THE SYNDEMIC OF STDS AMONG GAY MEN
By Dale O'Leary
November 30, 2012
It has been over 30 years since the first gay men were diagnosed with what would later be called AIDS. Since then over 300,000 men who have sex with men (MSM) have died of AIDS, and 6,000 are expected to die this year and every year for the foreseeable future. In 2008, 17,940 MSM were diagnosed with HIV infections, an increase of 17% from 2005. MSM accounted for 53% of all new infections. It is estimated that one half million MSM are currently infected with HIV. According to a report from the CDC, one in five sexually active gay and bisexuals is carrying the AIDS virus and nearly half of those infected don’t know it. MSM are 44 to 86 times more likely to be diagnosed HIV positive than men who don’t.
The continuing spread of HIV among MSM is not a simple epidemic, but a syndemic.
A syndemic occurs when a number of different and interrelated health problems come together and interact. The various elements of the syndemic have an additive effect, each one intensifying the others. According to an article by Dr. Ron Stall and associates, an analysis of the data from a large number of studies reveals that:
In addition to the effects of depression, drug use, and a history of childhood abuse and/or violence on HIV infection rates, MSM are more likely to suffer from other psychological disorders, paraphilias, and sexual addiction and compulsion. They are far more likely to be diagnosed with any of an array of other sexually transmitted disease (STDs), some of which have become resistant to commonly used antibiotics, and some of which can make them more vulnerable to infection with HIV. They are more likely than other men to engage in a wide variety of sexual practices which have the potential to spread STDs, to do so with a larger number of partners in venues which cater to multiple and anonymous sexual encounters. And in spite of the known risks, gay activists have consistently — and in many cases successfully — resisted proven public health strategies for the prevention of the transmission of STDs.
The STD Epidemic before AIDS
It was not an accident that the AIDS epidemic first struck the gay community. Even before the first gay man was infected with the virus, gay men were already in the midst of an epidemic of STDs.
In the 1970s, physicians were treating the large number of conditions affecting the lower intestinal tract of MSM under the classification “gay bowel syndrome.” These included viral infections, infectious diarrheal diseases caused by bacteria and parasites, and injuries caused by anal sexual activity. Infectious agents included Shigella sonnei, Shigella flexneri, Campylobacter enteritis, Campylobacter jejuni, or Salmonella enteritis; intestinal parasites such as Giardia lamblia, Entamoeba histolytica, and Entamoeba coli; herpes simplex (HSV) and Chlamydia trachomatis.
According to Randy Shilts, author of The Band Played On, a gay man who later died of AIDS:
At one point, health officials, uneducated as to homosexual practices, were so concerned about an unexpected outbreak of dysentery in the Greenwich Village section of New York City that they ordered an inspection of the water supply, fearing contamination with raw sewage.
In addition, MSM were at risk for syphilis, gonorrhea, hepatitis (HAV, HBV HCV), cytomegalovirus (HCMV), Epstein-Barr, cancer causing human papilloma virus (HPV) chancrodie, lymphogranuloma vereum, granuloma inguinale, pediculosis (pubic lice), pinworms, scabies, and fleabites. Many MSM had multiple recurrences of the same disease. Research revealed that “the number of different lifetime sexual partners was the very best predictor of previous infections with syphilis, gonorrhea, and other sex-related infections.”
During the pre-AIDS period, infection with a STD carried no stigma within the gay community. The ritual of repeated infection and treatment had become part of the homosexual lifestyle:
Doctors were pessimistic:
According to Shilts, “Promiscuity … was central to the raucous gay movement of the 1970s.” By 1980:
What was so troubling was that nobody in the gay community seemed to care about these waves of infection. Ever since he had worked at the New York City Department of Public Health, Dan Williams had delivered his lecture about the dangers of undiagnosed venereal diseases and, in particular, such practices as rimming. But he had his “regulars” who came in with infection after infection, waiting for the magic bullet that could put them back in the sack again. Williams began to feel like a parent as he admonished the boys: “I have to tell you that you’re being very unhealthy.”
In the fall of 1980, Dr. Selma Dritz, the infectious disease specialist for the San Francisco Department of Public Health, warned;
Even as she spoke, the infectious agent Dr. Dritz feared was already spreading through the gay community.
Human immunodeficiency virus (HIV) is not easily transmitted. It requires fluid-to-fluid contact, but HIV has a long latency period before the infected person’s health deteriorates and during which he is capable of infecting others. Once a homosexually active man became infected with HIV and visited a commercial sex establishment, where men routinely had unprotected insertive and receptive anal intercourse with several partners in a single evening, an epidemic was inevitable. However, given the long latency period, it was several years before anyone realized that a deadly disease was spreading through the gay community
When an infectious disease is introduced into a susceptible population, the speed at which it spreads depends on the number of contacts between infected and uninfected persons. Epidemiologists working to understand the spread of HIV/AIDS conducted in-depth interviews with patients. They were shocked by the sheer number of sexual partners reported. Among the first gay AIDS cases, the typical number of sexual partners was over 1,000. 
A study conducted in the Baltimore STD clinic revealed how quickly HIV infection spread. In 1983, the HIV seroprevalence among MSM was 14%. One year later, it had jumped to 58%.
During the first decade of the epidemic, HIV infection was the equivalent of a death sentence. HIV infection doesn’t kill outright, but destroys the immune system, making its victims prone to a range of other diseases, some of which under other conditions would have been treatable. The first victims died of pneumocystis pneumonia. The failure of their immune systems left victims vulnerable to a host of diseases, including toxoplasmosis (a cat disease), crypococcal meningitis, candidiasis, severe herpes, cryptosporidium (a parasite that affects sheep), encephalitis, and a fulminate form Kaposi’s sarcoma (a skin cancer previously found mainly in older men of Mediterranean origin).
By late February of 1982, 251 Americans had been diagnosed with AIDS and 99 had died. Although the pathogen responsible had not been identified, experts were convinced that they were dealing with a disease caused by a virus and transmitted by sex and blood, and that the gay bathhouses were a likely venue for transmission, since many of the first victims could be linked to these establishments.
When Dr. Dan Williams, a prominent gay NY physician, suggested that bathhouses be required to post signs warning patrons about the danger of infection, the gay community reacted angrily, refusing to consider anything that would turn back the sexual liberation the bathhouses represented. Williams was castigated as a ‘monogamist’ and accused of stirring up unnecessary panic and fear.
By 1985, the pathogen that causes AIDS had been identified, the modes of transmission known, and a test developed to identify those infected. All that would have been necessary at that point was to test all MSM, and encourage positives to have sex only with positives, negatives with negatives. Positive/negative couples should use condoms for every encounter to avoid fluid exchange.
The gay community rejected this plan and all strategies perceived as endangering the absolute sexual liberation of gay men. Instead, they proposed a “condom code:” Everyone should use a condom every time. No one needed to be tested unless they wanted too. All testing information should be absolutely confidential to avoid outing gay men. The gay AIDS activists rejected the standard public health procedures used for other STDs, namely:
Instead, the names of the infected would not be reported. There would be no routine testing, no contact tracing, no notification of possibly infected persons. The right to privacy was paramount. No one had a moral responsibility to tell their sexual partners they were HIV positive. 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.
