diabetes. You take some pills and it's no problem.

Dr. Lee R. Anisman, an Atlanta physician who treats a large number of gay patients, said he saw a significant correlation in his practice between substance abuse, unsafe sexual behavior and an increased prevalence of H.I.V.

"I hear it every single week," Dr. Anisman said. "There are so many people who come into my office and say, 'I was out this weekend, I got high on cocaine, I was high on GHB, I was high on acid, I was at a sex party with tons of different guys, none of them were using rubbers, and I have no idea what happened to me.' "

Because states are required to collect data on AIDS but not on H.I.V., it is unknown whether H.I.V. is on the rise among gay men. But several recent studies, including a number that have found alarming increases in cases of gonorrhea in gay men, suggest that both the prevalence of H.I.V. and of risky sexual behavior remain high among young gay men.

"In my travels around the country, I've encountered a number of young gay men who are cavalier in their attitude about both recreational drug use and H.I.V. risk," said Daniel Zingale, executive director of AIDS Action, a national advocacy group. "We saw one generation of gay men nearly decimated, and to see a new generation complacent about it is just disheartening." (Sack 1999)

Of even more concern is the fact that the virus is mutating and becoming resistant to the newer drugs and that men infected with HIV and on medication are engaging in unprotected sex and spreading resistant strains of the virus to uninfected men. The following is a news report from the 1998 AIDS conference:

Geneva: Scientists have found for the first time that strains of the AIDS virus resistant to protease inhibitors and other widely used AIDS drugs can be transmitted from one person to another, it was reported Tuesday at the 12th World AIDS Conference.

Only two individuals with such multiple-resistant HIV have been identified so far. But the cases have started many because they are the first involving transmission of strains of HIV resistant to protease inhibitors, which sparked a revolution in treatment two years ago.

Scientists did not believe that such highly mutated viruses were capable of passing from person to person. the finding that they are indeed able to do so has potential implications for people who may become infected, experts said. "This should be a wake-up call for people who continue high-risk practices with the expectation that they can be easily treated if they become infected," said Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious disease.

As many as one in six newly infected individuals now contracts viruses resistant to the older AIDS drugs, such as AZT.

A recent study showed that only 60% of patients took most or all of their AIDS drugs over a seven-day period.

As a result, up to 50% of some groups of patient have viruses in their bodies resistant to many drugs.

Dr. Frederick Hecht of UC San Francisco, who discovered one of the patients...His subject was a middle age male from the San Francisco area who caught the virus after participating in anal intercourse without a condom. That one act was the only incidence of high-risk behavior that could have produced transmission.

The virus was shown in laboratory tests to be at least partially resistant to all four protease inhibitors that have been approved for sale, as well as to both AZT and 3TC – in short, to six of the 11 drugs now approved for AIDS treatment. That resistance as confirmed clinically by the inability of treatment regimes containing the drugs to bring his viral levels down.

The virus had a total of 11 separate mutations... The same mutations were found in a virus isolated from the infected man's sexual partner.

The results will be reported at greater length in the July 30 New England Journal of Medicine.

Dr. Sabine Yerly of University Hospital in Geneva reported Tuesday on 67 patients ... one of the patients was infected with a virus resistant to two conventional drugs. .. Six of the other patients, however, were found to be wholly or partially resistant to one or one protease inhibitors, suggesting that resistance to these valuable drugs may become more common in the future. (Maugh 1998)

In 1999 at another conference devoted to this problem several papers were presented which documented to spread of resistant forms of the HIV virus. The following are excerpts from the abstracts of these reports:

We performed antiretroviral (ARV) susceptibility testing for reverse transcriptase and protease inhibitors for 69 subjects from 5 sites in the US with HIV seroconversion within the preceding 12 months... The percentage of subjects with reduced susceptibility to... any drug 28%. (Little 1999)

...

We analyzed plasma from 114 drug naive subjects, with documented infection within the last three years for evidence of drug resistance. ... Overall prevalence of any genotypic or signficant phenotypic change was 21%. The substantial prevalence of drug resistance in this therapy naive cohort suggests resistance testing prior to starting treatment may be useful to optimize inital therapy. (Wegner 1999)

While the public and many in the homosexual community believe that HIV is under control because of changes in behavior and new treatments, the fact is that men who have sex with men continue to be at risk. And yet in spite of all this the pressure for absolute sexual liberation as the sine qua non of homosexual liberation remains. The following report on bathhouses in San Francisco reveals the problems involved in controlling STDs in the homosexual male community.

AIDS closed the bathhouses here when the city tried and failed. It was 15 years ago, when the epidemic was raging and bathhouses, as bastions of anonymous, unsafe sex, were considered major contributors to the spread of the disease. The bathhouses sued the city to remain open, but their reputation as a breeding ground for AIDS scared their customers off and put them out of business anyway.

