Should Gay Men Be Getting Anal Pap Smears?

A doctor counseling a patient.
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This post is part of Outward, Slate’s home for coverage of LGBTQ life, thought, and culture. Read more here.

It’s time to talk about Pap smears, guys.

More specifically, if you’re a man who has sex with other men, or MSM, you should consider talking to your medical provider about getting an anal Pap smear.

Most men outside the medical profession probably have only a vague idea at best of what a Pap smear is in the first place. It’s a screening test first developed for cervical cancer, known by a shortened version of its discoverer’s name. It’s performed by collecting a small sample of cells from the cervix, which are then examined for changes in their structure that might be signs of precancerous states. By routinely screening and initiating treatment early, what was once a leading cause of death among women of childbearing age now ranks 14th in cancer frequency.

In recent decades, the link between human papillomavirus and cervical cancer has been clearly established. The overwhelming majority of cervical cancer cases are caused by HPV infection, with two strains of the virus causing over 70 percent of them.

Which brings us back to the guys.

“We know that HPV infects cells that line the anal canal the same as it infects cells that line the cervix,” Dr. Stephen Abbott told me. Abbott is a physician specializing in infectious diseases at Whitman-Walker Health, which offers comprehensive health and wellness services to LGBTQ people throughout the D.C. area.

Abbott credits researchers in San Francisco and New York for recent efforts to promote early detection of anal cancer in patients who may be at increased risk, and for training medical providers in the procedures involved. But there isn’t a clear consensus about which patients should be getting anal Pap smears.

“Routine screening is controversial, and there are no universally accepted guidelines,” said Dr. Alfred Torrence, site medical director for Howard Brown Health, which serves LGBTQ patients at numerous locations throughout Chicago.

“Howard Brown Health has made the decision to screen certain subgroups of patients because we believe that early detection of anal cancer or precancerous areas will potentially circumvent greater morbidity and mortality associated with advanced anal cancer,” Torrence told me.

While the idea of getting a Pap smear may be off-putting to a man, it’s not as alarming as it may sound. The patient lies on his side, and a swab is inserted a few centimeters into the anus, rotated, and then put into a liquid medium for later examination. Abbott hastened to assure me that it’s not painful.

When it comes to precisely which patients should get an anal Pap smear and when, there is some variation from center to center.

“I would definitely recommend it for any man who has sex with men or any woman (cis or trans) who has HIV,” said Abbott. “We know for sure that the risk of developing cancer when HIV-positive, regardless of whether you’re MSM, cis, or a trans woman, is high enough that you should at least get an anal Pap once a year.”

Torrence told me, however, that Howard Brown Health doesn’t routinely screen patients living with HIV under the age of 30, both because detected abnormalities do not tend to progress until that age, and because the recommended follow-up testing every six months can generate anxiety and what he called “butt fatigue.” Guidelines from Howard Brown Health from last year also recommend anal cancer screening for any woman over 30 who has had a high-grade precancerous lesion in her cervix, vulva, or vagina.

While both centers recommend anal Pap screening even for HIV-negative MSM starting at age 40, they vary about which patients they advise to get it. Howard Brown Health’s guidelines recommend screening more specifically for men who have had anally receptive sex (more commonly referred to as bottoming). Abbott, however, does not make that distinction.

“HPV is like glitter,” he told me. “It goes everywhere. They’ve done studies of women who have never had anal sex that have had HPV in their anal canal, probably just from friction and moisture. Exchange of fluid during any type of rigorous sex can lead to HPV getting in the anal canal. So, particularly if you’re HIV-positive, even if you are a ‘total top,’ you should still get an anal Pap because HPV could have made its way up there somewhere along the line.”

One area of agreement is that anal Pap smears should not be offered by providers who cannot refer patients with positive findings for follow-up testing, known as high-resolution anoscopy. If there are cellular changes of concern, anoscopy allows for direct visualization and possible biopsy of any suspicious lesions.

“The follow-up procedure sounds very invasive, but it’s not. You don’t need local or general anesthesia,” said Abbott. “It’s not like getting a colonoscopy. The person doing the procedure is only going 5 to 7 centimeters into the anal canal. I think a lot of people avoid it because they’re afraid of pain or discomfort and are unaware that it’s minimally invasive.”

Of course, not everyone who could benefit from early screening has access to places like Howard Brown or Whitman-Walker, or providers trained in proper follow-up procedures. Men who are over 35 and HIV-positive and want to find someone close to them who is trained to perform appropriate screening tests for anal cancer can get more information by visiting the website for the Anchor Study.

Though there is not yet consensus on anal Pap screening for MSM, awareness of the issue is necessary for those who deliver medical care to the LGBTQ community. It highlights the need for LGBTQ health literacy to be included in medical school curricula, and for clinicians to keep abreast of our specific medical needs. Sexual or gender minorities can get wonderful care from a straight, cis medical provider; I have wonderful straight colleagues, and have gotten great care from straight doctors myself. But when those providers don’t have access to new information about the needs of our community, their ignorance can cause our health to suffer. Worse, if doctors and other clinicians make LGBTQ patients too uncomfortable to even mention their sex lives, they are doing those patients harm.

With the advent of a safe, effective vaccine that can substantially reduce the risk of cancers caused by HPV, the recommendations for screening may change even more over time. (If you are a man who has sex with other men, even if you’re older than the usual time frame for getting the HPV vaccine, ask your own medical provider if you would benefit from it anyway.)  But for now, MSM should consider asking their doctors or other providers if anal Pap smears are appropriate for them. And if they don’t feel comfortable asking about it, then they deserve better providers.