Under the ‘condom code’ MSM could go on engaging in anal sex with multiple and/or anonymous partners. Given the known failure rate of condoms, this was not a prevention programs, but a risk ‘reduction’ program. In an opinion piece in the New England Journal of Medicine, Ronald Bayer expressed concern because:
Initially, some gay men changed their behavior and new infections declined. The “condom code” was deemed a success. However, research into the behavior gay men found that many were not following the code. A 1985 survey of gay men in San Francisco found that:
In a sample of New York City gay men, 49.6% reported they had not changed their behavior. In another sample, 67% of gay men admitted engaging in anal intercourse without condoms during the previous year.
Many of those who initially adopted safer sex practices failed to persist. According to one study:
It appears, then, that some of the factors associated with the continued participation in high-risk sexual behavior are resistant to current educative intervention. Educational campaigns, however well executed and well intentioned, have been insufficient to stem the spread of HIV infections.
The problem was not ignorance:
The findings suggest that the mere transfer of information concerning safer sex practices is not sufficient to induce the desired behavior changes in a substantial proportion of gay men.
The authors acknowledged the “mass behavior change” necessary to stop the transmission of HIV would be difficult because gay men would have to change sexual practices that:
These deeply meaningful interpersonal acts included using body parts and orifices in ways that not only spread infection, but involved risk of serious injury, with large numbers of virtual strangers.
Gay AIDS activists insisted that AIDS education must be sex positive, avoid moralizing, and not distinguish between those who were HIV positive and those who were HIV negative. The gay 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. They wanted gay bathhouses keep open, arguing that they could be places to impart prevention education and distribute condoms. 
Prevention efforts were focused on self-protection rather than the duty to protect others:
For gay activists, the proper of goal of AIDS prevention was defense of the gay sexual revolution, and since gay liberation was founded on a “sexual brotherhood of promiscuity … any abandonment of that promiscuity would amount to a communal betrayal of gargantuan proportions.”
AIDS educators were:
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.”
It was assumed by those outside the gay community that fear of contracting an incurable, debilitating disease would motivate gay men to refrain from risky sexual activity, but the gay community reacted to the crisis by romanticizing HIV infection:
HIV-positive status was portrayed in some homosexual publications as more fun. An editorial in Steam, a magazine aimed at gay men, quotes a man who has been positive since the early years of the epidemic:
According to Scott O’Hara, Steam’s HIV-positive editor who died of AIDS in 1998:
Those who died of AIDS were memorialized as martyrs. Rather than calling for changes in the behaviors, which led to these deaths, the AIDS establishment blamed the government, religion, and the straight world for not finding a cure, for not funding education, for its homophobia, for causing homosexuals’ low self-esteem, and for denying their ‘right’ to marry.
Because the thought of using condoms for the rest of their lives was unacceptable to many MSM, in 1992 the AIDS activists came up with the slogan “Be Here for the Cure.” They demanded that government funded scientists immediately find a cure for HIV/AIDS, one which would allow MSM to return to their previous behavior without the risk of dying. This was totally unrealistic, as a physician who treated HIV patients explained, “There are no viral illness we’ve successfully found a cure for yet.” Nevertheless, “the idea that there would surely be a cure, and soon was vital to many gay men’s determination to use condoms or take other safer-sex precautions.”
For some, even the harm reduction compromise of ‘condom code’ was too sex negative. According to Dr. Walt Odets, a gay psychologist and author of In the Shadow of the Epidemic, – writing when the AIDS diagnosis was still a death sentence — argued that if it was 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. 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.” Odets insisted that the values of the gay community should not be sacrificed so that individuals could live meaningless lives:
The condom code had the effect of making MSM feel guilty about unprotected sex, but the message was rejected because gay men, having just escaped from a shaming culture, were very reluctant to establish another one. Odets felt that those designed the condom code ignore the realities of gay life:
Odets condemned the social marketing model embodied in the condom code, as “simplistic,” “incompetent,” “responsible for a considerable psychological damage to gay men,” and unacceptable “moralizing.” He criticized AIDS education advocates for holding on to the illusion that education had “worked at one time and should work again.” He did not believe that this approach had ever really been successful. In this Odets was correct, a careful study of the epidemic revealed that the dramatic drop in new infections in the late 1980’s was mainly the result of epidemic saturation.
Epidemic saturation occurs when a significant portion of an at-risk population is infected, usually those most vulnerable — in this case promiscuous gay men. Since, as the number of the infected increased, the number of uninfected decreased and since those uninfected at this stage of the epidemic were likely to be less promiscuous, the epidemic has fewer and fewer potential victims. It was burning itself out. However, as soon as more young men entered the gay community, the rate of new infections began to rise and continues to rise.
Researchers found a record in blood samples of the process of epidemic saturation. In preparation for a Hepatitis B vaccine trial, blood samples of MSM were taken from 1978-1988. When a test for HIV was developed, the samples were tested for HIV. The tests showed that by 1985, 73.1% of the original sample was HIV positive. 
A study of young HIV negative gay men revealed that prevention campaigns are ineffective:
The motivations for high risk behavior include:
In the 1990’s the revolt against safe-sex education took the form of open advocacy for “barebacking” — unprotected anal intercourse (UAI). At a round table discussion on barebacking, Michael Scarce, a San Francisco writer and activist, attacked those who were trying to change the gay culture:
If barebacking takes place between two men who are both positive, there is still the risk on contracting another STD or a different variety of HIV. Men who have tested HIV negative and are in a relationship, could engage in the behavior without risk, assuming that both continue to be faithful. Unfortunately, monogamy among gay men is rare. A study done in the Netherlands, concluded that gay men in relationships were actually at higher risk of infection. But the greatest risk involves HIV negative gay men who engage in UAI (barebacking) with partners who are HIV positive or whose status is unknown. There are even reports of men barebacking for the purpose of becoming infected (bugchasing) or infecting others (giftgiving) 
Bugchasers are said to be ‘impregnated’ by the masculine and male giftgivers when they are infected. HIV positive giftgivers, following receptive anal intercourse with another HIV positive giftgiver, are said to have been ‘repozzed’
The development of highly aggressive anti-retroviral therapy (HAART) transformed HIV infection from a death sentence to a chronic disease. However, optimism about treatment caused many MSM, to become even more careless about prevention.
A study tracking changes in behavior among MSM in San Francisco found that:
A study published in 2003 found that 42% of HIV positive MSM reported sex without disclosing their infection, predominantly with nonexclusive relationships. It is not therefore surprising that the rate of new infections among young MSM continued to rise.
In 2003 in an editorial in the American Journal of Public Health, entitled “When Plagues don’t End,” recognized the failure of prevention strategies, and called for, among other things, a:
But nothing really changed. A 2008 article in the prestigious British journal The Lancet was blunt, “US efforts to prevent HIV have failed miserably.”
Gay AIDS activists refuse to admit their strategy has failed and continue to push for more money for education, particularly in schools. There is, however, no evidence that the thousands of MSM, who become HIV positive each year, have not heard of AIDS, do not know how it is spread, and do not know how to prevent infection. What causes HIV to spread is men who know they are at risk and yet do not get tested, if they are tested don’t pick up the results and continue to engage in high risk activity.
A study of 28,530 MSM who attended STD clinics in England revealed the core of the problem. Between 1999 and 2002, MSM who came to the clinics for treatment of other STDs were anonymously tested for HIV. Of these 3,593 (12.9%) were HIV positive. 2,520 of these had been previously diagnosed. This alone should be of concern since infection with another STD is a sign that these HIV positive men or their partners were having sex with other partners. Not only could these encounters spread HIV, but infection with a new STDs could complicate treatment for HIV.