Now, in a city still in an official state of health emergency after 26,000 reported cases of AIDS and 17,800 deaths, a movement is growing to allow the reopening of bathhouses where men can meet and have sex in private cubicles. San Francisco's current policy on public sex, adopted in 1997 in an effort to prevent the spread of AIDS, is believed to be the only one of its kind in the United States.

In the clubs that have sprung up to replace the bathhouses, sex is allowed as long as it is public – that is, as long as it is performed in a place where monitors can determine whether partners are using condoms, where safe sex rules are posted and where safe sex information and products are provided. About a dozen such businesses are operating, some of which have glass-walled rooms.

The current movement, which has prompted a furious debate here, is spearheaded by a group of gay men who say that while promoting unmonitored anonymous sex sounds foolhardy, what they are really promoting is safe sex: bathhouses could provide a safe-sex alternative for those who do not want to perform in front of an audience in a sex club and who may resort now to picking up strangers and engaging in unsafe sex in cars or bathroom stalls...

San Francisco's public sex regulations were adopted in 1997 in response to concern about unsafe sex taking place in sex clubs. The regulations, said Katz, are based on a 1984 court decision that allowed the bathhouses here to remain open as long as they mandated safe sex, and also by guidelines recommended in 1991 by a coalition of AIDS groups and operators of sex businesses. "One of the things that very few people have talked about is, what does it mean to change the policy?" Katz said. Implicit in the belief that the policy should change, he said, is a belief that HIV is no longer the threat it was.

In San Francisco, proponents of the bathhouses have begun a petition drive to put the issue to the voters. "You have no privacy in sex clubs," said Steven Filandrinos, one of the petitioners. "It's group sex. Imagine trying to ask someone their HIV status in a dark, crowded room. It's very difficult. And people working in prevention say that dignity and self-respect provided by a private room lead to greater discussion."

But Ron Stall, an associate professor at the Center for AIDS Prevention, which is affiliated with the University of California at San Francisco, said the center's surveys found that men did not ask each other questions about their HIV status. "These are not situations where men talk – period," he said. "That's a disingenuous argument."

Stall says he believes the current debate in San Francisco obscures the underlying issue of public health versus private freedoms. "That's what this debate is about," he said. "What counts more: the need to reduce HIV transmission to the lowest possible level, or the need for a community to express itself sexually in the fullest possible way? This is a place where reasonable people who really do care about gay men's health can disagree in profound ways." (Nieves 1999)

On Sept. 10, 1999, there was a report in Morbidity and Mortality Weekly Report on resurgent bacterial sexually transmitted disease among men who have sex with men in King County, Washington. Men who have sex with men and especially young men are at extremely high risk. Since there is no evidence that prevention of disease transmission is working, isn't it long past time to at least offer treatment of the underlying problem of homosexual attraction. Our report on change shows that such treatment is successful in the majority of cases in eliminating homosexual behavior and without the behavior the diseases are not spread.


LESBIAN RISKS -Women who have sex with women

While this report has focused on the risks of sexually transmitted disease among men who have sex with men, this should not lead to the conclusion that women who have sex with women are not at risk. A doctor in Boston documented a case of HIV transmission from an woman infected with HIV through IV drug use to her female partner ("Lesbian" 1994) and a doctor in Texas reported treating two HIV-positive lesbians who became infected through sex with women. ("Lesbian" 1993)

Furthermore, women who have sex with women are at higher risk for HIV than married women. A study done by Lemp and associates in 1995 found that among a group of 498 lesbian and bisexual women surveyed in bars and clubs, the HIV seroprevalence was 1.2% In addition:

Ten percent of participants reported injecting drugs since 1978. Forty percent of the participants reported unprotected vaginal or anal sex with men during the past 3 years, including unprotected sex with gay and bisexual men and male injection drug use.(Lemp 1995)

The prevalence of 1.2% is higher than the 0.4% found among women sampled through population based household surveys. The seroprevalence for hepatitis B was 5.4%.


Commonly Used Abreviations

AIDS – Acquired Immune Definciency Syndrome

CDC – Centers for Disease Control

HAV – Hepatitis A Virus

HBV – Hepatitis B Virus

HCMV – Human Cytomegalovirus

HCV – Hepatitis C Virus

HIV – Human Immunodeficiency Disease

HPV – Human Papilloma Virus

HSV – Herpes Simplex Virus

GID – Gender Identity Disorder

GRID – Gay Related Immune Deficiency

KS – Kaposi's Sarcoma

MMWR – Morbidity and Mortality Weekly Report

STDs – Sexually Transmitted Diseases


Bibliography

ONE OUT OF TWO — Table of Contents
Dale's Web Pages — HOME

Original text on Dale's Disk — aids6.rtf - Oct.14, 1999
Reformatted to HTML — 2000 10 21, —WHS