Before clinicians can provide culturally appropriate healthcare and preventive services, they need to know the sexual orientation/gender identity of the patient sitting in front of them. Sexual minorities are more likely to self-identify by completing an LGBT-inclusive intake form (paper or computer entry) prior to being seen. Asking open-ended, nonjudgmental, gender-neutral questions about their social situation and history establishes a respectful clinician-patient relationship, which is critical to making patients feel comfortable enough to disclose their sexual orientation/gender identity and to discuss their personal health issues. Clinicians can also identify sexual orientation by asking patients whether they have sex with men, women, or both, but taking this approach may not be directly relevant to patients’ reasons for their visits unless they are having sexually related symptoms [24].

An important component of the gay/bisexual man’s history is whether he has accepted his sexual orientation, a process that usually takes several years, and whether he is “out of the closet” and open to families, friends, co-workers, etc. While identifying negative risk factors is important, it is also important to identify positive support systems. MSM who are “out” are usually better prepared to face negative or hostile environments, have fewer risky behaviors, and have more healthy and productive lives overall [12].

Clinicians can help MSM through the process of self-acceptance and coming out to others, but under no circumstances should clinicians “out” anyone without their permission. For gay and bisexual youth who may face the adverse consequences of nonaccepting parents, an assessment of the home environment prior to coming out is especially important. Community support organizations, such as PFLAG (Parents, Families, and Friends of Lesbians and Gays; https://​community.​pflag.​org), can also assist in personal and family acceptance of one’s sexual orientation and provide connections to others in the gay/bisexual community for additional social support [25].

See Chap. 9 for information and an algorithm for taking the sexual history ; this section will emphasize topics specifically relevant to MSM. The 5 Ps (partners, practices, protection from STIs, past history of STIs, and prevention of pregnancy) is a useful tool/mnemonic for taking the routine sexual history for all patients [8, 26]. After a transition statement that introduces and normalizes the sexual history and assures confidentiality, patients should be asked the following three screening questions:

Based on the patients’ responses, the clinician can stratify patients into low- and high-risk groups for STI/HIV and follow-up with appropriate questions.

Finally, clinicians should not forget to ask about sexual function and satisfaction as well as sexual abuse/trauma to complete the sexual history.

Extensive reviews of the literature reveal a strong association of smoking by gay/bisexual men with an odds 2–2.5 times that for heterosexuals [27]. A 2013 national survey found that 26 % of gay men and 29 % of bisexual men smoke compared to 20 % of heterosexual men [28].

Risk factors for smoking by MSM include internalized homophobia, victimization and discrimination, younger age, lower educational level, alcohol use, depression, and stress. Tobacco companies also have specifically targeted the sexual minority population, and the relatively safe haven of bars where MSM congregate and smoking is common has contributed to higher rates of smoking [7].

Compared to heterosexual men, eating disorders and body image issues are more common in gay men who are twice as likely to describe themselves as underweight while bisexual men are 2.5 times as likely to think of themselves as overweight. Gay men also have four times the odds of engaging in recent unhealthy weight control behaviors (e.g., fasting, using diet products/laxatives, and purging) [29]. It has been hypothesized that gay men feel greater pressure to be thin than heterosexual males and to achieve the ideal male model look as promoted by the mass media to attract other MSM; the use of performance-enhancing drugs to build muscle ties into the body image problem.

Substance abuse by gay youth is associated with anti-gay school bullying, which leads to associations with other “deviant” peers (defined as those more likely to take risks and not fit in with the norm) [30]. The prevalence in the past year of any substance use disorder was 31.4 % for gay men, 27.6 % for bisexual men, and 15.6 % for heterosexual men [31]. A 2013 national survey found that 39 % of gay men and 52 % of bisexual men drank five or more drinks in one day at least once a year compared to 31 % of heterosexual men [28]. Drugs of abuse are also more commonly used by MSM to manage/reduce stress, and their use may lead to risky sexual behaviors and injuries while under their influence [12].

Substantial mental health disparities exist between gay/bisexual men and heterosexual men including depression, generalized anxiety disorder, panic disorder, eating disorders, and drug and alcohol dependencies; these differences are greater in young gay and bisexual men [32]. Lifetime suicidal ideation and attempts by gay men are 2–4 times greater compared to those of heterosexual men [32, 33], and bisexual men experience more suicide ideation and mental distress than either gay or heterosexual men [34].

Intimate partner violence (IPV) against men partnered with men is up to three times that for men in heterosexual relationships (21.5 % vs. 7.1 %). However, most professionals called upon to assist these men do not receive specific training in sexual minority intimate partner violence management, and few shelters and services are available for this population [35, 36]. Unwanted sex was experienced by 18 % of gay men, 12 % of bisexual men, and 2.2 % of heterosexual men. Childhood violence/maltreatment was recalled by 31.5 % of gay men vs. 19.8 % of heterosexual men [37].

MSM also have more personal violence and knowledge of trauma to close friends/relatives. Types of violence (MSM vs. heterosexuals) include getting beaten (20.7 % vs. 11.7 %), getting mugged (27.5 % vs. 16.2 %), and being stalked (8.1 % vs. 2.6 %) [37]. Gay men have experienced property crime (28.1 %), attempted crime (21.5 %), objects thrown at them (21.1 %), threats of violence (35.4 %), verbal abuse (63.0 %), and employment/housing discrimination (17.7 %); these acts were experienced less often by bisexual men [38].

Crimes against gay men are most often committed by heterosexual men. Gay men are more visible as targets compared to lesbians and bisexuals because gay men are more likely to visit gay-oriented public establishments and to disclose their sexual orientation socially and at work [38].

STIs, including syphilis, gonorrhea, chlamydia, and HIV, have increased in the past few years for MSM following an increase in unsafe sexual practices. It is believed that some MSM take more risks now because newer HIV medications have changed HIV infection from a death warrant to a chronic, manageable disease. MSM have reported that they also do not like using condoms as they interfere with a feeling of intimacy or they believe that others have the same HIV status as they do and therefore they do not ask about their partner’s status [4, 8, 39]. See Chap. 10 for more details and treatment recommendations.

MSM account for about two-thirds of new HIV cases with 4 % derived from injection drug use. The incidence of HIV has increased 12 % from 2008 to 2010 for MSM, especially in adolescent and young adult MSM (22 % increase). MSM make up over one-half of all persons with HIV in the USA, and about one-third do not know that they are infected [4].

Criteria for taking PrEP for MSM include all of the following [16]:

And at least one of the following:

Insurance companies generally are covering the cost of PrEP with the rationale that preventing HIV infections is cheaper than treating HIV/AIDS. The manufacturer (Gilead) also has an online medication assistance program for those without insurance and co-pay assistance for those with insurance.

Anal cancer and cervical cancer are caused by the same strains of HPV (see above). Proponents argue for anal Pap screening based on the model for cervical screening and the higher incidence of anal cancer in MSM (20 times) and especially in MSM with HIV (40 times) [45]. However, progression of anal cancer precursors to cancer appears to be much lower than for cervical cancer. No definitive evidence exists that screening reduces the incidence of anal cancer and well-designed prospective trials are needed [49].