Of the remaining 25,910, 11,655 (45 %) refused voluntary counseling and HIV testing (VCT) even though the fact that they were infected with another STD meant that they were engaging in sex with multiple partners and at high risk for HIV infection. Of those 11,655 who refused VCT, the anonymous testing revealed that 737 were HIV positive. These HIV positive men went back into the community, untreated, and purposefully ignorant of the threat they posed to others.
According to Dr. Philip Alcabes, an epidemiologist at HunterCollege:
In 2010 the Obama administration recently announced new strategy designed to cut the number of new HIV infections in the U.S. by 25% over the next five years, but the “new” strategy is simply more of the old failed strategy.
While recognizing the failure of previous educational efforts, rather than turning to proven strategies for containing STDs, experts called for more respect for the voices of gay men:
The voices of gay men, however, continue to insist that all education efforts present a positive image of gay life. Even minor challenges to the gay activists’ prevention strategy continue to meet resistance. In order to combat the growing perception that advances in drug therapy have made HIV infections ‘no big deal,’ an ad campaign was rolled out in 2011. The commercial showed a “melancholy-looking men standing against a shadowy black-and-white backdrop of menacing New York City streets. “When you get HIV,” the narrator intones, “it’s never just HIV.” The ad focused on the other diseases that those on drug therapy may suffer from. But this emphasis on disease was not acceptable to AIDS activists. They demanded the ad be pulled. Marjorie Hill of the Gay Men’s Health Crisis complained:
A letter from a coalition of activist groups to the Mayor suggested that rather than using scare tactics communication strategies to gay men insisted that:
The images of “sickness dying, and death” may be old, but they are not outdated. Each year over 6,000 MSM die of AIDS.
The on-going syndemic is proof that the “condom code” with its rejection of proven public health strategies for preventing infection with STDs is a colossal failure, but the consequences of this failure extend beyond the community of MSM. Gay AIDS activists insisted that the “condom code” applied to universally. They sold their failed strategy to the world, and nowhere have the consequences been more devastating than in Sub-Sahara Africa, where millions were wasted on condom education and distribution. It was only when countries like Uganda and Zimbabwe instituted programs which involved abstinence and sexual fidelity did the rate of new infections decline.
HIV is not the only problem confronting MSM. Wave after wave of other STDs are still sweeping through the gay community. In 2008 there was a report of the emergence of Multidrug-Resistant, Community Associated, Methicillin Resistant Staphylococcus aureus Clone USA300 (MRSA) commonly known as the flesh eating bacteria among MSM.”
In 2004, there was an outbreak of lymphogranuloma venereum (LGV) in a previously rare sexually transmitted disease among MSM engaging in “leather parties.” in the Netherlands. Outbreaks of LGV were reported in England and the U.S.
Given the proliferation of sexual networks and international travel, new diseases and mutated forms of old diseases present a constant challenge to the medical profession. For example, a new variant of Chlamydia trachomatis was recently discovered in Sweden, one that was not picked up by standard testing.
HIV positive gay men on retroviral therapy continued to have unprotected sex and spread other sexually transmitted diseases. Hepatitis C which can lead to liver cancer can be sexually transmitted and is spreading not only among HIV positive gay men, but also among HIV negative MSM.
Human papilloma virus is epidemic and has lead to a dramatic increase in anal cancer among MSM, especially those who are HIV positive.
The behavior of gay men in the midst of a syndemic has led to a situation in which men already diagnosed with HIV and on therapy continue to engage in unprotected sex and to contract and spread a wide variety of STDs. Their suppressed immune system, the amount of medication they already take needed to control the virus and deal with the numerous opportunistic infections, plus the multiple infections with other STDs creates a perfect breeding ground for drug resistant strains of previously easily treatable infectious diseases. These diseases then spread to HIV negative MSM and can spread through bisexual men to the general public.
A number of venues allowed MSM to acquire the large number of sexual partners reported in AIDS studies. Gay bars, gay bookstores, and theaters that showed gay porno films have traditionally provided places where MSM could engage in various forms of sexual activity. What is known as the Tearoom Trade takes place in public bathrooms, where men interested in quick anonymous sexual encounters can find willing partners.
There were, however other options. Larry Kramer in his 1979 novel Faggots described in detail the unbridled sexual activity on Fire Island, a summer resort near New York City. The gay community was outraged that their private — and shocking — behavior was exposed to the public.
In the 1970s the rise of well-appointed gay bathhouses offered private rooms and other spaces where anal intercourse (AI) could be engaged in with numerous partners during a single visit. The result was that diseases contracted mainly by AI spread quickly through the gay community. Even those who did not frequent a bathhouse were at risk of encountering a partner who had been infected in one.
The experts who tracked the early HIV/AIDS epidemic immediately recognized the part that bathhouses played in spreading the disease and sought to have them closed. The gay community resisted. As the death toll climbed in the late 1980’s the clients stopped coming and the bathhouses shut their doors. Recently, however, some have reopened.
The closure of the bathhouses did not stop gay men from seeking multiple, anonymous partners. The 1990 saw the rise of the “Circuit.” Originally organized to raise funds for AIDS and other causes:
For example, during 1997, an estimated 100,000 homosexual men attended at least one of the more than 50 circuit parties, According to an article on HIV and circuit parties:
Circuit parties are venues for drug abuse and unsafe sex, which is particularly ironic since many of these events are fund raisers for AIDS research, care, and education. In spite of the risks, gay activists defended the activity:
Men looking for partners could also reach them through telephone and Internet chat rooms. In the 21st century the most popular resource for meeting willing partners is Manhunt.net. Billed as “The world’s fastest —growing gay website,” it is “quietly abetting a revolution in social and sexual mores, under the slogan “get on, get off.”  Michael J. Gross, in an article entitled “Has Manhunt Destroyed Gay culture: A cost-benefit analysis of our quest to get laid,” published in Out, a magazine for gay men, expressed his concerns.
Gay urban life has always been a meat market, and cruising, you could argue, has always been a form of consumption. For gay men seeking sex, as for all kinds of shoppers, the Internet removed constraints of space and time on access to the market — and at the same time offered an unprecedented range of products to choose from. Basile says that, from the start, he wanted Manhunt to be “like eBay for men,” where users could find anything they wanted.
Gross found Manhunt is unapologetic:
Other gay men have also expressed concern. Simon Fanshawe, British writer and broadcaster created the documentary “The Trouble With Gay Men.” He explained the problem:
Some, for instance, claimed the “right” to cruise for sex. How ridiculous. We may well enjoy it, but it’s not a right. The rights and wrongs are about not being arrested for it, not being killed for it. But in public spaces the issue is not whether it’s gay or straight cruising, it’s about whether you offend other people. Anyone, hetero or homo, runs the risk of upsetting others if they shag in public. Now we’re grown-ups we have a responsibility to make those kind of judgments. But we don’t. It’s still almost impossible, for instance, to wonder out loud whether it really is acceptable to walk down the main street of Brighton dressed only in a thong, just because it’s gay “pride”. It’s fun, it’s a lark, but is it antisocial? Well, we still don’t stop to ask. Just shut up! It’s gay, honey …
The sexual excesses of the gay community including the weekend long parties of the circuit are only possible through the use of various drugs.  Besides the more traditional substances –alcohol, marijuana and cocaine —gay men used a number of substances which are taken singly or in combination to enhance the circuit party, club, or sexual experience. These include
Ecstasy or MDMA acts as a stimulant and a hallucinogen, gives users a sense of well-being and sensory distortion. It has been shown to cause significant impairment in cognitive functioning, including visual and verbal memory, reasoning and the ability to sustain attention.
