HPV: a Hidden Epidemic that’s Killing Gay Men

   David Fawcett, PhD, LCSW



    Albert, a gay man, came back to my psychotherapy office for the first time in three months.  He looked thinner, pale, and depressed.  He was still on a significant amount of pain medications after suffering three painful rectal surgeries in an attempt to treat aggressive anal cancer.  His prognosis remained uncertain and he was tired and discouraged.

    Albert is also not alone.  There is a largely-unrecognized epidemic of gay men, many also HIV positive, coming down with anal cancer.  Several of my own clients have been diagnosed and I hear of other cases with disturbing frequency.

    Anal cancer is caused by exposure to HPV (Human Papillomavirus) and can usually be successfully treated when discovered early.  While there is no definitive diagnostic test, a simple annual screening with a Pap smear can be highly effective at finding cellular irregularities before they become cancer.  Even gay-friendly physicians often don’t think to offer a Pap, and gay men don’t know to ask for one.  This needs to change.

What is HPV?

    HPV is the most common sexually transmitted infection.  At least half of all sexually active individuals get HPV at some time in their lives. These infections frequently create no symptoms and resolve on their own, but a few of the more than 40 types of HPV can have serious and even fatal consequences.  Some strains cause cervical and anal cancers; others cause genital warts. 

How common is HPV among gay men?

    One study reported that 95% of gay men with HIV also have HPV, and 60% of HIV-negative men have HPV.  Gay and bisexual men are 17 times more likely to develop anal cancer than heterosexual men. 

How is it contracted?

    HPV is contracted skin-to-skin – no penetration is required.  This can include genital to genital contact, touching someone else’s genitals and then your own; sharing sex toys, and (rarely) oral sex.  Condoms offer minimal protection but some risk remains because of exposed skin. 

What can go wrong if I am exposed to HPV?

    Cervical cancer in women is the best-researched consequence of HPV, but the virus can also result in significant, lesser- known concerns for gay men.  The same HPV strains that cause cervical cancer in women can cause anal cancer (and rarely penile cancer) in men.  Gay men who practice receptive anal intercourse are at high risk; if they are HIV positive they have even higher risk.   If undetected, anal cancer is very dangerous.  In HIV positive men its progression appears unrelated to taking antivirals, length of time since HIV diagnosis, or CD4 counts.  It is treated with advanced forms of radiation, chemotherapy, and surgery, although a combined UK/US study found survival rates of just 66% for the first year which declined thereafter. 

    Another, less virulent consequence of exposure to HPV is genital warts.  These are highly contagious and caused by an HPV strain that doesn’t lead to cancer.  They need to be treated by freezing with liquid nitrogen, cauterizing, or surgically removing them.

What about Prevention?

    An HPV vaccine called Gardasil, shown to prevent cervical cancer and genital warts, has been introduced and approved only for girls ages 9-26.  It protects against four types of HPV, including the two that cause 70% of cervical cancer.  It is administered in three shots and is usually not covered by insurance (cost around $300).  The vaccine will not offer protection for prior exposure to specific strains, although studies indicate it might slow progression of warts or cancer. The vaccine is not approved for men although (finally!) there are studies underway to test its safety and efficacy in men.

     We don’t have to wait for the vaccine.  There is an easy and effective screening tool that every sexually active gay man should have every year: a Pap test (also known as a Pap smear).  This can detect abnormal cells that could become cancer and which can be removed.  The CDC doesn’t recommended Pap tests for men because there is not yet enough data on how HPV leads to cancer in men, although other leading gay men’s health organizations such as Fenway in Boston recommend annual Pap test screening.  

    If a Pap test is negative you’re in good shape.  If it’s positive your doctor will conduct a biopsy, remove suspicious cells with a laser, and monitor through regular follow up.   

    As gay men we need to take charge of our health care.  Ask your doctor about a Pap test – if you detect surprise at the question you may need to evaluate how knowledgeable he or she is about gay men’s health.


“Inspot” website lets you anonymously notify others about your STD


Imagine receiving this email: “No one wants to be the bearer of bad news but I got diagnosed with STDs (sexually transmitted diseases) and you might have one too.” This email might be from someone you know, or it could be anonymous. While unpleasant, such a message has tremendous benefit because it notifies you of possible exposure. With such knowledge you can seek early treatment and hopefully avoid having to send such an email yourself. This new service is available through Inspot, a not-for-profit agency funded by the Florida Department of Health.

New options for notifying sex partners couldn’t come at a better time. Last week a CDC (Centers for Disease Control and Prevention) report announced that syphilis cases in the US were up a staggering 15.2% over the year before, and worse, gay and bisexual men (including a disproportionate number of African-American men) accounted for a whopping 65% of those cases.  These numbers represent an unfortunate continuation of a seven year rising trend in syphilis rates.

Syphilis, untreated, is dangerous enough, but it also increases exposure risk for HIV by causing breaks in the skin, giving these statistics an ominous significance. While there is a simple blood test for syphilis, the symptoms (sores on the genitals or in the mouth) often go undiagnosed and the disease is easily spread. The CDC recommends annual testing for those in a partner relationship, and every six months for others.

Why are these numbers so high for gay and bisexual men?” The CDC speculates that we are suffering from prevention fatigue (certainly true) and being less vigilant with safer sex. Dr. John Douglas, head of STD Prevention for the CDC, also suspects that a rise in serosorting, the practice of choosing sex partners with the same HIV status, plays a role. Such unprotected sex leaves men exposed to other sexually transmitted diseases like syphilis.

I suspect an additional factor: substance abuse, particularly methamphetamine. Meth is the perfect storm for STDs: it increases risky sexual behavior, leads to multiple sexual partners, and eliminates cares about protected sex. The clients I see in the Meth and Men program at Sunserve bear this out: tina, out of control sex, and STDs go together.

No one wants to tell a friend or even a trick that you have exposed them to an STD. And realistically, you may not even know his name or phone number. But chances are that if you hooked up online you can find that profile and send him (or them!) an email that can be anonymous or personalized. In Florida, you can do this knowing that no governmental authority is involved, and that there will be no reporting or follow up by the health department.

Inspot provides six templates with sharp graphics and catchy phrases (“It’s not what you brought to the party, it’s what you left with”). If you wish you can add a personal message. The site also has links for information about sexually transmitted diseases and testing locations.

Getting tested for HIV and other sexually transmitted diseases is essential. Most infections occur not because people lie (although some do) but because they don’t know their status. When you get bad news don’t let embarrassment keep you from notifying someone you might have infected. Use these Inspot notification emails to help stop this cycle and keep our community healthy.

For more information visit Inspot at http://inspot.org/florida.