Screening for Gonorrhea and Syphilis in the Gay BathsDenver, Colorado FRANKLYN N. JUDSON, MD, KENNETH G. MILLER, BA, AND THOMAS R. SCHAFFNIT, GN
Abstract: During 33 screening sessions in Denver gay steambaths, 48 of 419 (11.5 per cent) men were found to have asymptomatic gonorrhea and six (1.4 per cent) had early latent syphilis. Questionnaires were administered to 160 men who reported a mean of 7.9 different male sex contacts per month. Female sex contacts were also reported by 30 per cent. The respond-
ents used the baths an average of 2.2 times per month, having an average of 2.7 different sex contacts per visit, 84 per cent of whom were not previously known to the respondent. Gay steambaths are productive locations for detecting asymptomatic gonorrhea and syphilis. (Am. J. Public Health 67:740-742, 1977)
Introduction
local gay steam baths could provide settings for efficiently screening sexually-active gays for gonorrhea and syphillis. In addition, we felt it was time to administer questionnaires to learn more about gay sexual habits and attitudes towards STD health-care options. This paper presents the results of the steam bath screening program and analyzes responses to the
In some populations, gay (homosexual) men have much higher rates of gonorrhea and syphilis infections 1-3 than heterosexual men. These higher rates of infection may be a function of homosexual acts, greater promiscuity, lesser utilization of health care facilities, or infections of body sites that rarely produce symptoms. Public health agencies have done relatively little to address the problem of sexually transmitted diseases (STDs) in gays.* Gays, in turn, have shown an understandable reluctance to trust their health to medical authorities who may discriminate against them. The Denver Metro Health Clinic (DMHC) provides the Denver metropolitan area with walk-in diagnostic and treatment services for STDs. In recent years DMHC has made special efforts to be sensitive to gays and their STD problems. Nevertheless, many sexually active gays were either not aware of the need for periodic testing for asymptomatic gonorrhea and syphilis, or did not choose to be tested at the Clinic. In August 1975, the Clinic Director met with ten representatives of Denver area gay organizations to discuss Clinic outreach programs for the gay community. We agreed that From the Denver Metro Health Clinic, Denver Health and Hospitals. Address reprint requests to Dr. Franklyn N. Judson, Director, Disease Control Service, City and County of Denver, 605 Bannock Street, Denver, CO 80204. This paper, submitted to the Joumal November 23, 1976, was revised and accepted for publication February 15, 1977. *Gay Caucus. American Public Health Association Meeting. Miami Beach, Florida, October 18, 1976
740
questionnaire.
Materials and Methods A DMHC team of two gay male clinicians conducted a four hour screening session each week in one of Denver's three steam baths. Testing was voluntary and performed in a small private room. Patients were given cards telling them when to call DMHC for test results. Name, address, and phone number were requested, but not required. The team brought supplies for drawing bloods and taking urethral, pharyngeal, and rectal specimens for direct plating on Thayer-Martin media. Men who disclaimed sexual contact at a particular site were not cultured from that site. Media were placed in candle jars and transported back to the DMHC's 36°C incubator which contains 5-10 per cent carbon dioxide. Isolates were identified after 48 hours by oxidase reaction and Gram stain. Pharyngeal isolates were confirmed as Neisseria gonorrhoeae by standard sugar fermentation reactions. A questionnaireT was designed to gather limited informatCopies of the questionnaire are available from the authors. AJPH August, 1977, Vol. 67, No. 8
VD SCREENING IN GAY BATHS
tion on the bath patron's use of STD health care facilities, his desire for confidentiality, and his sexual activity. It was hoped that this information might help both patrons and bath managements appreciate a potential need for screening and help us tailor a more acceptable program. The questionnaire was administered to the first 87 patrons to accept screening. To learn if there were important response differences between those who did and those who did not accept screening, an attempt was made to administer the questionnaire to an equal number who did not volunteer to be screened; 73 of 87 complied. In total, 160 patrons filled out the questionnaire.
