Saturday, June 18, 2011

Response To J. Diggs' "The Health Risks of Gay Sex"

A Full Response To: "The Health Risks of Gay Sex" by John R. Diggs, Jr.
http://www.catholiceducation.org/en/marriage-and-family/sexuality/the-health-risks-of-gay-sex.html

The following is a full rebuttal of an essay constructed by Dr. John R. Diggs, Jr. that seeks to pathologize homosexuality. It is advised that any readers simultaneously read Diggs essay (located at the link above) while reading this. This response corresponds reference by reference to Diggs' essay.

Diggs' essay is not a peer reviewed study published in a scientific journal. It is an individual's essay, published upon a right wing, Christian website. Some references that make irrelevant or barely relevant points may be ignored in the interest of conciseness.



CONTENTS

Executive Summary
Introduction
I. Differences Between Homosexual And Heterosexual Relationships
        A. Promiscuity (Ref. 4-18)
        B. Physical Health (Ref. 20-77)
                1. Male Homosexual Behavior
                          a. Anal-Genital
                          b. Oral-Anal
                          c. Human Waste
                          d. Fisting
                          e. Sadism
                          f. Conclusion
                2. Female Homosexual Behavior
        C. Mental Health (Ref. 78-97)
                          1. Psychiatric Illness
                          2. Reckless Sexual Behavior
        D. Shortened Lifespan (Ref. 98-102)
        E. "Monogamy" (Ref. 103-108)
II. Cultural Implications Of Promiscuity (Ref. 109-123)
Conclusion
Appendix A
Definitional Impediments To Research (Ref. 124-133)
End Summary

- Ref. = Reference numbers. These represent the range of references that are covered within a subsection.
- Clicking upon a contents section that covers any references will take you directly to that section.
- A yellow background denotes that Diggs is being quoted.
- A light orange background denotes that another source is being quoted.



EXECUTIVE SUMMARY - This first section is ignored, as the full version will be countered.


INTRODUCTION:

Diggs suggests the motive for the construction of his essay as follows:
"As a physician, it is my duty to inform patients of the health risks of gay sex, and to discourage them from indulging in harmful behavior"

Risk is distributed along a spectrum. The determination of what constitutes too great a risk is subjective. As every sexual act performed by homosexuals can be and is also performed by heterosexuals, there also seems to be no such thing as "gay sex". Multiple studies show similar statistics to the one below.

CDC's National Survey of Family Growth:
"Percent of males and females 25-44 years of age who have ever had anal sex with an opposite sex partner, 2002:   Males: 40.0%   Females: 34.7%"




DIFFERENCES BETWEEN HOMOSEXUAL AND HETEROSEXUAL RELATIONSHIPS

A. PROMISCUITY

REFERENCE 4

Diggs citing reference 4:
"Gay author Gabriel Rotello notes the perspective of many gays that "Gay liberation was founded...on a sexual brotherhood of promiscuity"".

The fact that Gabriel Rotello is gay is used here to lend illusory credibility to what is simply an anecdotal opinion of the author of a book, not an empirically verified hypothesis. The idea that quoting homosexuals saying seemingly negative things about homosexuals somehow proves their point is common among heterosexist essays but their opinion remains anecdotal hearsay.

Rotello's key message is that HIV was not prevalent among homosexuals as a result of HIV alone but also as a result of behaviour, which increases risk. Rotello makes this point for numerous other pathologies, including cardiovascular disease and cancer, which are the biggest killers in developed nations. His contribution therefore appears to be little more applicable to homosexuals than to the general population, even if he is correct. Rotello is referenced by Diggs about 5 times despite the fact that he merely provides anecdotal opinion, as opposed to peer-reviewed research.

Rotello is correct about cancer and with approximately 64 percent of the U.S. population obese or overweight, "risky behaviour" clearly isn't the exclusive reserve of gay men, The World Cancer Research Fund:
"About a third of the most common cancers could be prevented through eating a healthy diet, being physically active and maintaining a healthy weight."



REFERENCE 5

Diggs supports Rotello's anecdotal claim with statistics from the a study from 1978, the representativeness of which is refuted by the authors of the study themselves. Bell & Weinberg, "Homosexualities" (page 22):
"It should be pointed out that reaching any consensus about the exact number of homosexual men or women exhibiting this or that characteristic is not an aim of the present study. The nonrepresentative nature of other investigators' samples as well as of our own precludes any generalization about the incidence of a particular phenomenon even to persons living in the locale where the interviews were conducted, much less homosexuals in general."

Among the study's homosexual sample population, 22% were from singles bars, 9% from gay bath houses, 5% from sex clubs etc. Rotello also noted that promiscuity was particularly high in the 1970s and so if Rotello's opinions are to be believed then that would further preclude the representativeness of this study.



REFERENCE 6

This reference is used to further justify Diggs' promiscuity claim, whilst playing down the fact that promiscuity decreased dramatically after the 1970s:
"Instead of more than 6 partners per month in 1982, the average non-monogamous respondent in San Francisco reported having about 4 partners per month in 1984".

McKusick et al. 1985, Public Health Reports, 100(6), 622-629 (Diggs' reference 6):
"We found substantial changes in reported sexual behavior with persons other than a primary partner. The average number of male partners declined from 6.3 in November 1982 to 3.9 in May 1984. Receptive anal intercourse without condom declined from 1.9 to 0.7, oral-anal contact declined from 1.1 to 0.3, and swallowing semen declined from 2.8 to 0.7 in terms of the number of times that the respondent engaged in the act in the last month."

Reference 6 therefore shows dramatic decreases in sexual activity over a 2 year period, making it hard to see how such statistics could relate to the present day when the study is over 30 years old. The non-monogamous participants of the study were recruited from bath houses and gay bars. The "mode of recruitment into the study resulted in a participant group with higher overall levels of sexual activity than were found in random samples of the gay male population" (p624). This quote relates to the entire sample population, even including the monogamous group, who were recruited separately from the bathhouse/gay-bar attendees.

As Diggs has also not provided statistics for matched heterosexuals, there is nothing to compare the homosexual statistics to and so no accurate conclusions can really be drawn. Furthermore, Diggs rounds up the values he quotes to "about 4" and "more than 6" which is already a clear indication that he is trying to exaggerate his negative claims, suggesting a biased mindset, not one of a "dutiful physician".

A recent, nationally representative Swedish study found a substantially different level of promiscuity, Langstrom et al. 2010, Archives of Sexual Behavior, 39(1), 75-80:
"The average number of (lifetime) same-sex sexual partners among those reporting any such partner was 12.86 in men and 3.53 in women".
http://link.springer.com/article/10.1007%2Fs10508-008-9386-1



REFERENCE 7

Diggs, citing reference 7, describes how:
"From 1994 to 1997, the percentage of homosexual men reporting multiple partners and unprotected anal sex rose from 23.6 percent to 33.3 percent, with the largest increase among men under 25."

Reference 7:
"The proportion of surveyed MSM who reported having had anal sex increased from 57.6% (95% confidence interval {CI}=56.4%-58.9%) in 1994 to 61.2% (95% CI=60.1%-63.1%) in 1997".

Diggs is literally referring to "more than 1" partner when he says "multiple partners". While this increase is negligible, particularly in comparison to the decrease in promiscuity in Diggs' reference 6, it shows that ~40% of the gay men surveyed aren't having anal sex at all. This is in stark contrast to Diggs' claims about gay men's promiscuity. Just as among heterosexuals, promiscuity varies from individual to individual among homosexuals.

Even ignoring the fact that each individual is free to choose the degree of risk they expose themselves to, there are clearly promiscuous heterosexuals and homosexuals and a criticism of homosexuality based upon promiscuity would therefore be far better directed as simply being a criticism of promiscuity. Education rather than condemnation may be even better. Diggs' own sources actually show the great fluidity of sexual risk behaviour and promiscuity over time, therefore contradicting his core underlying claim that homosexuality (or even any other sexual orientation) has a fixed inter-relationship with promiscuity.



REFERENCE 10

Diggs tries to twist reference 10 by asserting that "it is riskier to be out than closeted". This is all just Diggs' speculation though, tainted by prejudice. Unfortunately reference 10 no longer seems to be available online (ISBN 1875978437). Another study refers to it as follows though (it is the second survey mentioned):

Jin et al. 2002, HIV Medicine,  3(4), 271–276:
"Levels of HIV testing in this study were similar to those found in other Australian samples of gay community-attached men. In a 1996 national phone-in survey of homosexually active men, 83.0% of gay community-attached men and 58.4% of non-gay community-attached men had been tested, and in a survey included in sex video catalogues in 2000, these figures were 84.6% and 66.1%, respectively".
http://onlinelibrary.wiley.com/doi/10.1046/j.1468-1293.2002.00121.x/full

The above study and reference 10, which share the same authors, therefore found that gay men attached to the gay community actually choose to get tested for HIV far more frequently than those who are not. This seems to directly oppose Diggs' speculation that being part of a gay community is riskier than not being so. Additionally, contrary to Diggs' suggestion, being out is not synonymous with being gay community-attached. Perhaps most importantly however "a survey included in sex video catalogues" clearly doesn't provide information that is representative of the average gay male. Diggs' "more than 50 sex partners" claim equates to 0.5% vs 0.1% of the sample populations for all we know, particularly given that he uses this dishonest statistical inflation tactic when making a similar point about lesbians with reference 17. Diggs' references 11 and 12 are both simply the anecdotal opinion of book author Gabriel Rotello.



REFERENCE 13 is also reference 8.

Diggs uses reference 13 to claim that:
"A study based upon statistics from 1986 through 1990 estimated that 20-year-old gay men had a 50 percent chance of becoming HIV positive by age 55".

