Yes, I’m Talking to You!
A Conspiracy of Silence about Gay Men’s Anal Health
By Jeff Huyett
If you have watched television over the last six months, you’ve seen public service announcements and advertisements about the advances in prevention of human papillomavirus (HPV)-related cancers.
Thankfully, a vaccine has been developed that will prevent nearly all cervical cancers and genital warts in women. Sadly, one will only see a female face in regards to the prevention of HPV-related cancers. Gay men, who face a much higher risk to develop HPV-related cancers, are non-existent in advertising and public health announcements about these medical breakthroughs.
Currently, gay men develop anal cancers due to HPV at the alarming rate that women developed cervical cancer forty years ago when preventive screening began. That means that HIV-negative gay men develop anal cancers at a rate four-times higher than cervical cancer in women today. HIV-positive gay men develop anal cancers at nine times the rate of cervical cancer. Yet most gay men haven’t even heard about HPV. They do not know that methods exist to prevent the development of anal cancer due to HPV. HPV is the most common sexually transmitted infection with six million new infections each year.
Policy-makers and public health officials have known that gay men are getting anal cancer at increasing rates. Scientific papers in medical journals have reported the increase of anal cancer in men in cities like San Francisco for some time now. Why is it that gay men are not afforded the same kind of preventive screening as women if the risk is so much higher?
Just twenty-five years ago, I was part of a small number of gay men’s health advocates sounding the alarm about the impending HIV tsunami in large Midwestern cities. We were told not to worry, this “gay cancer” was only going to happen in New York, Los Angeles, and San Francisco. We knew different. We’d already buried gay men whose families has refused their bodies after they died. We also developed a healthy skepticism for public health officials who relied heavily on outmoded data collection systems and worked in a homophobic climate.
As a gay men’s health advocate during those twenty-five years, I find myself, once again, sounding an alarm about a health issue that impacts gay men more heavily than others and, yet, is being ignored by policy makers, insurers, and even gay men and their health care providers. The alarm isn’t as loud as twenty-five years ago when I watched friends, lovers, and patients dying rapidly from HIV. Nearly 2,000 men a year will be diagnosed with anal cancer. The cancer is treatable with chemotherapy and radiation treatments and it’s dangerous if it spreads throughout the body. The most alarming part, the part about which I speak most loudly, is the ignorance and inaction of gay men, health care providers and policy makers.
While anal cancer isn’t that common, it’s preventable. But you can only prevent anal cancer if you know you have HPV, are screened and have the precancerous areas treated. You can only do this if you live in an area where anal Pap smear testing is available and resources exist to provide preventive follow-up.
So why aren’t these methods employed? Clearly, one reason is homophobia — on the parts of public health officials and gay men themselves. You only have to read the Center for Disease Control’s (CDC) webpage on “HPV in Men” to see the blatant disregard for our health:
“The risk for anal cancer is seventeen times higher among gay and bisexual men than among heterosexual men.”
“There are currently no tests approved to detect early evidence of HPV-associated cancers in men.”
The anal cytology test that screens for tissue changes can detect HPV-related cancers in the anal canal and is approved by the Food and Drug Administration. The test to screen for the HPV virus itself, while approved to screen a woman's cervix is not approved to screen the anal canal for HPV.
The medical establishment — including gay health providers — is waiting for the study that proves that the prevention methods work. Specialists, like me, have been employing various methods to prevent the growth of HPV-related tissue mutations for nearly 10 years. We see it work to prevent cancer. We do not witness cancer develop in those who have preventive treatment. But clinicians demand that therapy be absolutely proven before employing screening. How do you research a currently employed method? You give half the subjects the treatment and you give have the subjects no treatment and see who gets cancer. This just isn’t ethical research when the prevention method is already employed and appears effective in those who use it.
Some officials say we shouldn’t recommend screening and treatment until we have more answers. This was not the approach taken to prevent cervical cancer. We didn’t even know HPV caused cervical cancer when clinicians began screening and offering preventive treatment. But it was considered poor practice not to enlist the methods available at that time to do everything possible to prevent cervical cancer. And it worked. Cervical cancer has been reduced by 500%.
During the HIV epidemic, clinicians like me became used to working in an information vacuum. We learned to keenly read scientific papers, experiment for non-existent treatments, and give full attention to layers of homophobia that existed in policy and procedure. In this information void, with no HIV treatment, we heartily encouraged gay men to run and get tested for HIV.
Anal cancer, and the tissue in the anus that it affects, has many similarities to cervical cancer. We do have an existing model of information to rely on — gynecology. Like other health issues, one employs existing knowledge about a disease state until more details of the disease emerge. I readily employ the methods of anal screening and prevention and see it work! My skill as a gynecological practitioner has informed me in the treatment of these HPV-related tissue mutations. Any gay-friendly health care provider interested in providing comprehensive health can do this.
A simple swab in the anus can detect the presence of abnormal cells. “Anal cytology” is an FDA-approved test and it has utility to inform the patient and the clinician about abnormal anal tissue. More precise examination and testing of anal tissue can isolate precancerous lesions and then one of many “ablative” techniques can be employed to remove this mutated tissue in-office. So why aren’t these methods demanded by gay men who are at risk?
I believe that gay men are plague weary from HIV. I believe that we are reluctant to address another health issue related to our sexual practices so just don’t advocate on our behalves. But, I find it astonishing, that in the midst of the HIV pandemic, we are unaware of another important health risk. Clearly, anal cancer prevention means we have to acknowledge we have butt sex. It dredges up the feelings of homophobia that we thought we had dealt with long ago. To screen properly, and to achieve optimal health, we must honestly admit to our sexual practices.
There is, still, a stigma to anal sex even in gay male communities. Bottoms are considered “less than” tops. For some, anal sex is considered “dirty” and therefore shameful. Even though research shows 40% of heterosexual women have engaged in butt sex, gay men are considered to have a corner on the market of this equal opportunity sex organ. Our sex is still considered unnatural. And we continue to own the shame that is contributed to that part of our body.
The anus is a nether region of the body not commonly inspected or felt by health care consumers or their providers. Standards of care for gay men do not always include inspection of the anal canal if one is having anal sex. It would be unconscionable to forego inspection of the vagina in a sexually active woman. Again, we do not apply the same standard of care for gay men’s sexual health that we provide to women. There should be no more shame in having testing for anal cancer than there is for women who have annual cervical Pap smears.
Like HIV, nothing related to anal cancer will likely change until gay men speak out. We learned this lesson with HIV. No one is looking out for gay men’s health so we must do it ourselves. It is time to demand changes in the health care system to bring our health screening and prevention methods into the modern age to reflect our risk. We must educate ourselves better about potential health risks, especially those that are ignored by governmental and officious bodies who are going to reflect the climate of the federal administration.
It is time that we become aware of anal health risks and prevention practices. We must do this for ourselves. No on else will.
In a recent letter I wrote to the CDC, I exclaimed my dismay that they were doing nothing helpful to prevent anal cancer in gay men. I explained that I would not be silent. I would continue to dog them as they clearly did not have my ass covered.
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Jeff Huyett is a nurse practitioner living in NYC. His clinical work has primarily been in queer health with a focus on HIV, rectal and transgender care. He is the Radical Faerie Daisy Shaver and is involved with the development of Faerie Camp Destiny Radical Sanctuary in Vermont and can be reached at JeffANP@aol.com
Our Bodies is a regular feature of White Crane.