A quick Google search will tell you that, according to the Centers for Disease Control and Prevention (CDC), there is currently no available method for testing men for human papillomavirus, or HPV. But that’s not entirely true, at least not for gay and bisexual men. There is a test, and that test is a pap smear. It’s the same test as the cervical pap smear that people with vaginas get at their obstetrician-gynecologist, but this pap smear is done anally. Through this pap smear, doctors can collect cells which can then be tested for the strains of HPV linked to anal cancer. The CDC reports that almost 80 million Americans have at least one strain of HPV at any given time, making it the most common sexually transmitted infection (STI) in the United States.
While the most obvious benefit of these anal pap smears is to identify and monitor infections of high-risk strains of HPV, New York proctologist Evan Goldstein, D.O., says that the real benefit of performing anal pap smears on queer men is the open and honest dialogue it creates between doctor and patient. A dialogue he says is currently lacking. In conversations with other doctors, Goldstein has found that many don’t ask their patients questions about sex. He sees the anal pap smear as the first step in starting that necessary conversation.
“When you do an anal pap, you are now getting into the appropriate sexual history of the individual,” says Goldstein. “It forces you to look at their ass. Are they having pain? Is there any blood that’s there?”
So, what is an anal pap smear exactly? It’s as simple as two swabs. These swabs should be done with a Dacron swab that looks like a Q-tip, not a brush like the one used for cervical pap smears. Each swab is swirled in the anus to collect cells, which are then deposited onto slides for testing and analysis. The first swab is used to look for the presence of abnormal cells, which are then graded on their level of abnormality. The second swab tests for strains of HPV, and, in this case, specifically the high-risk strains 16 and 18, which have both been linked to anal cancer.
If your test results show abnormal cells and you test positive for one of the high-risk strains, you then have a few options. The most common next step is a test called a high-resolution anoscopy (HRA), in which your doctor dyes your anal cavity to highlight the areas of abnormal cells. These areas are then biopsied to assess risk. According to Goldstein, the average number of biopsies from one HRA, which he considers fairly invasive, is three to five.
“Those biopsies are pin-head biopsies, but they’re in your fucking asshole — and they bleed, and they’re painful, and it takes you off of your bottoming game,” he says.
If these biopsies come back positive, you will then undergo surgery to have the abnormal areas removed with either a laser or a blade, in which your doctor essentially slices out parts of your anal cavity, which Goldstein also considers quite invasive.
The problem that Goldstein sees with these tests and their level of invasiveness is that the tests are often prone to false positives. Anything that creates trauma in your anus, according to Goldstein, can create a false positive: Bottoming the night before an appointment or even douching before a visit can alter a result.
Goldstein worries that the prevalence of these false positives can lead patients down aggressive routes of treatment that may not only be unnecessary but can also have a net negative impact on a patient’s quality of life.
“The question is especially [with] a 20-year-old kid that comes to me, and I now need to do something that is going to take him off his enjoyment — and for what? For the unknown. Does that make sense?”
Goldstein cites these false positives — and their potential implications — as a possible reason more doctors aren’t recommending that their patients get a pap smear. Another contributing factor is likely that the CDC has yet to approve the test.
It’s important to know, though, that the HRA is not your only option should your pap smear come back positive for high-risk strains of HPV. There’s a new test that Goldstein and others are using to determine whether the HPV has penetrated into the cells. Only after the virus has entered the cell can it begin to alter the DNA, which in turn can lead to the cell becoming pre-cancerous and then cancerous.
“If the DNA is not altered, maybe we do nothing. Maybe we just watch it and see what happens, and come back and do [the HRA] if we need to,” says Goldstein. “Especially if 20 to 25 years from now is the usual course of when people are developing anal cancers. If someone is going to see [their doctor] and is being diligent about their health care, we’re going to catch it at some point.”
Most patients Goldstein has seen with anal cancer exhibit symptoms for some time. He also stressed that for a gay man in his 20s or 30s who is engaging in appropriate sexual health care, the likelihood of developing anal cancer is extremely low.
As far as “appropriate health care” goes, Goldstein stresses that there is no such thing as one-size-fits-all sexual health care. “It really depends on the person,” he said. He does recommend getting the HPV vaccine (the eligible age for which was just recently raised from twenty-six to forty-five) and getting tested regularly for STIs. For those who are HIV negative, he also recommends starting and adhering to a pre-exposure prophylaxis (PrEP) regimen. The most important thing, he says, is that we as a community keep having this conversation.
To Goldstein, the pressing issue is clear communication between doctors and their patients. “The key component is to actually have appropriate discussions where people are really able to disclose what they’re doing,” he says. That level of openness is hard to achieve, though. “Sex is taboo. People don’t feel comfortable talking about it. We’re trying to create a culture where we take away the taboo. Demystify. Destigmatize,” he says.
He added, “The reality is the more we’re talking about it — the more we’re exposing the inadequacies — the more we’re able to correct it. I think that a lot of what I see in [the young adult] generation is people who are health conscious and are comfortable in their own skin enough to ask the right questions. Now we’re of the mindset that we should demand those answers.”
The key, Goldstein says, is educating people so that they have the lowest risk and highest reward.
“We want everybody to fuck and to have a great time,” he says, with a smile.