I've been a practicing homosexual for more than two decades now and consider myself reasonably well-educated on gay men's health issues, but I'd never heard of anal Pap smears until very recently. Nor had most of the friends -- practicing homosexuals all -- to whom I mentioned the topic.
Live and learn. No one bats an eye when a woman says she has had a Pap smear to check for signs of cellular changes that can lead to cervical cancer. But ask the average gay man if he's ever had the rear-end version and he's likely to stare at you in confusion or horror or, in some cases, a barely suppressed titillation. Yet a small but growing number of gay health experts now argue that, for men who have sex with men, an anal Pap smear is an important preventative step for anal cancer.
Here's the reason: Human papillomavirus, or HPV, is an umbrella name for dozens of viral strains that can cause warts on different parts of the body, as well as some forms of cancer. About 20 types of HPV can lead to genital and anal infections in both women and men. Because the glands in the anus are similar to those in a woman's cervix, HPV infection in either area can result in cancerous cell changes.
Anal sex is the primary risk factor -- but not the only one -- for anal HPV infection. Dr. Stephen Goldstone, a gay surgeon who specializes in rectal and anal disorders, has been promoting the idea of routine anal Pap smears for men who have sex with men for several years, along with Dr. Joel Palefsky, a professor and research scientist at the University of California at San Francisco. Dr. Goldstone, who is also the medical director of GayHealth.com and the author of "The Ins and Outs of Gay Sex: A Medical Handbook for Men," says that although the procedure is starting to gain acceptance, even most gay doctors have still not heard of it.
Dr. Goldstone recently spoke with Salon from New York, where he maintains a private practice and is a professor of surgery at Mount Sinai Medical Center.
I'm a gay man, and before recently I'd never heard about this. Why isn't anyone talking about it?
It's an emerging health concern for gay men, that's for sure. And I think it's going to become a greater and greater problem. Everybody says, "How come I've never heard about it?" Part of the reason is that it probably takes 10 years or more for a normal cell to become a cancerous cell, and the people at greatest risk are those with HIV. But until the last few years, most people with HIV were not living long enough for the problem to become apparent. That's changed in the last five years because so many people are living longer.
How widespread is the problem?
Dr. Joel Palefsky at UCSF has done some screening studies and he's estimated that about 65 percent of HIV-negative gay men and close to 100 percent of HIV-positive men carry human papillomavirus in their anal canals. Some types of anal HPV are more likely to cause pre-cancerous cell changes, and a large percentage of the HIV-positive gay men carry that type.
As far as anal cancer, the incidence in HIV-negative gay men is 35 per 100,000, which is about what the cervical cancer rate in women was before doctors began doing routine Pap smears. The incidence of anal cancer among HIV-positive gay men is estimated to be about 70 per 100,000. These may seem like tiny numbers, but they are actually very significant because this is a disease we never really used to see. And it's becoming more widespread, like all sexually transmitted diseases.
At this point there is no treatment that can eradicate the virus. Right now there is research taking place on both preventive vaccines, which would be administered before someone was ever infected, and treatment vaccines, which might, for example, be able to prevent the progression of an existing infection to cancer.
So is anal sex the main culprit here?
Yes. The biggest risk factors for anal HPV are multiple sexual partners and anal sex. But even if someone has never had anal sex, every man who has sex with men is at risk for it. Genital HPV can spread from skin-to-skin contact. It doesn't require penetration. A finger can spread it, or someone might rub his penis on the outside of his partner's anus during foreplay, and from there it's easy for the virus to spread inside. And a condom may not be protective. It doesn't cover the base of the penile shaft, the pubic hair or the scrotum, which are all places where HPV can be found.
Probably a majority of all men have penile HPV even if they don't have warts there. It's pretty rare that the virus will migrate from a man's penis to the anus, but it can be spread to a sexual partner's anus or vagina, and in a woman it's easier for it to migrate from the vaginal area to her anus. That's why women should also be screened routinely for anal HPV.
Now I've never had anal warts. Do I have to worry about this?