Michelangelo Signorile, a gay activist and author of Life Outside, has expressed concerned about drug use among gay men, however when researching his book at a circuit party he discovered that because he was sober the “party was boring and monotonous.” And so he took ‘a hit of Ecstasy” and “soon enough, the night whirls into frenzied and fuzzy collage of colored lights and bodies as the feeling of well being takes over.”
However, the feelings are short lived. When the drug wears off:
Signorile supposed that Ecstasy was less harmful than cocaine which was habit forming, but later learned it can cause serious and permanent brain damage.
Crystal Meth, a form of the powerful stimulant methamphetamine, which is used to intensify the sexual experience. Crystal meth appears to be the new drug of choice because it is cheap and can keep a user high for 48 to 72 hours at a time. Patrick Moore author of Tweaking: A Crystal Myth Memoir, warns:
For gay MSM, addiction to crystal meth is difficult to overcome because:
A book — Crystal Meth and Men who have Sex with Men: What mental health care professionals need to know–published simultaneously published as two issues of the Journal of Gay & Lesbian Psychotherapy, lays out in graphic detail the risks both physical and psychological of crystal meth, particularly on men who are HIV positive.
Ketamine or Special K, an animal tranquilizer, which can disrupt attentional function explicit memory and verbal fluency. Schizophrenia-like and dissociative symptoms can also result as well as problems with working memory. It facilitates AI.
GHB (gamma hydroxyl buyrate) a nervous system depressant, which relaxes and sedates the body. When used with alcohol it can result in respiratory depression. A sedative with unpredictable side effects that causes some revelers at circuit parties to require medical attention.
Viagra or other drugs prescribed for erectile dysfunction, are used to facilitate multiple sexual encounters.
Trail Mix is the slang for a mixture of various drugs, often crushed together.
Multidrug use has been positively linked to infection with STDs. Drugs lead to disinhibition and feelings of invincibility and unsafe sex. They also undermine the body’s defense system. Bruce Kellerhouse speaking at a public forum “Challenging the Culture of Disease: The Crystal Meth-HIV Connection,” explained the problem:
The forum was a gathering of professionals and gay men trying to confront the problem of crystal meth in the gay community. Physicians expressed concern about the culture of circuit parties and how the use of party drugs can lead to overdoses, dehydration, unsafe sex, and STD infections. Crystal Meth has qualities that are appealing to gay men, “including a potent sense of connection, increases in general energy level, libido surge and sexual energy that last for hours.” According to one physician, 75% of his gay male patients have experimented with illegal substances. Warning gay men about the dangers of multi-drug use may be ineffective. Odets argues that gay men are not having unprotected sex because they are using mind altering drugs, but using drugs in order to have sex.
The gay communities defense of promiscuity as central to their identity leads to defense of venues that make the acquisition of multiple, anonymous parties possible, which in turn leads to a need for drugs to sustain their sexual availability, and overcome concerns about the risks, all of which leads to exposure to STDs including HIV and puts in jeopardy those already HIV positive.
Steroids and the Cult of Masculinity.
Steroids and sharing of needles used for steroid injection also pose a threat to the health of gay men. The majority of gay men (although by no means all) evidenced symptoms of Gender Identity Disorder (GID) as children. They were often teased by others as being “effeminate.” Gay advocates not only acknowledge this, but argue that since GID is the most common path to SSA in adolescence and a gay identity, and since, according to them SSA is a normal and healthy variety of sexuality, then GID in boys should not be considered a disorder but a normal stage in the development of gay men. Children with GID, according to this view, should be supported and their gender behavior encouraged and protected. In addition, some gay men as boys did not have obvious symptoms of GID, but suffered from chronic feelings of unmasculinity. They didn’t identify with girls, but felt excluded from the world of boys. They had a phobic fear of rough and tumble play and an aversion to contact sports.
Since many gay men grew up without a close relationship with their father or male peers, they long for the acceptance they did not achieve as children. Gay men are attracted to men and the more masculine a man is the more attractive he is to other gay men. Therefore, in order to attract other gay men, a gay man must be as masculine as possible. In order to achieve the perfect body, gay men are more likely to work out to build up their bodies and to take steroids. Typical of those caught up in the cult of masculinity is Mark who takes steroids to attract ‘muscle gods’:
Another steroids user explained his reasons:
Continued steroid use has side effects, both physical and psychological. Excessive doses of steroids can damage the liver and kidneys and lead to breast and prostate cancer. Stopping steroid use can cause the enlarged muscles to shrink. Steroids cause irrational aggression, mood swings, hypomania and depression.
Childhood Sexual abuse
Gay men are more likely to have been victims of childhood sexual abuse. Stall and associates note that a history of childhood sexual abuse (CSA) has been linked to increase risk of HIV infection.
This was confirmed by other studies, including one by Zieler and associates which found that men reporting childhood sexual abuse were 8 times more likely to be involved in prostitution, 2.4 times to have multiple partners, and 1.2 time fore likely to have anonymous partners. Such behavior would increase the risk of contracting HIV
A study by Bartholow and associates found that gay men, who had been victims of forced sexual contact as children were more likely to engage in unprotected sex, exchange sex for money or drugs and be HIV or syphilis positive.
A study by Brennan and associates found that
Trauma and Adverse Events
New research has found that people who experience trauma or disruption in their childhoods were more likely to have engaged in homosexual behavior or self-identify as gay. A New Zealand study found that:
A study by Jorm and associates found more childhood adversity among those with same-sex partners than those without. Still another study found that:
Sexual coercion and outright rape is not uncommon among MSM. One study of MSM found that:
Another study found that 12% of gay men reported being victims of forced sex by their current or most recent partners, while 5.9% reported being perpetrators of forced sex.
A study of university students found that “sexual victimization experienced by gay/bisexual students is greater than experienced by heterosexual students.”
In another study of 2881 MSM, 34% reported psychological battering, 22% physical battering, and 5% sexual battering. This rate is higher than for heterosexual men and women.
The book Men who beat the Men who Love Them: Battered Gay Men and Domestic Violence, documents in detail the problem of domestic violence among gay men.
STDs, including HIV, could not have spread so widely without frequent partner change. If a person who is completely monogamous becomes infected with an STD by non-sexual means (such as a blood transfusion), the disease does not spread beyond that person’s partner or children conceived after the infection. Many experts believe that HIV was around for years, perhaps decades, but because those infected had a very limited number of sexual partners, there was no epidemic. It was only when it invaded a population where multiple, concurrent sexual partners were the norm, did it spread rapidly.