However, the study covered the height of the HIV epidemic, over two decades ago. It showed a significant decline in new HIV infections over its course:
"Overall, the annual seroconversion hazard rose progressively from 0.4% in 1978 to 13.8% in 1983, dropped to 4.6% in 1985, and remained relatively stable at 1.1–2.2% from 1986 to 1990... Age, education, and ethnicity were all associated with 1978-1990 seroconversion rates."
http://aje.oxfordjournals.org/content/134/10/1190.abstract

Furthermore, a nationally representative study finds the prediction to be totally inaccurate, Xu et al. 2010, Sexually Transmitted Diseases, 37(6), 399-405:
"Among MSM, the prevalence of HIV... was 9.1%"
http://www.ncbi.nlm.nih.gov/pubmed/20473245



REFERENCE 14

Diggs uses reference 14 to point out that:
"As of june 2001, nearly 64 percent of men with AIDS were men who have had sex with men"

The CDC estimate statistics based upon transmission route for 2009 show that 56% of HIV infections were diagnosed among men who have sex with men (MSM) and this combined with those who were MSM and IDU (injecting drug users) accounted for 59.7% of cases.

Based upon race/ethnicity, 53% of HIV infections were diagnosed among African Americans. African Americans and hispanics/latino combined accounted for 69% of HIV infections. White people accounted for only 28% of infections (CDC).

African-Americans make up about 13% of the U.S. population. We can therefore quite clearly see that being a member of a racial minority constitutes a similarly high statistical risk for HIV infection as does being a MSM. As an African American, this should particularly worry Diggs and the great concern that he feels for his fellow man should perhaps be redirected towards compiling statistics on the health risks of being a member of a racial minority. Diggs goes on to point out that "Syphilis is also more common among gay men".  It is also several times higher among African Americans than white people (see statistic in Reference 15 response).

It should also be noted that while the above statistics may reflect the situation in the US, globally, homosexual men are not significantly overrepresented among those infected with HIV:

Joint United Nations Programme on HIV/AIDS, Fact Sheet 1 July 1996, Page 2:
"Heterosexual (male-female) intercourse accounts for more than 70% of all adult HIV infections to date and homosexual (male-male) intercourse for a further 5-10%."



REFERENCE 15

This source is a newspaper article and so is by default not really relevant. Diggs uses it to suggest that "experts" believe syphilis is on the rise among MSM due to promiscuity but those experts are actually only referring to those who have contracted syphilis, not an analysis of the MSM population as a whole. Given that 23% of the people infected with syphilis reported meeting partners in sex clubs, 20% in adult book stores and 18% in bathhouses, it is quite obvious that this is not representative of the average person.

Additionally, Diggs makes what looks like a reasonably shocking claim when he quotes the article as saying "The new data will show that in the 93 cases involving gay and bisexual men this year, the group reported having 1,225 sexual partners." Those "93 cases" are actually the 93 cases where a MSM was infected with syphilis and therefore only represent at absolute most, those MSM who have been infected with syphilis. It is also not 1225 partners per person, it is 1225 for that group of syphilis infected MSM, which works out at a mean of 13 partners each. If anything, that is surprisingly low given the venues these people attend and the fact that they are all infected with syphilis. It is vastly below the hundreds of partners that Diggs attempts to attribute to gay men in general and not massively above values we would expect for heterosexuals, let alone heterosexuals infected with syphilis. Additionally, according to the CDC, around the same time that this article was written, "in 2000... the rate (of syphilis infection) among blacks was 24 times greater than among whites".



REFERENCE 16

Diggs:
"A study... found that gay men contracted syphilis at three to four times the rate of heterosexuals (16)".

Given the statistic for black people's syphilis rates, the above statistic becomes laughable as an indicator of the pathological nature of the "homosexual lifestyle". Diggs asserts that promiscuity is "most responsible" for this difference in MSM infection rate but does not substantiate this claim.



REFERENCES 17-18
17 consists of one study.
18 consists of 3 studies.

Diggs claims that:
"Australian investigators reported that lesbian women were 4.5 times more likely to have had more than 50 life time male partners than heterosexual women (9 percent of lesbians versus 2 percent of heterosexual women); and 93 percent of women who identified themselves as lesbian reported a history of sex with men (17)".

Diggs misrepresents this study in a number of ways:
- The study was on WSW. This is women who have a history of sex with women, which includes bisexuals/pansexuals, not just lesbians. It would also include any heterosexual women who had ever experimented with another woman.
- The study is of those attending an STI clinic, which skews it away from being representative of the general lesbian population.
What these facts actually tell us are that;
Of those WSW attending an STI clinic, most are bisexual. It is therefore likely their heterosexual interactions that have necessitated the services of an STI clinic, rather than lesbianism.

Responses to this study published within the same journal by a senior researcher and a specialist registrar launch a rather devastating critique, including the points that:
"Over twice as many of the WSW as the control group were current sex workers"
"The researchers themselves say their "clinic population... may not be representative of the WSW in the general community". This is an understatement".


Based upon reference 18, which refers to 3 studies, Diggs tries to back his assertion up as follows:
"Other studies similarly show that 75-90% of women who have sex with women have also had sex with men".

18.1 is a case study of a single lesbian and so cannot be used to form any conclusions about lesbians as a whole. The claim that Diggs attributes to it is not a finding of this study.

18.2 is another study on people attending an STI clinic for WSW, not just lesbians, and is therefore not representative. Even if we ignore this and accept Diggs' claim that most lesbians have slept with men, this itself says nothing of relevance about them, particularly without knowing why it occurred. It would not be especially surprising if, given, cultural heteronormativity and the lack of the requirement for arousal in order to "perform", young lesbians in denial about their sexuality may well sleep with men. Diggs' reference 18.2 appears to support this possibility (Skinner et al. 1996):
"Of the lesbians, 218 (91%) had experienced heterosexual intercourse but in only four (2%) had this occured in the lst 90 days and none within the last 60 days.  In 34 (14%) of the lesbians, heterosexual intercourse had not occured within the last 10 years."

18.3 unfortunately doesn't state its sample population's source or the experiment's definition of "lesbian" in it's abstract, though it likewise does not appear to investigate why lesbians would have slept with men.

A more thorough look at the phenomenon of lesbians who have had sex with men can be found here. The explanations advanced above are demonstrated to be highly probable, based upon multiple other studies.


SECTION SUMMARY:

At most, Diggs establishes the prevalence of female bisexuality relative to lesbianism, which really isn't relevant to his attempt to show homosexuality to be pathological. At least 2 out of 3, perhaps even all 3 of his sources are from STI clinics, which seriously skews findings away from any representativeness of the general WSW population, let alone lesbians.

Studies on self-identified lesbians partaking in penile-vaginal sex need to explore the motivations behind that sex and the age and frequency with which it occurred etc before any reliable conclusions can be drawn about why lesbians might have had sex with men. Presumably Diggs intends the point to support his claims of lesbian promiscuity, though having partners of both genders by no means equates to a greater overall quantity of partners.

The heterosexual control population was not matched to the WSW population properly in reference 17, with the differing number of sex workers in each group making any accurate comparisons impossible. This is Diggs' only study on WSW promiscuity and numerous other studies indicate that lesbians are no more promiscuous than heterosexuals.

Diggs' gay male promiscuity claims use a combination of anecdotal evidence, non-representative sample populations and outdated studies, some of which actually contradict Diggs' claim. Prevalence of certain STIs is very high among both black Americans and gay American men, further demonstrating the flaws and inconsistency in Diggs' attempt to pathologize homosexuality.




B. PHYSICAL HEALTH

1. MALE HOMOSEXUAL BEHAVIOR

REFERENCE 19

Diggs uses reference 19 to claim that:
"Men having sex with other men leads to greater health risks than men having sex with women".

This isn't accurate, in that a multitude of factors determine the relative risk, such as the type of sex engaged in, whether or not the participants have any STIs and whether or not they use condoms. Many heterosexuals engage in anal sex for instance and they and homosexuals engage in oral sex and mutual masturbation, which have a lower risk than penile-vaginal sex for STI transmission.

Diggs' reference for the claim is simply a list of the top 10 MSM health concerns, which is irrelevant as there will be a top 10 MSW (men who have sex with women) health concerns too.



REFERENCE 20

Diggs uses this reference to suggest a plethora of points about gay male sexual practises and their frequency of occurrence:
- It may be prudent to consider why Diggs is using a paper from over 30 years ago.
- Reference 20 notes on page 168 that there are "non-promiscous male homosexuals".
- Diggs' reference 6, a study conducted just a few years after reference 20, specifically shows major decreases in all forms of sexual activity among homosexuals.
- Reference 20 doesn't actually involve taking a sample of homosexuals at all. It is merely a general review by a single author and seemingly not a very good one as no references are provided for the entirety of the section that Diggs quotes or for any similar points throughout the whole paper.
- In the absence of any data to base it's conclusions upon it therefore seems to be little more than an anecdotal opinion. It is additionally totally qualitative, not quantitative.



REFERENCES 21-22

Diggs uses reference 21 to conclude that:
"Although the specific activities addressed below may be practiced by heterosexuals at times, homosexual men engage in these activities to a far greater extent".

Reference 21 cites both Gabriel Rotello (anecdotal opinion) and another book (more anecdotal opinion). The fact that he cites no studies or reputable medical associations betrays the fact that he has no solid evidence to support this claim. Reference 22 is also just Rotello again.




a. ANAL-GENITAL

REFERENCES 23-24

Diggs comparison of the anatomical predisposition of the vagina towards intercourse relative to the anus is entirely unreferenced. The natural lubrication of the vagina is not required as artificial lubricants, which are widely used by heterosexuals, are available and massively reduce friction. In addition, condoms totally prevent any "immunological actions caused by semen and sperm".

A nationally representative study of the general U.S. population found that the majority of women use lubricants with their male partners. Herbenick et al. 2014, The Journal of Sexual Medicine, 11(3), 642–652, DOI: 10.1111/jsm.12427
"Of the women who participated in the study, 65.5% (n = 1,021) reported ever having used lubricant and 20% had used a lubricant within the past 30 days. Across age groups, lubricant was most commonly used during intercourse (58.3% of women) or partnered sexual play (49.6%)."
http://onlinelibrary.wiley.com/doi/10.1111/jsm.12427/abstract

Vaginal-penile intercourse involves tearing of the hymen during a woman's first intercourse, mixing her blood with the man's penis and semen. Subsequent intercourse anywhere near her period also risk doing the same. The man's semen and the women's vaginal fluid will also mix together, along with all the microorganisms of the vaginal and penile flora during intercourse. This parodies Diggs' attempts to make anal sex sound as repugnant as possible.

