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What gay trans guys wish their doctors knew

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Vancouver study peers into the lives and troubles of trans MSM

Sam Larkham organizes sexual health clinics across Metro Vancouver with the Health Initiative for Men (HIM). He says he was once referred by his doctor to a trans health care clinic that had been closed for years.

By Niko Bell

Speaking to gay and bisexual trans men, the word “invisibility” comes up a lot. Invisibility in the bathhouse and on dating apps, invisibility among cisgender people, straight people, trans people and gay people. And, too often, invisibility in the doctor’s office.

“I have tried just going to walk-in clinics and stuff like that to ask questions or request tests,” one trans man recently told researchers in Vancouver. “And I just found the doctors were generally confused about me and my body. And I had to go into great detail. That made me not so comfortable talking to them about it because they were just kind of sitting there confused.”

“People have tried to talk me out of testing . . . saying I was low-risk behaviour,” another man told the researchers. “They didn’t understand my behaviour really. . . I’ve had practitioners as well say they don’t know what to do; they don’t know what to look for.”

Both men were speaking to researchers for a new study on the sexual health of trans men who have sex with men — a group social scientists know remarkably little about. Many of the men spoke about being on the margins of mainstream culture, gay culture and of the healthcare system.

It should be no surprise, then, that the study happened almost by accident. When PhD student Ashleigh Rich started work with the Momentum Health Study — a five-year, in-depth research project on the sexual health of men who have sex with men (MSM) conducted out of the BC Centre for Excellence in HIV/AIDS — she never intended to write a paper about trans MSM.

But a small group of trans men volunteered for the study, some pointing out ways the Momentum researchers could change their surveys to be more inclusive.

There were too few for quantitative research — only 14 — but Rich asked if they would sit down for an hour and talk about their experiences. Eleven agreed.

The result is a slim, 11-page paper that hints at a world of things we don’t yet know about transgender gay and bisexual men. We do know they form a large part of the trans population; nearly two thirds of trans men say they are not straight. We also know trans MSM participate in the same rich world of sexuality as other men who have sex with men — from dating apps to anonymous sex to sex work and a broad range of sexual behaviour.

We don’t know much about trans MSM risk for HIV; estimates range from much less than cisgender gay and bi men to somewhat more. We also don’t know much about how a combination of stigma, invisibility and limited healthcare options may be affecting trans men’s health.

Rich is cautious about drawing any broad conclusions from her study. Not only is it a tiny sample, but the men she spoke to are also mostly urban, white and educated. This study was less about answering questions, and more about figuring out which questions to ask.

A few themes, though, emerge clearly. One is that trans MSM often find themselves falling through the cracks when it comes to sexual health. Doctors are increasingly aware of how to talk to gay men, but don’t always see trans gay men as “real” MSM. They assume trans men are heterosexual, or fail to bring up sexual health altogether.

Some doctors give trans men information on PrEP — a preventative anti-HIV medication that can drastically reduce the risk of contracting HIV if taken every day — based on studies on cisgender men, without checking to see if different anatomy requires different doses. When trans men come in for HIV tests, they are sometimes urged to get pap smears instead.

“We come in with specific issues we want to talk about in a health care consult, and sometimes once people discover we’re trans they’ll want to do a pregnancy test or something,” says Kai Scott, a trans inclusivity consultant who collaborated on the study with Rich. “And we’re not there for that. They’re giving us things we don’t want, and not telling us the things we do need to know.”

Sam Larkham, a trans man who organizes sexual health clinics across Metro Vancouver with the Health Initiative for Men (HIM), says he was once referred by his doctor to a trans health care clinic that had been closed for years. Experiences like that make him think the best path for trans MSM is to rely on queer-focused health care providers like HIM.

“It would be ideal if it were the whole medical system, but that’s impossible,” Larkham says. “I think we have to look at what we can do, and that’s have specific places where we have nurses who are well trained to handle trans MSM. I think that’s the more doable thing. I would love to have every clinic be culturally competent, but that’s not the reality and never will be.”

Scott is more sanguine. He points to Trans Care BC, a provincial health program that has pushed for more education for doctors. Education needs to happen on both fronts, Scott says, among MSM organizations and in the health care system at large.

