Information for gay / bi / bi-curious men

HIV Prevention Is Different Now
Up to 75% of new infections in gay, bisexual and bi-curious men are the result of condom-less anal sex with a male partner who DOES NOT YET KNOW he is HIV+. For several reasons, newly infected people are highly infectious to others, and frequently it is newly infected men who are the source of infection for other men. Early and regular testing for all sexually active gay, bisexual, and bi-curious men is our best chance to interrupt this cycle.

HIV Treatment Is ALSO Different Now 
Advances in HIV treatments have moved HIV away from being the automatic death sentence it was once considered to being a chronic but “manageable illness.” As well, recent research indicates that those who are on HIV treatments and maintain undetectable HIV viral loads can greatly reduce infectiousness to others (early research indicates by as much as 96%). Early detection and treatment has become important, not only for the long-term health of the HIV+ person, but for the prevention of other HIV infections as well.

Getting Tested For All STIs
We now know that having other sexually transmitted infections (STIs) profoundly increases the risk of HIV transmission – getting OR giving – by as much as 400%!

HIV is actually very difficult to get, as it needs to get directly into your bloodstream to actually infect you. For HIV negative men having another STI may provide a doorway for HIV to enter your body by causing sores, lesions or inflammation on or inside delicate tissues. For HIV + men, having another STI will significantly increase your viral load (so long as your body is fighting infection) making you much more infectious. As well, an STI may provide an unexpected doorway for HIV to leave your body and enter someone else’s. STIs can also be more serious, and progress more quickly for people who are HIV+.

Syphilis, in particular, is increasing amongst men in HRM at significant rates – check out Public Health’s syphilis campaign, The Hard Facts here.

But… wouldn’t I know if I had an STI?
Men can have any STI (including HIV) without having any obvious symptoms. Without testing, you simply wouldn’t know you were infected.

However, a lack of symptoms does not mean damage (even permanent damage) isn’t being done to your health, or that you cannot pass that infection on to others. STIs do not go away without treatment. Getting tested regularly is the only way to protect both yourself (by getting treatment ASAP if infected), and your sexual partners (by avoiding passing on HIV or other STIs to them).

What Tests Should I Get and How Often?
We recommend all sexually active gay, bisexual and bi-curious men get tested at least once a year for:

• HIV, Syphilis, and Hepatitis B & C (blood test)
• Gonorrhoea and Chlamydia (urine test for penis, swab for oral or anal contact)
• If you have multiple sexual partners (6 or more per year) we recommend testing every 3-6 months.

What about Traditional “Safer Sex?”
Condom use for anal sex is still the gold standard in HIV prevention for men who play with men. Other harm reduction approaches can be used even in the absence of condoms. You can download a pamphlet on reducing the harm when  pdf barebacking (216 KB)

Sexual Health beyond STIs
How you manage your sexual health outside of “having sex” is just as important as practicing “safer sex” or “harm reduction” approaches. Sexual health maintenance also means getting regular STI tests and exams with your doctor or other healthcare professional. This includes getting checked for testicular, prostate and colorectal cancer, and getting vaccinated for those STIs for which a vaccination exists.

We recommend that you consider vaccination against:

• Hepatitis A&B (coved by MSI if you identify as gay, bi or other “man who has sex with men”)
• HPV (not yet covered by MSI, but research recommends it for men under 26 and for HIV+ men)

Partnering With Your Family Doctor
Looking after your sexual health is something that we all can do in a variety of ways. Starting a conversation with your doctor can be a key part of that, and hopefully the Check Me Out Checklist can make that happen. See 'Downloadable Resources' below to get your copy of the Checklist for men.

If you have questions about any aspect of this campaign – or any other sexual health question – please contact the Gay Men’s Health Coordinator at This email address is being protected from spambots. You need JavaScript enabled to view it. or phone 425-4882, ext. 222

PART 1: The Larger Social Context

MSM & Healthcare
Many “men who have sex with men” (or “MSM,” and this includes those who identify as gay and bisexual, but also may include some who identify as straight or bi-curious) in Canada are less likely to seek out tests and treatments for their overall health, and especially their sexual health, even when they know their health may be at risk. (This applies to many lesbian, female bisexual and transgender people too.) There are several reasons.