If, on observing the obvious consequences of HIV infection and watching scores of friends sicken and die, gay men had decided to enter into monogamous relationships, or even practice serial monogamy, the epidemic would have been brought under control, but this did not happen
In the late 1980’s, epidemic saturation had set in, the most promiscuous were sick or dying. The virus was running out of people to infect. However, by the 1990’s a new generation of young men were coming out and engaging in behavior in the urban gay ghettos that put them at risk for HIV infection. The results were predictable. HIV infection among MSM, in particular, young MSM continues to rise. Today, gay men continued to engage in unprotected sex at rates high enough to sustain the epidemic indefinitely.  Epidemiologist Morris and Dean predicted that HIV would become endemic with a seroprevalence of 65% among the oldest group and 35% among the youngest. Another group of epidemiologists predicted that:
Although the push for “gay marriage” might lead the general public to believe that gay men want their monogamous faithful relationships recognized by law, in fact fidelity for same-sex couples is not defined by sexual monogamy, but honesty about outside sexual relationships. A recent article in New York Times confirmed what has long been known, namely that many same-sex relationships whether formalized by marriage ceremonies, civil partnerships, or commitment ceremonies are “open.” According to the Gay Couples Study conducted at San Francisco which followed 556 male couples for three years 50% had sex outside their relationship, with the knowledge and approval of their partners. As time passed the number of faithful couples declined. A study of 156 male couples found that after 5 years all of the couples “had incorporated some provision for outside sexual activity in their relationship.
Those who wish to understand the scope of this openness should read a recently published report Beyond Monogamy: Lessons from Long-Term Male Couples in Non-Monogamous Relationships, the couples interviewed candidly admitted not just occasional affairs, but a consistent pattern of sex outside the relationship, some anonymous in clubs, some with acquaintances, and some threesomes. The couples generally had rules about what was acceptable, but these appeared to be fairly flexible. One of the participants explained, “I’m gay; you’re gay; you’ll play; I’ll play. Let’s be realistic and open about it.” They frequently discussed their outside adventures in detail. It should be noted that almost half of the participants in the study were HIV positive.
MSM have in general more sexual partners than men attracted to women. Odets links the pursuit of sex to adolescent experiences:
As adolescents caught in confusing webs of sexual drive, hopelessness and societal prohibition, many men found sex itself the only completely convincing, natural, and conflict-free aspect of being gay.
The Gay Prophets
In 1979 Larry Kramer’s brutally frank novel and prophetic novel, Faggots, about the sex lives of gay men on Fire Island — a summer resort outside New York City — was published. He was roundly castigated, not because what he said was untrue, but for exposing the dark side of his own community.
In 1981 when gay men started dying from strange diseases, Kramer organized gay men and demanded action. He was able to draw attention to the need for funding and medication to treat the symptoms, but his pleas for changes in behavior were rejected.
In 2004 Kramer gave a speech at Cooper Union which has been published under the title The Tragedy of Today’s Gays in which he railed against all those he blamed for not acting effectively enough to stop the AIDS epidemic. But under the rage, there was guilt, because Kramer remembered those whom he might have infected:
Other gay men sounded warnings. Randy Shilts covered the epidemic as a reporter for the San Francisco Chronicle. In his book As the Band Played On, he revealed how the gay community fought sensible public health initiatives. Gabrielle Rotello, in Sexual Ecology: AIDS and the Destiny of Gay Men, wondered about the future:
Michelangelo Signorile, author of Life Outside: The Signorile Report on Gay Men: Sex, drugs, muscles, and the passages of life, worried that “a legacy of narcissistic attention to physical ideals, excessive drug use, and unsafe sex continue to bring on new waves of anxiety, emotional insecurity, and HIV transmission.”
The prophets’ warnings were ignored. The gay community continued its reckless behavior. The media focus shifted to the marriage debate and public has been led to believe that the epidemic is, if not over, then under control.
Report after report reveals that educational interventions have failed to achieve significant results. A study reported in the British Medical Journal compared gay men who received “behavioral intervention to reduce sexually transmitted infections” with a control group who didn’t receive any special education. The researchers found that “the intervention was more likely to be harmful.” There was a “higher risk of acquiring a sexually transmitted infection among the participants in the intervention …” This was “unexpected … And clearly a cause for concern.” The authors theorized that “the intervention engendered in the participants a misplaced sense of confidence in their ability to negotiate high risk sexual situation.” 
These interventions can be compared to interventions that tried to teach alcoholics to drink responsibly. After the first drink and the alcoholism kicks in and the education is forgotten. Gay men do not contract STDs because they are uneducated about the risks or the ways to prevent infection, but because they were driven by disordered psychological needs:
Part of the problem is that gay men become quickly bored.
Raunch involves practices that involve exposure to feces, urine, and filth. Aggression involves rough sex or sado-masochism. Risk is one way to increase the excitement and overcome boredom.
The existence of a syndemic of STDs and HIV/AIDS is undeniable. Gay men are 44 to 86 times more likely to become HIV positive than other men. MSM are also more likely to become infected with other STDs, including those resistant to standard treatment, making then more susceptible to HIV or complicating the treatment of HIV. Exposure to these STDs, plus other lifestyle choices, make them more likely to have cancer, including anal cancer, throat and mouth cancer, lung cancer, and liver cancer. Since a higher percentage of MSM are HIV positive, there is a real possibility that a male sex partner of a man who has sex partner will be HIV positive.
Gay men are more likely than other men to have problems with substance use and abuse, including alcohol, marijuana, crystal meth, ecstasy, special K, poppers, GBH and Viagra and to use substances during or in order to facilitate sex — in particularly UAI with multiple partners.
Gay men are more likely to frequent venues where HIV positive men socialize and where unsafe sex and drug use with multiple partners are facilitated.
Gay men are more likely to suffer from a wide range of psychological disorders, including depression and suicidal ideation.
Gay men are more likely to have been victims of childhood sexual abuse, other abuse, and life trauma and this in turn makes them more vulnerable to psychological disorders, and to substance abuse, which in turn leads to high risk sexual behavior.
Gay men are more likely to have had GID as children and use steroids to create the perfect body that is attractive to other men.
Gay men belong to communities which see unbridled sexual activity as the very definition of who they are. They reject proven public health strategies for controlling the spread of STDs. They reject as moralizing attempts to encourage them to practice monogamy or use a condom every time or close those venues which encourage sexual relations with multiple partners and drug use. They rejects routine testing, partner notification, and contact tracing. They have fought a ban on blood donations by MSM. Fear of stigmatizing the infected has impeded prevention.
The cost of the syndemic is massive both in lives and money. 6,000 MSM will die this year and every year for the foreseeable future. Drug therapy can prolong the life of those infected for an average of 24 extra years at an estimated total cost of $618,900. Given that 500,000 MSM are currently HIV positive, the cost of care will be massive.
No one in the government or media is willing to admit the obvious: the strategies designed and supported by gay AIDS activists to prevent new infections have failed, yet they are allowed to continue to sabotage standard public health measures.
It is long passed time that HIV prevention is taken out of the hands of gay AIDS activists and given to public health professionals instructed to use all means available to them to prevent the infected from infecting others.
The syndemic goes on unchecked because prevention efforts are controlled by gay AIDS activists and those who defer to them. Currently, it is estimated that in the U.S. 500,000 MSM are HIV positive. Drug therapy can prolong the life of those infected for an average of 24 extra years at an estimated total cost of $618,900 per person.
The gay community sees the devastation: the dead, the dying, the chronically ill. They demand a vaccine, a cure, more money, more education. They claim victim status, and in a sense they are victims. The government and media, by desiring to be thought compassionate, allow gay AIDS activists to exempt MSM from reasonable, proven public health strategies.
