Wednesday, December 23, 2009

One Less!

Thus far in this series of articles, I have focused almost exclusively on sexual orientation as a kind of romantic identity, blissfully avoiding the 800 pound gorilla in the room: the physical act of sex. Therefore, I plan to make my next few blog entries about sex. To say that sex is not frequently on my mind would be a lie, as I often find myself pondering the idea of melting physically and spiritually into another guy. In fact, it is this very prospect of human warmth that ultimately shook me out of my comfortable asexual shell to face the hurdles the world had to throw at me as a gay man. I came out, I met guys, I was disappointed, and I press on to that holiest of grails: a loving relationship, yes, but one that will undoubtedly also have sexual contact at its core. On the journey I hoped to even make good friends.

However, there is as much frightening as there is exciting about realizing a sex life, and having sex (even once) can have serious and life-altering consequences. For heterosexual unions, one night of pleasure could ultimately lead to a child and a lifetime connection with the sexual partner, even though the two parties might not otherwise wish to spend further time together. For both heterosexuals and LGBTQetcs, all parties must overcome qualms about the style, the performance and the comfort of certain sexual acts. Furthermore, engaging in sex while not emotionally or psychologically prepared may have strikingly powerful and negative consequences on self esteem and well-being. At the same time, controlling a sexually-charged situation, once initiated, may be very difficult and can significantly complicate and harm valued social relationships. But perhaps most importantly, with one act, a slip-up, or a mistake, sex can provide us with infections and diseases that can significantly stigmatize and shorten our lives. For example, it is well known that the gay community has been particularly ravaged by HIV and Hepatitis B, and rates of infection are actually increasing among young heterosexuals and gays, who are often blithely unaware of the deaths in the 80’s and 90’s and the continuing dangers of the disease even with advances in treatment. Many gays who are aware of the dangers of HIV are misinformed, sometimes erroneously believing, for example, that unprotected oral sex does not transmit HIV. Furthermore, the promiscuity encouraged among certain groups and venues in the community may lead to a faster and more comprehensive sharing of STIs (sexually transmitted infections) than in the general population.

Fortunately, the risk of transmission for many STIs (including HIV) spread by fluids can be significantly reduced by practicing safer sex, particularly latex condoms or other devices accompanied by lubrication. However, some STIs, such as herpes (a virus), HPV (a virus), and syphilis (rarer these days, a bacteria), can be spread by touch outside of areas normally protected by condoms and other protective devices. Viruses are particularly difficult to deal with, as there is no cure, most cases are asymptomatic, and many people remain infected with the virus and may remain contagious for the rest of their lives. For these reasons, approximately 20% of Americans are infected with Herpes, and 80% of Americans are infected with HPV (this latter virus can cause genital warts and cancers). With these scary statistics, it becomes clear that sexual contact with anyone who is not a complete virgin could lead to an irreversible infection.

Fortunately, there is some hope on the HPV front, as a couple of vaccines (Gardasil and Cervarix) are now available that prevent infection for some of the most dangerous and uncomfortable strains of HPV. Cervarix protects against the two strains most likely to cause cancer, particularly cervical cancer for women, anal and oral/throat cancers in women and men, and penile cancers in men. Gardasil protects against the same two strains plus prevents two strains responsible for the visible symptoms of HPV (experienced by relatively few of the 80%, but particularly unpleasant when they arise): genital warts. However, as a vaccine, it is preventative and does not work if someone has already been infected. Since virtually everyone who has had sex has been infected with some form of HPV (and probably several strains), the vaccines are most promising for people who have had little or no previous sexual contact. Therefore, the younger the recipient, generally the more effective the vaccine, given that teenagers and young adults are more likely to eventually engage in some form of sexual act.

The good news: for young women, the HPV vaccine Gardasil is often available and covered by health insurance plans at little or no cost. In some places it is even mandatory for young girls to receive it before attending school. Gardasil has been intentionally marketed as a “cervical cancer vaccine” rather than what it is, a vaccine to prevent a potentially-dangerous sexually transmitted infection. This strategy puts emphasis on the vaccine’s nature as prevention for a common cancer in women instead of admitting to the socially-uncomfortable fact that the young recipients probably are or will be engaging in sexual activity. The disease is particularly problematic for gay men as well, as infection (or post-infection transfer) of the virus to anal or oral tissue can also lead to cancer. However, the risk to men, especially gay men, has been played down in favour of the more common and intrinsically more heterosexual transfer between men and women, with women receiving the necessary protection to their cervixes. Men get a bad deal, as they are not encouraged to be vaccinated with the “cervical cancer vaccine” and thus are likely to be infected when having sexual contact (either heterosexual or homosexual). Men thus become carriers of the virus and may give other non-vaccinated women (or men) a potentially cancer-causing infection.

