from Medical Issues

The prestigious Journal of the American Public Health Association has devoted a substantial portion of its latest edition (June 2003, Vol.93, No. 6) to the risks associated with homosexual practices.

The following statement is one of several that glare at readers from the journal's cover:

"I gave my lover everything including HIV. I didn't mean to. We made a mistake. Maybe deep down we felt it would be better if we both had it..."

"Having struggled to come to terms with the catastrophic HIV epidemic among MSM [MSM is the new politically correct term for homosexual men i.e., Men who have Sex with Men] in the 1980s by addressing the pointed issues of sexuality and heterosexism, are we set to backslide a mere 20 years later as HIV incidence rates move steadily upward, especially among MSM?" ("HIV Returns," Editor's Choice section, page 860)

Those rates are devastating. Gross notes, "To prevent HIV transmission, we have little more today than we had two decades ago, when it became clear that the virus causing AIDS is sexually transmitted: behavioral interventions."

After emphasizing the need for new biomedical technologies and effective translation and dissemination of behavioral approaches, he concludes with, "Perhaps most important, somehow we need to immunize prevention science, programs, and policies against stigma, political opportunism, and sanctimony."

In his article on "Black Men Who Have Sex With Men and the HIV Epidemic: Next Steps for Public Health," David J. Malebranche, addresses risk assessment and risk reduction. Malebranche references a recent six-site, US metropolitan area study that concluded that 93% of African American Men who were HIV infected felt that they were at low risk for HIV and did not know they had contracted the virus.

Malebranche's study contradicts the view that coming out of the closet or disclosing one's homosexuality is associated with improved mental health, responsible behavior, and lower rates of HIV infection. To the contrary, African-American men who disclose their homosexuality have a higher HIV prevalence than those who do not choose to do so (24% versus 14%). They also engaged in more unprotected anal sex (41% versus 32%) than those who do not disclose.

As Malebranche searches for reasons and conclusions, he--like most politically correct writers--inevitably lays the blame upon society, stating "....racial and sexual prejudice may impair delivery of services, helping to perpetuate rather than ameliorate the HIV epidemic." (Editorial section, pages 862-865).

Vincent M.B. Silenzio advocates an "Anthropological Assessment for Culturally Appropriate Interventions Targeting Men Who Have Sex with Men." He considers the public-health education approach to be inadequate because it fails "to sufficiently take socio-cultural factors into account." Silenzio concluded that

"same-sex desire, attraction, sexual behavior, and identity are dynamic historical processes profoundly influenced by culture. Public health practitioners, advocates, and others need to be sensitive and open to how target populations of MSM frame these issues and experience these phenomena.

Culturally sensitive and appropriate interventions for MSM should ideally be based in ethnographic data specific to the population of interest in order to be effective. Using the comparative lenses of anthropology and cultural studies, we may begin to appreciate the needs of MSM and other sexual minority populations in fundamentally different ways."
(Commentary section, pages 867-871).

As Gross searches for explanations, he theorizes that the blame lies with several factors: the difficulty of condom use, changes in milieus where HIV is spread, slow development of biomedical interventions, the separation of prevention and treatment, and moralism--declaring that homophobia "exacerbates rather than alleviates the threat."

Gross concludes that "behavioral interventions to promote condom use-the only strategy currently available to stem the MSM epidemic-are failing."

He notes an emerging visible subculture of "barebacking" (anal intercourse without condoms among homosexual men). He blames homophobia, which "inhibits prevention at all levels, not least the broader culture, which delivers anti-gay messages, institutionalizes homophobia through structural mechanisms, such as laws that regulate intimate sexual behavior, and lags in support of sensitive and honest prevention for gay and bisexual youth, young adults and older men."

Gross's article concludes with a moralistic monologue which includes the following statements:

• "...prevention efforts fall prey to political opportunism, misplaced moralism, stigmatization, and homophobia."
• "...distraught parents still evict gay youths, propelling them into lives of inner-city scavenging and vulnerability to exploitation."
• "Most schools continue to refrain from even the meekest adaptation to gay adolescents' needs for safety and mutual affiliation, much less the authentic respect that might nourish self-respect. In turn, whatever normalization school and after-school settings might be providing for concurrent emotional and sexual maturation among heterosexual adolescents is denied to most of their gay counterparts, who instead are apt to retreat into furtiveness, shame, or precocious pairings with older partners."

Gross offers an interesting comparison:

"On the same day that seven astronauts and fragments of the vehicle that failed them plummeted to the fields and woods of East Texas, six times that many US MSM became infected. Maybe the number was higher, since it occurred on a weekend; perhaps lower if news of the catastrophe interrupted libidinous pursuits. ...

"On the basis of CDC estimates of the lifetime expenditures for treating a single case of HIV infection, MSM infections acquired that single day will cost $6.5 million. The cost in human potential need not enter the calculus even for a voodoo economist, unless so muddled by moral outrage that he thinks sex between men is indeed something to 'die for'." (Going Public section, pages 872-881).

The editor chose to include a historical article entitled "Sexual Behavior in the Human Male," by Alfred Kinsey in a section devoted to voices from the past. That Kinsey has been thoroughly discredited seemed of little consequence to the editor. Perhaps a reading of the highly acclaimed biography of Kinsey by James H. Jones would have resulted in a different perspective of him. Consider the following excerpt of the Kinsey biography published in New Yorker Magazine:

"According to William Dellenback, the institute's photographer, Kinsey was becoming overtly exhibitionist-to the point of having himself filmed, always from the chest down, while engaged in masochistic masturbation. The world's foremost expert on sexual behavior would insert an object such as a pipe cleaner or swizzle stick into his urethra, tie a rope around his scrotum and then tug hard on the rope...