Reference 23 supports the claim that rabbits may suffer slight immunological impairment when repeatedly receiving semen anally. Reference 24 however doesn't support Diggs' claim and simply concludes that repeated exposure to semen may elicit the production of antibodies to sperm, just as occurs with any non-native proteins/cells. Condoms would be fully preventative, assuming this phenomenon even applies to humans.

Carey et al. 1992, Sexually Transmitted Diseases, 19(4), 230-234:
"Worst-case condom barrier effectiveness (fluid transfer prevention), however, is shown to be at least 10,000 times better than not using a condom at all".
http://www.ncbi.nlm.nih.gov/pubmed/1411838

One of Diggs' unsubstantiated claims is that:
"Anal sex leads to leakage of fecal material that can easily become chronic".

One study (Chun et al. 1997, The American Journal of Gastroenterology, 92(3), 465-8) found no evidence of anal incontinence among those practising ARI (anoreceptive intercourse):
"There were no IAS or EAS defects, as well as no fecal incontinence, in our subjects."
http://www.ncbi.nlm.nih.gov/pubmed/9068471

A further study (Laine et al. 2011, Acta Obstetricia, 90(4), 319–324) found that anal and urinary incontinence were both risks associated with childbirth:
"Anal as well as urinary incontinence after delivery with obstetric anal sphincter rupture is common".
http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0412.2010.01057.x/abstract

Yet another study (Lunniss et al. Journal of the Royal Society of Medicine 2004, 97(3), 111-116) claimed that:
"The overwhelming risk factor for the development of faecal incontinence in women is childbirth, and in males anal surgery... In women, the principal risk factor was childbirth (91%)".
http://jrsm.rsmjournals.com/cgi/content/full/97/3/111

We can therefore conclude, from Diggs' reasoning that child birth is pathological. Note that conversely, this particular "pathology" would be very unlikely to affect lesbian women.



REFERENCE 25 Involves two citations:

Diggs uses reference 25 to identify some diseases found among homosexuals and exaggerates their prevalence when describing their "extraordinary frequency". The free-to-view portion of his reference 25 does not actually confirm any of what he says. All of the infections identified by Diggs also affect heterosexuals and will be discussed below.


BACTERIAL INFECTIONS:

Syphilis - Condoms reduce risk of transmission.
Gonorrhoea - Condoms prevent transmission.
Chlamydia - Condoms prevent transmission.

All three are entirely curable with antibiotics. Racial minorities are also disproportionately affected by all three and just as that it not due specifically to their race, neither are heightened rates of some STIs among MSM as "black and white" in their aetiology as Diggs insinuates. Further African-American statistics for virtually every STI Diggs uses to criticise homosexuality can be found here.

According to the American Academy of Family Physicians, 15/03/2008, 77(6), 819-824:
"The USPSTF recommends that physicians be aware that in some communities black and Hispanic men and women (including pregnant women) may be at increased risk of chlamydia, gonorrhea, and syphilis, irrespective of age or sexual behaviors, and may need to be screened."

"Research has documented that many social-contextual factors contribute to varying STI prevalence rates within communities. Through a variety of direct and indirect mechanisms, factors in a community (e.g., poverty, discrimination, illicit drug use, male-to-female ratio, incarceration rate, racial segregation) influence sexual behaviors and networks, subsequently affecting the spread of infection."

The CDC:
"In 2004, the gonorrhea rate among African-Americans was 19 times greater than the rate for whites, down from 28 times greater in 2000."



REFERENCE 26:

MSM account for about 60% of syphilis cases in America, not 85% as Diggs implies, with the most extreme example he could find, although this is admittedly still high. Even in Diggs' reference 26, which surveyed syphilis cases in King County and which estimated that "40,000 MSM reside in King County", the 75 cases of syphilis in 1999 which his statistic refers to only amount to 0.1875% of the MSM population of King county. In other words, even in the most extreme case Diggs was able to find, less than a fifth of a percentage of the MSM in the surveillance area were infected with syphilis. Reference 27 is the medically irrelevant newspaper article used by Diggs as reference 15.


INTESTINAL PARASITES:

The CDC, 2015, on cryptosporidium:
"While this parasite can be spread in several different ways, water (drinking water and recreational water) is the most common method of transmission...The infection is treatable and preventable."

Thanks to Diggs, we now know that using swimming pools is pathological. Cryptospodiosis infection typically lasts 1-2 weeks with "tummy-bug" type symptoms before the body's immune system destroys it. Gardia Lamblia and isopora belli infection are very similar. Microsporidium is another infection of the intestinal tract which, like the others, really only tends to be a problem for immunocompromised individuals. Unsurprisingly AIDS victims are therefore more likely to suffer from them, just as they are from the common cold.


VIRAL INFECTIONS:

HPV - Vaccine available (Guardisil).
HSV - Condoms reduce transmission - A nationally representative US study found that differences in HSV-2 prevalence between MSM and non-MSM were "not statistically significant" (Xu et al. 2010, DOI: 10.1097/OLQ.0b013e3181ce122b)
HIV - Condoms prevent transmission.
HEP B - Vaccine available.
HEP C - "HCV is not efficiently transmitted sexually... Multiple published studies have demonstrated that the prevalence of HCV infection among MSM who have not reported a history of injecting-drug use is no higher than that of heterosexuals." (CDC).



REFERENCES 28-29:

Diggs deceptively uses statistics from a source that goes on to explain how they have already significantly changed:
"A 1988 CDC survey identified 21 percent of Hepatitis B cases as being homosexually transmitted while 18 percent were heterosexually transmitted".

Above is Diggs' claim regarding the period of 1982-1985 but his own source goes on to say that:
"Since 1985,... the proportion of patients whose risk factor for HB was heterosexual exposure (as defined above) also increased to 24%; in contrast, the percentage of patients reporting male homosexual activity declined to 9%".

This is however of little significance anyway as the source is out of date and a vaccine exists for hepatitis B. As is typical of heterosexists, Diggs also selects those references that indicate the lowest percentage of homosexuals in the population. A nationally representative US study found that 4% self-identified as LGB, 8% had same-sex sexual contact in the last year and 9.6% across their lifetime (Chandra et al. 2013, CDC's 2006–2010 NSFG, for 18-44 year olds).



ANAL CANCER (REFERENCES 30-31)

Risk factors include HIV infection and smoking, but human papiloma virus (HPV) is believed to account for about 90% of anal cancers. HPV is extremely common in the general population and is believed to cause virtually all instances of cervical cancer, which obviously only affects women. There are 2 vaccines for HPV. Anal cancer simply equates to a change in the location that the cancer/HPV affects. Between a heterosexual couple practising penile-vaginal intercourse, it would instead be cervical cancer that was the main risk for the woman, with regards to the HPV virus.

The American Cancer Society:
"About one-half to three-fourths of the people who have ever had sex will have HPV at some time in their life."

Newman et al. 2008, Journal of Gay Lesbian Social Services, 20(4), 328–353:
"Experts suggest that the rate of anal cancer diagnosed among immunocompetent gay men rivals the cervical cancer rate observed among women prior to the introduction of mass cytology screening strategies begun in the mid 1950s".
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3002049

The CDC, 2012:
"More black men get anal cancer than men of other races."

B. Walker et al. 1995, Environmental Health Perspectives, 103(8), 275-81:
"During the years 1987 to 1991, African Americans experienced higher incidence and mortality rates than whites for multiple myeloma and for cancers of the oropharynx, colorectum, lung and bronchus, cervix, and prostate."
http://www.ncbi.nlm.nih.gov/pubmed/8741798

American Cancer Society, 2011-2012:
"African Americans have the highest death rate and shortest survival of any racial and ethnic group in the US for most cancers... The incidence rate of cervical cancer remains 39% higher in African American women".

HIV, Syphilis, Gonorrhoea, anal cancer and intestinal parasites are all more prevalent among gay men. Black people are also at a significantly increased risk of HIV, Syphilis, Gonorrhoea, Chlamydia, anal cancer and cervical cancer and a range of other cancers and infections when compared to white people.

The dutiful physician's approach is to find out how to cure these diseases and ameliorate their symptoms, not to stigmatize those most affected by them, under the guise of benevolent, dutiful medical concern. Diggs should be promoting condom and vaccine usage to everybody, especially black people and MSM if he is truly concerned.



REFERENCE 32:

Diggs uses this reference to claim that:
"Other physical problems associated with anal sex are: hemorrhoids, anal fissures, anorectal trauma, retained foreign bodies".

The CDC identifies "birth to an infected mother" among its "primary risk factors" for hepatitis B.

If we then look at anal fissures described on the National Institutes of Health's website:
"Studies suggest 80% of infants will have had an anal fissure by the end of the first year".
"Anal fissures are also common in women after childbirth".
http://www.nlm.nih.gov/medlineplus/ency/article/001130.htm

Then hemorrhoids:
"They often result from straining to have a bowel movement. Other factors include pregnancy".
"About half of all people have hemorrhoids by age 50."
http://www.nlm.nih.gov/medlineplus/hemorrhoids.html

Diggs' rationale again appears to pathologize pregnancy and child birth, if applied consistently. Haemorrhoids are not caused by anal sex but might be exacerbated by it. "Anorectal trauma" is not a specific disease but just damage that might happen during anal sex or pregnancy etc and "retained foreign bodies" are an enormously rare occurrence which is simply solved by not putting anything small and unattached in to the anus. They can involve anybody, including in non-sexual settings, such as depicted in the film "Jackass: The Movie" during the "Butt X-Ray" skit.