Informed & welcoming Healthcare Professionals?
Until 1969, gay sex was a criminal offence in Canada, and until 1973 the medical community formally pathologized just BEING homosexual (in the DSM). The distrust many MSM have of formal institutions (including health care) continues to the present. Especially for older community members, that continues to influence their feelings about accessing the healthcare system.

Healthcare professionals are not often adequately trained for, or aware of, many of the unique health challenges that MSM (and others in the LGBT community) experience (see PART 3 for details on some of these unique health challenges).As well, health professionals themselves are not immune to prejudice and may be intolerant of MSM or their relationships (whether knowingly or not).

Internalized Homophobia
Many MSM (and other LGBT people) may have internalized society’s homophobia to some degree. This may make them less likely to identify themselves to health care professionals as gay / bi (or lesbian or transgender), or even see health care professionals at all. If people value themselves less, they will also value their health less.
Being a member of a group that still experiences prejudice, discrimination, and even the threat of violence in their lives, LGBT community members typically experience heightened levels of long-term systemic stress.Not surprisingly (and not unlike other minority groups), LGBT community members seek out ways to ‘self-medicate’ to relieve or escape from that stress via various coping behaviours. This shows in higher levels of smoking, alcohol and drug use, and even in sexual behaviour (sex as escape).These external pressures, often coupled with internalized homophobia (that results from living in these external pressures), also informs higher rates of depression, related mental health issues and suicide.

A Perfect Storm…
The combination of societal homophobia / internalized homophobia + heightened level of stress + unhealthy coping mechanisms + an often inadequately informed health care system contribute to many unique health challenges for LGBT community members. For these and other reasons, MSM are much more prone to certain health challenges than their exclusively heterosexual counterparts.The Check Me Out Campaign seeks to begin to remedy those healthcare disparities for MSM, primarily with regard to their sexual health, but also with a look to other (often intersecting) health issues as well.What follows in Parts 2 and 3 is a list of the major areas of concern regarding sexual health, and broader health areas respectively, that you might wish to explore with your gay, bisexual and ‘bi-curious’ male clients.

For our Annual Sexual Health Checklist for My Gay, Bisexual and Bi-Curious Male Patients, click here to download a copy. 

PART 2: Sexual Health Recommendations

HIV & Men who have Sex with Men (MSM)
Worldwide, most of the people with HIV and AIDS are heterosexual. But in developed nations like Canada, the largest single affected group continues to be “men who have sex with men” (MSM) which includes those who identify as gay and bisexual, but also those who identify as straight or maybe ‘bi-curious.’ In Nova Scotia, 50% of new HIV infections diagnosed each year are still from male-male sexual contact.

HIV Prevention Is Different Now
Up to 75% of new HIV infections amongst MSM are the result of having unprotected anal sex with a partner who is infected but not yet tested. He is also likely in the acute stage of infection, not undergoing treatment, has a homogenous and highly virulent strain, and so is highly infectious. Early and regular testing for all sexually active MSM is our best chance to interrupt this cycle of newly infected men being the source of infection for other men.

HIV Treatment Is ALSO Different Now 
Advances in HIV treatments have moved HIV away from being the automatic death sentence it was once considered to being a chronic but “manageable illness.” As well, recent research indicates that those who are on HIV treatments, and maintain undetectable HIV viral loads, can greatly reduce infectiousness to others (early research indicates by as much as 96%). Early detection and treatment has become important, not only for the long-term health of the HIV+ person, but for the prevention of other HIV infections as well.

Getting Tested For All STIs
Certain sexually transmitted infections (STIs) are also more common amongst MSM men (and the reticence to see a doctor for testing and/or treatment facilitates those rates). Syphilis, in particular, is increasing amongst men in HRM at significant rates – check out Public Health’s syphilis campaign, The Hard Facts here. The prevalence of anal sex play amongst MSM makes them more vulnerable to acquiring some STIs (esp. HIV, Hep B & C, and certain parasites). While having any STI is a cause for concern, having an untreated STI increases the risk of acquiring, or passing on, HIV by as much as five times.

