Rectal microbicide gels, applied either daily or before and after sex, are currently being investigated as an option for HIV pre-exposure prophylaxis (PrEP). Given that many people who have anal sex already use lube, one hope is for an HIV-prevention product that people could essentially use in place of a lube. But can gels provide enough coverage across rectal tissue if people don’t use an applicator?
Studies of rectal tenofovir microbicide gels, such as the MTN-017 study, provide rectal-specific applicators for people to use to insert the gel. Although applicators deliver a precise dose, they may challenge product acceptability by being bulky, inconvenient and unappealing to users.
“Use of applicators does not mimic real world lubricant use during sex,” explained Eugenie Shieh, MD, from The Johns Hopkins Hospital.
If a rectal microbicide gel is approved for HIV PrEP, finding an effective application that works in the lives of potential users will be crucial to its success.
At CROI 2016, Shieh presented results from a study investigating whether a gel, applied by men in the way they would normally apply lube, could deliver a similar volume, in the same areas of the colon, as gel delivered by an applicator. Five men with a history of receptive anal intercourse used a radiolabeled gel that could later be detected on a SPECT/CT body scan.
Participants tested three different deliveries: gel via applicator (3.5 or 10 mL) and a radiolabeled lube (up to 10 mL) that they were told to apply as they normally would before sex. After applying the lube, participants were asked to “simulate anal intercourse” with an artificial phallus (which would effectively push the lube into the colon).
Although this was a small study, her team found that manual dosing delivered a smaller amount of gel that was retained in the colon, with more variability between users. About 3% of the gel was retained inside the colon after manual gel use. This is compared to 95% of gel retained in the colon with a 10 mL dose delivered by applicator, and 88% of gel retained with a 3.5 mL applicator dose.
“For manual dosing, the dose retained was 32-fold less than the 10 mL applicator dosing,” explained Shieh.
Detection of radiolabeled gel on SPECT/CT scan with manual gel application. Slide: Eugenie Shieh, MD
The researchers also measured how far the gel distributed along the colon by looking at the SPECT/CT scan images and using a computer algorithm to estimate concentrations of the gel. Shieh reported that the manual and applicator distributions were similar, but that manual dosing was associated with less consistent distribution of gel across the colon.
Shieh concluded that rectal microbicides applied as a lube “may not provide adequate drug concentrations or reliable mucosal coverage where needed,” and that, “lube dosing may require a different formulation than applicator dosing.” Increasing the concentration of the drug contained in the microbicide lube, from 1% (the percentage of tenofovir currently being tested as a rectal microbicide) to 10% may help, said Shieh, but that “ultimately, the feasibility of manual dosing will vary with each rectal microbicide.”
The World Psychiatric Association is calling “ex-gay” or “conversation” therapy “unscientific, unethical, ineffective, and harmful” in a statement released today to BuzzFeed News.
The association will release a report tomorrow that will declare its opposition “to any attempts to turn LGBT people heterosexual,” in reference to the effectiveness of so-called conversion therapy.
Along with declaring the inefficacy of such therapy, the WPA also called on governments around the world to decrimalize homosexuality: “WPA supports the need to de-criminalise same-sex sexual orientation and behaviour and transgender gender identity, and to recognise LGBT rights to include human, civil, and political rights.”
“There is no sound scientific evidence that innate sexual orientation can be changed,” the WPA wrote in the statement provided to BuzzFeed News.
Conversion therapy — which aims to turn LGBT people straight and cisgender — has been denounced as junk science by every major medical and psychological organization in the country. In addition to the state-level bans mentioned above, congressional Democrats earlier this year introduced a bill that asks the Federal Trade Commission to ban all conversion therapy practices (for any age) nationwide, labeling the ineffective, harmful “therapy” as fraud.
The statement from the WPA will be available in full Tuesday, reports BuzzFeed News. The group is the world’s largest association for psychiatrists, representing more than 200,000 of them in over 118 countries. Many of these countries continue to criminalize homosexuality or support the idea of conversion therapy.
The U.S. Transportation Security Administration (TSA) has announced a final rule that codifies discrimination against transgender people. The rule implements the widespread use of body-scan technology which requires a TSA agent to choose a pink or blue button based on the perceived gender of the person traveling through U.S. airports. Transgender people, as a result of the policy’s gender bias, are stopped by TSA agents and forced to undergo pat downs and inspections of genital areas and chests.