Diggs' 1983 study is so old that no full version is available online. It features 101 patients attending a hospital over an unspecified number of years. Prolonged surveillance at any hospital is likely to identify multiple cases of injuries sustained while performing relatively safe activities. Goldstone & Welton, 2004, Clinics in Colon and Rectal Surgery, 17(4), 235–239:
"Anal sex can be performed safely."
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2780055/

A study at another hospital identified 445 patients with injuries sustained from intercourse, none of which appear to be associated with anal sex. Pfortmueller et al. 2013, Emergency Medicine Journal, 30(10), 846-850, DOI: 10.1136/emermed-2012-201845
"10.3%... of our patients suffered from trauma... [among these patients]... 78.0%... suffered injuries to the genitals... The most frequent trauma to the genitals was a torn frenulum (58.0%)."
"Neurological emergencies occurred in... 12.4%; the most frequent were headaches in 49.0%, followed by subarachnoid haemorrhage (22.0%) and transient global amnesia (20.0%)."
"A study by Zink et al... found that anogenital injuries occur during sexual activity in at least 11% of adult women."
http://www.medscape.com/viewarticle/811076_3




b. ORAL-ANAL

REFERENCES 33-35

Diggs:
"There is an extremely high rate of parasitic and other intestinal infections documented among male homosexual practitioners because of oral-anal contact.  In fact, there are so many infections that a syndrome called "the Gay Bowel" is described in medical literature (33)."

Reference 33 does not enlighten us about the rates of parasitic/intestinal infections among homosexuals as it is exclusively based upon "homosexual men comprising 10% of a private proctological practice". In other words, these men were all from a clinic specializing in treatment of bowel disorders and so this reveals nothing about the general population of homosexuals. Analogically, the rate of cancer among those attending a cancer treatment clinic would not be indicative of the prevalence of cancer in the general population. Even were it to be representative of the general population at the time, the study is over 35 years old and reference 35 is similarly three decades old, placing both prior to the major changes in sexual behaviour reported in Diggs reference 6. Furthermore, MSM aren't even substantially overrepresented at this proctological practice, where the study authors refer to the other 90% as the "heterosexual majority".

While Diggs gives the impression that the parasites he refers to are harbingers of an apocalypse, his own source (Reference 35) notes that the infections were frequently asymptomatic: "No correlation between symptoms and the presence or absence of infections could be detected".
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1010925/?page=2

"Gay Bowel Syndrom" was described previously but has since become a redundant term. The CDC and Canadian Association of Gastroenterologists no longer use it. A review (Scarce, 1997) of the term "gay bowel syndrom" concluded that:
"It is apparent that Gay Bowel Syndrome is an essentialized category of difference that is neither gay-specific, confined to the bowel, nor a syndrome."
http://www.ncbi.nlm.nih.gov/pubmed/9328857



REFERENCES 36-44

Hepatitis A

Diggs lists some diseases though does not establish their frequency of occurrence except for hepatitis A for which 78% of infected people were MSM in his study. This is not an accurate representation of the overall percentage of cases attributable to MSM but relates to a particular epidemic at a particular time. Diggs' own study identifies that MSM typically aren't over-represented among hepatitis A (HAV) cases. Other studies from Italy and Spain similarly found no HAV disparity.

CDC MMWR Weekly, 06/03/1992, 41(09), 155, 161-164:
"The frequency with which homosexual activity was reported by persons with hepatitis A was less than 10% during 1982-1989".
http://www.cdc.gov/mmwr/preview/mmwrhtml/00016243.htm

Ballestros, 1996, Epidemiology & Infection, 117(1), 145–148:
"These results indicated that in an area of intermediate endemicity young homosexual men are not at increased risk of having acquired hepatitis A infection than heterosexuals."
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2271671/

Corona, 1999, Epidemiology & Infection, 123(1), 89–93:
"Homosexuals were not found to be at increased risk of previous HAV exposure than heterosexuals... In a recent US study, the HAV prevalence among homosexuals was similar to the age-adjusted prevalence estimated for the general United States population".
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2810731/

Furthermore, HAV infection is a self-limiting disease, that typically lasts just a few weeks and has mild flu-like symptoms. Once convalesced, an individual is immune for life. There is also a hepatitis A vaccine which similarly provides this immunity.


Typhoid

Diggs next identifies an example of the homosexual transmission of typhoid as being "most unsettling". There is a vaccine for typhoid and antibiotics to treat anybody post-infection. This sexual transmission focused around a particularly promiscuous individual, not a population, and is an anecdotal instance, notable only because it was the first discovery of sexual transmission of typhoid.

The sensible approach is to vaccinate against typhoid before overseas travel, regardless of sexual orientation, rather than pathologize travelling abroad, as Diggs would seem inclined to do. Several years on, the CDC indicate no increase in typhoid prevalence in the U.S.

CDC National Prevention Information Network, 26/04/2001:
"About 400 cases of typhoid are reported annually in the United States, four-fifths of which can be traced to overseas travel."
http://www.thebody.com/content/art22866.html

The first known sexual transmission of the zika virus was from a heterosexual man (Brian Foy) to his wife. This indicates no more about heterosexuals than Diggs' anecdote about typhoid does about homosexuals.

Researchers and medical associations identify at risk groups specifically in order that they may be given vaccines and any similar precautionary measures, not so that, as Diggs attempts to do, those groups can be pathologized and stigmatized.



REFERENCES 45-46

Diggs claims that:
"In America, Human Herpes Virus 8 (called Herpes Type 8 or HHV-8) is a disease found exclusively among male homosexual practitioners".

This is incorrect as HHV-8 is found among heterosexuals too. This is particularly evident when Diggs goes on to point out that "Men who contract HIV/AIDS through heterosexual or intravenous drug use rarely display this cancer" (Kaposi's sarcoma - KS). Given that HHV-8 infection is essential to the development of KS, some heterosexuals must be infected with it if they acquire KS.

J N Martin, 2011, Advances in Dental Research, 23(1), 76-78:
"Kaposi sarcoma-associated herpesvirus (KSHV) was discovered in 1994 and is now known to be a necessary but not sufficient causative agent of Kaposi sarcoma."
http://adr.sagepub.com/content/23/1/76.abstract

Two thirds (400/600) of the MSM in Diggs' study were selected specifically because they were HIV positive, which would drastically skew the prevalence of HSV-8 upwards, assuming a sexual mode of transmission. Despite Diggs' insinuation about the 38% prevalence of HHV-8, another study found a seroprevalence among MSM of 8.2% and identified a higher prevalence among racial minorities in the US than their white counterparts (Engels et al. 2007, The Journal of Infectious Diseases, 196(2), 199-207, DOI: 10.1086/518791).

Diggs' reference 46 is simply an online article and his link for it no longer works. HHV-8 is transmitted via saliva and while it does primarily affect MSM in the US, in other countries it is far more prevalent in the general population, such as in Brazilian Amazonians, where ~75 percent of adults are infected.

HHV-8 does not generally lead to KS except in the immunocompromised and is typically asymptomatic, just like herpes type 3, which causes chickenpox in 90 percent of children and then persists in the body asymptomatically for life. A dutiful physician's efforts therefore need to be directed towards preventing HIV transmission, with sex education and the promotion of safe-sex being one of the best ways to do this.

Cunha et al. 2005, Journal of General Virology, 86(9), 2433-2437 (on Brazilian Amazonians):
"Seroprevalence was... 72.9 % in adults and 82.3 % in adults aged >50 years. Interestingly, 44.4 % of children under 2 years of age were HHV-8-seropositive."
http://vir.sgmjournals.org/content/86/9/2433.long

Martin et al. 1999, Current Opinion in Oncology, 11(6), 508-15:
"In endemic areas of Europe and Africa, nonsexual horizontal and perhaps vertical spread are the dominant modes of transmission."
http://www.ncbi.nlm.nih.gov/pubmed/10550016

Butler et al. 2011, The Journal of Infectious Diseases, 203(5), 625-34:
"HHV-8 seroprevalence increased from 16% among children aged 1.5-2 years to 32% among children aged 10-13 years (P <.001) and from 37% among participants aged 14-19 years to 49% among adults aged =50 years... Among 1404 participants ≥15 years of age, there was no association between correlates of sexual behavior (eg, number of lifetime sex partners, genital ulcers, discharge, or HIV infection) and HHV-8 seropositivity."
http://jid.oxfordjournals.org/content/203/5/625.full

Bagni et al. 2009, Current Opinion in HIV and AIDS, 4(1), 22-26:
"KSHV and HIV are both common in southern Africa where KSHV infection occurs during childhood via saliva."
http://www.ncbi.nlm.nih.gov/pubmed/19339936

Minhas et al. 2010, American Journal of Epidemiology, DOI: 10.1093/aje/kwq465:
"The epidemic of human immunodeficiency virus in Zambia has led to a dramatic rise in the incidence of human herpesvirus-8 (HHV-8)–associated Kaposi's sarcoma in both adults and children."
http://aje.oxfordjournals.org/content/early/2011/03/28/aje.kwq465.abstract




c. HUMAN WASTE

REFERENCE 47

Reference 47 consists of the DSM, which states that coprophilia is a paraphilia, which is irrelevant, and "The Gay Report", which is not remotely scientific or able to provide an accurate representation of homosexuals. It is frequently used by heterosexists, who ignore its non-scientific origin and methodological flaws. A full refutation of its accuracy and scientific validity can be found here.

There is very limited research on coprophilia, although a 1999 study found that 18% of heterosexuals and 17% of homosexuals in the study group had tried coprophilia (Sandnabba et al. Journal of Sex Research, 36(3), 273-282). Not only is this irrelevant to both homo and heterosexuals as a whole but Diggs attempts to deceive the reader here by implying that coprophilia is exclusive to gay men.

References to excrement as an attempt to incite disgust at gay men are misguided, given that a study of the general population found that "of the 404 people sampled 28% were found to have bacteria of faecal origin on their hands". (Donachie et al. 2009, Epidemiology & Infection, 138(3), 409-14).




d. FISTING

REFERENCE 48

This reference is again the entirely useless "Gay Report". That this is Diggs' only reference for the last two sections is perhaps an indication of the deficiency of evidence he has for his assertions.

