The Ins and Outs of Gay Sex (11 page)

H
e zipped up his pants, his expression clearly troubled.
“I don’t know how I got this,” he said.
“I mean, my sex is so safe it’s practically nonexistent.”

I smiled.
“Nevertheless, you’ve got a discharge and I bet it’s gonorrhea.
We won’t know for sure until the culture comes back, but it’s best to treat you anyway.”
I cleared my throat.
“There’s something else.
You’ve got to notify your sexual partners.”

“That’s just it, there aren’t any.
Not since Brian and I broke up.”

I shook my head.
“You didn’t get this from a toilet seat.
You must have slept with someone.”

“No … well, I did get a blow job from this guy.
That can’t give it to you, can it?”

We all know how prevalent sexually transmitted diseases are among men who have sex with men; now we need to learn how to prevent them.
But first, we must have a thorough understanding of each disease, its route of transmission, and its signs and symptoms.
Nonviral STDs are still the most common, but in the last decade, they have certainly been overshadowed by AIDS.
The pity is that these diseases are virtually 100 percent curable, but without treatment
they can be lethal.
Unfortunately, as our focus has shifted to AIDS, both physicians and gay men are less aware of these problems.
In effect, what we are now seeing is our failure to treat curable infections because physicians and patients don’t know about them.
And don’t think for a minute that syphilis and gonorrhea are no longer a threat.
They’re out there in daunting numbers, and the longer it takes to make the correct diagnosis, the greater the chance infection will spread between unaware partners.
As we saw with HIV, transmission is exponential.

Why, you ask, am I bothering to mention a historic disease, virtually extinct in our very modern times?
Because syphilis is far from gone.
An estimated 101,000 new cases were reported last year in this country, and half were thought to be in men who have sex with men.
That’s more than the yearly estimated new cases of HIV.
According to the Centers for Disease Control in Atlanta, Baltimore had the dubious distinction of having the most cases of syphilis for 1997 in this country.
(Anyone thinking of moving?
)

Although legend has it that syphilis was carried to Europe from the Western Hemisphere by Columbus’s crew, this probably was not the case.
Descriptions of venereal diseases with characteristics similar to syphilis appear in ancient literature, and anthropologists have found signs of bone destruction in human prehistoric remains similar to what we see in late syphilis.
Syphilis is caused by a spirochete type of bacteria called
Treponema pallidum.
It was first identified in 1905 by Fritz Schaudinn.
The following year Dr.
August von Wassermann developed a famous test for syphilis that bears his name and is still used today.
The real breakthrough in syphilis treatment came in 1943, when penicillin first was used to treat the disease successfully.

Syphilis is transmitted through direct sexual contact between mucous membranes and, rarely, by close skin-to-skin contact.
The organism cannot survive drying and is easily killed by soap and water.
Infection most often occurs on the penis or anal canal after unprotected sex, but the mouth also can be a site.
The first sign of syphilis is a
painless
red ulcer called a chancre at the site where the organism invaded the body.
(See
Figure 3.
1
.
) On your penis, look for a chancre on or close to your glans (head), although it also can be on the shaft or scrotum.
Chancres are extremely contagious.
If you see one on your partner’s penis, avoid sexual contact until he’s treated.
Unfortunately, it is nearly impossible to see a chancre within the anal canal without medical equipment.

Figure 3.
1:
Syphilis Chancre

Though usually single, chancres can be multiple and appear within ninety days after infection (average two to four weeks).
At this stage, syphilis is diagnosed by collecting some clear fluid the ulcer weeps and examining it under a
special darkfield microscope.
This fluid teems with wiggling spirochetes.
Unfortunately, most physicians don’t own darkfield microscopes, since these days syphilis occurs relatively infrequently.
Chancres heal by themselves without any treatment within three to eight weeks.

When syphilis infects the anus, the chancre may be painful and often misdiagnosed as a fissure.
Anal syphilis frequently causes bloody bowel movements, diarrhea, and a mucus discharge.
Many gay men undergo needless anal surgery (sometimes involving radical resections for a presumed cancer) because their doctors did not make the correct diagnosis—a frightening fact considering that the disease could have been cured with antibiotics alone.

Although a penile chancre has a fairly distinct appearance, it can be confused with other more common problems, such as genital herpes.
A culture for the herpes virus provides an answer within a day or two, and if negative, think of syphilis.
A penile or anal ulcer also can result from injury, but you or your partner usually will remember this.

After the chancre heals, syphilis enters a secondary stage as spirochetes spread throughout the body.
Symptoms are similar to those of a viral illness:
fever, joint pains, runny nose, and lethargy.
Although copper-colored skin lesions can cover the body, they typically appear only on palms and soles.
As syphilis spreads to other parts of the body, lymph node enlargement (swollen glands), liver enlargement, and eye and nervous system problems are also common.
You are still infectious, but the disease is easily diagnosed through various tests that detect antibodies in your blood to the organism.
The most common test is the VDRL (venereal disease research laboratory).
If your VDRL is positive, infection is confirmed by the more sensitive, though harder to perform, FTA-ABS (fluorescent treponemal antibody absorption) test.

