Many people overlook the serious direct and indirect impacts of men’s sexual health. Some conditions are specific to men, but many are intrinsically related to sexual and general health in both men and women. Sexually transmitted infections (STIs) are a major cause of morbidity with a direct economic burden. They may also have psychological consequences.
Most STIs are easy to diagnose and have effective and low-cost medical treatments. The critical issues are people’s awareness of their own health, and access to care. Timely treatment is crucial in preventing chronic conditions and limiting their spread. Three factors contribute to the timely treatment of STIs: people seeking medical advice, the practice of caregivers and how sexual health services are given.
The risk of getting and spreading HIV is greatly increased when another STI is present in either partner. Serious illnesses such as syphilis can be life-threatening. Recurring genital conditions such as herpes cause direct physical and emotional strain.
Many men have a low perception of the risks associated with their behaviour. They are often unaware of what and where services are available, and are often reluctant to use them. Sexual health is also affected by factors such as the increasing use of social media to meet partners. Travel, changing relationship patterns and use of pharmacological agents have also affected sexual practices at differing ages.
The Royal College of Physicians (RCPI), with clinicians, community partners, schools and patient support groups, hosts Sexual Health Awareness Weeks (see rcpi.ie/shaw) to promote good communication, which is vital when addressing sexual health and sexuality.
A service well structured to deal with sexual health in men, as for women, can lead to health improvements, economic gain and the removal of stigma; many men say they are too embarrassed to go to their GP for a sexual health examination.
When HIV/Aids emerged in the 1980s, there was a decrease in the reported incidence of acute STIs in Ireland and the EU. However, since the mid-1990s there have been sustained, significant increases in the incidence of STIs, especially gonorrhoea, syphilis, Chlamydia, HPV and urethritis. These increases have been especially evident in young people, ethnic minorities and men who have sex with men.
Urethritis
Urethritis is the most common STI affecting men. It is most frequently due to infection by Chlamydia trachomatis or Neisseria gonorrhoea. It can also be due to other organisms or non-infectious causes. Infection is asymptomatic in most cases of Chlamydia, highlighting the importance of testing and being aware of one’s own health. Gonorrhoea is mainly reported in men and found in high-risk groups such as men who have sex with men.
Complications can occur with both Chlamydia and gonorrhoea. Disseminated infection can occur with certain serotypes of Neisseria gonorrhoea, causing fever, rash, and tenosynovitis. About 30 per cent of men infected with gonorrhoea are co-infected with Chlamydia.
HPV infection
Genital herpes and ano-genital warts, caused by human papillomavirus or HPV infection, are a major reason for referral to a sexual health clinic for men and women. About 400 cases of genital herpes and 4,000 of ano-genital warts are reported every year but both may be under-reported as HPV is a clinical, rather than laboratory, diagnosis. Treatment is available for both, although recurrences are common.
S
yphilis Since 2000 there has been a marked increase in
syphilis cases. A distinct outbreak in Ireland between 2000 and 2002, predominantly among men who have sex with men, has been well described. The epidemic peaked a number of years ago but incidence of syphilis remains higher than before the outbreak. A worrying feature of this is the fact that syphilis and HIV show epidemiologic synergy: the presence of either infection facilitates the transmission of the other and, as a consequence, we continue to see a significant increase in the annual incidence of HIV infections in men who have sex with men, many of whom may present late.
HIV
HIV remains a significant illness affecting men in Ireland. Sexual health advice, education, access to health screening and condom usage are the most effective measures to reduce risks. The 2013 national data published by the Health Protection Surveillance Centre of the HSE (see hpsc.ie) are of concern, given the continued rise in the number of new cases. We need to improve testing and use innovative ways to engage people to test and then link to care.
A team at St James’s Hospital in Dublin is working on an opt-out programme for HIV, hepatitis B and hep C testing in all patients attending and having blood tests taken at the hospital’s emergency department. In the first eight weeks there has been an uptake of more than 60 per cent, and a significant number of new cases of HIV, hep B and hep C have been identified and linked to care.
There have been other reported outbreaks primarily affecting men in recent years. The incidence of infectious hep B has dramatically increased in recent years but it can be prevented with vaccination. Cases of sexual transmission of hep C infection have also been reported.
There has been a marked rise in the number of Irish cases of international health-related infections, which occur due to population migration or increasing travel. Implications include a wider spectrum of disease being identified and consequences of antimicrobial resistance.
Health services
Historically, sexual health services have been hospital-based or provided by GPs . Increasingly, patient demand and improving awareness, enabled by the use of technology, will drive a change in the model of care delivery. Recent service developments have included the introduction of an electronic record that retains patient confidentiality and may facilitate an online interface for patients, as well as building standard procedures and care pathways for patients to self-test and screen.
The HPV vaccination programme for girls has been successful but boys should also be vaccinated, as they now are in Australia; our national guidelines afford only a permissive recommendation for vaccine use in men who have sex with men and in men who are HIV-positive or immunosuppressed for other reasons. This requires critical review in light of the recent WHO report identifying that cancer-causing viral infections such as hepatitis and HPV are responsible for up to 20 per cent of cancer deaths in low- and middle-income countries. Recent medical publications have also suggested benefits of HPV vaccination in reducing head and neck cancers, in particular, in both men and women.
Testicular examination is a common reason for presentation to sexual health services. Only 50 per cent of men in a study in the HSE South had heard of the role of testicular self-examination, and of these only one in five performed self-examination.
Awareness and access
It is obvious that we need to improve awareness of health and wellbeing for men. We need to test more. We need better access to sexual health services for men and adapt to a changing mechanism for care delivery and patient-centred engagement, enabled by technology.
We need improved sex education for young people; better public awareness of sexual health services, especially directed at men; and better training in men’s health issues for sexual health professionals. We need to give men better access to condoms and other preventative interventions, including vaccinations against hepatitis B and HPV infections. Pre- and post-exposure prophylaxis for men at risk of HIV infection will also provide significant population health gains. Greater awareness will lead to less stigma and more health-seeking behaviour from men.
Prof Colm Bergin is consultant physician in infectious diseases at St James’s Hospital, Dublin; clinical professor of medicine at Trinity College Dublin; national specialty director of infectious diseases and dean of postgraduate medical training at RCPI.
Embarrassment a problem in sex advice An Irish survey reported that embarrassment was a major barrier to men seeking advice about sexual health, with 35 per cent saying they would be embarrassed to attend a GP for a sexual health examination. Some 5.5 per cent of men said that despite knowing they needed to attend sexual health services, they had not done so. Some 14 per cent who attended did so because of symptoms of an STI. Fewer than 2 per cent of men questioned avail of sexual health services.
In addition, 20 per cent of men said they never used a condom for vaginal sex with a casual partner; 42 per cent admitted to never using a condom for anal sex with a casual partner; and 90 per cent never used a condom when receiving oral sex from a casual partner.