Given the fast-spreading nature of STIs and the commonality of HPV, it is inherently obvious that the eradication of the most dangerous strains of the virus will only be possible when both men and women are given access to preventative treatment. But given the necessity of marketing the vaccine in an erotophobic, heterosexist society, major testing and marketing was first applied to women. Even today it is still “the cervical cancer vaccine,” as if boys and young men should give it no heed.

As a virgin to all forms of sexual contact, already 24 years old, interested in finally doing something with my sexual/gender/romantic orientation and living within the reality of a sexually-liberated gay community, I’ve always understood the underlying importance of obtaining the vaccine. I was aware of Gardasil as an HPV vaccine for several years, since before even my official coming out, and it was always something of a comfort to know that it existed. So I did what so many gays do when looking forward to their civil rights (or in this case, basic right to preventative health care) to come to fruition: I waited patiently for the world to change. I knew that it was available for men in several European countries, and I figured that the U.S. and Canada would not be far behind. I didn’t let the lack of my access to Gardasil in any way prevent my pressing forward with building my sexual identity and engaging with people in the gay community, but as it so happened, nothing in any way romantic or sexual evolved from these encounters. I checked with Merck Canada about receiving the vaccine in the summer of 2008, and I received a rather cold response that as a man I would absolutely not be allowed to receive it without taking part in their experimental trials on men. I asked how I could do this, and they never bothered to inform me that the trials on men were ongoing and largely being performed in my own city at the Université de Montréal, which needed new subjects with my sexual background (I found this out much later).

Finally, in the summer of 2009 I decided that I had enough of waiting and was going to try to obtain the vaccine off-label, as many informed gay men have successfully done. The full immunity provided by the vaccine is not instantaneous, but it instead takes six months (and three separate vaccinations). I’m not willing to hold off on living based on my progress with Gardasil, but it would be best to get it as soon as possible so that lifestyle and health concerns do not conflict. I called the most convenient clinic to me and asked if they provided Gardasil shots to men upon request. The receptionist went off to check if it was possible, and she said ‘yes’ and we made my appointment for some time in late September (but I had to see a doctor first, apparently).

When I went to the appointment, the doctor was completely clueless to my special request and asked me “so what are you in here for?” I then launched into explaining my desire to receive Gardasil. I did not feel it necessary for me to ‘come out’ to him, to put more emphasis on my condition (although I did identify as a virgin). He first asked me if I had any allergies, as if getting ready to deliver it. Then he walked out of the room for a while and came back looking even more puzzled. Then he called someone at the CLSC public health clinic to inquire whether they have given Gardasil to men (of course, they hadn’t), and the two doctors had a large chuckle at my expense over the phone. He told me that they don’t generally give it to men, and the fact that I knew more about the vaccine and its recent recommendation by a board of the FDA for men my age seemed to make him less interested in giving it to me. After all, I’m sure it hurt his ego that I knew more about the vaccine than he did (and he clearly wasn't willing to investigate further). Then he went out of the room and said “wait a minute, let me see if the nurse will give it to you.” I was shocked by his lack of gall to make his own decision. When he came back, he essentially rejected me; apparently the nurse wasn't going to do it. He said that it was good that I wanted to protect myself, but he wouldn’t give it to me, despite admitting that it posed virtually no risk. It was his right not to prescribe it to me, although the worst part was he had given the vaccine off-label to women before (even though Gardasil has been outright rejected by the FDA for women age 27-50 but has been tested and recommended for men in my age range). I offered to sign a release so absolve them of responsibility in case I had a bad reaction, but still he shrugged my request away. I had known this could possibly happen, but I honestly thought after the receptionist’s verification that I wouldn’t have any problem receiving it off-label at the clinic.