Vaginal fisting is well known to be engaged in by heterosexuals. Anal fisting is additionally not limited to gay men. An account in the American Journal of Forensic Medicine & Pathology for instance cites a case of a husband doing this to his wife. The husband "at first claimed to have stimulated his wife sexually only with a finger, later, though, he admitted that he had introduced, as was his usual practice, his whole forearm in to her anus" (Prof. Torre. 1987, 8(1):91). This is no more representative of all heterosexuals than incidents of homosexual fisting are of all homosexuals.




e. SADISM

REFERENCES 49-53

Diggs entire paragraph on this doesn't even mention homosexuality until the very last sentence and once again, the "Gay Report" is used as his only reference. All other references are simply general websites on sadism and a reference to the despicable case of Jesse Dirkhising, which is an anecdote, of no more relevance than Elisabeth Fritzl is to heterosexuality.




f. CONCLUSION

REFERENCES 54-55

Diggs now tries to demonstrate that gay men negatively impact others, firstly by suggesting that medical practises must be altered due to them. Reference 55 is used to make an irrelevant point, which is not specific to any sexual orientation. Reference 54 is merely a guideline/suggestion, rather than something "Doctors must" now do and makes no reference to hemorrhoids.

The evaluation of a sore throat for instance, could involve several questions, such as how persistent it was, before any mention of oral sex would come up, as is the case when treating anybody, irrespective of sexual orientation. Surveys indicate that the vast majority of the population (80%) practise oral sex and so suggesting that oral medical conditions, that may occasionally result from it, are uniquely attributable to homosexuals is incorrect. Regarding haemorrhoids, anal sex does not cause them and is far from unique to gay men either.



REFERENCES 56-58

Diggs next advances that gay men economically disadvantage the general population via the cost of HIV research. However, black Americans, such as Diggs, account for over 50 percent of HIV infections in the US, despite comprising only ~13% of the population.

Even ignoring this, Diggs argument fails as his statistics are based upon US research spending, not on the overall health bill. The US only spends ~5.5% of its annual health budget on research, meaning that this component of the health bill is almost negligible when it comes to calculating overall cost. Globally, HIV/AIDS is just as much of a problem for heterosexuals as homosexuals and research in one country will have global benefits.
http://www.researchamerica.org/uploads/healthdollar09.pdf

Money is typically donated to research where it is thought it will have the greatest impact. It is funded based upon what will benefit the population as a whole the most, not based upon helping specific groups. The 69% of U.S. adults that are obese or overweight (CDC, 2012) likely put an unnecessary monetary burden upon medical care providers, relative to their slimmer counterparts but that does not mean that those 69% of Americans are betraying the remaining 31%.

Those 31% may even contribute to the remainder of the population being overweight through their attitudes and actions. This may apply to anybody involved in the production, promotion and distribution of unhealthy food and anybody who inadvertently induces comfort eating and/or discourages obese people from exercising, through mocking their attempts to do so, for instance. As detailed earlier with STIs, a range of factors may put people at risk, many of which are not of their own making.

Diggs identifies 2001's AIDS research spending at $2.247 billion in reference 57. This pales in comparison to the US's military expenditure in that year, which was over $300 billion and was over $650 billion as of 2009. Many US citizens may feel that those who are pro-war are disadvantaging their medical prospects by wasting the annual budget. Budgeting is complex and attempts to pit groups against each other based upon it is petty and unlikely to be consistently maintainable.
http://www.gpoaccess.gov/usbudget/fy09/pdf/budget/defense.pdf




SECTION SUMMARY:

At best, Diggs pathologizes certain behaviours, not certain sexual orientations. However, given that he has not established any nosological criteria and that many non-pathological activities, that are perfectly accepted by society, involve a heightened degree of risk, his approach fails.

Most of his sub-sections rely solely on "The Gay Report" and are notably short as a result. Diggs provides no evidence of prevalence or aetiology for most diseases discussed and does not attempt to pathologize the other risk factors associated with them. Ironically, were he to do so, he would likely end up pathologizing childbirth.

Similarly, pathologizing based upon STI disparities would require the pathologizing of black Americans, were he to be consistent. Diggs also uses the most extreme examples available, which is why his sources are almost invariably at least a decade old and this further evidences his bias.  




2. FEMALE HOMOSEXUAL BEHAVIOR

REFERENCE 59

Diggs starts this section with the assertion that "lesbians are also at higher risk for STDs and other health problems". He attempts substantiation using a link to the GLMA. This is a is a list of the top-10 health concerns for lesbians. There will also be a top-10 health concerns for heterosexual men and women. This reveals nothing of their relative health. Only one of the top-10 is even related to STIs.


An Analysis of The top-10 Lesbian Health Concerns is provided below:

1) Breast Cancer
2) Depression/Anxiety
3) Heart Health
4) Gynaecological Cancer
5) Fitness
6) Tobacco
7) Alcohol
8) Substance Use
9) Domestic Violence
10) Osteoporosis.

They are actually inter-related, except perhaps domestic abuse, and as Diggs' source points out:
"Domestic violence is reported to occur in about 11 percent of lesbian homes, about half the rate of 20 percent reported by heterosexual women. But the question is where do lesbians go when they are battered? Shelters need to welcome and include battered lesbians, and offer counselling to the offending partners."

Both 1 and 4 (according to the GLMA description) are due to a lack of regular check ups, which is something we might expect from a group that is generally healthy and/or that feels alienated by heteronormativity. Mcintre et al. describe how "lesbians are said to feel excluded by sexual health messages that presume heterosexuality, a finding linked to lower levels of Papanicolaou (Pap) testing." (Culture, Health & Sexuality, 2010, DOI: 10.1080/13691058.2010.508844). Note that Pap tests identify gynaecological cancers.

Tracy et al. 2010, Journal of Women's Health, 19(2), 229-237:
"Many lesbians do not screen for cervical cancer at recommended rates. Nonroutine screeners perceive fewer benefits, more barriers, and more discrimination".
http://www.liebertonline.com/doi/abs/10.1089/jwh.2009.1393

Diggs' rationale would pathologise all women; "Men can develop breast cancer, but this disease is about 100 times more common among women than men" (American Cancer Society).

As with Pap smears and domestic abuse, according to a 1999 study by Lauver et al. (Women's Health Issues, 9(5), 264-274) on mammography utilization:
"Lesbians face unique barriers to health care... some issues identified were particular to lesbians; many issues were common to those identified by general samples of women (which include lesbians)."

There is considerable inter-relationship between the top-10. For example, mental health problems, such as depression/anxiety, increase comfort eating and proclivity for substance abuse; as a coping mechanism/self-medication. Substance abuse in turn can exacerbate or cause mental health problems. Numerous studies link increased mental health issues and substance abuse, among sexual minorities, with heterosexism and minority stress.

Zigman et al. 2011, Journal of Clinical Investigation, DOI: 10.1172/JCI57660:
"The popular media and personal anecdotes are rich with examples of stress-induced eating of calorically dense “comfort foods.” Such behavioral reactions likely contribute to the increased prevalence of obesity in humans experiencing chronic stress or atypical depression."
http://www.jci.org/articles/view/57660

Dallman, 2010, Trends in Endocrinology & Metabolism, 21(3), 159–165:
"Stress also induces secretion of both glucocorticoids, which increases motivation for food, and insulin, which promotes food intake and obesity."
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2831158

Richardson et al. 2003, Archives of Pediatric & Adolescent Medicine, 157(8), 739-745:
"Depressed late adolescent girls were at a greater than 2-fold increased risk for obesity in adulthood compared with their nondepressed female peers.  A dose-response relationship between the number of episodes of depression during adolescence and risk for adult obesity was also observed in female subjects."
http://archpedi.ama-assn.org/cgi/content/full/157/8/739





As depicted, all of the lesbian top-10 health concerns are inter-related in a causal matrix which is initially caused by heterosexism/homophobia. That heterosexists cause the top-10 health concerns for lesbians makes it enormously hypocritical for them to then criticise homosexuals based upon these health issues.

Diggs goes on to try and explain away his inability to find studies that support his stance and concludes that "much of the pathology is associated with heterosexual activity by lesbians", which appears to contradict his overall claim.



REFERENCES 60-67

References 60-61 are used to make irrelevant points, while reference 62 is reference 18 (previously addressed). 63-67 are the same reference and are also the same as reference 17. Diggs claims that:
"Australian researchers at an STD clinic found that only 7 percent of their lesbian sample had never had sexual contact with a male (63)".

Diggs lies here about reference 63 as it was not on lesbians, it was on WSW, which according to the study was defined as "all women with any history of sex with a woman". This includes bisexuals/pansexuals and does not exclude heterosexual women that have ever experimented with another women in any way. The fact that only 7% of these women had never had sexual contact with a man simply further reinforces this point.

Patrons of an STI clinic are not representative of the general population of lesbians, or even WSW. It in fact suggests that, as Diggs himself indicated earlier, heterosexual interactions are far more likely to lead to STI clinic attendance than lesbian ones. If we therefore pathologize those who are more affected by STIs, it would seem that heterosexuality is pathological, while lesbianism is not.

Diggs repeatedly cites new reference numbers but all of them are actually reference 67. This suggests an attempt to create the illusion that his lesbian promiscuity claim is widely corroborated. 67 is also reference 17, the only study he used earlier to indicate lesbian promiscuity.

Diggs repeats his earlier claim, that:
"They (lesbians) were 4.5 times as likely as exclusively heterosexual control to have had more than 50 lifetime male sex partners" (64).  Consequently, the lesbians' median number of male partners was twice that of exclusively heterosexual women" (65).

Not only do we already know that this study is not representative of lesbians in general but two responses to this study, posted by medical professionals within the same journal, make it very clear that the control group was not properly matched to the WSW and that comparisons are therefore useless:

Linda Semple, Senior Researcher:
"Over twice as many of the WSW as the control group were current sex workers; 38% of the WSW had had a previous termination of pregnancy; nearly six times as many of the WSW had a history of injecting drug use... The researchers themselves say their "clinic population... may not be representative of the WSW in the general community". This is an understatement - and any reporting of this study must make very clear statements about the dangers of inappropriate conclusions about STIs amongst women who have sex with women generally."