Yes. A lot of patients who come in just for screening end up having warts they didn't realize they had. They say they don't have anal warts, and then we find a tiny anal wart. And when people do have anal warts, we need to start taking that seriously. Many people will go to dermatologists or internists and just have their external anal warts removed. But often it's just the tip of the iceberg, and no one looks inside.
How did you first start recognizing this as an issue?
It was about 1996 or 1997. I would be taking out anal warts and I'd send them out for analysis if they were a little funny-looking. Anal warts have been a problem for gay men for a long time but most of them never get analyzed. At that time, however, I started getting back these weird pathology reports of the kind of cellular abnormalities that can lead to cervical cancer in women.
So then what exactly is an anal Pap smear?
You do it like a regular Pap smear, except in the anus. You insert a non-lubricated swab inside the anus and it picks up a sample of the cells. The cells are sent to a specially trained doctor called a cytologist, who examines them for abnormalities. Just as in women, a Pap smear is basically a predictor of abnormality, but it's not specific about what kind of abnormality. So if there's an abnormal Pap smear, then we do a procedure called a high-resolution anoscopy, which is actually looking inside the rectum to see what abnormalities are there.
You can find different grades. You get atypical cells of unknown significance, which are very slightly abnormal. Then there are greater but still moderate cellular abnormalities, which is called low-grade dysplasia, and more advanced abnormalities, called high-grade dysplasia. If we see changes indicative of high-grade dysplasia, we do a biopsy and a pathologist can tell us if it's high-grade or even cancer. Less than 10 percent of high-grade dysplasia goes on to cancer, but we don't know which 10 percent.
So let's say it's high-grade. What then?
Then you treat it. If it's a small amount of high-grade dysplasia, you can freeze it or burn it or put a little acid on it right in the office, the same way you would treat a wart. If it's a truly invading anal cancer, the treatment is chemotherapy and radiation. But you'd like to find these people before they actually have cancer.
Joel Palefsky and I have been trying to get the word out for a while that this is a major health concern and we need to deal with it. One of the things HIV has done is made it seem like AIDS is the only illness gay men get. And in the medical community, we find that it's possible to go to an HIV doctor and just have your T-cell count and viral load looked at and never have to take off your clothes for an examination.
But if it's so simple, why are so few doctors doing it?
There has been reluctance, even among gay doctors with gay patients, to deal with anal-rectal disease. I get e-mails from people all over the world asking questions about rectal disease when they won't bring it up with their own doctor. Straight docs don't understand gay sexual practices and are reluctant to talk about it, and most people who go to HIV doctors don't even get asked about their sexual habits.
Some doctors will not recognize it as an issue until one of their patients actually gets anal cancer. The doctor will be totally upset about it, and then will start doing anal Pap smears on other patients. One gay doctor referred someone to me who supposedly had hemorrhoids, and I examined him and found anal cancer. I called the doctor to tell him, and after that he started doing anal Pap smears on all of his other patients. Then he called me back and said, "Ohmigod, they're all coming back with abnormalities."
You would never blink an eye if woman said she went for a Pap smear. And if she comes back with a positive result, we don't look at her and assume she's promiscuous, even though it's a sexually transmitted disease. There's no negative social connotation for women because we know that many women get HPV with their first or second sexual experience.
But men get tremendous embarrassment from the diagnosis. They want to know, "What do I tell my partner or boyfriend?" When a patient comes to me with warts, I tell them that they probably didn't catch it from the current boyfriend, since they can appear years after the initial HPV infection. If you're in a monogamous relationship, you want to come home and kill your partner because you assume he's cheating, when in reality you probably caught it during one of your first sexual experiences.
So how often should I be getting an anal Pap smear?
Primary care physicians should be doing routine anal Pap smears on men who have sex with men. HIV-positive men should have an anal Pap smear every year, and HIV-negative men every two or three years, starting in their 20s. Heterosexual HIV-positive men are also at increased risk for HPV infection, although not nearly as much as men who have sex with men. And women should have routine anal Pap smears just as they have routine cervical Pap smears because of the chances that the virus could spread.
Patients themselves should be asking for this because they have tremendous power within the medical community. We're all healthcare consumers, and if more and more of us start asking our doctors about anal Pap smears, it will motivate them to learn more about it.