HIV is very difficult to get, as it needs to get directly into your bloodstream to actually infect you. For HIV negative men having another STI may provide a doorway for HIV to enter their body by causing sores, lesions or inflammation on or inside delicate tissues. For HIV+ men, having another STI will significantly increase their viral load (so long as their body is fighting infection) making them much more infectious. As well, an STI may provide an unexpected doorway for HIV to leave their body and enter someone else’s. STIs can also be more serious, and progress more quickly for people who are HIV+.

We recommend that all sexually active MSM:

• be vaccinated for Hepatitis A&B; this is covered by MSI for MSM as an “at risk” population for Hepatitis
• get at least an annual test for HIV, Syphilis, and Hepatitis B & C, as well as Gonorrhoea and Chlamydia (and include oral and anal (if sites of sexual contact) swabs for Gonorrhoea and Chlamydia in addition to the standardurine test)
• Stool test for ova / parasites, especially Blastocustis hominis
• checked for lymphadenopathy, especially inguinal (forLGV) neck and axilla

HPV & Anal / Genital Cancers 
Genital and anal warts are caused by infection with HPV. Genital warts on the penis are common in both heterosexual and MSM. However, anal warts in males tend to occur more frequently in gay/ bi men.
Some strains of HPV cause genital and anal warts, and some strains are linked to certain forms of cancer. When HPV causes cancer in men, it most often causes anal cancer. Anal cancer occurs more frequently in men with damaged immune systems (including those with HIV).

We recommend that all sexually active MSM:

• be vaccinated for HPV, especially for HIV+ men and men under 26; this is currently not covered in Nova Scotia by MSI for MSM, but research recommends the vaccine for this population;
• have an annual rectal exam, including anal lesions; especially for men over 50, and all HIV+ men;
• be checked for lymphadenopathy, especially inguinal for LGV, neck and axillary.

Broader Sexual Health 
In encouraging MSM to be more proactive about the sexual health issues that are more prevalent for them as a population (through getting regular HIV and other STI tests) we are also hopefully making this behaviour seem more comfortable and “routine.” To further strengthen that “routine,” we are also including broader “men’s” sexual health recommendations on the Check Me Out Checklists too.

Therefore… we also recommend that all MSM:

• over 21 – learn to do a testicular self-exam
• over 40 – be assessed for early detection of prostate cancer
• over 50 – have a colorectal cancer screen

For our Annual Sexual Health Checklist for My Gay, Bisexual and Bi-Curious Male Patients, click pdf here (1.01 MB)  to download a copy.

PART 3: Broader Health Considerations

Sex, And Alcohol & Drug Use 
Gay and bi men are more likely to have increased rates of use of alcohol and other intoxicants (legal or not) that may contribute to liver disease. The use of intoxicants can also contribute to behaviours that increase the risk for HIV and other STIs. While under the influence of alcohol or another intoxicant, people tend to have sex more often, are less likely to use condoms, and/or are less likely to use condoms correctly.

If MSM use intravenous drugs, then the inherent risks for both HIV transmission and Hepatitis C transmission via drug paraphernalia are also causes for concern. More recently, the transmission of Hepatitis C through sexual contact between HIV+ MSM has come to light. As with other STIs, MSM are also considered at increased risk for Hepatitis B infection, which has been linked to liver cancer and other forms of liver disease, including cirrhosis of the liver.

We recommend that all MSM who make excessive use of alcohol and/or drugs:

• be encouraged / supported to consider addictions counselling

Smoking & Lung Cancer
Like alcohol and drug use, smoking rates among gay and bi men are higher than the general population (as are exposures to second-hand smoke because of social interactions with higher concentration of smokers), so gay and bi men may be at increased risk for lung cancer, and other smoking-related illnesses (e.g., emphysema and heart disease).

