Sexually transmitted diseases are infectious diseases that are passed on from one person to another through sexual contact via blood, semen or vaginal fluid. Examples include gonorrhea, syphilis and AIDS. The risk of sexually transmitted infection (STIs) among men who have sex with men (MSM) is higher than in males who have sex with women. Men who have sex with men and women are at a greater risk of getting infected with STIs than the MSM. A common STI that afflicts people with multiple partners is gonorrhoeae. Gonorrhea is caused by the bacterium Neisseria gonorrhoeae. The infection is usually asymptomatic and may cause urethritis, pharyngitis, cervicitis, salpingitis or proctitis (CDC, 2014). Men and women can get affected with this infectious disease. The infection makes people susceptible to infection due to transmission of HIV, so it is important that patients seek timely treatment and safeguard themselves from AIDS. It has been observed that gonorrhoeae infection can be evidenced in extragenital regions of the body that can be detected after a rectal or oropharyngeal diagnosis (Lutz, 2015). So, screening in asymptomatic MSM is recommended for detection of gonorrhoeae and appropriate therapy should be started even if there is no presence of gonorrhoeae infection in the urogenital region. A study has reported 0.2 to 24% cases of rectal gonorrhoeae among MSM and a 0.5 to 16.5% prevalence of pharyngeal gonorrhoeae (Chan, et al., 2016). The problem of gonorrhoeae infections is therefore a serious public health problem and the propensity of people in same sex relationships increases when they have multiple partners. In case of MSMW, the transmission of the infection to and from female partners results in higher risk of transmission.
Belonging to the (lesbian, gay, bisexual and transgender) LGBT community makes the patients difficult to access healthcare than the heterosexual individuals in any population. The social and sexual stigma associated with this community makes it very likely for them to experience healthcare disparities. Compared to the heterosexuals the LGBT are discredited due to their sexual orientation and may even be denigrated by the society. Health professionals are known to show positive approach when dealing with patients from LGBT community but there are cases where negative experiences mar the treatment process. Much of this misled attitude is because the curricula at medical schools do not teach content related to specific health issues that affect the gay community (Brennan, Barnsteiner, Siantz, Cotter, & Everett, 2011). This makes the healthcare providers uncomfortable when dealing with issues that are specific to the care that the LGBT patients require. Many of them display homophobic attitudes and do not have knowledge about specific health issues that the LGBT patients face. This means that the training is deficient in making health professionals culturally competent when dealing with developmental health problems faced by homosexuals across their life spans. Often lack of exposure to issues faced by the LGBT community, nursing or medical staff is ill-equipped to address the medical needs. Lack of sensitivity also affects the patients because in the absence of empathy they feel discouraged to share their illness related issues with healthcare personnel. STIs are even less understood and staff may fail to advise patients about safe practices and to reduce risky behaviour.
Prevention of STIs is a public health priority. Risky behaviour by MSM contributes to the growing risk of infection with HIV, syphilis, gonorrhoeae and other diseases. Behavioural interventions can reduce the risk of STIs in men who have sex with men. Multiple anonymous partners increase the risk of gonorrhoeae and other STIs. Substance abuse through use of crystal methamphetamine taken for improving sexual performance also increases risk. Gonococcal rates in rectum have increased among MSM in cases where they are already infected with HIV. This makes it important for the healthcare professionals to take an accurate history about the patient's history about multiple partners and confirmation about repeated use of crystal methamphetamine. Insertive oral sex is an additional risk for suffering from pharyngeal gonorrhoeae (at a rate of 7%) and urethral gonorrhoeae. Rectal gonorrhoeae has been diagnosed in 5.4% of the cases. MSM with a prior diagnosis of HIV have a greater likelihood of being diagnosed with asymptomatic gonorrhoeae than those who have not tested positive for HIV. Screening the MSM for gonorrhoeae may reduce risky behaviour.
Precautionary approach involves nucleic acid amplification testing of men who report insertive intercourse during the past one year for urethral infection of Neisseria gonorrhoeae. A nucleic acid amplification test for rectal infection may be done in individuals for Neisseria gonorrhoeae if they report receptive anal intercourse during the past year. Pharyngeal specimen tests to check for infection with Neisseria gonorrhoeae are required in case where oral intercourse is reported by the patient (Workowski, 2015)In case of women who have sex with women (WSW) may also indulge in risky behaviour that makes them prone to acquire sexually transmitted infections (Trebach, Chaulk, Page, Tuddenham, & Ghanem, 2015).
