Men who have sex with men

• 1. Introduction

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  Men who have sex with men is a phrase built to describe behavior and nothing more. A man may call himself straight and still have sex with other men. Another man may call himself gay and not be sexually active with men at all. Health researchers needed one label that could hold both cases, and the abbreviation MSM became that label. Today it appears throughout medical papers and social research. Who invented it, and what problem was it meant to solve? How does it differ from words such as gay and homosexual? What do the numbers say about HIV, other infections and mental health? And why do many countries attach special rules to blood donation for these men?

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• 2. A Category Is Coined

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  In 1994, a research team led by Glick published the initialism MSM, and one account says the moment "signaled the crystallization of a new concept." The phrase itself was older. Public health discussions of HIV/AIDS had been using it since 1990 or earlier.

  Epidemiologists in the 1990s wanted to track how sexually transmitted infections spread among all sexually active males. They did not want to count only men who called themselves gay, bisexual or pansexual. Male prostitutes are one example of men who might otherwise fall outside the count.

  Two academic traditions pushed the idea forward. Disease researchers wanted behavioral categories because these gave better tools for studying risk than identity labels did. Separately, writers in the social construction literature had criticized sexual identity terms. They typically rejected applying identity-based concepts across different cultures and historical periods.

  The term does not name any particular sexual act. Which activities it covers depends on the context. Some writers prefer the alternative "males who have sex with males" when the people described may not be legal adults.

  The Huffington Post postulates that the term MSM was created by Cleo Manago, who is also credited with coining the phrase "same gender loving," abbreviated SGL.

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• 3. Behavior Versus Identity

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  Dowsett, Grierson and McNally set out to assess what was known about the sexual networks and behaviors of MSM in Asia. They concluded that the category did not match a single social identity in any country they studied. The only trait shared by the whole population was being male and having sex with other men.

  That finding explains why researchers keep MSM separate from the word gay. MSM refers to sexual activity between men, whatever label those men use. Gay is broader and is more often seen as a cultural identity. Homosexuality means sexual or romantic attraction between members of the same sex, and it may or may not include romantic relationships.

  Gay is generally the preferred social term, while homosexual tends to appear in formal contexts. The two are not entirely interchangeable. Men who are non-heterosexual or questioning may identify with all of these words, none of them, or a combination. Some choose newer terms such as bi-curious.

  MSM are not limited to small, self-identified and visible groups. In some countries, homosexual relationships may be illegal or taboo, which makes these men difficult to reach.

  Definitions get harder at the edges. How the term applies to transgender and intersex people, who do not fall neatly into binary sex categories, has varied from one use to the next.

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• 4. Practices and Partners

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  Anal sex has historically been popularly associated with male homosexuality and with MSM. Many MSM, however, do not have anal sex. They may choose oral sex, frotting or mutual masturbation instead.

  Among men who do have anal sex, the insertive partner may be called the top. The partner being penetrated may be called the bottom. Those who take either role are called versatile, and men who do not prefer or practice anal sex are sometimes called side.

  A 2007 study reported that two large population surveys found "the majority of gay men had similar numbers of unprotected sexual partners annually as straight men and women." The 2013 NATSAL, a representative population study in the UK, found that MSM typically had 17 lifetime sexual partners, as a median. That count included every form of sexual contact, from oral to anal sex.

  The method of counting matters. An epidemiological article in The BMJ reported that national probability surveys like NATSAL better reflect the MSM population, but their samples of MSM are smaller. Convenience surveys recruit larger samples. They tend to over-represent MSM who identify as gay and who report more sexual risk behaviors.

  A 2024 meta-analysis of United States population surveys found that 3.3% of men reported sex with another man in the past year. The figure was 4.7% over the previous 5 years and 6.2% across a lifetime.

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• 5. The HIV Burden

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  Worldwide, an estimated 5-10% of HIV infections result from sex between men. HIV can infect anybody, regardless of sex, ethnicity or sexual orientation. Yet in many developed countries, sex between men accounts for more HIV transmission than any other route.

  The United States shows the gap clearly. Men who have had sex with men since 1977 have an HIV prevalence "60 times higher than the general population." Prevalence here means the total number of cases present in a population at one point in time.