Rudiger Pittrof, Specialist Registrar, Genitourinary Medicine:
"All I learn from this paper at present is that women who have sex with women also take other risks."
http://sti.bmj.com/content/76/5/345.abstract/reply#sextrans_el_3


Diggs' claims of lesbian promiscuity are further disproven by other studies. The second study below, disconfirms his claim despite consisting of a sample population largely derived from an STI clinic:

Koh et al. 2005, Sexually Transmitted Diseases, 32(9), 563-569:
"Lesbians were more likely to be in committed relationships (78%) in comparison to the bisexual (60%) and heterosexual women (69%)".
"Among those who had sex in the past year, women reported similar numbers of male and female sex partners (mean = 1.4 and 1.5, respectively)."
http://journals.lww.com/stdjournal/Fulltext/2005/09000/Sexual_Risk_Factors_Among_Self_Identified.8.aspx

Bailey et al. 2003, Sexually Transmitted Infections, 79(2), 147-150:
"803 lesbians and bisexual women attending, as new patients, lesbian sexual health clinics, and 415 lesbians and bisexual women from a community sample."
"98% of the whole sample gave a history of sexual activity with women, 83% within the past year, with a median of one female partner in that year."
http://sti.bmj.com/content/79/2/147.abstract



REFERENCES 68-70
Reference 68 consists of three new sources and reference 17, which is also 69.
Reference 70 consists of one new source.

Diggs argues that:
"Bacterial vaginosis, Hepatitis B, Hepatitis C, heavy cigarette smoking, alcohol abuse, intravenous drug use, and prostitution were present in much higher proportions among female homosexual practitioners (68)".

Substance Abuse

The first of the three reference 68 studies only shows that "lesbians/bisexual women exhibited greater prevalence rates of obesity, alcohol use, and tobacco use", points which are already fully countered previously (see ref. 59 response).

Prostitution

The other two studies were actually performed by the same group of researchers, using the same data set (February 1996 "496 were recruited at the Gay and Lesbian Mardi Gras Fair Day"). This carnival occurs in New South Wales. Diggs' prostitution claim is based upon that one Mardi Gras data set, which the studies' authors summarise as follows: "Fifty-five women (9%) had done sex work in the past six months."

According to the Australian Institute of Family Studies:
"There are approximately 20,000 sex industry workers in Australia... It was estimated that New South Wales has the largest population of sex workers, with about 10,000 workers based in that state (Sex Services Premises Planning Advisory Council (SSPPAC), 2004)... Economic necessity is regarded as the primary motivation for sex working (Perkins, 1991; Pivot Legal Society, 2006; Woodward, Fischer, Najman & Dunne, 2004)... Substance use can also be a factor influencing entry into sex work, however the relationship between sex work and drug use is complex (Johnson, 2004; Maher, 2000; Perkins, 1991; Surratt, Inciardi, Kurtz & Kiley, 2004)."
http://www.aifs.gov.au/acssa/pubs/issue/i8.html

It should hardly be surprising that a disproportionately high number of people are sex workers in a study performed in a state that accounts for half of all sex workers in the entire country (New South Wales). Further Points:
- Minority stress induced substance abuse or homelessness, may mediate passage in to prostitution.
- Sex workers may have been more drawn to completing what the study describes as a "questionnaire about HIV risk practices" than average because sexual health is part of their daily working lives.
- They may additionally have been drawn to a parade themed around the liberation of a stigmatized sexual minority, more than an average member of the population.
- 21% of respondents were actually heterosexual.

A later study by the same authors (DOI: 10.1080/09540120220104703) found that those having ever done sex work decreased by a third, which is a significant change. This low reproducibility is suggestive of confounding variables at play: "Forty-eight women (6%) had done sex work."

A larger study, conducted at a primary health care setting, rather than an STI clinic or carnival, found no prostitution disparity between sexual orientations. Koh et al. 2005, Sexually Transmitted Diseases, 32(9), 563-569:
"A total of 1,304 women (self-identified as 49% heterosexual, 11% bisexual, and 40% lesbian) were surveyed... Only nine women (1%) reported having sex for money, drugs, or shelter in the past year... Sex for trade did not differ by sexual orientation in this sample."
http://journals.lww.com/stdjournal/Fulltext/2005/09000/Sexual_Risk_Factors_Among_Self_Identified.8.aspx


Bacterial Vaginosis, Hepatitis B and C

The only remaining reference for Diggs' prostitution claim is 67, which is part of reference 68, and the only points raised by Diggs that have not yet been countered above are the supposedly increased prevalence of "Bacterial vaginosis, Hepatitis B, Hepatitis C" among lesbians.


HEPATITIS B/C:

We already know that reference 67 is not on a sample that is representative of the general WSW population and especially not of the general lesbian population. We also know that the non-WSW "control" population was not properly matched with the WSW population. However, even ignoring these flaws, if we look at what the study actually found regarding hepatitis C, which likely applies to hepatitis B too:

Fethers et al. 2000, Sex Transmitted Infections, 76(5), 345-349:
"The prevalence of hepatitis C was significantly greater in WSW (OR 7.7, p<0.001), consistent with the more frequent history of injecting drug use in this group (OR 8.0, p<0.001)."
http://sti.bmj.com/content/76/5/345.abstract

It has already been clearly demonstrated that IDU (injecting drug usage) is strongly related to heterosexism/minority stress. It therefore seems that it is actually heterosexism that is indirectly responsible for this increased hep B/C transmission and that criticisms of homosexuals based upon it are, once again, counter-productive hypocrisy.


BACTERIAL VAGINOSIS (BV):

Reference 70 used a sample population of "lesbians who sought gynecologic care at a community clinic and in a private gynecology practice". In other words, it was another STI clinic population, which Diggs uses to try and suggest a high incidence of BV in lesbians.

A subsequent study (Evans et al. 2007, Sexually Transmitted Infections, 83(6), 470-475), published in the same journal as Diggs' infamous reference 67, found that:
"Higher concordance of vaginal flora within lesbian partnerships may support the hypothesis of a sexually transmissible factor or reflect common risk factors such as smoking."
http://sti.bmj.com/content/83/6/470.abstract

Smoking, which is a known risk factor for BV and occurred far more among the lesbians in the study, than the heterosexuals, accounts for most, perhaps even all, of the increased incidence of BV among lesbians. According to The Family Planning Association (FPA):
"[risk factors for BV include] use (of) scented soaps or perfumed bubble bath [and] Semen in the vagina after sex without a condom".
"Around half of women with bacterial vaginosis will not have any signs and symptoms at all... Sometimes bacterial vaginosis is noticed during a cervical screening test, but you will only need treatment if you have problems with discharge... One in three women will get it at some time."
http://www.fpa.org.uk/media/uploads/helpandadvice/thrushandbacterialvaginosisjan09.pdf

BV can also arise in virgins (Bump et al. 1988) and there are significantly higher rates of BV among black women than lesbians. This appears to be due to minority stress related factors for both racial and sexual minorities. Koumans et al. 2007, Sexually Transmitted Diseases, 34(11), 864-869:
"Prevalence was 51.4% among non-Hispanic blacks, 31.9% among Mexican Americans, and 23.2% among non-Hispanic whites."
http://journals.lww.com/stdjournal/Fulltext/2007/11000/The_Prevalence_of_Bacterial_Vaginosis_in_the.6.aspx



REFERENCE 71 consists of 2 studies:

Reference 71 is used by Diggs to suggest that BV has a wide range of negative consequences. The first study indicates pregnancy complications as a potential concern for those infected with BV, which obviously is not relevant to lesbians. The thrust of the review however is simply that "better understanding is needed concerning the etiology, epidemiology, and natural history of bacterial vaginosis".

HIV was also mentioned as a possible risk in the first study, as was pelvic inflammatory disease (PID) after abortion, which again is not a concern for lesbians.
"Bacterial vaginosis is associated with an increased risk of gynecologic complications, including pelvic inflammatory disease, postoperative infection, cervicitis, human immunodeficiency virus (HIV), and possibly cervical intraepithelial neoplasia (CIN)."

Centers for Disease Control and Prevention (CDC), 2005:
"To date, there are no confirmed cases of female-to-female sexual transmission of HIV in the United States database."

PID and cervicitis are relatively general terms, denoting inflammation in various areas of the female genitalia and cervicitis's link to BV is poorly established. "Major gaps in our knowledge of this common condition remain" (Marrazzo et al. 2007). Ultimately, BV is a very benign STI to smear lesbians with and Diggs is clutching at straws when attempting to magnify its deleteriousness. BV's substantially heightened prevalence among African-Americans serves to further weaken his stance.



REFERENCE 72-73 (which are the same reference).

Diggs claims that:
"Among lesbians, diseases such as "crabs", genital warts, chlamydia and herpes have been reported (72). Even women who have never had sex with men have been found to have HPV, trichomoniasis and anogenital warts (73)".

All of these STIs occur among heterosexuals and Diggs has persistently tried to argue that STIs occur with higher frequency among homosexuals but here appears limited to pointing out simply that STIs do occur among lesbians, whilst ignoring their prevalence.

HPV causes anogenital (and genital) warts, which Diggs, as a physician, would know and it therefore appears that he is trying to deceptively flesh out his list. Perhaps he doesn't discuss prevalence here because from Diggs' reference 67 we can actually see that genital warts were "significantly less common in WSW" than the exclusively heterosexual women.

Fethers et al. 2000, Sexually Transmitted Infections, 76(5), 345-349:
"Abnormalities on cervical cytology were equally prevalent in both groups, except for the higher cytological BV detection rate in WSW (OR 5.3, p=0.003). Genital herpes and genital warts were common in both groups, although warts were significantly less common in WSW (OR 0.7, p=0.001)."
http://sti.bmj.com/content/76/5/345.abstract

From Diggs' reference 18 (Skinner et al. 1996), we can see that:
"Genital herpes (p = 0.05) and genital warts (p = 0.005) were more common in the heterosexual women. Gonorrhoea and chlamydia infection were infrequent diagnoses in both groups, occurring in four (2%) lesbians and 14 (7%) heterosexuals."