Lauren Goldman is a nurse educator for Trans Care BC. Since she was hired last fall, she’s been giving workshops to healthcare providers on how to treat trans patients. For now, though, the workshops are aimed at small groups of sexual health professionals, such as at the BC Centre for Disease Control or HIM. Goldman wants the program to expand to include everyone.

“We know trans patients are accessing care through a number of places all across the province,” she says. “We want everyone to have access to this information as soon as possible.”

Goldman says Trans Care is designing an online course that could bring trans cultural competency to primary care doctors everywhere as part of mandatory continuing education. Trans Care has also designed a primary care “toolkit” for doctors, and is in talks with UBC’s medical school about including trans-focused sexual health education for doctors in training.

Without specialized knowledge, Goldman says, there’s a lot doctors can miss. Testosterone can make vaginal tissue more sensitive and inflexible, for example, meaning trans men might have special difficulties with genital sex. Bacterial vaginosis is more common, and the usual antibiotics given to cis women may not solve the problem. Vaginal and rectal tissue may need different doses of PrEP to be effective.

And, most importantly, doctors need trans patients to know they will be heard.

“We need to be providing really obvious cues that show people that our services are trans inclusive,” Goldman says. “Including how we design our services, how we market our services, how we educate our clinicians, what signs we hang up, letting people know that our clinicians have a greater understanding of gender diversity.”

While Goldman is educating doctors, the trans men Rich studied were already very well educated about their own sexual health. They told Rich about careful risk assessments they make around sex, sharing information with other men, and advocating for STI screening to their reluctant doctors.

One man described slipping in HIV tests while getting regular testosterone-level screening: “Yeah, oh, I’m already getting blood drawn. I probably need to get tested, let’s just draw two more vials for HIV and syphilis.”

It’s not surprising that many trans men are so health-conscious, Scott says. “We’ve had to be champions of our own bodies for a while, and so that ethos carries through when it comes to health information.”

But it would be a mistake to overstate how safe trans MSM are, he adds. For one, the urban, white and well-educated men in Rich’s study may be more likely to have access to resources and care than less wealthy or more rural trans people. Also, the very reason trans MSM seem so safe might be because they aren’t getting the opportunities for sex they want.

“To some extent, we’re still on the sidelines,” Scott says. “I don’t think that systemic rejection should be the means of HIV prevention for trans and nonbinary people. We’re dealing with a lot of rejection, and so I don’t think we’ve really had the opportunity to be exposed to that risk.”

The theme of rejection is echoed frequently by the study subjects.

“I remember meeting this one guy at a friend’s party and we were flirting the whole time,” one participant recounted. “He was like, ‘Oh we should totally go for a beer’ and so we connected and then I told him I was trans and he was like, ‘Oh I’m not looking for anything.’”

“Cis men often shut down immediately, out of a sort of fear of the unknown, and being unaware of what can and can’t happen,” Scott says. “They can assume all trans guys are bottoms, which isn’t true.”

Constant rejection can wear trans men down, Larkham says. Not only does it damage mental health, but constant rejection can weaken trans men’s resolve to negotiate sexual safety.

Many trans men, the study notes, rely on online hookup sites, where they can be upfront about being trans, and avoid rejection by anyone who isn’t interested.

The burden of rejection is one reason trans MSM need better mental health services too, Larkham says. Too many men show up to sexual health clinics after being exposed to sexual risks. Mental health support, he thinks, could reach people earlier.

But again, Scott strikes a positive note. “It’s a source of celebration to me that despite huge barriers we’re still having the sex that we want,” he says.

In the end, the clearest message to emerge from Rich’s study is that there’s a lot more to learn. She hopes to get more answers from the next stage of the Momentum study, which will recruit a larger sample of MSM from across Canada. That study, she hopes, will be large enough to deliver the kind of precise, quantitative answers that this one couldn’t.

Scott is also eager to move forward.

“There’s so much you want to pack in and so much you want to report on,” he says. “There’s such a dire need to research these issues. People are really hurting, and I really feel that. But you’ve got to take it one step at a time.”

Complete Article HERE!

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The New Gay Sexual Revolution

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PrEP, TasP, and fearless sex remind us we can’t advance social justice without including sex in the equation.