Results From January through October 1976, 33 screening sessions for gonorrhea and syphilis were held. Of 1,982 persons attending the baths during the hours when testing was offered, 419 (21.1 per cent) accepted testing. Table 1 presents the culture results. A total of 48 sites were positive for gonorrhea in 48 of 419 (11.5 per cent) asymptomatic men. All patients accepted treatment and interviewing for contacts at DMHC. TABLE 1-Results of Gonorrhea Cultures
Site Urethral Pharyngeal Rectal
No. of Cuitures
No. Positive
(% Positive)
410 419 367
9 11 28
(2.2) (2.6) (7.6)
Of 416 men tested for syphilis, six (1.4 per cent) were found to have early latent disease as defined by a reactive VDRL and FTA-ABS, a negative history for syphilis, the absence of signs (anoscopy and lumbar punctures were not performed), and a documented negative VDRL within the past year. Each accepted a contact interview by a state investigator and treatment, five from DMHC and one from a private physician. In summary, 54 cases of asymptomatic gonorrhea and syphilis were detected in 52 (two had both gonorrhea and syphilis) of 419 men, for an overall yield of 12.4 per cent infected. There were no significant differences (P > .20 for each question) between the responses of the 87 who did and the 73 who did not accept screening and their responses have been combined (N = 160). A few respondents did not answer every question as indicated by a denominator less than 160. Respondents were 17 to 60 years of age (median of 31.8). During the past two years 68 per cent (105/155) had made at least one STD related visit (X = 2.6 visits) to a health care facility: 27 per cent to DMHC, 38 per cent to other public health clinics, and 36 per cent to private clinics or physicians. Fifty-eight per cent (92/160) did not want "people in general" to know they were gay, and most (94/149) felt this confidentiality could be better protected in DMHC than in a private physician's office. Eighty-four per cent (130/154) gave us their correct name, address, and phone number. AJPH August, 1977, Vol. 67, No. 8
When asked to list in order of preference the kind of person they preferred to examine them for STDs, 68 per cent (104/153) selected as first choice "the most competent person, regardless of sexual preference"; 27 per cent (42/153), "a gay male"; 3 per cent (5/153), "a heterosexual male"; and 1 per cent (2/153), "a female". Eighty-three per cent picked a female as the fourth or least preferable choice. The respondents had a mean of 7.9 different male sex contacts per month (range: 0 to 41) and 32 per cent (51/160) estimated more than 10. Of 138 respondents to answer the same question regarding female sex contacts, 70 per cent had no contacts with women while the other 30 per cent had a mean of .82 female sex contacts per month. Respondents used the steam baths an average of 2.2 times per month (range: I to 12) and had an average of 2.7 different sex contacts per visit. Only 16 per cent (22/139) of respondents knew their sex contacts prior to meeting in the baths.
Discussion Although there are no general population data, gays who attend STD clinics have been shown to experience disproportionately higher rates of infection with gonorrheal' 2 and syphilis'-3 than heterosexuals. Recent statistics from the Center for Disease Control now attribute more than 45 per cent of early syphilis to gays.** To better serve this high risk group, we developed a gonorrhea and syphilis screening program in Denver's gay steam baths. Steam baths may be found in many large cities and exist for men who desire anonymous sex with other men in a comfortable setting. We chose gay health workers to perform the screening because the bath managements were "up tight" about representatives of the "straight" community inspecting their operations. In addition, patrons indicated through the questionnaire that their first choice for an examiner was either the "most competent person, regardless of sexual preference" (68 per cent) or a "gay male" (27 per cent). We felt our workers combined both attributes. The questionnaire was useful in documenting for ourselves and the bath patrons their potential risk for STD infections. In particular, we were concerned about the high level of sexual activity (a mean of 7.9 different male contacts per month), the anonymity of these contacts (only 16 per cent knew their bath contacts), the implied links with the "straight" community (30 per cent reported some female sex contact), and the relative underutilization of STD health care facilities (32 per cent had received no STD health care within the past two years). Our concerns proved warranted when we discovered an overall infection rate for gonorrhea and syphilis of 12.4 per cent. From the viewpoint of an uninfected bath patron, the average risk of contacting someone with gonorrhea or syphilis in a typical visit to the baths would be about 33 per cent, i.e.,
**Personal communication: Venereal Disease Control Division, Center for Disease Control, Atlanta, Georgia 741
JUDSON, ET AL.
