By HOWARD GROSSMAN, M.D.
The last thing we gay men need to hear is more bad news about our sex lives. Last year there were announcements about continued increases in HIV diagnoses and syphilis cases, and earlier this year new data came out about how crystal meth use might be fueling the spread of HIV and STDs. Now there are reports of increasing cases of gonorrhea among gay and bisexual men, a growing number of which are resistant to commonly used antibiotics.
On the gay health spectrum, gonorrhea may not seem like a big deal. But with an estimated 700,000 people infected in the U.S. each year, gonorrhea is one of the most common sexually transmitted diseases. And like syphilis, it may be contributing to new HIV infections in our community.
Gonorrhea is spread more easily than HIV. It can be transmitted through oral sex and oral-anal contact (rimming) as well as through intercourse—even if ejaculation does not occur. Symptoms can include a burning sensation when urinating, discharge from the penis, and painful or swollen testicles. In the rectum, symptoms may include discharge, itching, bleeding, and painful bowel movements. In the throat, it can cause discomfort, which may be mistaken for a simple sore throat.
But sometimes there aren’t any signs. Gonorrhea is often asymptomatic, particularly in the throat and anus, and it is not unusual for people to go undiagnosed and untreated, spreading the infection to others. Without treatment, gonorrhea can cause sterility, scarring of the urethra, and potentially serious blood and joint disorders.
Just like syphilis and other STDs, gonorrhea greatly increases the chances of someone transmitting or acquiring HIV infection. It disrupts mucous membranes and lowers the body’s ability to keep out HIV. Unfortunately, there is ample evidence that many gay men with HIV are not taking the effects of gonorrhea and other STDs seriously enough. In one CDC study, gay men with HIV were twice as likely to test positive for gonorrhea as men who were HIV-negative. Similar results were seen for syphilis. In another study of gay and bisexual men, conducted at Boston’s Fenway Community Health Center, being HIV-positive was one of the main predictors of receiving a new STD diagnosis.
What’s especially troubling today for gay men is the rapid rise of gonorrhea cases that are resistant to the generally recommended oral antibiotics—fluoroquinolones such as ciprofloxacin (Cipro), ofloxacin, and levofloxacin. After increases were reported in Seattle, Boston, and other areas, new data from the Centers for Disease Control and Prevention (CDC) showed a nearly three-fold nationwide increase in resistant cases among gay and bisexual men between 2002 and 2003—from 1.8 percent to 4.9 percent of cases.
Here in New York, one in eight gay men with gonorrhea has the drug-resistant strain; in Boston it’s one in nine. And in both cities, gay men are at least six times more likely to have drug-resistant gonorrhea than heterosexual men.
Due to these data, the CDC has now changed gonorrhea treatment recommendations, and is asking physicians not to use fluoroquinolones for gonorrhea among gay and bisexual men. Instead, doctors should now prescribe an intramuscular injection of one of two antibiotics, ceftriaxone or spectinomycin, followed by an oral drug, either azithromycin or doxycycline, to treat relatively common co-infection with chlamydia. In other words, treatment is going to be a bit more painful, less convenient, and—for those without good health insurance—more expensive.
While new treatment recommendations will help ensure that people with gonorrhea receive proper treatments, public health officials can’t solve this problem alone. We need to take steps to protect our own health.
First, all gay and bisexual men should take the time to learn more about gonorrhea. Many people have been so focused on HIV prevention that they have not learned about other STDs like gonorrhea. Learn the signs and symptoms. Next, if you think you may be at risk, take the initiative to get tested, as part of your annual physical if you are at low risk, or more often if you have sex with multiple partners.
Remember, in the late 1970s and early 1980s it was routine for gay men with multiple partners to get tested as often as once per month. Contact your primary care doctor, or find the STD testing site nearest you by calling CDC’s National STD Hotline anytime at 800 227 8922 (in Spanish, 800 344 7432). If you test positive for gonorrhea, stop having sex immediately and do your best to notify your partners of possible exposure. You can resume having sex seven days after being treated.
Above all, gay men need to take steps to avoid getting infected in the first place. Talk with your partners openly and honestly about your sexual history and HIV and STD status. Take a hard look at how drug and alcohol use affect your sexual practices. And use latex condoms, which can greatly reduce—though not completely eliminate—the risk of gonorrhea transmission when used consistently and correctly. It is important to remember that while condomless oral sex may be relatively low risk when it comes to HIV, it’s a high-risk activity for gonorrhea.
With all the serious problems that gay men have to face, we do not need to add gonorrhea to the list. We know how to prevent it, and even with growing drug resistance, we know how to treat it. In other parts of our lives, gay and lesbian communities are achieving things that once seemed impossible. Let’s make sure that we’re all healthy enough to enjoy them.
Howard Grossman, M.D., is a New York City clinician and a member of the American Academy of HIV Medicine.