I was upset and embarrassed, having felt like I had wasted my time and energy. Furthermore, I later caught a cold from that visit to the clinic after sitting in a room full of sick people. That same day, however, I made an appointment at another clinic, an STI clinic, which I thought might be more informed on the recently-published trial research recommending that Gardasil be given to men to prevent HPV infection. I made very sure to specify to the receptionist more details this time: I am a gay man, I would like Gardasil, do you provide Gardasil to men, are you absolutely sure? The receptionist quite confidently said “yes, we do, some doctors do to men who request it, but first you have to come in to build a profile at our clinic.” Apparently building a profile involved going in for every STI test known to man. I then spent the next couple of weeks squirming at the prospect—I was probably going to have to give blood and get swabbed and prodded in the genital area. It was a very uncomfortable thought, as I haven’t been undressed in the view of another person since I was a child.

Even though there was no chance of me actually testing positive for an STI, and I should have felt at ease, the entire prospect was still rather unnerving. I went to consult a friend from South Africa, who is in a stable, long-term relationship (and has been 6 years, I believe) with a very loving man. She said something quite stark and probably also quite wise: she said that it will be a good experience, that I should get used to doing this kind of thing, because I'll want to do it in the future. I was a little taken aback; is she assuming, according to some gay stereotype, that I will be significantly sexually active in the future? I reinforced for her that I didn't plan to be very active at all (she already knows my neo-Platonist philosophies regarding the nature of sexual activity), and she mentioned that she still gets herself tested for STIs. She said the couldn't imagine that her partner would ever cheat on her, but there's not a 100% chance of anything in life, and "there's no room for romance when it comes to your health."

I therefore resigned myself to the idea of getting unnecessarily tested for STIs. For the end result of obtaining Gardasil, it would be worth it, plus it would be another ‘experience’ or rite-of-passage as a gay man. When I went to the clinic, at which I was informed that I would have to pay $100 for the consultation and additional money for individual tests. At that point I was hopeful, as I was going to refuse to take the tests and make clear my real intentions, considering I was going to have to pay more than the $20 lab fee I was initially quoted. I made it very clear that I was not sexually active and had never been on the forms I had to fill out. It was clear from those sitting in the waiting room with me that I was rather unique relative to the usual clientele (many of whom, from the conversations I overheard, seemed to be homeless or ex-drug addicts). When I was called into the doctor’s office, looking at my chart he said to me “I don’t know why you’re here, as we’re a high-risk STI clinic, and there’s clearly no risk present.” I told him that I wanted Gardasil, and he was stern and direct but informative. He told me that it wasn’t approved for men in Canada (of course, something I already knew), and he wouldn’t give it to me, in contrast to what the receptionist said. I was dejected. I didn’t necessarily believe him, as I’m sure another doctor in that clinic probably does provide it to male patients. According to him, Canada was often behind the U.S. in terms of approving treatments, and Québec even more so (only reviewing a limited number of new submissions twice a year). However, he said that I could go to a country where it was available (several in Europe) and get a prescription there and bring it back to Canada, obtain my prescription at a pharmacy, and take it to a private vaccination clinic. We discussed my options for about 10 minutes, and he instructed the receptionist not to charge me for the consultation. I was disappointed, but at least I wasn’t out any money. I was even more bothered that evening, when I learned that my friend in Montréal, Henri, had obtained the vaccine two years previously from his doctor at the Clinique St-Denis (a place where I hadn’t tried). But identifying these scattered doctors in the battle for Gardasil is the hard part!

I had been keeping an eye on the FDA’s decisions during the fall of 2009, and I got lucky. The FDA in the U.S. officially approved Gardasil for men ages 9-26 a couple of weeks later. After what I had been through, I was elated; I finally knew what I had to do. When I went to the U.S. over my holiday break in December, I would get the vaccine. I waited a month (no big rush) and called my doctor’s office in the U.S. I got the usual reception: a hesitant voice, a “let me go check,” and one person said, “Are you sure you want Gardasil, because that’s a cervical cancer vaccine…”. I thought about giving a speech to correct the awkwardness of the situation, but I decided to passively state “and HPV more generally” as my rebuttal. Not long later they got back to me: my relatively young, open-minded doctor apparently said “yes, no problem.” Furthermore, there was no issue with him writing my prescriptions so I could get my other two shots in Canada (and that would be less expensive for me as well). I received my first vaccination a few days ago. It was expensive, as my Canadian private insurance won’t fund a vaccine that is, according to the standards of their country, not recommended for men (even though it is in the U.S.). Alas, the geopolitics of global health can be a complicated and very serious affair. I may be out $156 U.S., but at least, after waiting for this vaccine for so long, I am proud to say that I too will be “one less.” I see no reason why I, as a man, should be expected to suck up and deal with the inevitability of being infected with HPV when certain dangerous strains are clearly avoidable.

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