12.4 per cent x 2.7 (average number of different sex contacts per visit). However, the actual risk of contracting infection is totally unknown and is complicated by the variety of sex acts and infected body sites. It is appropriate during times of limited public health resources to offer some cost benefit justification for a new program. The princiDal costs for the 10-month period were 120 hours compensation time for a DMHC laboratory technician, $400 work-study payment to a student nurse, and about $200 for Thayer-Martin media (@ .12 per plate) and blood drawing supplies. Serologies were performed free of charge by the Colorado State Laboratory and cultures were processed by the DMHC laboratory, utilizing existing capacity. The benefits consisted of removing 48 cases of gonorrhea and six cases of early latent syphilis from the infected population. By virtue of being asymptomatic, each case could have resulted in further transmission before eventual detection. Beyond this, over 400 bath patrons had the opportunity to meet gay health workers sensitive to their problems, and to learn about the need for periodic screening and the public clinics established for this purpose. We recommend that similar screening programs be ini-
I
tiated in gay steam baths in other cities and that gay health workers be employed when possible. Local gay organizations can do much to encourage the bath managements to cooperate. We plan to continue our screening program for as long as the gonorrhea infection rate remains above 5 per cent and the gay community accepts our services.
REFERENCES 1. Fluker, J. V. A 10-year study of homosexually transmitted infection. Br. J. Vener. Dis. 52:155-160, 1976. 2. Thin, R. N., Smith, D. M. Some characteristics of homosexual men. Br. J. Vener. Dis. 52:161-164, 1976. 3. Dans, P. E., The establishment of a university-based venereal disease clinic: I. Description of the clinic and its population. J. Am. Vener. Dis. Assoc. 1:70-78, 1974. 4. Judson, F. N. Update in the sexually transmitted diseases. J. Am. Wom. Med. Assoc. 31:11-19, 1976.
ACKNOWLEDGMENTS The encouragement and financial assistance of the Colorado Department of Health, Venereal Disease Control Unit is gratefully acknowledged, as is the cooperation of various Denver Gay Organizations and the steam bath managements. Thanks also to Katie Andersen for secretarial assistance.
Nominations Sought for Mindel C. Sheps Award
Nominations are requested for the Mindel C. Sheps Award in Mathematical Demography, to be presented for the third time in 1978 and every second year thereafter. The award, established by the Mindel C. Sheps Memorial Fund, and sponsored by the Population Association of America and the University of North Carolina School of Public Health, is given in recognition of outstanding contributions to mathematical demography or demographic methodology. Individuals should be nominated for this award on the basis of important contributions to knowledge, either in the form of a single piece of work or a continuing record of high accomplishment. The award is intended to honor an individual whose future research achievements are likely to continue a past record of excellence rather than as a tribute to a demographer who is ending an active professional career. There are no specific requirements as to age, nationality, or place of residence; nor is the award restricted to members of the Population Association of America. The recipient of the award will be selected by a committee appointed by the President of the Population Association of America and the Dean of the University of North Carolina School of Public Health. Presentation of the award, comprising a certificate and $1000, will be made at the annual meeting of the Population Association of America. Previous recipients of the award are Ansley J. Coale and Nathan Keyfitz. To be considered for the third award, nominations must be received by February 15, 1978. Nomination forms may be obtained from the: Chairman, Mindel C. Sheps Award Committee, Population Association of America, P.O. Box 14182, Benjamin Franklin Station, Washington, DC 20044.