“Transgender people are regularly harassed and humiliated by current screening procedures, which treats transgender people’s bodies as ‘alarms’ and thus subjecting them to physical and emotional mistreatment. Current policies create a situation where transgender people are dehumanized and placed in harm’s way by constantly outing them and forcing them to disclose their personal lives with TSA agents in front of everyone in order to travel by airplane,” said Victoria Rodriguez-Roldan, Trans/Gender Non-Conforming Justice Project Director, National LGBTQ Task Force.
Last year, the National LGBTQ Task Force met with TSA’s executive, Administrator Peter Neffinger, alongside coalition partners urging the agency to adopt non-discriminatory policies relating to transgender people. The Task Force has also called TSA’s civil liberties office attention to known civil rights violations against transgender people.
“TSA needs to institute screening algorithms in their scanners that are universal instead of relying on stereotypical notions of what a person of one gender or another must look like. We will continue pushing TSA to implement policies that ensures the dignity, safety, and respect of each traveler, including transgender people,” said Rodriguez-Roldan.
In at least nine countries and 15 U.S. states, you can find the Eagle.
In Montreal, it’s called L’Aigle Noir; in Minneapolis, it’s the Eagle Bolt Bar; in New Orleans, it’s a room above another bird bar. But all of these places are unmistakably the Eagle: A family of gay bars with no formal relationship.
Think black walls, Bud Light, bearded men and perhaps a large wooden cross with cuffs dangling off.
It’s the closest thing gay men have to a global franchise. You can walk into one in many cities and know what you’re in for, like a gay McDonalds.
“I would call the Eagle an idea. A concept that has spread,” said Dan Henders, general manager of the Eagle Portland.
Over the years, he told me, he has become more curious of the history behind the name.
Curious myself, I set off to catalog every outpost I could find, and to try and make sense of this ad-hoc network of bars.
The first came in 1970, right after the Stonewall riots, when a longshoreman’s pub on Manhattan’s far west side was transformed from the Eagle Open Kitchen into a leather and cruising bar called the Eagle’s Nest.
A year after its New York founding, an outpost opened in Washington, DC. By 1981, not only had the bars moved west to California and Washington, they popped up in Munich and Amsterdam.
Over time, independent Eagle-branded bars opened in at least 59 cities. When one closes — or burns down — a new one frequently takes its place in the same city. In at least five instances, when one closed, a bar called The Eagle in Exile popped up to fill the void, itself a small tradition.
Most have evolved from a leather crowd to something more akin to a cruisy sports bar — though you probably won’t find sports on the TV. You can still find men strutting around in a harness and chaps, but you’ll more likely come across people in jeans and a t-shirt.
A selection of similarly themed posters from Eagles around the U.S.
What’s in a name?
So why propagate the Eagle name specifically?
“It’s an interesting question, but a tough one to answer,” said Gayle Rubin, Assosciate Professor of Anthropology and Women’s Studies at the University of Michigan.
“Eagles are the biggest diurnal predatory birds, and all that power and deadly equipment is easy to absorb into the semiotics of potency, strength and domination,” she said.
When I asked Alan Kachin, owner of the former Eagle bar in Fort Lauderdale, Fla., why he chose the name, he told me it was because of the manly connotation.
“Eagle Bars were and still are remembered as masculine meeting places. Therefore, Fort Lauderdale Eagle,” he said.
However, its history is diffuse, a casualty of its nature. Pegging the locations involved hunting down liquor licenses, emailing owners and comparing websites, which frequently list the locations of sister bars.
Going online
Unsurprisingly, gay bars were early adopters of the Internet, and some Eagle websites go back to 1998. With the help of the WayBackMachine, I was able to peer back at parties, messages, drink specials and a lot of low-resolution flesh.
Many of the sites served, like the bars themselves, as community hubs. More than one hosted a guestbook where people chatted and left reviews. One site hosted photos of the patrons’ pets — among them cats and dogs named Foo Foo, Argus and Titan.
When the Eagle in Charlotte, N.C., shut down, the bar posted an outpouring of messages from regulars. “I can’t begin to tell you how many people I now know because of visiting the Eagle,” said one man. “Thank you for some of the best years of my life.”
I put together an exhaustive list of cities, dates and names of Eagle bars. Each row has the date the first opened its doors to the date the last one turned out the lights, as well as the different names the bars went by.
Here all the cities that have current and former Eagles. How many have you been to? Do you spot a missing city? A wrong date? Please let me know: ken@thethrust.net.
The Thrust’s Eagle Atlas
Check off all of the Eagles you’ve visited to show off.
