The Ins and Outs of Gay Sex (14 page)

Men who have suffered through multiple prior herpes outbreaks generally can recognize their first symptoms (localized pain or burning in their anogenital region) and begin medication even before their blisters appear.
Not only will this make their attack more tolerable by lessening pain and shortening its course, it also may decrease their chance of transmitting the virus to a partner.

People with HIV or severely compromised immune systems who suffer from repeated attacks may obtain relief by taking medications continuously.
(See
Chapter 5
.
) Called chronic suppression therapy, the standard dose of acyclovir is usually 800 mg daily but can be adjusted depending on immune status.
The standard suppression dose of valacyclovir is 500 mg once a day; the dose for famciclovir is 125 mg twice a day.
The extremely rare downside to chronic suppression is that herpes can become resistant to the common medications, and intravenous drugs will be required to fight outbreaks.

If you have herpes, it is best to inform all potential partners.
Doctors used to think that you could transmit the virus only during outbreaks.
Now we know transmission is possible, although less likely, even when you are symptom free.
Clearly, abstinence at the first sign of a flare-up is key to preventing transmission and should continue until crusting is complete.
If your anal canal is the only area infected, your penis is probably safe as long as your partner keeps his hands off your butt.
Problems arise because many people are infected at multiple sites (penis, rectum, mouth, or in any combination).

No one wants to believe he has herpes, and I have had patients come into my office with painful sores attributed to everything from getting their penis caught in their zipper (wear underwear) to a partner’s overzealous fellatio.
When I tell patients they have herpes, most stare in disbelief, swearing that the penis they sucked or the ass they fucked was completely clean.
That may be what they thought, but herpes blisters are hard to spot and easily hidden—especially in a partner’s mouth and anus.
Although the infection is usually painful and most people don’t feel up to sex, attacks can be mild, and as blisters heal, pain abates but a partner can still infect you.
Unfortunately, the herpes virus can be present without any symptoms, and your partner may not even know that he has it while he is passing the disease to you.

A common mistake men make (other than catching herpes in the first place) is assuming that a canker sore (aphthous ulcer) is herpes.
Canker sores are usually solitary and covered with a white membrane; herpes blisters tend to be multiple and red once the blister pops.
Canker sores affect different parts of your mouth with each outbreak and often are painless.
A mild steroid cream applied directly to the ulcer speeds healing.

Molluscum contagiosum is not a shellfish but a sexually transmitted virus belonging to the pox family of viruses.
Smallpox is also a member of this group, but thankfully, molluscum does not have the same grave prognosis.
Molluscum contagiosum generally infects the skin, and in adults it is sexually transmitted through direct skin-to-skin contact.
If your partner has the virus and you rub against an infected part of his body, chances are great that you’ll catch it too.
But as with herpes, transmission also has been reported
after close nonsexual contact with an infected individual (massages, contact sports).

Approximately one to three months after exposure, molluscum causes a distinct pin-size pimple with a central depression (like a moon crater).
(See
Figure 4.
2
.
) If left untreated, the sores gradually increase in size, sometimes reaching pea-size proportions.
If you squeeze a sore, a cheesy white material oozes out.
The lesions are often multiple and may not be clustered in one area.
The most frequent sites of infection are the anogenital region with spread to your thighs and lower abdomen.
It is also possible to spread the virus with your hands to more distant sites (arms, back, and face).

Figure 4.
2:
Molluscum Contagiosum

Molluscum typically produces few symptoms other than its characteristic skin lesions.
If untreated, the virus runs its course within two to four months, but occasionally it persists
for years.
If you think you have molluscum, see your physician, who can make the diagnosis with just a look.
A biopsy is rarely necessary.
Treatment will help you get rid of the unsightly skin ulcers faster and prevent spread to other parts of your body and to sexual partners.

Treatment for molluscum aims directly at the skin lesions.
Oral and topical medications don’t work, so the doctor must scrape, burn, or freeze the blisters away.
(Don’t worry, it doesn’t hurt.
) If treatment becomes painful, a bit of local anesthesia is more than adequate.
Catching molluscum early is key (especially for men with HIV) before the virus multiplies and soon you have sores everywhere.
In men with AIDS, neglected molluscum can become impossible to cure.