742
AJPH August, 1977, Vol. 67, No. 8
Abstract: During 33 screening sessions in Denver gay steambaths, 48 of 419 (11.5 per cent) men were found to have asymptomatic gonorrhea and six (1.4 per cent) had early latent syphilis. Questionnaires were administered to 160 men who reported a mean of 7.9 different male sex contacts per month. Female sex contacts were also reported by 30 per cent. The respond-
ents used the baths an average of 2.2 times per month, having an average of 2.7 different sex contacts per visit, 84 per cent of whom were not previously known to the respondent. Gay steambaths are productive locations for detecting asymptomatic gonorrhea and syphilis. (Am. J. Public Health 67:740-742, 1977)
Introduction
local gay steam baths could provide settings for efficiently screening sexually-active gays for gonorrhea and syphillis. In addition, we felt it was time to administer questionnaires to learn more about gay sexual habits and attitudes towards STD health-care options. This paper presents the results of the steam bath screening program and analyzes responses to the
In some populations, gay (homosexual) men have much higher rates of gonorrhea and syphilis infections 1-3 than heterosexual men. These higher rates of infection may be a function of homosexual acts, greater promiscuity, lesser utilization of health care facilities, or infections of body sites that rarely produce symptoms. Public health agencies have done relatively little to address the problem of sexually transmitted diseases (STDs) in gays.* Gays, in turn, have shown an understandable reluctance to trust their health to medical authorities who may discriminate against them. The Denver Metro Health Clinic (DMHC) provides the Denver metropolitan area with walk-in diagnostic and treatment services for STDs. In recent years DMHC has made special efforts to be sensitive to gays and their STD problems. Nevertheless, many sexually active gays were either not aware of the need for periodic testing for asymptomatic gonorrhea and syphilis, or did not choose to be tested at the Clinic. In August 1975, the Clinic Director met with ten representatives of Denver area gay organizations to discuss Clinic outreach programs for the gay community. We agreed that From the Denver Metro Health Clinic, Denver Health and Hospitals. Address reprint requests to Dr. Franklyn N. Judson, Director, Disease Control Service, City and County of Denver, 605 Bannock Street, Denver, CO 80204. This paper, submitted to the Joumal November 23, 1976, was revised and accepted for publication February 15, 1977. *Gay Caucus. American Public Health Association Meeting. Miami Beach, Florida, October 18, 1976
740
questionnaire.
Materials and Methods A DMHC team of two gay male clinicians conducted a four hour screening session each week in one of Denver's three steam baths. Testing was voluntary and performed in a small private room. Patients were given cards telling them when to call DMHC for test results. Name, address, and phone number were requested, but not required. The team brought supplies for drawing bloods and taking urethral, pharyngeal, and rectal specimens for direct plating on Thayer-Martin media. Men who disclaimed sexual contact at a particular site were not cultured from that site. Media were placed in candle jars and transported back to the DMHC's 36°C incubator which contains 5-10 per cent carbon dioxide. Isolates were identified after 48 hours by oxidase reaction and Gram stain. Pharyngeal isolates were confirmed as Neisseria gonorrhoeae by standard sugar fermentation reactions. A questionnaireT was designed to gather limited informatCopies of the questionnaire are available from the authors. AJPH August, 1977, Vol. 67, No. 8
VD SCREENING IN GAY BATHS
tion on the bath patron's use of STD health care facilities, his desire for confidentiality, and his sexual activity. It was hoped that this information might help both patrons and bath managements appreciate a potential need for screening and help us tailor a more acceptable program. The questionnaire was administered to the first 87 patrons to accept screening. To learn if there were important response differences between those who did and those who did not accept screening, an attempt was made to administer the questionnaire to an equal number who did not volunteer to be screened; 73 of 87 complied. In total, 160 patrons filled out the questionnaire.