City
Bar names
Years with active bar
Amsterdam
Eagle Amsterdam
1979
Today
Atlanta
Atlanta Eagle
1988
Today
Auckland
Eagle Bar
Today
Benidorm
Eagle Bar Benidorm
2011
Today
Boston
Boston Eagle
1976
Today
Cardiff
Eagle Cardiff
2012
Today
Dallas
Eagle Dallas
1995
Today
Denver
Denver Eagle
2007
Today
Houston
Eagle Houston
Today
Indianapolis
501 Eagle
1993
Today
Las Vegas
Las Vegas Eagle
1988
Today
London
Eagle London
2004
Today
Long Island
Long Island Eagle, Veranda at The Long Island Eagle
1992
Today
Los Angeles
Eagle LA
1980
Today
Malaga
Free Eagle
Today
Manchester
Eagle Manchester
2010
Today
Minneapolis
Minneapolis Eagle, Eagle BOLT Bar
1998
Today
Montreal
L’Aigle Noir, Black Eagle
Today
New Orleans
Eagle
1994
Today
New York
Eagle NYC, The Eagle’s Nest
1970
Today
Nice
Eagle Nice
2005
Today
Portland
Eagle Portland, Eagle PDX, Eagle Bar
1986
Today
Providence
Providence Eagle
1995
Today
Salzburg
Dark Eagle
Today
San Diego
San Diego Eagle, Eagle in Exile, Golden Eagle
1980
Today
San Francisco
SF Eagle, Eagle Tavern, Eagle in Exile
1981
Today
Seattle
Seattle Eagle
1980
Today
Stuttgart
Eagle Stuttgart
2000
Today
Toronto
Black Eagle
1994
Today
Tulsa
Tulsa Eagle
Today
Vienna
Eagle Vienna
1990
Today
Washington
DC Eagle, Eagle in Exile
1971
Today
City
Bar names
Years with active bar
Baltimore
Baltimore Eagle
1991
2012
Barcelona
Eagle Barcelona
1998
2007
Calgary
Calgary Eagle
2002
2012
Canton
540 Eagle
1976
2005
Charlotte
Charlotte Eagle
2001
2009
Chicago
Chicago Eagle
1993
2008
Cocoa Beach
Space Coast Eagle
—
2003
Columbus
Columbus Eagle, Eagle Tavern, Eagle in Exile
1975
2009
Detroit
Detroit Eagle
1984
2010
Fort Lauderdale
Fort Lauderdale Eagle, The Eagle in Exile, Eagle at Large
1991
2011
Grand Rapids
Eagle’s Nest
2004
2008
Guernville
Russian River Eagle
—
2005
Hartford
Hartford Eagle
2000
2014
Madrid
Eagle Madrid
1995
2013
Miami
Eagle in Miami
1995
2002
Milwaukee
Milwaukee Eagle
1997
2001
Munich
Eagle Munich
1974
2009
Orlando
Orlando Eagle
1992
1996
Paris
Paris Eagle
2008
2012
Phoenix
Eagle Phoenix
—
2008
Pittsburgh
Pittsburgh Eagle
—
2012
San Antonio
Eagle San Antonio
San Juan
San Juan Eagle
2010
2013
St. Louis
St. Louis Eagle, Eagle in Exile
1994
2006
St. Petersburg
Suncoast Eagle
1998
2007
Tampa
Ybor Eagle, Tampa Eagle, The Eagle
1997
2010
Waterbury
Brass City Eagle
2003
2005
Random Eagle facts
The Eagle Amsterdam claims to be in the city’s oldest building. The wooden skeleton apparently dates to 1485.
The Long Island Eagle has rebranded to “The Veranda at The Long Island Eagle,” touting its serene deck in lieu of its previously “dark and seedy patio.” In spite of this, I’ve kept it marked as open.
At least four have been gutted by fire. The 501 Eagle in Indianaoplis, Ind., posted on their website that “the men are as hot as the bar.” The Houston Eagle was the most recent to burn, forcing it from its home in early 2016.
The Boston Eagle is the oldest one in continuous operation. It’s been at the same location for 40 years.
Florida has had an outpoust in at least six cities — Tampa, St. Petersburg, Orlando, Cocoa Beach, Fort Lauderdale and Miami — the most of any state, yet none remain open.
As for the original building, the Eagle’s Nest on 11th Ave? Like all things in New York, it’s been knocked down to make way for condos. But don’t worry: you can get a beer at the Eagle NYC, just 7 blocks north on 28th St.