"Toward the end of his life, Kinsey's boundaries shifted again-to the point where he was apparently prepared to withhold moral disapproval of adult-child sexual contacts....

"Kinsey died believing that his crusade to promote more enlightened sexual attitudes had not succeeded. Yet in 1957, a year after his death the Supreme Court's Roth decision narrowed the legal definition of obscenity, expanding the umbrella of constitutional protection to cover a broader range of works portraying sex in art, literature, and film.

"In 1960, the birth control pill was introduced, offering a highly effective method of contraception. In 1961, Illinois became the first state to repeal its sodomy statutes. The next year, the Supreme Court ruled that a magazine featuring photographs of male nudes was not obscene and as therefore not subject to censorship.

Then, in 1973, in a dramatic reversal, the American Psychiatric Association removed homosexuality from its list of psychopathologies. Kinsey, the anguished man of science, had prevailed." (Voices From the Past section, pages 894-898, quoted from New Yorker magazine article "Annals of Sexology: Dr.Yes," New Yorker, September 1, 1997, page 113).

The authors described the prevalence of risk behaviors at baseline among MSM who participated in a randomized behavioral intervention study conducted in six US Cities: Boston, Chicago, Denver, New York, San Francisco, and Seattle. The data gathered involved homosexual men who were HIV-negative and who reported engaging in anal sex with one or more partners during the previous year. The results were staggering: among the 4,295 homosexual men,

"48.0% and 54.9%, respectively reported unprotected receptive and insertive anal sex in the previous six months. Unprotected sex was significantly more likely with one primary partner or multiple partners than with one non-primary partner. Drug and alcohol use were significantly associated with unprotected anal sex." (Research and Practice section, Beryl A. Koblin, PhD, Margaret A.Chesney, PhD, Marla J. Husnik, MS, Sam Bozeman, MPH, Connie.L. Celum, MD, Susan Buchbinder, MD, Kenneth Mayer, MD, David McKirnan, PhD, Franklyn N. Judson,MD, Yijian Huang, PhD, Thomas J.Coates, PhD, and the EXPLORE Study Team, pages 926-932.)

The authors conclude,

"The results of this study indicate that sex without disclosure of HIV status is relatively common among persons living with HIV. The rates of sex without disclosure found in our sample of HIV-positive individuals translate into 45,300 gay or bisexual men, 8,000 heterosexual men and 7,500 women-all HIV-infected-engaging in sex without disclosure in our reference population of individuals who were in care for HIV...

"...these numbers should be considered a lower-bound estimate." (Daniel H. Ciccarone, MD, MPH, David E. Kanouse, PhD, Rebecca L Collins, PhD, Angela Miu, MS, James L. Chen,MPH, Sally C. Morton, PhD, and Ron Stall PhD., pages 949-954.)

The editors of the American Journal of Public Health are to be commended for addressing health risks associated with homosexual practices. However, themes of activism replaced science in many of the Journal's articles.

Nowhere did the authors cite the scientific evidence which has concluded that homosexuality is neither innate nor immutable. Nowhere did the authors note that homosexual men and women have choices in how they respond to their attractions. In no case did they even offer the view that homosexuality represents an adaptation--not an identity--and that homosexual attractions are more fluid than once thought.

Most importantly, the preoccupation of many of the authors with "homophobia" allows little room to adequately consider other hypotheses. Perhaps it is not homophobia but misguided activism that is responsible for the current health problems that plague homosexual individuals.

"Rights" issues seem to have replaced individual and community health concerns. For example, the scientific evidence is clear that homosexual practices place their participants at risk for mental and physical illness. J. Michael Bailey, in his commentary on the research on homosexuality and mental illness (Archives of General Psychiatry, 1999, Vol. 56, 883-884), concluded,

"These studies contain arguably the best published data on the association between homosexuality and psychopathology, and both converge on the same unhappy conclusion: homosexual people are at a substantially higher risk for some forms of emotional problems, including suicidality, major depression and anxiety disorder."

Bailey offers alternative hypotheses for the data associating mental illness with homosexuality. He suggests that homosexuality may be a "developmental error," "representing a deviation from normal development and is associated with other such deviations that may lead to mental illness." He also suggests another hypothesis-- that "increased psychopathology among homosexual people is a consequence of lifestyle differences associated with sexual orientation...such behavioral risk factors associated with male homosexuality such as receptive anal sex and promiscuity."

Regarding physical health, there is increasing evidence that mortality and morbidity rates are substantially higher for those who engage in homosexual practices. For example, the risk of anal cancer soars by as much as 4,000% for men who engage in anal intercourse with other men. The host of medical consequences of those who practice anal intercourse is large, from the tearing of the rectal lining with all of its accompanying problems to the diseases associated with subsequent contact with fecal matter.

The American Public Health Association, along with other such national associations, needs to be aggressively pressed and held responsible for the activist spin placed on the research reported in the pages of their journal.

On the issue of risks of homosexual practices, the national organizations have become reckless guardians of the public health. The failure to report morbidity and mortality rates associated with homosexual practices should be cause for governmental scrutiny. The furthering of an agenda--no matter whose agenda--must not be placed above the lives of those whose interests must be protected.

Activism must not be placed above science in informing public policy. It is an injustice to homosexual men and women to allow activism, including accusations of homophobia, to silence discussion of health risks or to suppress research.

A civil society has an obligation to implement policies that promote the health and well-being of its citizens.

Bailey himself warns, "...it would be a shame if sociopolitical concerns prevented researchers from conscientious consideration of any reasonable hypothesis" regarding homosexuality. ("Homosexuality and Mental Illness," J. Michael Bailey, Archives of General Psychiatry, Oct.,1999, Volume 56, P. 884.)

I would agree.

Updated: 8 February 2008

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