  In 2007, MSM made up only 2% of the American population. They nonetheless accounted for 53% of all HIV/AIDS diagnoses and 71% of diagnoses among men. A 2010 federal study found that one in five MSM were HIV positive, and nearly half of them did not realize it.

  A CDC study found that prevalence varies widely by ethnicity. "As many as 46% of black MSM have HIV," while the rate is estimated at 21% for white MSM and 17% for Hispanic MSM. From 2001 to 2005, sex between men made up 40-49% of new cases. High-risk heterosexual sex made up 32-35%.

  Among American MSM aged 13-24, HIV infection was rising at 12% annually. Experts blamed "AIDS fatigue" among younger people with no memory of the worst phase of the epidemic in the 1980s and early 1990s. They also cited "condom fatigue" among those weary of the unrelenting safer sex message. New treatments may have played a part as well.

  In developing countries, infection rates among MSM have been described as skyrocketing. Studies have found that fewer than 5% of MSM in Africa, Asia and Latin America have access to HIV-related health care.

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• 6. Prevention and PrEP

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  Condoms are more likely to break during anal sex than during vaginal sex. Even with a condom, anal sex can therefore carry risk. Without a condom it is considered high-risk for transmitting sexually transmitted infections. A person who inserts his penis into an infected partner is exposed because infections can enter through the urethra or through small cuts, abrasions or open sores on the penis.

  Pre-exposure prophylaxis, known as PrEP, offers another layer of protection. It means taking medication to prevent HIV in people who have not yet been exposed to the virus. When used as directed, PrEP has been shown to reduce the risk of contracting HIV by up to 99%.

  Numerous countries have approved PrEP. The list includes the United States, South Korea, France, Norway, Australia, Israel, Canada, Kenya, South Africa, Peru, Thailand, the European Union and Taiwan.

  New Zealand was one of the first countries in the world to publicly fund PrEP, doing so in March 2018.

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• 7. Other Infections

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  Men who have sex with men face higher risk of hepatitis A and hepatitis B through unprotected sexual contact. The U.S. CDC and ACIP recommend vaccination against both. Hepatitis B is caused by the hepatitis B virus, which infects the liver and causes inflammation.

  Syphilis is caused by infection with Treponema pallidum. It passes through direct contact with a syphilis sore, and these appear mainly on the external genitals or in the vagina, anus or rectum. Sores can also form on the lips and in the mouth. In 2006-64% of reported syphilis cases in the United States were among MSM. Australian and UK authors attributed a similar rise in other developed nations to increased rates of unprotected sex among MSM.

  Genital human papillomavirus, or HPV, is a common virus that most sexually active people in the U.S. will have at some point. It spreads through genital contact and also lives on areas that condoms do not cover. Most men who get it never develop symptoms. Some types cause genital warts, penile cancer or anal cancer.

  MSM and men with compromised immune systems are more likely than other men to develop anal cancer. Among HIV-positive MSM the incidence is nine times higher than among HIV-negative MSM, even with antiretroviral therapy. HIV-negative MSM still have a higher incidence than the general population. Men with HIV are also more likely to get severe, hard-to-treat genital warts.

  Giardiasis is not commonly classified as an STI, yet it can pass between gay men. In people with compromised immune systems, especially those with HIV, it can cause severe weight loss and death.

  In the United States, mpox has been shown to disproportionately affect men who have sex with men.

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• 8. Mental Health and Donation

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  According to the U.S. Centers for Disease Control, the majority of gay and bisexual men have and maintain good mental health. Research has nonetheless shown that they face greater risk of mental health problems. Stigma and homophobia can have negative consequences for health. Compared with other men, gay and bisexual men have a higher chance of depression and anxiety disorders.

  Many countries restrict blood donation by men who have, or have had, sex with men. The restrictions often extend to their female sexual partners as well. Similar rules in many countries bar these men from donating tissues such as corneas, often with far longer deferral periods than apply to blood.

  Most national standards require direct questioning about a donor's sexual history, but the length of the deferral varies from country to country.

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