By Jacob Anderson-Minshall

The sexual revolution of the 1960s and ’70s came to an abrupt and brutal end for many gay and bi men the moment AIDS was traced to sexual contact. In the early days of the epidemic, sex between men was equated with AIDS, not just in the mainstream media, but also in prevention efforts by other gay men. Since AIDS in those days was seen as a death sentence, for men who had sex with men, every sexual interaction carried the risk of death. Indeed, tens of thousands died of AIDS-related conditions.

“I was alive when homosexuality was [still] considered to be a psychological illness,” David Russell, pop star Sia’s manager, recently told Plus magazine. “The two generations ahead of mine, and a good portion of my generation, were completely decimated by AIDS. They’re gone.”

While some men with HIV outlasted all predictions and became long-term survivors, the widespread adoption of condoms is credited with dramatically reducing HIV transmissions among gay and bi men in subsequent years. Yet reliance on nothing but that layer of silicone — a barrier some complain prevents true intimacy and pleasure — couldn’t erase the gnawing dread gay men felt that every sexual encounter could be the one where HIV caught up to them.

There have been, of course, moments when nearly every gay or bi man has allowed their passions to override their fears and enjoyed the skin-on-skin contact that opposite-sex couples often take for granted. Thinking back on those unbridled and unprotected moments of passion filled many of these men with terror, regret, and guilt.

“Shame and gay sex have a very long history,” acknowledges Alex Garner, senior health and innovation strategist with the gay dating app Hornet. “And it takes much self-reflection — and often therapy — to feel proud and unashamed of our sex when everything around us tells us that it’s dirty, immoral, or illegitimate.”

Since the late 1990s and the advent of lifesaving antiretroviral drugs, some of the angst around sex between men faded — and with that came changes in behavior. Condom use, once reliably high among gay and bisexual men, has dropped off in the past two decades. According to a recent study published in the journal AIDS, over 40 percent of HIV-negative and 45 percent of HIV-positive gay and bi men admitted to having condomless sex in 2014. Researchers found the decrease in condom use wasn’t explained by serosorting (choosing only partners believed to have the same HIV status) or antiretroviral drug use. And despite what alarmists say, condom use had been declining long before the introduction of PrEP.

Garner, who has been HIV-positive for over two decades, says he’s almost relieved he acquired the virus at 23, because “My entire adult life I have never had to worry about getting HIV.”

The Rise of PrEP

Now there’s hope the younger generation may also experience worry-free sex lives — without the side effects of living with HIV.

The use of the antiretroviral drug Truvada as pre-exposure prophylaxis, or PrEP (it’s the only medication approved for HIV prevention), has been shown to reduce the chance of HIV transmission to near zero. Since the medication was first approved as PrEP in 2012, only two verified cases of transmission have been documented among those who adhere to the daily schedule (a third, according to HIV expert Howard Grossman, could not be confirmed). New, longer-lasting PrEP injectables should reach market in the next few years. Studies suggest that on-demand PrEP (such as taking it before and after sexual activity) may also be effective.

“This is a revolution!” Gary Cohan, MD, who prescribes PrEP, told us in 2016. “This should be above the fold in The New York Times and on the cover of Time magazine. A pill to prevent HIV?”

Undetectable Equals Untransmittable

Those who are already HIV-positive also have a sure-fire option for preventing the transmission of HIV that doesn’t rely on condoms. It’s called treatment as prevention, or TasP. Those who are poz, take antiretroviral medication, and get their viral load down to an undetectable level, can’t transmit HIV to sexual partners. Last year, The New England Journal of Medicine published the final results of HPTN 052, a study that proved antiretroviral medication alone is enough to prevent HIV transmission among serodiscordant couples. In a Facebook Live interview for AIDS.gov, Dr. Carl Dieffenbach, director of the Division of AIDS at the National Institute of Allergy and Infectious Diseases, noted, “The chance of transmitting [HIV] if you are virally durably suppressed is zero.

Since Dieffenbach’s statement, a number of HIV organizations and medical groups have joined the “Undetectable Equals Untransmittable” bandwagon, including GMHC, APLA Health, and the Latino Commission on AIDS.

The Centers for Disease Control and Prevention recommends the use of condoms in addition to PrEP or TasP, primarily because neither biomedical approach prevents other sexually transmitted infections like gonorrhea or syphilis. Still, PrEP and TasP make it safer to have condomless sex — and that could jump-start the new sexual revolution. “When the threat of HIV is removed from sex there is a profound sense of liberation,” Garner says. “Sex can just be about sex.”