Members of the Amnesty International LGBTIQ network march during the MidSumma festival Pride march in Australia, calling for marriage equality
Reuters Health – People who are transgender may have difficulty finding endocrinologists who feel comfortable and competent in providing needed care, according to a new survey of physicians.
Endocrinologists are often key healthcare providers for people who are transgender. But about a third of endocrinologists are unwilling to care for patients who are transgender, and less than half say they feel at least somewhat competent in providing that care, said Dr. Michael Irwig, who surveyed the doctors at an endocrinology meeting last year.
“There is still a big access problem,” said Irwig, associate professor of medicine at the George Washington University School of Medicine and Health Sciences in Washington, D.C. “The fact that 30 percent won’t see transgender patients wouldn’t happen with any other diagnosis.”
“Basically, nobody had really done a similar survey before,” said Irwig, who is also director of the Andrology Center at GW Medical Faculty Associates.
He asked 80 endocrinology providers from Delaware, Maryland, North Carolina, Virginia and Washington, D.C. to answer a 19-item survey. About 80 percent answered the survey.
Overall, 15 percent said they were not at all comfortable discussing gender identity, and another 34 percent said they were only slightly comfortable discussing the subject, according to the study online now in Endocrine Practice.
Fifty-eight percent reported being less comfortable with transgender patients than with non-transgender patients.
Fellowship training on transgender care was uncommon, reported by less than one-third of the doctors overall and by 58 percent of those ages 25 to 39.
Only 41 percent of participants felt at least somewhat competent in providing care to transgender people.
And only 63 percent said transgender patients could be seen at their practice. Irwig said he asked participants to explain why such patients couldn’t be seen, “but a lot of them didn’t fill in that open-ended question.”
He told Reuters Health there could be a number of reasons for doctors refusing to see transgender patients, including prejudice, lack of understanding and not feeling competent in providing the needed care.
More training and experience may help improve healthcare access, said Irwig.
The Endocrine Society is updating its 2009 guidelines for caring for people who are transgender. The guidelines provide guidance and legitimacy, said Dr. Josh Safer, who is working on the update.
“The guidelines are an evidence-based, thoughtful approach from the ultimate mainstream endocrinology professional society and that is very strong for those needing reliable sources,” said Safer, of the Boston University School of Medicine, in an email to Reuters Health.
The updated guidelines include changes to terminology, new practices on how to care for transgender adolescents and how transgender care fits within the larger medical community, he added in a phone interview.
Irwig said transgender people likely know healthcare access is an issue. To find endocrinologists who can provide culturally competent care, he suggests that patients calling doctors’ offices “ask their staff how many transgender patients are seen in the practice, because that will give them a good idea.”
Safer said he considers it a priority to train endocrinologists in transgender medical care. He is educating his own trainees on the subject.
The two chefs were having a good time at Wild Goat Bistro in Petaluma.
“Gutty note,” said one guy to the other. “It won’t take long, it’s just a ball of cheese.”
Then he started humming, as he prepared the real dish: The Nutty Goat, a signature platter with a large round of warm local chevre crusted in chunky pistachio and dried fruit crumbles, presented with toasted pepitas and orange marmalade for spreading on crostini ($11).
Throughout the evening, the duo bantered, teasing the servers and nimbly excusing themselves when it was learned that no one would be eating the French-cut pork chop that night. They were missing a key ingredient for the popular winter creation, served with polenta cake, Brussels sprouts, Nueske applewood smoked lardons, Madeira and pan jus ($23).
“Either the meat company forgot to deliver it, or we forgot to order it,” one chef said with a shrug.
That playful nature is just one of the many charms of this 20-seat café, where every chair — including four at the front counter and four at the window overlooking the edge of the riverfront — offers a view and eavesdropping privileges into the kitchen. Servers smile at us; regular customers greet each other; and it’s not tacky to look at other guest’s dinner plates and admire their meals out loud.
Owner Nancy DeLorenzo clearly has put a lot of personal attention into her Cal-American eatery, and since the place opened in 2010, it has become a locals’ favorite, requiring some geographical knowledge since it’s hidden in the back of the historic, 1854 brick Great Petaluma Mill.
It’s tiny, indeed, housed in space once used as a butcher’s wild game storage locker. You’ll see a small sign and a few patio tables outside, but you’ll have to enter the Mill itself to find the front door.