In approximately 40 percent of untreated patients, infection
progresses to tertiary syphilis within ten to twenty years.
Although no longer contagious, it can attack your nervous system (causing blindness, deafness, and insanity), or heart and major arteries (resulting in heart valve damage, aneurysm of the aorta, and cardiac failure).
At this stage syphilis can be lethal.

Antibiotics cure primary or secondary syphilis; the most common is penicillin, given in one high-dose injection.
For men allergic to penicillin, erythromycin or doxycycline taken orally for two weeks is an acceptable alternative.
When syphilis remains untreated for more than a year, penicillin injections weekly for three weeks or oral antibiotics for one month are necessary.
Occasionally in men with HIV, the disease is harder to eradicate and may require higher doses and prolonged administration of antibiotics.

If you have syphilis, you must be checked for other STDs as well.
Very often, where there is one STD, there is also another.
So if your physician hasn’t already checked you for HIV, gonorrhea, and other STDs, ask that it be done.

Taking your antibiotic is not enough; all sexual partners you placed at risk must be notified and tested.
Syphilis has been virtually eliminated from Canada, Sweden, and other industrialized countries.
This notable accomplishment occurred only through vigorous screening, treatment, and notification of sexual partners.
With the gay community’s cooperation, this country can move a step closer to eliminating this terrible disease.

How about these frightening tidbits:
Worldwide, gonorrhea is the most common STD, and in the United States it is the most commonly reported communicable disease.
The Centers for Disease Control counted almost 1 million new cases of gonorrhea in 1997, while some researchers estimated
that the number of unreported cases was more than double that.
Gonorrhea is caused by a tiny bacterium called
Neisseria gonorrhoeae,
which won’t grow in anything less than optimal conditions.
It needs a warm, moist environment with high levels of carbon dioxide.
The bacterium is extremely susceptible to drying and rarely transmitted outside of sex.
Although sharing dildos can be risky, fingers, toilets, and saunas are usually safe.

Gonorrhea can infect the mouth, throat, urethra (the tube in your penis that carries urine and semen), and anal canal.
Your anus becomes infected after anoreceptive intercourse with a man who has gonococcal urethritis.
While kissing is probably safe, fellating an infected partner is not.
Your urethra can be infected through insertive anal intercourse (but it is easier to give than to receive) or direct contact with a man’s infected penis.

Gonorrhea most commonly infects your urethra, with symptoms beginning within two to five days.
Most men complain of pain when urinating (dysuria) and a purulent (infected) penile discharge.
The amount of the highly infectious discharge can vary.
Some men notice green or yellow fluid dripping from their penis, while others only have a stain on their underwear.
When examining a potential partner for signs of gonorrhea, the typical discharge usually can be distinguished from pre-cum because that tends to be clear.
(See
Chapter 10
.
)

The anorectal canal is another frequent site of gonorrhea, but because the infection is often painless, it may persist undiagnosed.
In the anal canal, gonorrhea produces a discharge that often is first mistaken for leaking stool.
Some men report blood or mucus in their bowel movements and discomfort.

When gonorrhea infects your mouth and throat, the symptoms may be similar to those of a typical strep throat, with redness, pain on swallowing, and enlarged lymph
nodes.
Most men are unaware of the seriousness of their oral infection.

Doctors often diagnose gonorrhea from “typical” symptoms and then confirm it by culture.
Although the bacteria have a unique appearance under a microscope, most physicians lack the appropriate equipment in their offices.
Therefore, most doctors sample your discharge with a cotton swab and send it to a laboratory for culture.
The cultures must be handled carefully and in accordance with strict protocols, since the bacteria require optimal conditions for growth.
DNA probes are another useful tool in diagnosing gonorrhea.

With a penile infection, your discharge is obtained by milking your urethra and culturing fluid that collects at the tip.
If your discharge is not readily apparent, a physician may need to pass a tiny cotton swab about one inch into your urethra.
I assure you that this procedure is more painful psychologically than physically.
Your mouth and anus are easier to culture, requiring only a swab rubbed inside to collect any bacteria.

Make your physician aware of the possibility of gonorrhea before he examines you, because your mouth and anus can look perfectly normal.
If your doctor suspects gonorrhea in one place, every orifice must be cultured, because the incidence of asymptomatic infections occurring at multiple sites is great.
In other words, if you have it in one hole, you probably have it in another.
Approximately 20 percent of patients with urethral gonorrhea also have oral gonorrhea.