 Terminology used in this paper will try to be specific, and therefore the term “homosexual” will be used only when quoting an article that employs that designation or as an adjective. In other instances the terms men with same-sex attraction (SSA), men who have sex with men (MSM), and gay men (that is men who self-identify as gay) will be used as appropriate. These categories are overlapping but not identical since some men with SSA do not have sex with men and not all MSM self-identify as gay.
 CDC, “HIV among gay, bisexual and other men who have sex with men (MSM),” (Sept. 2010).
 Susan Cochran, et al., “Estimates of alcohol use and clinical treatment needs among homosexually active men and women in the US population,” Journal of Consulting Clinical Psychology, (2000) 68: pp. 1062-1071.
D. J. McKirnan, P.L. Peterson, “Alcohol and drug use among homosexual men and women: Epidemiology and population characteristics,” Addictive Behavior, (1989) 14:pp. 545-543.
Ron Stall, et al., “Alcohol use, drug use and alcohol-related problems among men who have sex with men: the Urban Men’s Health Study,” Addiction. (2001) 96: pp. 1589-1601.
Ron Stall, D.W. Purcell, “Intertwining epidemics: a review of research on substance use among men who have sex with men and its connection to the AIDS epidemic,” AIDS Behavior (2000) 4: pp. 181-192.
 Theo Sandfort et al., “Same-sex sexual behavior and psychiatric disorders: findings from the Netherlands Mental Health Survey and Incidence Study (NEMESIS),” Archives of General Psychiatry (2001) 58: pp. 85-91.
J.A. Ciesla, J.E. Roberts, “Meta-analysis of the relationship between HIV infection and risk for depressive disorders,” American Journal of Psychiatry (2001) 158: pp. 725-730.
David Frost, Jeffrey Parsons, Jose Nanin, “Stigma, Concealment, and Symptoms of Depression as Explanations for Sexually Transmitted Infections among Gay Men,” Journal of Health Psychology (2007) 12 (4): pp. 636-640.
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D. J. Brennan et al., “History of childhood sexual abuse and HIV risk behaviors in homosexual and bisexual men,” American Journal of Public Health (2007) 97 (6): pp. 1107-12.
 G.L. Greenwood et al., “Battering victimization among a probability-based sample of men who have sex with men,” American Journal of Public Health (2002) 92: pp.1964-1969.
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K. H. Choi, et al., “Sexual harassment, sexual coercion, and HIV risk among US adults 18—49 years,” AIDS Behavior (1998) 2: pp. 33-40.
 Ron Stall et al., “Association of co-occurring psychosocial health problems and increased vulnerability to HIV/AIDS among urban men who have sex with men,” American Journal of Public Health (2003) 93 (6): pp. 941.
 Neil Buhrich, “The association of erotic piercing with homosexuality, sadomasochism, bondage, fetishism, and tattoos, “ Archives of Sexual Behavior, (1983)) 12 (2): pp 167-171.
 J. Downtown, “Overdrive: When is too much sex a good thing,” The Advocate. (Aug. 22, 1995): p. 48.
William Elder, “Normative gay male sexual socialization: Harmless fun or sexual trauma?” http:www.apatramadivision.org/program/2007_trafficking/elder_paper.pdf
A. Froese, et al., “Sex differences in evaluating heterosexual and homosexual promiscuity,” Psychological Report, (1990) 68: 579-582.
E. Goode, R. Troiden, “Correlates and accompaniments of promiscuous sex among male homosexuals.” Psychiatry (1980) 43: 51.
Charles Socarides, “Homosexuality and Compulsion,” in Addiction and Compulsive Behaviors, (Boston: NCBC, 2000) p. 225-238.
 S.J. Mitchell et al., “Azithromycin-resistant syphilis infection: San Francisco California,” Clinical Infectious Diseases (2006) 42(3): pp. 337-45. Epub 2005, Dec.8.
Kimberly Workowske, et al., “Emerging antimicrobial resistance in Neisseria gonorrhoeae: Urgent need to strengthen prevention strategies,” Annals of Internal Medicines, (2008) 148: 606-613.
Binh An Diep et al. “Emergence of Multidrug-Resistant, Community-Associated, Methicillin-Resistant Staphylococcus aureus Clone USA300 in men who have sex with men,” Annals of Internal Medicine (2008), 148 (4): p. 249
Enrique Rivero, “Study predicts HIV drug resistance will surge,” UCLANews.com (Jan. 22, 2010). http://newsroomucla.edu/oportal/ucla/study-predicts-hiv-drug-resistance-152122.aspx.
Marc Santora, Lawrence Altman, “Rage and aggressive HIV reported in New York,” New York Times (Feb 12, 2005).
Robert Smith et al., “Evolutionary dynamics of complex networds of HIV drug-resistant strains: The case of San Francisco; http://www.natap.org/2010/newsUpdates/science.pdf
Thomas Maugh, “Transmission of drug resistant HIV reported “Los Angles Times (July 1, 1998).
 Douglas Fleming, Judith Wasserheit, “From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection” Sexually Transmitted Infections, (1999) 75: pp. 3-17.
 Chandler Burr, “The AIDS Exception: Privacy vs. Public Health,” The Atlantic Monthly, June 1997.
 Randy Shilts,, And the Band Played On: Politics, people, and the AIDS epidemic, (NY: St. Martins Press, 1987) p.18.
 Shilts, p. 39.
 W Darrow et al., “The Gay Report on Sexually Transmitted Diseases,” American Journal of Public Health, (1981) 71 (9): pp. 1004-1011.
 Shilts, p. 39.
 H. Handsfield, “Sexually Transmitted Diseases in Homosexual Men,” American Journal of Public Health. (1981) 71 (9): pp. 989-990.
 Shilts, p.18.
 Shilts, p. 19.
 Shilts, p. 40.
 Shilts, p.132.
 A Rompalo, ”Sexually Transmitted Causes of Gastrointestinal Symptoms in Homosexual Men,” Medical Clinics of North America, (1990) 74 (6): pp. 1633-1645.
 The disease at that time was labeled GRID gay related immune deficiency.
 Chandler Burr, “The AIDS exception: Privacy vs. Public Health,” The Atlantic Monthly, (June 1997) p. 37.
 Bayer quoted in Burr, p. 59.
 Research and Decisions Corporation, Designing an Effective AIDS Prevention Campaign Strategy for San Francisco: Results from the Third Probability Sample of an Urban Gay Male Community (San Francisco: San Francisco AIDS Foundation, 1986).
 Karolyn Siegel, et al., “Patterns of Change in Sexual Behavior Among Gay Men in New York City,” Archives of Sexual Behavior, (1988) 17(6): pp. 481-497.
 D. Feldman, “AIDS health promotion and clinically applied anthropology,” in The Social Dimensions of AIDS: Methods and Theory, (NY: Praeger, 1986).
 C. Jones, et al., “Persistence in high risk sexual activity among homosexual in an area of low incidence of Acquired Immunodeficiency Syndrome,” Sexually Transmitted Diseases, (1987) 14: 79-82.
 E. Nieves, “San Francisco again debates bathhouses,” New York Times, (May 29, 1999).
 Gabriel Rotello, Sexual Ecology: AIDS and the Destiny of Gay Men, (NY: Dutton, 1997) p. 109.