The Goat recently expanded, adding another two dozen seats in the Mill’s entry hallway, including a long communal table.
And in October, DeLorenzo opened The Social Hall right next door, bringing another dining room and private party space. This area is more modern than original, decorated in mostly reclaimed materials that include a floor made from 100-year-old hop house siding saved from the scrap heap by Heritage Salvage.
In the Goat proper, stone walls are hung with local artwork for sale, menus are affixed to wood clipboards, and specials are hand-drawn on chalkboards, while the new hall is sleek with leather banquettes and polished wood.
While the chefs like their jokes, they’re serious about coaxing the best flavors from their ingredients, no matter how basic.
A Get Chopped salad is classic Cobb, but the way every Cobb dreams it could taste. Baby greens are layered with Mary’s chicken breast, bacon, sliced egg and avocado slabs so fresh they practically dance under the creamy blue cheese dressing ($9 small/$14 large).
Off-the-Hook salad puts art into Nicoise, too, molding the line-caught albacore, olives, sun-dried tomatoes, capers and baby greens into a tidy tower, capping it with sliced egg and rimming it with kalamata olives, crisp green beans and fingerling potato drizzled in sparkly bright lemon olive oil vinaigrette ($10/$15).
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The broth is little more than white wine, lemon and herbs for the Beans-N-Greens bowl, meanwhile, but the dish is sumptuous, nearly a stew, with giant, al dente Rancho Gordo and Iacopi Farms heirloom legumes tumbled with soft, salty braising greens ($7.50).
Excellent ingredients also elevate the 10-inch Fig and Pig pizza ($15.50), arriving as six slices of thin crust, golden-edged pie topped in housemade fig spread, prosciutto, fontina, Grana Padano, goat and blue cheeses finished with arugula.
The sweet-tangy fruit gets a lusty jolt from the bleu cheese, the greens add a shot of pepper, and each bite is complex.
Such balance would make the sandwiches better, though. The Favorite Burger ($16) brings a fine Niman Ranch patty, bacon, blue cheese and aioli, but it’s overwhelmed by the thick baguette roll that could easily hold double the meat.
I ended up dismantling it, removing the clever skewer of sautéed fingerling potatoes holding the sandwich together and pulling the bread apart to make a more beefy chew.
It was the same problem with a daily special chicken Parmesan ($13), with the breast pounded thin and ever-so-slightly pan-burned on its lightly breaded edges, as I like it.
I discarded half the bread and wished for a lot more arugula, lemon aioli, marinara and the entirely meager mozzarella topping.
Perhaps the fanciest dish here is the duck two ways, of pan seared Liberty breast and leg confit, though the recipe remains relaxed and comforting with mixed root vegetables and smashed red potatoes ($28).
“Can you do a duck?” I heard the server say as she put my order in. The comedian chef replied, “Well, I can give it the old college try.”
He nailed it.
We don’t have to ask what’s for dessert. It’s on display on the counter, tempting with glass-topped stands bearing home-baked cakes like chocolate hazelnut or salted caramel chocolate (all $7.50/slice).
They’re all delicious, but the Italian lemon cream cake is light, fluffy and brimming with a tart silken interior that brings a clean finish to our meal. It’s a pride of Petaluma, this Gild Woat — um, Wild Goat.
Twenty-one percent of transgender women have spent time in prison or jail, versus 5 percent of all people in general.
The number of people in prison or jail who identify as LGBTQ is roughly twice that of their general population. And whereas about 8 percent of all youth identify as LGBTQ or gender non-conforming, 20 percent of youth in several juvenile detention sites across the country identified that way, including 40 percent of girls.
All these findings are included in a new report from the Center for American Progress and the Movement Advancement Project called Unjust: How the Broken Criminal Justice System Fails LGBT People. The report details how LGBT people of color are particularly affected.
According to the report, LGBT people are more likely to interact with law enforcement and enter a criminal justice system where they are treated unfairly and more likely to be locked up and to face abuse once there. They also face additional challenges upon leaving incarceration and trying to rebuild their lives.
The report frames the issue in the broader context of a criminal justice system that is more likely to seek out and punish people of color, particularly African Americans. It also highlights individual stories, such as that of a gay youth mistreated by the child welfare system who spent time on the streets; several accounts from transgender people in prison; and a black gay man’s ongoing consequences of being convicted under an HIV criminalization statue in Louisiana.
A comprehensive, 10-year study of Fortune 500 companies has conclude that greater gender diversity at boardroom level makes for a far more inclusive workplace for LGBT people.