One hurdle is PrEP stigma, furthered by the myth of “Truvada whores,” and AIDS Healthcare Foundation’s Michael Weinstein’s deliberate efforts to portray the HIV prevention pill as “a party drug.”

“Fear and shame have been ingrained in gay sex for decades,” Garner admits. “And it will take time and a great deal of work to extricate those elements.” But he remains optimistic that “together negative and poz men can shift the culture away from fear and toward liberation.”

He argues that what’s at stake is far more than just a better orgasm.

“Our sexuality is at the core of our humanity,” Garner says. “Our sexuality is as integral to us as our appetite. We can’t advance social justice without including sex. As queer people and as people of color, our bodies have been criminalized, our sexuality has been pathologized, and structures continue to dehumanize us. It’s a radical act of resistance when, as gay men, we choose to find pleasure and intimacy in our sex. Our sex has been, and will continue to be, intensely political. It can change our culture and our politics if we embrace it and run to it instead of away from it.”

Complete Article HERE!

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My Son Might Be Gay. What Should I Say to Him?

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There’s a reason he hasn’t come out to you yet.

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Making your way through this cruel, confounding, ever-changing world is difficult. Something make you anxious this week, or any week? Lay it on me at askdaveholmes@gmail.com. I’m here to help you minimize the damage you will necessarily inflict on the world just by being alive.

So, what’s your problem?

Dave,

I have a 17-year-old son, and I am fairly sure he is gay. He is not out, although I don’t know if he might be to any close friends. What’s hardest for me as his dad is that I know that this time of life can be confusing and frustrating to any kid, and I only know the experience of a straight guy. I can’t imagine how much harder or more complicated it must be for him. I would love to be able to be more supportive of him, but I certainly am not going to confront him.
Since your column a couple of weeks ago was advice for coming out to your family, my related question is: What advice do you have for the family of someone who hasn’t yet come out?
Many thanks,

Mark

Mark, you are one hell of a father, so first and foremost: thank you. You’re attuned to your kid’s developing identity, you’re not trying to change him, and you’re considering how your words and behavior will affect him down the road. I’m not a parent, but I know these are all difficult and necessary things. You are actively improving your son’s quality of life just by thinking about them. Well done.

Here’s a story to illustrate what you should definitely not do. Years ago, when I was not much older than your son, I was at home on a Sunday night flipping through the TV channels with my mother. Not much was on: a Murder She Wrote we’d already seen; a Parker Lewis Can’t Lose she wouldn’t have understood; probably an actual opera in Italian on A&E or Bravo, because that’s actually what those networks used to give you. I paused on our local PBS affiliate, where a huge choir was singing, and after a few seconds I realized it was the Gay Men’s Chorus of some city or another doing a fundraising concert.

I stopped there, just to see what would happen. At this time in my life, I was 99 percent certain I was gay, though nowhere near ready to spring it on my parents. We had no gay people in our lives back then, no way to gauge my family’s level of tolerance. And here it was: the most passive, least courageous way I could drag the topic into the family room, kicking and singing.

We had no gay people in our lives back then, no way to gauge my family’s level of tolerance.

We watched as they delivered a rendition of what I remember as “Somewhere Over the Rainbow,” because either they or my memory are unforgivably basic. But it was gorgeous. Stirring and brave and subversive, coming as it did in a time before marriage equality was on the map, a time when you only saw gay people on the news. I got chills.

Then they finished, and my mom turned to me and said, “I really pity them.”

I switched it to Parker Lewis and left the room.

Now, I am comfortable telling you this story now because it was ages ago, she has come a long way since then, and also there’s a zero percent chance she’s ever going to read this because it’s on the computer. But it stands as evidence that sometimes saying nothing is the stronger choice

Good on you for not point-blank asking your son whether he’s gay. You are probably going to be the last person he tells. That doesn’t mean that he doesn’t trust you or that you didn’t make it an easy enough process for him. It means one simple, inescapable thing: Once you have told your dad you’re gay, there is no going back. You have given your final answer, and you are locking it in. And what if it all just lifts one day, and you wake up straight, and then you get married and have to spend your whole wedding day wondering whether your dad is thinking about what you told him that one time?