 Rotello, p. 109.
 Ronald Bayer, “AIDS Prevention–Sexual Ethics and Responsibility,” New England Journal of Medicine, (June 6, 1996): 1540-1542.
 Rotello, p. 241
 Larry Kramer, The Tragedy of Today’s Gays (New York: Tarcher, 2005)
 Patrick Califia, Speaking Sex to Power: The Politics of Queer Sex (San Franciso, Cleis, 2002).p. 287.
 Ibid, p. 291
 Ibid, p. 289
 Walt Odets, “AIDS Education” (1994).
 Walt Odets, In the Shadow of the Epidemic: Being HIV negative in the age of AIDS, (Durham, NC: Duke U.P. 1995), p.205
 The Advocate, (Dec.22, 1998) p. 45
 Odets, (1994)
 Odets, (1994) p. 9
 Odets, (1994) p. 10
 Odets, (1995) p. 205.
 Odets (1994).
 Gabriel Rotello, Sexual Ecology, (NY: Dutton,1997)
 M Morris, L. Dean, “Effect of sexual behavior change on long-term human immunodeficiency virus prevalence among homosexual men,” American Journal of Epidemiology, (1994) 140(3): pp. 217-32.
Donald Hoover, et al., “Estimating the 1978-1990 and future spread of human immunodeficiency virus type 1 subgroups of homosexual men,” American Journal of Epidemiology, (1991) 134 (10): pp. 1190-1205.
 Nancy Hessol et al., “Prevalence, incidence and progression of human immunodeficiency virus infection in homosexual and bisexual men in Hepatitis B Vaccine Trials, 1978-1988,” American Journal of Epidemiology, (1989). 1130 (6): 1167-1175.
 Perry Halkitis, et al., “Facilitators of barebacking among emergent adult gay and bisexual men: implications for HIV prevention” Journal of LGBT Res. (2008) 4 (1): pp. 11-26 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2748929/
 Ibid, also
L. Wilton et al., “An exploratory study of barebacking, club drug use, and meanings of sex in Black and Latino gay and bisexual men in the age of AIDS,” Journal of Gay & Lesbian Psychotherapy, (2005) 9(34): pp. 49-72.
R.J. Wolitski “The emergence of barebacking among gay and bisexual men in the United States: A public health perspective,” Journal of Gay & Lesbian Psychotherapy (2005) 9 (34): pp. 9-34.
A. Carballo-Dieguez. J. Bauermeister, “Barebacking: Intentional condomless anal sex in HIV-risk contexts. Reasons for and against it,” Journal of Homosexuality (2004) 47 (1): pp. 1-16.
 Michael Scarce, speaking at a HIV InSite round table on bareback sex organized by Nicolas Sheon, HIV InSite Prevention editor, “Bareback Sex: Implications for the Future of HIV Prevention,” May 1999.
 Maria Xirdou, et al., “The contribution of steady and casual partnerships to the incidence of HIV infection among homosexual men in Amsterdam,” AIDS (2003) 17 (7): pp. 1029-1038.
 Richard Wolitski, “The emergence of barebacking among gay and bisexual men in the United States: A public health perspective,” in Perry Halkitis, Leo Wilton, Jack Drescher, eds., Barebacking: Psychosocial and Public Health Approaches, (Binghamton NY: Haworth Medical Press, 2005), co-published as Journal of Gay and Lesbian Psychotherapy, 9 (3/4)
 Ellie Reynolds, “Material World: Becoming HIV: disease as agency,” University College London, http://blogs.nyu.edu/projects/materialworld/2007/02/becoming_hiv_disease_as_agency.html
 D. H. Osmond et al, “Changes in prevalence of HIV infection and sexual risk behavior in men who have sex with men in San Francisco, 1997-2002,”
 Daniel Ciccarone, et al., “Sex without disclosure of positive HIV serostatus in a US probability sample of persons receiving medical care for HIV infection,” American Journal of Public Health, (2003) 93, (6): p. 949.
 Michael Gross, “When plagues don’t end,” American Journal of Public Health, (2003) 93(6): p. 862
 “What is the incidence of HIV in USA? The Lancet, (June 21, 2008) 371 (9630).
 A.E. Brown, et al, “Implications for HIV testing policy derived from combining data on voluntary confidential testing with viral sequences of and serological analyses, “ Sexually Transmitted Infections, (2009) 85; p. 4-9. http://sti.bjm.com/content/85/1.4.full.
 This includes the 4% of MSM who are also intravenous drug users.
 Lawrence Altman, “HIV Study finds rate 40% higher than estimated,” New York Times. www.nytimes.com/2008/08/03/health/03aids.html.
 National HIV/AIDS Strategy for the United States, (July 2010) http://www.whitehouse.gov/site/default/files/uploads/NHAS.pdf.
 Perry Halkitis, “Reframing HIV prevention for gay men in the United States,” American Psychologist, (2010) 65(8).
 Anemona Hartocollis, “NYC’s graphic ad on the dangers of H.I.V. is dividing activists,” (NYT, Jan 6, 2011). http://www.nytimes.com/2011/01/04/nyregion/04hiv.html?partner.
 CDC, “HIV among gay, bisexual and other men who have sex with men (MSM),” (Sept. 2010)
 Edward Green, Rethinking AIDS Prevention: Learning from Successes in Developing Countries, (Westpport CT: Praeger, 2003)
 Binh An Diep et al. “Emergence of Multidrug-Resistant, Community Associated, Methicillin Resistant Staphylococcus aureus Clone USA300 in men who have sex with men,” Annals of Internal Medicine, (2008) 148, (4): pp. 249-257.
 R.F Nieuwenhuis et al., “Resurgence of lymphogranuloma venereum in Western Europe: an outbreak of Chlamydia trachomatis serovar 12 proctitis in The Netherlands among men who have sex with men,” Clinical Infectious Diseases, 39 (2004): 996-1003.
 Edwin Bernard, “LGV spreading throughout the UK, gay HIV positive men most affected,” AIDS Map News, (Jan.19, 2002). http:/aidsmap.com/en/news/ED5660D3-7737-4AAEA7DA-22690AB16CSF.asp
E. J. Savage, “Results of a Europe-wide investigation to assess the presence of a new variant of Chlamydia trachomatis” Euro Surveillance, (2007). 12 (10) Epub.
 Liz Highleyman, “HCV may be sexually transmitted in HIV negative as well as HIV positive men,” CROI 2007, (March 2, 2007), http://www.hivandhepatitis.com/2007/icr/croi/docs/030207_d.html.
M. Fisher, et al., “Acute Hepatitis C in men who have sex with men is not confined to those infected with HIV , and their number continues to increase, “ 14th Conference on retroviruses and opportunistic infections, (Los Angeles, Feb. 25-28, 2007).
M. Danta et al, “Recent epidemic of acute hepatitis C…” (Mau 11, 2007) 21 (8) :pp983-991
 Timothy Wilkins, “Anal Cancer increasing among people living with HIV,” GMHC (Gay Men’s Health Crisis), (Sept. 2010), p.2
Amin Ghaziani, Thomas Cook, “Reducing HIV infections at circuit parties,” Journal of International Association of Physicians in AIDS Care, (June 2004); http://web4.infotrac.galegroup.com/itw/infomark/346/366/7919935w4
 Simon Fanshawe, “Society now accepts gay men as equals. So why on earth do so many continue to behave like teenagers?” Guardian UK, (April 21, 2006). http://www.guardian.co.uk/commentisfree/2006/apr/21/gayrights.comment/print
 Milton Wainberg, Andrew Kolodny, Jack Drescher, ed., Crystal Meth and Men Who Have Sex with Men: What Mental Health Care Professionals Need to Know (BinghamtonNY: Haworth Medical Press, 2006).
