Judge not, respect all, and practice well

Dr. Katz: “Just as I do with any patient, I try to get to know my patients who are gay men and other men who have sex with men. Doing so helps build the patient-doctor relationship, and it also makes being a doctor more rewarding.”

Kenneth A. Katz, MD, MSc, MSCE, presented need-to-know guidelines and best practices in Saturday’s session “Taking Care of Gay Men and Other Men Who Have Sex With Men” (U025). Dr. Katz, who is a dermatologist and chief of outpatient pharmacy and therapeutics at Kaiser Permanente in San Francisco, shared his personal approach.

Environment

When patients walk in the door, the office staff and environment should communicate that dermatologists are welcome of all people. This is especially important when it comes to men who have sex with men (MSM), who often have had negative experiences in health care settings, said Dr. Katz. That initial impression greatly affects the remainder of a patient’s visit.

“What’s important is to try and be as prepared as possible for all patients, including gay men and non-gay-identified men who have sex with men,” he said.

Once inside the exam room, dermatologists should continue to exhibit respect. This means normalizing intake of sexual history — in cases where sexual history is relevant — so that patients don’t feel stigmatized, and then asking for consent to treat. It’s important to be thorough when eliciting a sexual history, while remaining sensitive. This helps in creating rapport with a patient and capturing all the necessary information needed to begin a comprehensive care plan.

After establishing whether a patient is sexually active, and, if so, with men, women, or both, questions should be phrased to determine, as needed, sexual behavior and/or sexual orientation. Doing so respectfully enables patients to feel more comfortable — and even appreciative of the opportunity — to discuss sexual health.

Strategies

As with all patients, Dr. Katz said his main goal in treating gay men and other MSM is to do so in a culturally sensitive way that addresses their health needs and produces high-quality outcomes. Often, this means making recommendations, based on MSM-specific guidelines from the Centers for Disease Control and Prevention (CDC) and other public health agencies, regarding sexual health-related screenings, vaccinations, and prevention methods, including pre- and/or post-exposure prophylaxis for HIV.

It is difficult to know the percentage of MSM who are at an increased risk of health conditions with dermatologic side effects, said Dr. Katz. This partially results from the failure of electronic health records and population-based studies to capture information related to sexual orientation and behavior. However, MSM are at a higher risk of acquiring HIV infection, Kaposi sarcoma, and some STDs, such as syphilis. Also reported among MSM are outbreaks of other infectious diseases, including invasive meningococcal disease and methicillin-resistant Staphylococcus aureus infections. Additionally, emerging evidence supports an increased risk among gay men for skin cancer and indoor tanning, as well as mental health concerns in those with acne. These are all in addition to common dermatologic complaints and conditions not specific to sexual orientation or behavior.

Regardless of someone’s sexual history or range of symptoms and health issues, Dr. Katz looks to ensure a positive health experience to the best of his ability.

“Just as I do with any patient, I try to get to know my patients who are gay men and other men who have sex with men,” he said. “Doing so helps build the patient-doctor relationship, and it also makes being a doctor more rewarding. Hopefully I ask enough [questions], and do so in a way that demonstrates that I’m delighted to care for them and will do my best for them.”

Parameters

Dr. Katz referred to multiple guidelines and resources published by the CDC that can aid dermatologists in managing MSM.

According to the CDC, MSM should be screened at least annually for:

  • HIV serology, if HIV status is unknown or negative and the patient himself or his sex partner(s) has had more than one sex partner since most recent HIV test.
  • Syphilis serology to establish whether persons with reactive tests have untreated syphilis, have partially treated syphilis, are manifesting a slow serologic response to appropriate prior therapy, or are serofast.
  • A test for urethral infection* with  gonorrhoeae and C. trachomatis in men who have had insertive intercourse** during the preceding year (testing of the urine using NAAT* is the preferred approach).
  • A test for rectal infection* with  gonorrhoeae and C. trachomatis in men who have had receptive anal intercourse** during the preceding year (NAAT of a rectal specimen is the preferred approach).
  • A test for pharyngeal infection* with  gonorrhoeae in men who have had receptive oral intercourse** during the preceding year (NAAT of a pharyngeal specimen is the preferred approach). Testing for C. trachomatis pharyngeal infection is not recommended.

* Regardless of condom use during exposure.
** Commercially available NAATs have not been cleared by FDA for these indications, but they can be used by laboratories that have met all regulatory requirements for an off-label procedure.

MSM who have HIV should also be screened for gonorrhea, chlamydia, and syphilis. The frequency of these screenings depends on the patient’s sexual history and behavior. There is not enough evidence to support regular anal-cancer screening in MSM.

The CDC recommends that MSM who are at least 19 years of age should receive several vaccinations, including hepatitis A, hepatitis B, and 4- or 9-valent HPV. Certain localities also recommend the meningococcal vaccination for HIV-negative MSM. All persons living with HIV should receive meningoccal vaccination.

Per the CDC, adult MSM who present with certain indications should be considered for pre-exposure prophylaxis (PrEP) to prevent HIV if they meet the following criteria:

  • Do not have acute or established HIV infection.
  • Have had at least one male sex partner in the past 6 months.
  • Is not in a monogamous partnership with a recently tested, HIV-negative man.
  • Has at least one of the following:
    • Any anal sex without condoms (receptive or insertive) in the past six months.
    • A bacterial STD (syphilis, gonorrhea, or chlamydia) diagnosed or reported in the past six months.

Lastly, the CDC has published updated guidelines for non-occupational post-exposure prophylaxis (nPEP) for HIV, including for MSM.

 

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