Right now, if your instinct is correct, your son is sorting through all of his competing urges and trying to determine which are his and which belong to society. Right now, everything is possible. You are probably correct that the confusion and frustration he’s experiencing is different than what you and all teenagers have gone through. But as to whether it’s harder, it’s all relative. This is the only adolescence he’s ever going to have. And as you know from personal experience, it’s not like straight teenagers are dying for their parents’ involvement in their relationships and identity development. Right now, he has to be secretive, not because he’s gay, but because he’s 17. And if his personal experience is indeed tougher than his peers’, then he will end up tougher than his peers.

I’d love to say that you should do a big, showy “Hey, I sure do like those gay people” at the dinner table. I want to tell you to find out when Brokeback Mountain is on HBO and then accidentally turn it on right at the beginning when he’s in the room. I wish it were as simple and CBS-sitcommy as invite the gay guy from work to family bowling night. But it isn’t. Don’t do any of these things. At this age, kids are not only wildly self-conscious, they are also you-conscious. They know what you’re trying to do and what you’re asking without asking. Any well-meaning attempt to raise The Topic is only going to make him more nervous.

At this age, kids are not only wildly self-conscious, they are also you-conscious.

The one thing you can do, which I suspect you’re already doing, is to make him feel like a secure and separate person. To chisel away at the shame our culture hangs on all of us. To make him strong in his opinions and choices, even when they wouldn’t be yours. Discuss the news of the day with him, and when he makes a point that differs from yours, thank him for giving you a fresh perspective. Do what you can to make him feel like he can stand on his two feet, even when he’s standing apart from you. It’s a skill he’ll need, no matter which side of the fence he eventually lands on.

No matter what you do, know one important thing: He’s 17, and he’s probably going to react by rolling his eyes and going to his room. That’s what I did when my own father subtly tried to engage with me long ago. Teens can’t help it. It is their job. But trust me: Your son is listening, and he won’t forget it. (And Dad, wherever you are: I see now what you were doing playing so much Wham! in your car, and I appreciate it.)

But again, by simply being the kind of person who asks a question like this, you are doing more than most fathers. This kid is lucky to have you. We all are

Complete Article HERE!

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“Coming out” as a parent of a gay child

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By Alison Walsh

My elder son David was fifteen when he told us he was gay – not that he had actually intended to tell us quite then.

He said he was meeting someone but was evasive as to who this might be? I forced the issue never expecting to hear that this was some guy he had met on line through a gay website.

Alarm bells rung at the possible danger!

David must have guessed we might find the news of him being gay difficult as he kept repeating, “It’s OK Mum, there’s nothing wrong”.

My husband’s first thought was “I love my son. I don’t want to lose my relationship with him”.

As for me, I have an unfortunate knack of sometimes putting my big feet in things.

Whilst reeling from the shock, thankfully I avoided saying anything that my son would feel hurt or rejected by.

We both understood that what mattered most was for David to stay believing in himself and to know that our love and support was unconditional.

David appreciated the way we had accepted his sexuality and to stop us feeling anxious, he agreed to cancel the internet date.

David and Alison

Having “come out” to his friends and immediate family, David visibly looked happier by the day.

Now the ball was in our court. Was it our turn to “come out” as parents of a gay son? Would that be fair to David? Was it for him to decide who and when to tell others or not? At the young age of fifteen, we felt it was. That made it much harder because I wanted to feel accepted too.

Up to the point when David told us he was gay, I had no knowledge or experience of what being LGBT+ meant.

My head was full of fears which were further fuelled when I went on-line and came across far right materials discounting LGBT+ as wrong and blaming being gay on abuse or an unhealthy mother-son relationship.

Was I a bad Mum? I feared being judged. I was worried now how David would be treated. Would his school teachers who had praised him as a role model now think less of him?

Would he find himself rejected as unsuitable to be an RSY Summer Camp Leader?

Having brought my boys up to feel strongly Jewish, I now felt anxious that this might not sit comfortably with fully accepting and supporting David’s sexuality.

My Jewishness is all bound up in family and home, celebrating Friday night and all the family traditions. So for validation and support, I turned to my Jewish roots. As I said, I wasn’t ready to “come out” publicly and so like my son before he “came out”, I turned to the privacy of the internet for help. I tapped into Google “Jewish Mum of gay son” and up came “Parents of Jewish Gays and Lesbians” with a number you could phone in confidence.

