Promiscuous Gay Nerd: "If You Use It, Test It!" Toward a Gay Men's Sexual Health Standard of Care
December 12, 2013
"Tell me what you want to have done," the staid-faced nurse practitioner blurted out after I sat down in her office. It wasn't exactly the friendliest way to begin a patient interaction, but it was nonetheless music to my gay ears. For six years, I'd been coming to this very student health clinic at the university I attend for graduate school, trying desperately to get screened for sexually transmitted infections. And for six years, doctors have treated me like some kind of oddity they didn't want to touch with a ten-foot pole. Frustrated, I finally decided to specifically request an appointment with a nurse practitioner instead of a doctor.
I sat making a mental checklist for a second before prattling off my Christmas wish list. "Well, I need a blood draw for syphilis, RNA test for HIV, a urine test for gonorrhea and chlamydia, NAAT swab for pharyngeal gonorrhea, and a NAAT swab for rectal gonorrhea and chlamydia." Needless to say, I had done my homework. The nurse looked a bit surprised, but nonetheless turned to her computer to enter in all the lab requests. After a phone call to the lab and some serious computer sleuthing, she looked flummoxed. "The computer will only let me choose cervix or urogenital as the site for the NAAT swab." I leaned in with a wry smile: "Just tell the lab it's from my cervix." I thought maybe she would twerk the system for me. Alas, she said she'd have to do some research into the matter. Come back another day for the swabs, she said.
While I didn't get what I wanted that day, I left hopeful that she would triumph over the bureaucracy and finally get me screened. The truth is that I haven't been tested for gonorrhea or chlamydia in my throat or ass for years now. The few times when I suspected I had been infected, I got my hands on antibiotics through friends or family members and self-treated with guidance from websites. For many gay men with clueless providers, that's the unfortunate reality in which we live. So when the prospect of actually getting properly tested seemed to be materializing, I was genuinely excited.
The nurse finally got back to me after six weeks, only to tell me the administration refused to allow the test because it wasn't Food and Drug Administration approved for pharyngeal or rectal screening. "We could run a culture," she offered. But she and I both knew that cultures are piss-poor tools for gonorrhea and chlamydia screening. Unlike newer technologies such as NAAT tests, which are much more accurate, cultures get it right less than half the time. I told her I'd rather flip a coin.
Intent on getting the care I need and deserve, I turned again to my PrEP doctor, who works out of the local hospital. I thought he might be able to finagle the system on my behalf. His response was even more disappointing: "Well, you know, there generally aren't many complications for men. The only real concern is possibly spreading it around." I sat steaming, wondering to myself if my doctor actually had a functioning brain. I was on PrEP, for fuck's sake. Did he think I was just going around town shaking hands with other gay men? "We could do a urine analysis," he offered. I pursed my lips. "If I'm going to get gonorrhea or chlamydia, the last place it's going to be is in my dick. Most of my partners don't even touch it." That wasn't exactly true, but I wanted to make a point.
If you're lucky enough to live in a city like San Francisco, you have the advantage of access to skilled, knowledgeable, and nonjudgmental health clinics like Magnet, a project of the San Francisco AIDS Foundation. You can waltz in on any given day, confident that you'll be treated like a grown adult with legitimate health needs. But if you venture outside of these urban meccas, you're likely to find yourself face to face with ignorant and unhelpful providers who are more likely to judge you than offer you the appropriate sexual health services.
Before you imagine that the problem lies in the lack of a published standard of care, the Centers for Disease Control and Prevention publishes STI treatment guidelines that are updated every few years. The most recent, published in 2010, includes crystal-clear guidelines for men who have sex with men:
- HIV serology, if HIV negative or not tested within the previous year;
- syphilis serology, with a confirmatory testing to establish whether persons with reactive serologies have incident untreated syphilis, have partially treated syphilis, or are manifesting a slow serologic response to appropriate prior therapy;
- a test for urethral infection with N. gonorrhoeae and C. trachomatis in men who have had insertive intercourse during the preceding year; testing of the urine using nucleic acid amplification testing (NAAT) is the preferred approach;
- a test for rectal infection with N. gonorrhoeae and C. trachomatis in men who have had receptive anal intercourse during the preceding year (NAAT of a rectal swab is the preferred approach); and
- a test for pharyngeal infection with N. gonorrhoeae in men who have had receptive oral intercourse during the preceding year (NAAT is the preferred approach). Testing for C. trachomatis pharyngeal infection is not recommended.
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