David Heitz, “Men behaving badly,” The Advocate (July 8, 1997): pp. 28-29.
 Signorile, p. 109
 Patrick Moore, “We are not OK,” Village Voice (June 14, 2005).
 Sherry Larkins, Cathy Reback, Steven Shoptaw, “HIV risk behaviors among gay male methamphetamine users: Before and after treatment,” in Milton Wainberg, Andrew Kolodny, Jack Drescher, ed., Crystal Meth and Men Who Have Sex with Men: What Mental Health Care Professionals Need to Know (Binghamton NY: Haworth Medical Press, 2006) p 126.
 Antonio Urbina, “Medical complication of crystal methamphetamine,”(in Milton Wainberg et al., eds. Crystal Meth and Men who have Sex with Men: What mental health care professionals need to know, published simultaneously published in Journal of Gay & Lesbian Psychotherapy, 2006, 10 (3/4): p.53.
 Kevin Sack, “H.I.V. Peril and Rising Drug Use,” New York Times (January 29, 1999).
 Milton Wainberg, Andrew Kolodny, Jack Drescher, ed., Crystal Meth and Men Who Have Sex with Men: What Mental Health Care Professionals Need to Know (Binghamton NY: Haworth Medical Press, 2006) co-published as Journal of Gay and Lesbian Psychotherapy, 10, no.3/4 (2006): pp.-12-13
 Ibid, p. 1.
 http://en.wikipedia.org/wiki/Circuit_party. Referencing Amin Ghaziani Thomas D. Cook, “Reducing HIV Infections at Circuit Parties: From Description to Explanation and Principles of Intervention Design,” Journal of the International Association of Physicians in AIDS Care, (2005) 4 (2): p. 32.
 The Advocate (Dec 22, 1998) p. 39.
 Odets, (1994) p. 14.
 Edgardo Menvielle, Catherine Tuerk, “A support group for parents of gender-nonconforming boys, “ Journal of the American Academy of Child and Adolescent Psychiatry, (2001) 41 (8): pp 1010-1013.
 R. Friedman, L. Stern, “Juvenile Aggressivity and Sissiness in Homosexual and Heterosexual Males,” Journal of the American Academy of Psychoanalysis. (1980) 8(3): pp. 427-440.
 Signorile, p. 168.
 Signorile p. 169.
 Signorile, p. 163-165.
 S. Zierler, et al. “Adult survivors of childhood sexual abuse and subsequent risk of HIV infection,” American Journal of Public Health, (1999) 81: pp. 572-575
 B.N. Bartholow et al “Emotional and behavioral and HIV risk associated with sexual abuse among adult homosexual and bisexual men, Child Abuse and Neglect (1994) 18: pp. 747-761.
 Brennan, (2007) p.1107.
 Elizabeth Wells, Magnus McGee, Annette Beautrais, “ Multiple aspects of sexual orientation: Prevalence and sociodemographic correlates in a New Zealand National Survey, “ Archives of Sexual Behavior, (June 22, 2010).
 D. Jorm et al, “Sexual orientation and mental health: Results from a community survey of young and middle-aged adults,” British Journal of Psychiatry, (2002) 180: pp. 423-427.
 Andrea L. Roberts et al., “Pervasive Trauma Exposure Among US Sexual Orientation Minority Adults and Risk of Posttraumatic Stress Disorder,” American Journal of Public Health, (2010) 100 (12): pp. 2433-2441.
 Seit Kalichman, David Rompa, “Sexually coerced and noncoerced gay and bisexual men: Factors relevant to risk for human immunodeficiency virus (HIV) infection, Journal of Sex Research, (1995) 32 (1): p. 45.
 Caroline Waterman, et al., “Sexual coercion in gay male and lesbian relationships,” Journal of Sex Research, (1989) 26 (1): pp 118-124.
 John Baier et al., “Patterns of sexual behavior, coercion, and victimization in university students,” Journal of College Student Development, (1991) 32: p.317
 Gregory Greenwood et al., “Battering victimization among a probability-based sample of men who have sex with men,” American Journal of Public Health, (2002) 92 (12): pp. 1964-1968.
 David Island, Patrick Letellier, Men who beat the Men who Love Them: Battered Gay Men and Domestic Violence,(Binghamton NY: Haworth, 1991)
 Rotello, Sexual Ecology.
 M. Morris, L. Dean, “Effect of sexual behavior change on long-term human immunodeficiency virus prevalence among homosexual men,” American Journal of Epidemiology, 1994, 140 (3): pp. 217-232.
 Donald Hoover, et al., “Estimating the 19878-1990 and future spread of human immunodeficiency virus type 1 in subgroups of homosexual men,” American Journal of Epidemiology, (1991) 134 (10): p. 190.
 Joe Kort, “Are gay male couples monogamous ever after,” Psychology Today, (Sept. 16, 2008).
 Scott James, “Many successful gay marriages share an open secret,” New York Times (Jan. 29, 2010)
 David McWhirter, Andrew Mattison, The Male Couple: How Relationships develop (Englewood Cliffs, NJ: Prentice-Hall, 1984) p. 252.
 Blake Spears, Lanz Lowen, Beyond Monogamy: Lessons from Long-Term Male Couples in Non-Monogamous Relationships (2010); http://thecouplesstudy.com/wp-content/uploads/BeyondMonogamy_1_01.pdf
 Ibid, p. 4
 Ibid, p. 36
 Odets, (1995) p.198
 Larry Kramer, Report from the Holocaust: The making of an AIDS activist (NY: St. Martins Press, 1989)
 Larry Kramer, The Tragedy of Today’s Gays (New York: Tarcher, 2005) p. 57.
 Rotello, p.208.
 Michelangelo Signorile, Life Outside: The Signorile Report on Gay Men: Sex, drugs, muscles, and the passages of life, (NY; Harper Collins, 1997)
 John Imrie et al., “A cognitive behavioural intervention to reduce sexually transmitted infections among gay men: randomised trial,” British Medical Journal, (Jun 16, 2001); http://findarticles.com/p/articles/mi_m0999/is_7300_322/ai_n27568633/?tag=content
 Signorile, p. 20.
 Signorile, p. 21.
 Kirk, p. 304.
Anil K. Chaturvedi, Eric A. Engels, William F. Anderson, Maura L. Gillison, “Incidence Trends for Human Papillomavirus—Related and —Unrelated Oral Squamous Cell Carcinomas in the United States,” Journal of Clinical Oncology. (2008)
 Harold Jaffe et al., “The reemerging HIV/AIDS epidemic in men who have sex with men,” Journal of the American Medical Association, (2007) 298 (20): pp. 2412-2414.
 ____ “Got HIV? Lifetime Cost $618,900” http://www.cbsnews.com/stories/2006/11/02/health/webmd/main2146542.shtml
 ____ “Got HIV? Lifetime Cost $618,900” http://www.cbsnews.com/stories/2006/11/02/health/webmd/main2146542.shtml
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