Were we to treat these percentages in the same way that Diggs did with his claim of lesbian promiscuity, we could deduce that heterosexual women are 3.5 times more likely to contract chlamydia/gonorrhoea than WSW. A study on HPV transmission also suggests that lesbians are at lower risk than heterosexuals. Marrazzo, 2004, AIDS Patient Care and STDs, 14(8), 447-451:
"In a pilot study of 149 WSW in Seattle, Washington, prevalence of HPV as detected by DNA amplification assay was 30%, and was 19% among women reporting no prior sex with men."
http://www.liebertonline.com/doi/abs/10.1089/108729100416669

The CDC describes trichomoniasis as follows:
"Trichomoniasis is the most common curable STD in young, sexually active women... Women can acquire the disease from infected men or women, but men usually contract it only from infected women."

Diggs' reference 72 found that "Bisexual women were more likely to report a history of STD (than lesbians)" (Morrow et al. 2000), therefore further indicating that heterosexual interactions present a greater risk for STI transmission than do lesbian ones. A full refutation of the suggestion that lesbians are at heightened risk for STIs can be found here.




C. MENTAL HEALTH

1. PSYCHIATRIC ILLNESS

REFERENCES 74-81
74-76 are used to make irrelevant points. 77-81 are all the same study.

Diggs criticises the prevalence of mental health disorders among LGBT people, then attempts to play down the findings of the numerous studies as being somehow misused by gay activists:
"Some proponents of GLB rights have used these findings to conclude that mental illness is induced by other people's unwillingness to accept same-sex attraction and behavior as normal."

This is a total misrepresentation. Normality is irrelevant. Just as all exceptionally bad things are "abnormal", so are all exceptionally good things, as are many neutral, amoral things, such as having ginger hair. That aside, gay activists do not "conclude...", the studies' authors themselves "conclude..." and the link between minority stress and prevalence of mental illness is clearly established and self-evident from the data provided. Section 1 of this link includes quotations from over 20 separate studies that support this conclusion:

Diggs argument is that Dutch LGB people should not exhibit a difference in mental illness from their heterosexual counterparts because the Netherlands is more LGB-friendly. This of course ignores the fact that a nation being more LGB-friendly than the US, for instance, does not equate to it being totally devoid of heterosexism. The US likely has higher crime rates than the Netherlands but this does not inform us that no crimes are committed by the Dutch. A couple of Dutch studies not only confirm that heterosexism exists in the Netherlands but also find a link between it and LGB mental health problems.

Kuyper et al. 2011, Journal of Counselling Psychology, 58(2), 222-33, DOI: 10.1037/a0022688:
"Results showed that minority stress is also related to mental health of Dutch LGBs. Participants with a higher level of internalized homonegativity and those who more often encountered negative reactions from other people on their same-sex sexual attraction reported more mental health problems."

Gevonden et al. 2014, Psychological Medicine, 44(2), 421-33, DOI: 10.1017/S0033291713000718:
"The finding that LGB orientation is associated with psychotic symptoms adds to the growing body of literature linking minority status with psychosis and other mental health problems, and suggests that exposure to minority stress represents an important mechanism."

Diggs' own source (Reference 77-81) also notes that:
"The effects of social factors on the mental health status of homosexual men and women have been well documented in studies, which found a relationship between experiences of stigma, prejudice, and discrimination and mental health status.52, 53, 54, 55, 56, 57, 58, 59, 60, 61".

Diggs finishes this section by pointing out that in his study, "the researchers offer no opinion as to whether homosexual behavior causes psychiatric disorders, or whether it is the result of psychiatric disorders". The reason that they didn't even hint at this is because only somebody who is enormously biased towards pathologizing homosexuality, would even consider it a sensible possibility. Diggs attempt to criticise LGB people based upon mental illness simply demonstrates the hypocrisy of his stance.


SECTION SUMMARY:

The lesbian top-10 health concerns appear to be inter-related, with their initial cause(s) all related to heterosexism/minority stress. Diggs only provides one study in his entire essay to suggest lesbian promiscuity, which actually describes a WSW population, at an STI clinic, where more than twice as many WSW were sex workers than the heterosexual contingent.

For the most part, Diggs doesn't even try to claim that STIs are more prevalent among lesbians. Studies, including some of Diggs' own sources, actually suggest lower STI rates among lesbians. Diggs' study showing higher hep B/C prevalence considers this a result of IDU, which is explainable by minority stress. Likewise, with BV, a significant portion, if not all of the increased BV prevalence among lesbians is likely due to smoking. Interestingly, exactly the same kind of stressors suffered by homosexuals due to heterosexism correlate with increased BV in racial disparities.

Culhane et al. 2002, American Journal Obstet. Gynecol, 187(5), 1272-6:
"Black women had significantly higher rates of bacterial vaginosis (64%) compared with white women (35%). Exposure to chronic stressors at the individual level differed by race (eg, 32% of the black women reported threats to personal safety compared with 13% of white women). There were significant racial differences in exposure to stress at the community level (eg, 63% of the black women lived in neighborhoods with aggravated assault rates that were above the citywide mean compared with 25% of the white women)."
http://www.ncbi.nlm.nih.gov/pubmed/12439519

Paul K et al. 2008, Social Science and Medicine, 67(5), 824-33:
"A higher number of stressful life events was significantly associated with higher BV prevalence among both African American and White American women."
http://www.ncbi.nlm.nih.gov/pubmed/18573578




2. RECKLESS SEXUAL BEHAVIOR

REFERENCE 82-85 are all the same reference.

Diggs starts this section by generously identifying the link between depression, drug abuse and reckless sexual behaviour. Depression and drug abuse have been established as being linked to minority stress. His source however is a newspaper article and so is subject to all the usual drawbacks of using such a source (sensationalism etc). The article is hearsay and the few cases mentioned within it are anecdotal.

Diggs claims that "One fatalistic gay man with HIV makes no apologies for putting other men at risk" yet the person he refers to (John) goes on to say "I guess I could be seen as getting too comfortable with the level of risk I was willing to take." Furthermore, it is revealed that John's partner is also HIV positive in the article, therefore seeming to quash Diggs' assertion that his lack of condom usage is putting other men at risk. Regardless, this is still an anecdotal case and the article also points out that "many gay men remain meticulous in taking precautions, and many are in long-term monogamous relationships."



REFERENCE 86 is also a newspaper article.

Diggs references a study, as does the newspaper he refers to, but that study is not cited by either and so is impossible to find, which is one among many reasons that newspaper articles are not good sources. The article Diggs uses actually also states that "New studies released today highlight two key demographic groups, young gay men and poor black women, who are at alarming risk for becoming infected with HIV... A study of mostly low-income black women in Atlanta found that almost half had not used a condom in their most recent sexual encounter and that 60 percent did not know their partners' H.I.V. status".



REFERENCES 87-92 are all the same reference.

The points that Diggs makes from this study are irrelevant to his overall attempt to pathologize homosexuality as he is referring to a small minority of gay men and indicates himself that "there was a direct correlation between the number of drugs used during a circuit party weekend and the likelihood of unprotected anal sex". Not only are circuit party goers no more representative of gay men than brothall attendees are of straight men but the link between heterosexism and this criticism of Diggs' is once again established via substance abuse, which is known to be encouraged by heterosexism.

The study (Mansergh et al. 2001) actually claims that:
"Taken as a whole, these findings suggest that a substantial drug culture permeates the circuit party environment, a drug culture that is distinct from broader communities of gay and bisexual men".



REFERENCE 93 is another newspaper article.

It is not clear in Diggs' quotation of the article whether or not the men he refers to are having unprotected sex with regular partners of known HIV serostatus or random strangers. Diggs' article also claims that: "One of the report's authors, Dr Paul van de Ven, said most gay men did not engage in any sexual risk behaviour." In summary, Diggs' own sources repeatedly refute his claims.




D. SHORTENED LIFE SPAN

REFERENCES 94-96
Reference 95 concerns the topic of smoking and is not relevant. 94, 96 and 97 are all the same reference and 98 is a CDC publication.

The authors of this lifespan study (Reference 94, 96, 97) have published a response to the use of their study by people such as Diggs in the International Journal of Epidemiology:
"If we were to repeat this analysis today the life expectancy of gay and bisexual men would be greatly improved. Deaths from HIV infection have declined dramatically in this population since 1996. As we have previously reported there has been a threefold decrease in mortality in Vancouver as well as in other parts of British Columbia... It is essential to note that the life expectancy of any population is a descriptive and not a prescriptive measure... It cannot be attributed solely to their sexual orientation or any other ethnic or social factor... Overall, we do not condone the use of our research in a manner that restricts the political or human rights of gay and bisexual men or any other group."

Unsurprisingly, African-Americans, such as Diggs, also have lower lifespans than white Americans. Diggs uses the lifespan study to try to indicate that homosexual male lifespans may be even lower, due to "additional major causes of death related to gay sex". He suggests suicide as one using ref. 96 and then a few STIs, using ref. 98. However, his own source (Reference 96) contradicts him:
"The pattern of non-HIV mortality for gay and bisexual men may be distinctly different from that exhibited by all men. This is unlikely to be the case for most causes of death. For example, mortality data from the San Francisco City Clinic cohort has revealed that only HIV infection and suicide have a higher than expected rate of death."

Another study confirmed this, though it didn't find higher suicide rates either; Cochran et al. 2011, American Journal of Public Health, 101(6), 1133-1138:
"Mortality risk from non–HIV-related causes, including suicide, was not elevated among MSM".

Ryan et al. 2009, Pediatrics, 123(1), 346-352:
"Lesbian, gay, and bisexual young adults who reported higher levels of family rejection (of their orientation) during adolescence were 8.4 times more likely to report having attempted suicide, 5.9 times more likely to report high levels of depression, 3.4 times more likely to use illegal drugs, and 3.4 times more likely to report having engaged in unprotected sexual intercourse compared with peers (other LGBT people) from families that reported no or low levels of family rejection."