The study has been published by SAGE in the journal of Human Relations, in partnership with The Tavistock Institute.
The report’s authors note that non-discrimination policies and domestic partner health insurance benefits are implemented only with the support of top leadership.
They looked at whether the gender of the CEO influenced the likelihood of a company having LGBT inclusive policies, and then at the gender diversity of that company’s board. On both counts, it looked at the years 2001-2010.
It concluded that although the gender of a company’s CEO had an influence on its LGBT-friendly credentials, that influence was far more pronounced if there was diversity across the whole boardroom.
‘While women CEOs are vital for advancing a company’s commitment to domestic partnership benefits and gender identity non-discrimination polices, diverse boards are associated with the full range of LGBT-inclusive policies and practices,’ the author’s concluded.
‘Firms with a higher percentage of women on the board and those with influential women board members are more likely than other firms to adopt a broad range of LGBT- friendly policies and practices.’
‘Our study suggests that diversity advocates committed to advancing inclusive policies – including but perhaps not limited to policies related to sexual orientation and gender identity – should prioritize board diversity.’
In a press statement, one of the report’s co-authors, Alison Cook, Associate Professor at Utah State University, commented, ‘Our study is important because it shows that leadership diversity can significantly influence a company’ likelihood of adopting inclusive polices.
‘Gender diversity in the boardroom is key; women directors increase a company’s commitment to equity and fairness and advance firms’ strategic goals.’
In terms of measuring a company’s LGBT-inclusiveness, the author’s made use of Human Rights Campaign’s Corporate Equality Index – a ranking of US corporations based on their policies regarding gay, lesbian, bisexual and transgender staff.
Deena Fidas, head of HRC’s Workplace Equality Program, and co-author of the HRC Foundation’s Corporate Equality Index, told Gay Star Business, ‘Corporate LGBT inclusion is inextricably linked to race, gender and other salient attributes in the workplace. It’s not surprising then, that corporate boards with greater gender diversity reflect corporations that also value and engage LGBT diversity.’
The report was welcomed by others working in the field of LGBTI diversity and inclusion. Selisse Berry, CEO of Out & Equal Workplace Advocates, said, ‘It’s empowering to see that companies with a diverse board of directors are more likely to foster open and inclusive workplaces for LGBT employees and it’s not surprising that women understand the value of diversity and are willing to invest in developing it.
‘We all have attributes, skills and life experiences that contribute to the success of our work environment – LGBT employees are no different. Having a diverse board of directors that understands this helps bring together varied perspectives and ideas while also sending a strong message to LGBT employees that they are respected and valued.’
‘We strongly believe that increasing diversity within corporate governance structures has important direct and indirect impacts on company cultures and bottom-lines,’ said Juan Herrera, Director of Talent Initiatives at Out Leadership.
‘Our initiative Quorum, dedicated to increasing representation of LGBT directors on corporate boards, is particularly focused on the way that the intersectional nature of the LGBT community creates the opportunity for businesses to diversify their boards in more than one way at a time.’
The potent protection from HIV afforded by Truvada as PrEP allows men to have sex with less worry and fear of HIV. But some worry that the inclusion of PrEP as a public health strategy will lead people to abandon condoms—which still have a role to play in further reducing risk of HIV and other STIs. In San Francisco—even before PrEP’s availability in 2012—rates of STIs among men who have sex with men have been steadily increasing and rates of condom use have gone down.
BETA wanted to know—what do PrEP providers think? How do these practitioners, who see clients every three months for sexual health screenings and STI testing, talk to their clients about condom use, STIs and navigating the complicated landscape of protected, or safer, sex?
To find out, BETA talked to Stefan Rowniak, MSN, PhD, a PrEP provider and nurse practitioner at San Francisco City Clinic and researcher and assistant professor at University of San Francisco; Pierre-Cédric Crouch, PhD, ANP-BC, the nursing director at the San Francisco AIDS Foundation health and wellness center Strut; Robert Blue, a PrEP program coordinator for San Francisco City Clinic; and Hyman Scott, MD, who leads the Ward 86 PrEP Clinic at San Francisco General Hospital.
Here’s what they said.
The rates of gonorrhea, chlamydia and early syphilis infection have been on the rise in recent years in San Francisco. Do you see this as a major problem?