Going for the first time to the group “Parents of Jewish Gays and Lesbians”, I was scared as to quite who I would find there.

The wonderful thing was how unbelievably just like the two of us the other parents all were. They could have come straight out of any Shul – parents anxious to do right by their children. We were no longer on our own.

Hearing from other parents and sharing our own story in a Jewish group in which we felt understood and accepted, helped us feel better. The first pernicious lie it immediately destroyed for me was the idea that being gay had anything to do with upbringing or by extension anything I had done or not done. It was a fact of life, period.

A Dad said that the last thing he would ever wish on his son would be to be imprisoned in an unhappy marriage hiding his sexuality. That hit home and made me rethink the dream I had been nurturing of one day seeing my son under the Chuppah with grandchildren to follow. My son had his own life to lead. I just wanted him to be happy and true to himself. And so in the group we parents chatted on into the night. We discussed why it was that so many of our LGBT+ children were going to Shul less? Did our LGBT+ children no longer feel they could count themselves as proper members of the club?

Perhaps like me before I became aware of LGBT+, our kids assumed by default that within Shul life their sexuality was taboo and that they would not be understood or accepted unless they hid their sexuality.

To be fair, if I joined any club, I would want to feel that there was someone there a bit like me and that I wasn’t just going to be tolerated, but actually wanted by the club.

My journey has been much easier than for some as being of my own making – struggling with my own prejudices. Thankfully the positive attitude of both our Shul and my son’s school explains why David has never felt ashamed of his sexuality and why both his friends and our Shul friends when told have had no issues.

In the twilight zone before feeling ready to come out to the world as a Jewish parent of a gay child, it helps to share feelings in the trust of absolute confidentiality with likeminded parent souls who understand. I am now Co-Ordinator for the parents’ group, “Parents of Jewish Gays and Lesbians” which helped me so much and which I would like to see there for other parents.

It is a really important group not just for the parents but also for LGBT+ children as “happy parents make happy kids”. Unfortunately the group is hardly known about so if you get a chance to tell others about the group, I would ask you to please do so.

Complete Article HERE!

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Not all men who have sex with men are gay…

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Ever heard of the term gay-for-pay? What about MSM?

People are slowly coming to terms with the fact that straight is not the only sexual orientation there is out there, and sexuality while often conflated with gender is not the same thing. It has taken public marches and private protests and the lives of many black female activists (it is the same everywhere, even Nigeria) to get us here; what we currently have is at best a rudimentary, stereotyped understanding of other sexuality is. Especially homosexuality, which is often visible and vilified because of the far-reaching consequences of patriarchy.

In 2016 an American boxer named Yusuf Mack found himself at the centre of a media furore when a video of him being paid to have sex with two other men surfaced on a porn company’s website. He quickly denied that it was him in the video, then amended his statement after the production company threatened to sue him, to say that he was under the influence of drugs and wasn’t aware of the things he did. After even more pressure and social media furore he released a statement coming out as gay, apologizing to his wife and ex-wife and the 10 children he’d sired with them. In reality, Mack probably considered himself gay-for-pay, a term for men who are in long-term relationships with women but work in the homosexual adult entertainment industry. Many argue that Mack was forced to ‘choose a side’ so to speak, after being forcefully outed to his friends and family. It is a slippery slope.

Not all men who have sex with men themselves gay. Not all men who have sexual and or emotional attraction to other men consider themselves gay. Donnie McClurkin, the American singer and pastor has openly admitted to being sexually attracted to men but has affirmed that he hasn’t acted on these attractions. He doesn’t consider himself gay.

What makes a man gay?

It would be presumptuous to say for sure. But here are three places that are as good as any to start.

Attraction
If a man feels repeated or consistent sexual or emotional attraction to other men then he falls under the spectrum of other-sexuality.  He might not be gay or bisexual, but he is definitely not heterosexual.

Action
Repeated acts of sexual intercourse with other men is a good benchmark for other sexuality. Like attraction, this isn’t enough to label a man as gay, but it is more than enough to open the conversation for the spectrum of sexuality and where our hypothetical man falls under this spectrum.

Acknowledgement
Acknowledgment is the best way to tell a man is gay/bisexual. When a man affirms for himself that he is either attracted to other men or enjoys repeated acts of sexual intercourse with other men.

Complete Article HERE!

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