The hypocrisy of heterosexism is apparent from the above study as well as the many others that link the LGBT suicide disparity with minority stress. The other "potentially fatal ailments" that Diggs mentions are rarely fatal in developed nations and childbirth can be "potentially fatal" yet homosexuals are unlikely to go through it, while heterosexual women likely will.




E. "MONOGAMY"

REFERENCE 99-100 are Reference 21, a book.

Diggs uses them to argue that:
"94 percent of married people and 75 percent of cohabiting people had only one partner in the prior year".

However, According to the CDC, 2002:
"Among the findings in the report: unmarried cohabitations overall are less stable than marriages.  The probability of a first marriage ending in separation or divorce within 5 years is 20 percent, but the probability of a premarital cohabitation breaking up within 5 years is 49 percent. After 10 years, the probability of a first marriage ending is 33 percent, compared with 62 percent for cohabitations."

While these statistics are all largely irrelevant to Diggs' central claims, they do suggest that it is totally hypocritical to deny homosexuals marriage, therefore relegating them to cohabitation, while criticising the longevity of their relationships. Cohabiting and marriage statistics additionally do not account at all for those couples who are not living together, where infidelity among heterosexual couples may be far higher.



REFERENCE 101

This is nothing more than the anecdotal opinion of somebody who posted in an online magazine. The weakness of this source betrays that Diggs has no substantial evidence for his claims. Diggs' description of the author as "a lesbian critic" is presumably intended to lend their opinion some heightened plausibility but it is not uncommon for members of stigmatised minorities to criticise stereotypical caricatures as an attempt to publicly distance themselves from them.



REFERENCE 102 is reference 87.

The response to reference 87 addresses this source. Additionally, Diggs doesn't establish a justified condemnation of polyamory/open relationships, which incidentally, are not the preserve of gay men. They are also not practised by most gay men, or at least, Diggs has not established otherwise. Charlie Sheen exemplifies an individual who is or was in a highly publicized open heterosexual relationship, yet we would not consider him to be representative of all heterosexuals. Note that here a newspaper article is used to support an anecdotal claim, not a claim about an entire population.



REFERENCE 103 is a book written in 1984.

This is not a peer reviewed study. It is unlikely to be of any scientific merit and not freely accessible.



REFERENCE 104 is a book written in 1973.

Diggs appears to lie again here as he claims that "in one study..." but this source is not a peer reviewed study. It appears to be a book from over 40 years ago. How outlandish must Diggs' claims be that he has to rely on sources this old? Unfortunately, how the statistic Diggs claims was derived again can not be thoroughly investigated here due to the ancient and obscure nature of his source.


SECTION SUMMARY:

This section is almost entirely based around a collection of books and articles, as opposed to peer-reviewed scientific research, with the lifespan study being the only scientific contribution. However, the findings of this study have been identified as being totally out of date and misapplied. The study was additionally only on gay/bi men, not lesbians. Men also have shorter lifespans than women and black Americans have shorter lifespans than white ones.

American Psychological Association (APA), 2004:
"Research indicates that many gay men and lesbians want and have committed relationships. For example, survey data indicate that between 40% and 60% of gay men and between 45% and 80% of lesbians are currently involved in a romantic relationship (e.g., Bradford, Ryan, & Rothblum, 1994; Falkner & Garber, 2002; Morris, Balsam, & Rothblum, 2002)."
"Survey data indicate that between 18% and 28% of gay couples and between 8% and 21% of lesbian couples have lived together 10 or more years (e.g., Blumstein & Schwartz, 1983; Bryant & Demian, 1994; Falkner & Garber, 2002; Kurdek, 2003). Researchers (e.g., Kurdek, 2004) have also speculated that the stability of same-sex couples would be enhanced if partners from same-sex couples enjoyed the same levels of social support and public recognition of their relationships as partners from heterosexual couples do."




II CULTURAL IMPLICATIONS OF PROMISCUITY

REFERENCE 105

Diggs argues that:
"The ideal of sexual activity being limited to marriage, always defined as male-female, has been a fence erected in all civilizations around the world".

Ironically, Diggs admits that this is untrue in his reference endnotes section:
"The existence of limited homosexual relationships in primitive cultures, or even extensive homosexuality in declining civilizations... does not challenge the existence of a prevailing norm".

Clearly Diggs contradicts himself here, as do the numerous examples of marriage around the world that are defined as being between two people. Labelling societies that allow for same sex unions as "primitive" or "declining" is of course not a criticism justified here by Diggs and quite irrelevant given that those same societies allowed opposite sex unions. Some of the most magnificent, ancient civilizations did in fact allow for homosexual unions, such as in Ancient Egypt.

A statement by the American Anthropological Association (AAA) directly counters Diggs' claim:
The results of more than a century of anthropological research on households, kinship relationships, and families, across cultures and through time, provide no support whatsoever for the view that either civilization or viable social orders depend upon marriage as an exclusively heterosexual institution. Rather, anthropological research supports the conclusion that a vast array of family types, including families built upon same-sex partnerships, can contribute to stable and humane societies.

Historical precedent is independent of whether or not something is good or bad. Diggs doesn't substantiate otherwise. There is no historical precedent for technological advances yet this doesn't make them immoral. Furthermore, polygamy is legal in almost 50 nations, while the Age of Consent is a relatively modern phenomenon, though presumably not one that Diggs' would object to.



REFERENCES 106-119

This entire segment is largely speculation by Diggs, very poorly supported by newspaper articles and the anecdotal opinions of Rotello, with no scientific studies used, except 109, which is used to make an irrelevant point. The points made are largely not worth responding to as they are frequently unrelated to homosexuality or fallacious, such as the obvious "slippery slope" fallacy used by Diggs:
"If gay sex is socially acceptable, what logical reason can there be to deny social acceptance of adultery, polygamy, or pedophilia?"

This insultingly minimizes homosexuality to sex. Adultery deceptively violates an intimate agreement made with a partner. Paedophilia is the involuntary attraction to prepubescent children and is consequently amoral. Child molestation, which "paedophilia" is often erroneously conflated with, is effectively sexual assault, which is clearly non-consensual and harms others.

Homosexuality, unlike paedophilia and adultery, does not involve the harm of non-consenting individuals. Polygamy does not either and restricting the relationships of others simply because they are unappealing to you is unjust. Polygamy and child marriage are actually far more common in the most anti-gay nations than in those with legal same-sex marriage.

It could just as cogently be asked of Diggs, "If opposite sex marriage continues to be socially acceptable, what logical reason can there be to deny social acceptance of adultery, polygamy, or pedophilia?". Diggs could simply point out that marriage is between two consenting, opposite-sex adults and so excludes these. Likewise, it could be pointed out that same sex marriage is between two consenting adults and therefore excludes these possibilities.


Diggs states that:
"There is no scientific evidence that being gay or lesbian is genetically determined".

The cause of something is not necessarily relevant to whether or not it is a choice, whether or not it is good or bad, whether or not it can be changed and so on. Certainly the concept of a single "gay gene" appears to be an oversimplification but twin studies strongly indicate a genetic factor. The fraternal birth order effect and maternal immune hypothesis would be an example of a non-genetic effect that is prenatal and environmental. There are additionally other possible epigenetic causes.

Mustanski et al. 2002, Annual Review of Sex Research, 13, 89-140:
"Genetic research using family and twin methodologies has produced consistent evidence that genes influence sexual orientation".
http://www.ncbi.nlm.nih.gov/pubmed/12836730




CONCLUSION
APPENDIX A
DEFINITIONAL IMPEDIMENTS TO RESEARCH

REFERENCE 120

This seems to be an earlier book (likely reference 21), though it is unclearly cited. Diggs appears to hint that sexual orientation changes yet all it relates is that sexual behaviour changes, which is exactly what we would expect in a bisexual. Some LGBT people will label themselves as gay or lesbian despite being bi/pansexual. Likewise, many self-identified straight people may have had homosexual experiences previously.


REFERENCES 121-126 consist of more journalistic anecdotes and no studies.


REFERENCE 127 is reference 93.

This is the newspaper article that claimed:
"One of the report's authors, Dr Paul van de Ven, said most gay men did not engage in any sexual risk behaviour."

Diggs now uses this article to point out that:
"A 2000 survey in Australia found that 19 percent of gay men reported having sex with a woman in the six months prior to the survey (131)."

The source for the article's statistics (Facts & Figures: 2000 Male Out Survey. Sydney: NCHSR, 2001) is Diggs' reference 10, which is unfortunately no longer available online. It is however likely that the statistic is of MSM, not gay men and so includes bisexuals.


REFERENCE 128 makes an irrelevant point, that ignores the existence of bi/pansexuals, and biromantics.


REFERENCE 129 is just a reiteration that homosexuals are a minority, which continues to be irrelevant.


END SUMMARY:

Diggs leads in to his essay claiming to be a dutiful physician yet as his essay goes on, this facade gradually fades away. This is a rather disappointing end to an essay clearly designed to display a collection of the most extreme and unrepresentative data available to Diggs in an attempt to pathologize homosexuality and therefore legitimise his prejudices.

Diggs deserves credit for mostly providing well cited references, therefore allowing his claims to be evaluated, though his overall conclusion is not supported by his sources and he is grossly over-reliant on outdated and non-scientific sources. In many instances his own sources contradict him.

A pseudo-scientific, incomplete picture is painted by Diggs that involves ignoring other risk groups and factors involved in the disparities he attributes exclusively to homosexuality. He additionally fails to establish any criteria via which something may be considered "too" harmful or risky.

In contrast to this, there is overwhelming evidence available to support the claim that it is actually heterosexist attitudes, such as those portrayed by Diggs, and heterosexist propaganda, such as his essay, that play a major role in LGBT health disparities. Diggs' essay is therefore a disquisition of hypocrisy and arguably a violation of his Hippocratic oath.

Diggs is a member of the National Advisory Council of the Family Research Council. The Family Research Council is listed as a hate group upon the Southern Poverty Law Center's website, which is an internationally recognized civil rights organization.

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