Pierre-Cédric Crouch, PhD, ANP-BC
Pierre-Cédric Crouch, PhD, ANP-BC: Obviously nobody wants to get gonorrhea, chlamydia, or syphilis, but these are risks that we have from living. The only way to completely avoid them is to not have sex at all and that’s not who we are as humans. You can also get the flu from having sex, or strep throat. People die from the flu. People don’t die from gonorrhea, but there’s more stigma attached to gonorrhea than the flu. The levels of STIs are going up in San Francisco—and have been since before PrEP was available here—but they’re nowhere close to what they were in the 70s and 80s.
Stefan Rowniak, MSN, PhD
Stefan Rowniak, MSN, PhD: That’s a very difficult question—but one the community is going to have to answer. If people suddenly find themselves saying, ‘My god, this is the third time I’ve gotten gonorrhea in three months,’ they may think, ‘What can we do about this?’ It’s going to take people realizing that they don’t want to get gonorrhea over and over again every time they have a new sex partner. Health providers will be there to help the discussion along—but we’re not the sex police. We are there to inform and help people make those decisions themselves.
Since gonorrhea, chlamydia and syphilis can all be treated, how do you talk to clients about the potential harms associated with these STIs?
Hyman Scott, MD
Hyman Scott, MD: At this time, these STIs are all treatable with antibiotics, but just because they are treatable do not mean that they are benign. What is a concern is that we are seeing rising rates of drug-resistant gonorrhea, and we shouldn’t forget that gonorrhea can cause sterility. And while syphilis is still treatable with penicillin, with the increase in total cases, we’re seeing more of the complications that come along with syphilis such as neurosyphilis, vision impairment, and vision loss. Giving people the full picture is important—not to spread fear, because we want to have a sex-positive approach when we’re talking about sex—but so that people have the information they need to make decisions about their sexual health.
Some people worry that PrEP is, or will, cause people to abandon condoms. Are your clients changing their condom use now that they’re on PrEP?
Robert Blue
Robert Blue: Yes and no. There are some people who start taking PrEP and they actually start thinking more about their sexual health. Their thought seems to be, ‘Well, I’m taking PrEP for my sexual health, why would I then go out and not use condoms?’ There are people who didn’t use condoms before PrEP, and that doesn’t change. And there are some people who, once they started taking PrEP decided to stop using condoms.
Crouch: We haven’t seen much change, but it’s difficult to measure. Some people will come in and report that they used condoms all the time before they started PrEP. But when you ask a few more questions, you find out that there were exemptions to it—the person didn’t use condoms with their main partner or those few times with their fuck buddy. So it wasn’t really 100% condom use to begin with.
Scott: I think for some clients, there is a change in the way that they decide to use condoms [on PrEP], but there’s a lot of variability. Some people may change their condom use with certain partners, but not others. With the rise in STIs and increased uptake of PrEP, there is a real desire of some to make that linkage and say that one is causal to the other. We have seen a rise in STIs before the increased uptake of PrEP. Studies that have systematically looked at this haven’t found much of an overall change in the level of condom use among PrEP users, but it will also be important to monitor as PrEP roll-out expands in more real-world settings. Anecdotally, we’ve had people who don’t change their condom use at all. It’s definitely something we need to keep track of, but at this point we don’t have data to say that initiating PrEP is the reason people change their condom use, if they change it.
Do condoms still have a role to play in gay men’s sexual health alongside PrEP?
Crouch: Condoms still have value. They do a good job of reducing transmission of gonorrhea and chlamydia—less so for syphilis. They don’t provide 100% protection, but they do have value. All in all, we don’t know five years from know how people will use condoms when they’re on PrEP. I could see it being similar to what happened for oral sex—in the 90s, when people thought you could get HIV from oral sex, there was a big push for people to use condoms for oral sex. I don’t know if that’s what people really did, but now that we know the risk of HIV transmission from oral sex is so rare, I think people in general gave up on feeling like they should use condoms for oral sex. Of course there’s still a risk of getting or transmitting other STIs but the risk of HIV is so slight with oral sex. It’s the same way for anal sex if you’re on PrEP.
Rowniak: I don’t believe people will completely abandon condoms in favor of PrEP. Rather, I think people will use condoms with some partners and in some instances and not in others. I think people feel, to a certain extent, a little frightened after spending years and years using condoms, and all of a sudden not using them at all. So the pendulum might swing back and forth until it reaches a place to settle.
Blue: We know that while PrEP is highly effective in preventing HIV transmission, it is not 100%. Many people still feel more comfortable using condoms while taking PrEP. We also know that PrEP doesn’t prevent the transmission of other STIs and that condoms can be an effective STI-prevention strategy.