Results From January through October 1976, 33 screening sessions for gonorrhea and syphilis were held. Of 1,982 persons attending the baths during the hours when testing was offered, 419 (21.1 per cent) accepted testing. Table 1 presents the culture results. A total of 48 sites were positive for gonorrhea in 48 of 419 (11.5 per cent) asymptomatic men. All patients accepted treatment and interviewing for contacts at DMHC. TABLE 1-Results of Gonorrhea Cultures
Site Urethral Pharyngeal Rectal
No. of Cuitures
No. Positive
(% Positive)
410 419 367
9 11 28
(2.2) (2.6) (7.6)
Of 416 men tested for syphilis, six (1.4 per cent) were found to have early latent disease as defined by a reactive VDRL and FTA-ABS, a negative history for syphilis, the absence of signs (anoscopy and lumbar punctures were not performed), and a documented negative VDRL within the past year. Each accepted a contact interview by a state investigator and treatment, five from DMHC and one from a private physician. In summary, 54 cases of asymptomatic gonorrhea and syphilis were detected in 52 (two had both gonorrhea and syphilis) of 419 men, for an overall yield of 12.4 per cent infected. There were no significant differences (P > .20 for each question) between the responses of the 87 who did and the 73 who did not accept screening and their responses have been combined (N = 160). A few respondents did not answer every question as indicated by a denominator less than 160. Respondents were 17 to 60 years of age (median of 31.8). During the past two years 68 per cent (105/155) had made at least one STD related visit (X = 2.6 visits) to a health care facility: 27 per cent to DMHC, 38 per cent to other public health clinics, and 36 per cent to private clinics or physicians. Fifty-eight per cent (92/160) did not want "people in general" to know they were gay, and most (94/149) felt this confidentiality could be better protected in DMHC than in a private physician's office. Eighty-four per cent (130/154) gave us their correct name, address, and phone number. AJPH August, 1977, Vol. 67, No. 8
When asked to list in order of preference the kind of person they preferred to examine them for STDs, 68 per cent (104/153) selected as first choice "the most competent person, regardless of sexual preference"; 27 per cent (42/153), "a gay male"; 3 per cent (5/153), "a heterosexual male"; and 1 per cent (2/153), "a female". Eighty-three per cent picked a female as the fourth or least preferable choice. The respondents had a mean of 7.9 different male sex contacts per month (range: 0 to 41) and 32 per cent (51/160) estimated more than 10. Of 138 respondents to answer the same question regarding female sex contacts, 70 per cent had no contacts with women while the other 30 per cent had a mean of .82 female sex contacts per month. Respondents used the steam baths an average of 2.2 times per month (range: I to 12) and had an average of 2.7 different sex contacts per visit. Only 16 per cent (22/139) of respondents knew their sex contacts prior to meeting in the baths.
Discussion Although there are no general population data, gays who attend STD clinics have been shown to experience disproportionately higher rates of infection with gonorrheal' 2 and syphilis'-3 than heterosexuals. Recent statistics from the Center for Disease Control now attribute more than 45 per cent of early syphilis to gays.** To better serve this high risk group, we developed a gonorrhea and syphilis screening program in Denver's gay steam baths. Steam baths may be found in many large cities and exist for men who desire anonymous sex with other men in a comfortable setting. We chose gay health workers to perform the screening because the bath managements were "up tight" about representatives of the "straight" community inspecting their operations. In addition, patrons indicated through the questionnaire that their first choice for an examiner was either the "most competent person, regardless of sexual preference" (68 per cent) or a "gay male" (27 per cent). We felt our workers combined both attributes. The questionnaire was useful in documenting for ourselves and the bath patrons their potential risk for STD infections. In particular, we were concerned about the high level of sexual activity (a mean of 7.9 different male contacts per month), the anonymity of these contacts (only 16 per cent knew their bath contacts), the implied links with the "straight" community (30 per cent reported some female sex contact), and the relative underutilization of STD health care facilities (32 per cent had received no STD health care within the past two years). Our concerns proved warranted when we discovered an overall infection rate for gonorrhea and syphilis of 12.4 per cent. From the viewpoint of an uninfected bath patron, the average risk of contacting someone with gonorrhea or syphilis in a typical visit to the baths would be about 33 per cent, i.e.,
**Personal communication: Venereal Disease Control Division, Center for Disease Control, Atlanta, Georgia 741
JUDSON, ET AL.