We recommend that all MSM who smoke:

• be encouraged / supported to consider smoking cessation

Anti-Gay Violence / ‘Gay Bashing’
These are often not viewed as health concerns, but they should be. Physical violence can lead to bodily harm, emotional trauma, hospitalization, etc. ‘Gay bashing’ (and especially the threat of gay bashing) is far more common than most people realize and many anti-gay “hate crimes” never get reported, due to the victim’s fear of further discrimination, shame, intimidation by police and similar concerns.

We recommend that all MSM who experience violence:

• be supported to report violence, or threats of violence, where appropriate
• be encouraged to seek counselling to manage the emotional fallout of being a target of violence where appropriate

Gay Domestic Violence
Domestic violence can also lead to significant bodily harm, and is also very rarely reported by MSM, due to victims’ fears of discrimination, intimidation by police, and the lack of services for male victims of domestic violence, etc. Due to the lack of reporting of these crimes, the rates of gay bashing and gay domestic violence are most likely much higher than statistics indicate.

Same-sex partner abuse may ring the same alarms as heterosexual couple violence; however anti-gay sentiment and internalized homophobia add additional layers of complexity. The abusive partner may use society’s bias against their sexual orientation (or gender identity in the case of transgender persons) to abuse and isolate their partner.The most telling sign of anyone in an abusive situation is fear of their partner, or strong anxiety about displeasing their partner.

With men in same-sex relationships there are a few unique considerations:

• men (gay or straight) often fear that no one will believe them
• many gay/bi men hesitate to report abuse for fear of exposing of their sexuality
• many male couples share the same group of friends, so the victim may be worried about losing the support from both his partner and mutual friends
• gay men often feel they cannot seek help from agencies that mostly offer help and advice to heterosexual couples.
• few services, if any, cater to services for men (gay or straight) as victims of domestic violence

Warning signs specific to same-sex couples might include a partner who:

• threatens to tell friends, loved ones, colleagues or community members about their partner’s sexual orientation.
• tells you that authorities won’t help gay men.
• tells you that leaving the relationship means you’re admitting that homosexual relationships are deviant.
• tells you that domestic violence is a normal part of homosexual relationships or that men are naturally violent.

We recommend that all MSM:

• be supported to report domestic violence where appropriate;
• be encouraged to seek counselling to manage the emotional fallout of being a target of domestic violence.

Mental Health Issues
As is often seen with groups that experience persistent prejudice and/or discrimination (sometimes even from their own families), and possibly even the threat of violence as mentioned above, gay and bi men often experience lifelong elevated levels of stress that manifests in various ways. This accounts for higher levels of ‘self-medicating’ with tobacco, alcohol and other intoxicants and also contributes to other “escapist” behaviours – including escape through sex. Suicide rates are higher than that of heterosexual counterparts, and many gay men suffer from depression and low self-esteem. When a person has low self-esteem, they tend to value their life (and their health) less seriously. They are therefore less likely to protect themselves against HIV and other STIs, and other health problems.

We recommend that all MSM:

• be encouraged, where appropriate, to seek counselling and/or other supports if they show elevated signs of psychological stress.

For more information about depression and HIV, click here.

Body Image Concerns
Gay and bi men are more likely to experience body image problems and eating disorders (such as anorexia and bulimia nervosa) than are their straight counterparts. Gay men might also be more likely to view their (own and other men’s) bodies as sexual objects, which can lead to dissatisfaction and poor body image. While regular exercise is very good for cardiovascular health and in other areas, too much of a good thing can be harmful. As well, the use of substances such as anabolic steroids and certain supplements, to achieve that “perfect body,” can affect health adversely.

At the opposite end of the spectrum, being overweight and/or obese are problems that affect a large subset of the gay community: “bears” (hairy and often ‘big’ men) or “chubs” are fetishized within some parts of gay male culture. This can contribute to diabetes, high blood pressure, and heart disease.

We recommend that all MSM:

• be encouraged, where appropriate,to seek counselling and/or other supports if they show signs of body image problems, eating disorders, or overweight and obesity problems.

For our Annual Sexual Health Checklist for My Gay, Bisexual and Bi-Curious Male Patients, click   pdf here (1.01 MB)  to download a copy.