The very nature of the required tests and the kind of trust between the doctor and patient requires that the patient be treated with sufficient understanding so that disclosures of a private nature are made by the patient. Display of even a small hint of discomfort or differential treatment might be understood by the patient as hostility. Due to the social and sexual stigma attached to their sexual orientation many people from the LGBT community hesitate in accessing healthcare.
Many among the MSM have had a history of STIs, due to a large number of anonymous partners, a childhood history of sexual abuse, associated psychological problems and a history of substance abuse. As a result many people from the LGBT community face social exclusion and exhibit symptoms of anxiety and depression. The use of drugs increases their propensity to indulge in risky behaviour and unsafe sex. Many among the community have complained of having been victims of forced sex by their most recent partners. This possibility is much higher than that in the heterosexual population. There is now also an understanding that it is not because of lack of awareness that gay men get involved in risky behaviour but it is due to psychological reasons (O'Leary, 2014).
The sensitization of the medical professionals towards the LGBT patients, their psychology and their need to be understood should be part of the curriculum. Lack of prior exposure to the LGBT patients during practice should not make them uncomfortable when dealing with them. The fact that there is a stigma against the LGBT should not hamper their treatment. Several steps have been suggested to include LGBT content during nursing education so that comprehensive healthcare can be delivered to them. Teaching and learning of relevant courses can be enhanced through simulation and incorporation of case studies. Agencies that serve the interests of the LGBT community and understand their issues can be partnered with. Students should be able to interact with patients from sexually diverse backgrounds. It has been suggested that the nursing curriculum should be infused with content relevant to the LGBT. Even material such as films and documentaries on the LGBT can be utilized in the classroom for proper introduction to issues faced by the LGBT in the healthcare system (Fidelindo, Kim, & Min, 2014).
New and updated methods of diagnosis are required for the LGBT population when suspected of gonorrhoeae. The Centre for Disease Control recommends the use of Nucleic acid amplification test (NAAT) for the diagnosis of Neisseria gonorrhoeae infections rather than the culture test because of better sensitivity. However culture tests are important when checking for antibiotic sensitivity. The test allows for better testing of the extragenital testing for the presence of Neisseria gonorrhoeae infections (Barbee, Dombrowski, Kerani, & Golden, 2014).
Messages of prevention through messages targeted at MSM who are not yet identified as gay may respond positively to messages that promote safe sex and less risky behaviour. The altered behaviour may lead to lead to less transmission of STIs (Johnson, et al., 2008). Gonorrhoeae among women if left untreated can cause pelvic inflammatory disease.
Research on the health aspects that pertain to the LGBT is not very common. Very few papers on the subject of gonorrhoeae in the LGBT community are available. In the absence of sufficient research on the subject the understanding of the difficulties by this sub-population will be less. Policy makers depend on social activists backed by scientific research to be able to frame policy that can alleviate problems and difficulties faced by the LGBT in the healthcare system. So, more research in the area is required. Gay men and transgender individuals are more likely to suffer from STIs. Most health disparities faced by them are due to homophobia and stigma that lead to discrimination against them (Fidelindo & Nathan, 2011).
Patients from sexual and gender minorities re at a disadvantage because often physicians treating them lack the specific knowledge about health issues that are specific to them. Training of physicians in non-discriminatory approach while treating the sexual minorities is important (Jabson, Mitchell, & Doty, 2016). As many as 27% patients from the LGBT have reported that physicians were prejudiced against them, while 2% patients felt that the hostility was rather open. 21% patients have reported that the physician was non-supportive on learning that they were either gay or lesbian. In fact up to 30% physicians have been found to be homophobic (Lee, et al., 2008). Given such a homophobic environment in the health industry it is difficult for the people from the LGBT decide whether they should disclose their identity or not. In the absence of disclosure the specific health problems, particularly with respect to STIs cannot be treated effectively.
Apart from the social, medical difficulties and unique association of gonorrhoeae with the LGBT community, there is another problem that is raising its head, that of multidrug resistant Neisseria gonorrhoeae. To counter the menace of the public health concern posed by this organism, it is important to understand that the high usage of known antimicrobials, less than optimum monitoring of the antibiotic resistance the gonococcal infections may become more difficult to treat. The understanding of how the mechanism of resistance has evolved may pave the path for the discovery of novel antibiotics against this pathogen (Unemoa & Shafer, 2014).