12.4 per cent x 2.7 (average number of different sex contacts per visit). However, the actual risk of contracting infection is totally unknown and is complicated by the variety of sex acts and infected body sites. It is appropriate during times of limited public health resources to offer some cost benefit justification for a new program. The princiDal costs for the 10-month period were 120 hours compensation time for a DMHC laboratory technician, $400 work-study payment to a student nurse, and about $200 for Thayer-Martin media (@ .12 per plate) and blood drawing supplies. Serologies were performed free of charge by the Colorado State Laboratory and cultures were processed by the DMHC laboratory, utilizing existing capacity. The benefits consisted of removing 48 cases of gonorrhea and six cases of early latent syphilis from the infected population. By virtue of being asymptomatic, each case could have resulted in further transmission before eventual detection. Beyond this, over 400 bath patrons had the opportunity to meet gay health workers sensitive to their problems, and to learn about the need for periodic screening and the public clinics established for this purpose. We recommend that similar screening programs be ini-
I
tiated in gay steam baths in other cities and that gay health workers be employed when possible. Local gay organizations can do much to encourage the bath managements to cooperate. We plan to continue our screening program for as long as the gonorrhea infection rate remains above 5 per cent and the gay community accepts our services.
REFERENCES 1. Fluker, J. V. A 10-year study of homosexually transmitted infection. Br. J. Vener. Dis. 52:155-160, 1976. 2. Thin, R. N., Smith, D. M. Some characteristics of homosexual men. Br. J. Vener. Dis. 52:161-164, 1976. 3. Dans, P. E., The establishment of a university-based venereal disease clinic: I. Description of the clinic and its population. J. Am. Vener. Dis. Assoc. 1:70-78, 1974. 4. Judson, F. N. Update in the sexually transmitted diseases. J. Am. Wom. Med. Assoc. 31:11-19, 1976.
ACKNOWLEDGMENTS The encouragement and financial assistance of the Colorado Department of Health, Venereal Disease Control Unit is gratefully acknowledged, as is the cooperation of various Denver Gay Organizations and the steam bath managements. Thanks also to Katie Andersen for secretarial assistance.
Nominations Sought for Mindel C. Sheps Award
Nominations are requested for the Mindel C. Sheps Award in Mathematical Demography, to be presented for the third time in 1978 and every second year thereafter. The award, established by the Mindel C. Sheps Memorial Fund, and sponsored by the Population Association of America and the University of North Carolina School of Public Health, is given in recognition of outstanding contributions to mathematical demography or demographic methodology. Individuals should be nominated for this award on the basis of important contributions to knowledge, either in the form of a single piece of work or a continuing record of high accomplishment. The award is intended to honor an individual whose future research achievements are likely to continue a past record of excellence rather than as a tribute to a demographer who is ending an active professional career. There are no specific requirements as to age, nationality, or place of residence; nor is the award restricted to members of the Population Association of America. The recipient of the award will be selected by a committee appointed by the President of the Population Association of America and the Dean of the University of North Carolina School of Public Health. Presentation of the award, comprising a certificate and $1000, will be made at the annual meeting of the Population Association of America. Previous recipients of the award are Ansley J. Coale and Nathan Keyfitz. To be considered for the third award, nominations must be received by February 15, 1978. Nomination forms may be obtained from the: Chairman, Mindel C. Sheps Award Committee, Population Association of America, P.O. Box 14182, Benjamin Franklin Station, Washington, DC 20044.
742
AJPH August, 1977, Vol. 67, No. 8