Scott: Condoms absolutely have a role to play. One thing to remember is that we’ve never studied PrEP versus condoms—PrEP has always been inclusive of condoms. The package that includes PrEP is not just one pill per day. It’s about condom promotion, too. There are a variety of ways that people can have protected or safer sex, and we want to give people the tools that fit within their sex lives and support them with all of these options.
Do you advise your clients to use condoms? And if so, how do you have those conversations?
Blue: Yes, we do. Ultimately, we want people to think logically or rationally about their sex lives (acknowledging that sex is not often our most rational form of self-expression!). We want people to be able to evaluate their risk of HIV and STIs and decide on what prevention strategies make sense for them.
Rowniak: I make a point to talk with clients about when it might be appropriate to use condoms—and when it might make sense to reintroduce condoms back into sex. These conversations help get people to think about using condoms, and that’s really the first step. Introducing this new thought about condoms helps people think about ways they might like to be a little more circumspect.
Crouch: Our job is to provide education and have the client come up with their own informed sexual health plan. We tell clients that PrEP isn’t 100% effective at preventing HIV infection, even though we haven’t had any infections on PrEP yet—because nothing in life is 100%. Condoms provide extra protection against gonorrhea and chlamydia. We frame it as, ‘Using condoms with PrEP is your best overall protection.’ But we don’t lecture anyone to do, or not do, anything. We’re here to inform and help support people in whatever they decide to do. If condoms haven’t been a problem for a client, they should definitely continue to use them—though condoms aren’t always easy for people to use. They can break. Some people tell us they have trouble maintaining an erection with them. Some say condoms reduce intimacy in relationships. It’s ultimately an individual decision. There is no right or wrong answer.
Scott: I’m humble enough to know that I only get the opportunity to spend 30 minutes, maybe an hour, talking with patients about a variety of medical conditions including their sexual health, which is balanced with all the other needs and considerations in their daily lives. I give them guidance and recommendations but I don’t try to convince them to use condoms if they’ve already made up their mind about condom use. I meet my patients where they’re at and see how open they are to exploring condom use. Recently, I saw someone who was diagnosed with early syphilis. We started treatment [for syphilis] but then also talked about why he didn’t use a condom with this new partner, despite his ‘rule’ to use condoms with new partners. His response that, ‘The guy was just my type’ was incredibly insightful and understandable. So there was something powerful about desire and passion, and wanting to make a connection with his partner that influenced his decision making. So I explore the barriers and facilitators people may have for condom use, but never pass judgment on their decision.
For more information about PrEP services at the gay men’s health and wellness center in the Castro, Strut, visit www.strutsf.org. Find out more about the Ward 86 PrEP Clinic at San Francisco General Hospital. Continue learning more about PrEP at www.prepfacts.org or on BETA.
Transgender individuals may experience significant improvement in psychological functioning after as little as 3–6 months of hormone therapy, with improved quality of life reported within 12 months of initiating therapy by both female-to-male and male-to-female transgender individuals, according to an article published in Transgender Health, a new peer-reviewed open access journal from Mary Ann Liebert, Inc., publishers. The article is available open access on the Transgender Health Web site.
Jaclyn White Hughto and Sari Reisner, Fenway Health, Boston Children’s Hospital/Harvard Medical School, and Harvard T.H. Chan School of Public Health (Boston, MA), and Yale School of Public Health (New Haven, CT), reviewed the evidence from published studies of transgender adults treated with hormone therapy for gender identity disorder. The researchers report the changes in mental health status—including depression and anxiety—and quality of life outcomes after 3–6 months and 12 months of hormone treatment compared to baseline measures. They present the study design and results in “A Systematic Review of the Effects of Hormone Therapy on Psychological Functioning and Quality of Life in Transgender Individuals.”
“Reviews of the existing literature of this nature are hugely helpful in moving the field of transgender health forward,” says Editor-in-Chief Robert Garofalo MD, MPH, Professor of Pediatrics and Preventive Medicine, Northwestern University Feinberg School of Medicine, and Director, Center for Gender, Sexuality and HIV Prevention, Ann & Robert H. Lurie Children’s Hospital of Chicago. “This work highlights a healthcare disparity affecting transgender people—depression and anxiety—and offers a potential therapeutic option to help eliminate or reduce it: access to hormone therapy. It sets the bar for future research to be conducted in this area, which is sorely needed and may help some clinicians caring for transgender people.”