The prevalence of gonococcal disease among the LGBT community has become a public health challenge due to several factors. The risky behaviour associated with MSM wherein multiple partners, promiscuity and exposure to the pathogens causes the disease in many of the men in the sexually active age-group. The asymptomatic infection may cause urethritis, pharyngitis, cervicitis, salpingitis or proctitis and is usually diagnosed by culture tests of swabs of affected area or by nucleic acid amplification test on samples from the affected parts. In women, the propensity for the disease is there among the lesbian women. The social and sexual attached to the people from the sexual minorities makes it difficult for them to access treatment. Nursing staff and physicians may be homophobic and at times lack in training to be able to understand the problems specific to the LGBT because of deficient curricula. The nature of the disease makes it imperative that there be a relationship of trust between the doctor and the patient, Failing which the patient may not return for follow-up treatment if made to feel uncomfortable during the process of treatment and diagnosis. Several people from the LGBT community have been abused as children and thus resort to risky behaviour as adults. Research activity in the area of gonococcal treatment specifically for the LGBT is less. Therefore a lot of gaps remain in understanding of how to deal with the issue of STIs among this target population. The treatment of gonorrhoeae has also become a challenge due to the development of antibiotic resistance. Very few antibiotics are now effective against the pathogen. The mechanism of resistance when understood will provide clues for development of new therapy. Treatment will require understanding that envelops all aspects of disease transmission.
Barbee, L., Dombrowski, J., Kerani, R., & Golden, M. (2014). Effect of Nucleic Acid Amplification Testing on Detection of Extragenital Gonorrhea and Chlamydial Infections in Men Who Have Sex With Men Sexually Transmitted Disease Clinic Patients. Sexually Tramitted Diseases, 41 (3), 168-172.
Brennan, A., Barnsteiner, J., Siantz, M., Cotter, V., & Everett, J. (2011). Lesbian, gay, bisexual, transgendered, or intersexed content for nursing curricula. Journal of Professional Nursing, 28(2):96-104.
CDC. (2014). casedefinitions-2014.pdf. Retrieved from https://www.cdc.gov: https://www.cdc.gov/std/stats/casedefinitions-2014.pdf
Chan, P., Robinette, A., Montgomery, M., Almonte, A., Cu-Uvin, S., Lonks, J., . . . Hardy, E. (2016). Extragenital Infections Caused by Chlamydia trachomatis and Neisseria gonorrhoeae: A Review of the Literature. Infectious Diseses in Obstetrics and Gynaecology, 2016:5758387.
Fidelindo, A. D., Kim, J., & Min, S. (2014). Addressing Health Care Disparities in the Lesbian, Gay, Bisexual, and Transgender Population: A Review of Best Practices. American Journal of Nursing, 114(6):24-34.
Fidelindo, L., & Nathan, L. (2011). Lesbian, Gay, Bisexual, and Transgender Health. American Journal of Nursing, 111(11):11.
Jabson, J., Mitchell, J., & Doty, S. (2016). Associations between non-discrimination and training policies and physicians’ attitudes and knowledge about sexual and gender minority patients: a comparison of physicians from two hospitals. BMC Public Health, 16: 256 doi: 10.1186/s12889-016-2927-y.
Johnson, W., Diaz, R., Flanders, W., Goodman, M., Hill, A., Holtgrave, D., . . . McClellan, W. (2008). Behavioral interventions to reduce risk for sexual transmission of HIV among men who have sex with men. The Cochrane Database of Systematic Reviews, (3):CD001230.
Lee, R., Melhado, T., Chacko, K., White, K., Huebschmann, A., & Crane, L. (2008). The Dilemma of Disclosure: Patient Perspectives on Gay and Lesbian Providers. Journl of General Internal Medicine, 23(2): 142–147.
Lutz, A. (2015). Screening for Asymptomatic Extragenital Gonorrhea and Chlamydia in Men Who Have Sex with Men: Significance, Recommendations, and Options for Overcoming Barriers to Testing. LGBT Health, 2(1):27-34.
O'Leary, D. (2014). The syndemic of AIDS and STDS among MSM. The Linacre Quarterly, 81(1): 12–37.
Trebach, J., Chaulk, C., Page, K., Tuddenham, S., & Ghanem, K. (2015). Neisseria gonorrhoeae and Chlamydia trachomatis among women reporting extragenital exposures. Sexually Transmitted Diseases, 42(5):233-9.
Unemoa, M., & Shafer, W. (2014). Antimicrobial Resistance in Neisseria gonorrhoeae in the 21st Century: Past, Evolution, and Future. Clinical Microbiology Reviews, 27(3): 587–613.
Workowski, K. B. (2015). Sexually Transmitted Diseases Treatment Guidelines, 2015. Morbidity and Mortality Weekly Report, 64(RR3);1-137.
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