Skin lesions also can become secondarily infected with bacteria (usually staphylococcus), and then antibiotics are necessary.
Bacterial infection also increases the likelihood of scarring.
It is crucial that you be checked periodically for two to three months after treatment.
Doctors can treat only visible skin blisters, leaving behind virus at other sites that has not grown into the characteristic lesions.
Repeat checkups rid you of these viruses as soon as lesions appear and reduce your risk of another major infection.

Although molluscum has not been shown to enter a dormant state like herpes, recurrences are seen.
We don’t know whether recurrence represents a new infection or reactivation of molluscum from within the cell.

My patient narrowed his eyes in anger.
I had just told him he had anal warts.
“So Billy’s cheating on me,” he said.

I took a deep breath.
“No, it doesn’t mean that at all.”

“Well, I know I’m not cheating on him, so who else is there?”

“No one,” I said.
“These warts are caused by viruses.
Billy
could have carried it for years—from long before the two of you got together.”

“Even without his having anything on his penis?”
I nodded, and his face brightened for a moment.
“Are you just saying that so I don’t kill him when I get home?”

Condyloma acuminatum (also called venereal warts or genital warts) are caused by the human papillomavirus (HPV).
As the name “venereal” implies, the virus spreads from partner to partner during sex.
The Centers for Disease Control estimates that close to 1 million new HPV infections occur each year, with more than 24 million Americans already infected.
Gay men with healthy sex lives are finding it increasingly difficult to avoid condyloma.
It is estimated that more than half of all HIV-negative men who have sex with men carry the virus, and the number increases to almost 100 percent for HIV-positive men.
Unfortunately, you can carry HPV and infect sex partners without knowing you have it.
We don’t know why at times the virus grows into a wart and other times it does not.

As with other viral STDs we have discussed, transmission between partners can occur without penetration or ejaculation.
Your partner’s unprotected penis rubbing between your buttocks during seemingly innocuous foreplay is more than enough.
Even if he wears a condom, the base of his shaft, scrotum, and pubic region are not covered (unless he’s inside a plastic bag), and these are frequent sites for warts that rub against you during sex.
Read on, it gets worse.
The type of HPV responsible for venereal warts does not grow on hands, but a hand can carry the virus between sex partners or to another location on your own body.
Dildos and other toys can also transmit virus between partners.

I have had patients swear that they have never allowed anyone close to their anus and yet they still got anal condyloma.
(Are they lying?
) HPV does not always grow into warts, especially on a penis.
You touch his penis during sex and transport the virus to your anus the next time you wipe.
(So always wash your hands.
)

There are close to one hundred different numbered types of HPV, and although many cause genital warts, others cause different conditions, from hand and plantar warts, to laryngeal cancer.
Some types of HPV (type 16 and 18) are associated with anogenital cancers (cervical in women and anal in men).

Most patients I see are afraid to admit they have condyloma because it makes them feel dirty and cheap.
Instead, they come to my office complaining of hemorrhoids and are shocked when I tell them they have venereal warts.
I must say right now that you are not cheap, and you are not dirty.
(Or maybe I just don’t you well enough.
) The human papillomavirus is everywhere, and it may be next to impossible for an unattached gay man to have an active,
healthy
sex life and keep from getting condyloma.
It is far easier to transmit HPV than HIV during sex.

So many common misconceptions surround condyloma that I must dispel them before going on.

The type of human papillomavirus that causes condyloma is not the same type that causes hand warts.
It is possible to spread condyloma to other warm, moist parts of your body (under your breasts, armpits, mouth), but it is extremely rare to find them on your fingers.
You did not get venereal warts because some guy you were with had garden-variety hand warts.


Although there have been isolated reports, you did not catch warts from a toilet seat or sauna.
(Unless, of course, you did more in there than soak up the steam.
)


Straight men get anal warts too.
I once had the father of an obviously closeted gay teen storm into my office demanding to know how his “all-American” son got “those things.”
Clearly the father was afraid the
warts meant his son was gay, and his son was positively apoplectic over the idea that his father would learn the truth.
Well, I’m a surgeon, not a shrink, so I explained to the father that just because his son had warts did not mean he was gay.
Straight men are into butt play (the father nodded knowingly), and fingers can transmit the virus during hetero sex.
Men can also self-infect themselves from penis to anus.
Both father and son left smiling, but, as always, I caution you to be honest with your doctor and admit to anal sex so he or she can evaluate you properly.


The wart is not the actual virus.
It is your skin’s reaction to the virus within it.