That’s it. I’m done. Today, I have officially finished my last course at UBC (at least for the foreseeable future), and I become an alumnus.
I have had several conversations about being essentially graduated and I have mostly avoided talking about it. Mostly avoided confronting this reality, because it should be a happy occasion, and it’s not. But more on that later…
For now, I wanted to share my final paper for my HIV course below. We were allowed to write on pretty much any topic we wanted in relation to HIV, and I wanted to explore why HIV transmission is still so high in the gay population even though education, prevention, and treatment programs have been targeted at this population for a very long time.
Please feel free to share any thoughts and comments!
“Exploring the Role of Psychological Factors in Decision Making for HIV Transmission & HAART Adherence in Homosexual Males
1. Introduction: Why Psychological Factors Matter for HIV in Gay Men
AIDS became thought of as a gay man’s disease starting around 1980, when gay men showed symptoms of PCP and the HIV virus was not yet discovered or attributed to AIDS. To this day, in BC, there are over 150 new cases of HIV in men who have sex with men (MSM) per year, around 50% of all new diagnoses. MSM also has the highest total HIV prevalence, ahead of intravenous drug users and heterosexual contact. The question then becomes why HIV is still such a problem in the gay community today even though its members were many of the first to receive monitoring, treatment, and education for HIV.
Our preventative and educative measures are failing because sexual decision making is a particularly complicated psychological issue for homosexual males, and this complexity extends to HAART adherence. Here a distinction is made to focus exclusively on men who identify as gay, which is a subset of the MSM population.
2. Psychological Factors on Transmission
A study in Rio de Janeiro, Brazil (Elkington et al. 2010) distinguished between three domains of mental illness stigma and how each domain associated with sexual activity. The domains included personal experiences of stigma (e.g., “Has anyone made fun of you because you have a mental illness?”), perceived attractiveness (e.g., “I am an attractive man/woman”), and the belief that having a mental illness restricts opportunities for romantic relationships (e.g., “People think men/women with mental illness are sexually undesirable”). Even though there were three domains, only those who reported greater relationship discrimination stigma were significantly more likely to be sexually active and to have unprotected sex. Even though these findings were regarding mental illness, they hold important implications for HIV risk behaviours in homosexual males.
The aforementioned study clearly outlined how stigma affects sexual behaviour, potentially contributing to the continual prevalence of HIV in the gay population. Roehr (2010) describes how institutionalized homophobia and religious extremism have fuelled Africa’s HIV epidemic, as a gay Kenyan wedding leads to riots shutting down an HIV clinic for two days, two gay Malawians are sentenced to 14 years’ hard labour for hoping to wed, and Uganda proposes capital punishment for homosexual acts as well as punishment for families, friends, and colleagues who do not report them.
Though to a lesser extent, such institutionalized homophobia can be witnessed even in the developed world, with examples including the Don’t Ask, Don’t Tell policy and state bans on gay marriage in the United States. Even in Canada, where gay marriage is legal, institutionalized homophobia still exists with such antiquated policies as banning men who have had sex with at least one man since 1977 for blood donations. This blood donation policy saved many lives when technology failed to accurately screen blood for the HIV virus. However, that is no longer the case, and the policy today stands as discriminatory behaviour against MSM, an institutionalized judgment that MSM, even though they were born this way, are all public health risks regardless of the individual. Martucci (2010) describes how in the US, federal Committee members used the underlying flexibility in the meanings behind the term MSM to justify continuous support of a similar policy there. Just because there is a higher prevalence of a virus in a certain population, it does not justify such institutionalized discrimination.
Unfortunately, although reversing institutionalized homophobia is important, that is only the first step in eliminating homosexual stigma, as individual homophobia will still exist in the community. On Britain’s Tonight programme, Afraid to Be Gay, members of a community admitted to accepting gays in public but not being comfortable with seeing homosexuals holding hands on the street or performing in sports. This type of individual homophobia is passed on within families and within communities, and it will take governmental policies and support to educate and eradicate this homophobia over many generations.
Homophobia in the community also leads to internalized homophobia in the individual, and this has been linked to unprotected anal sex when individuals believe that getting the virus is based on fate rather than choice, or when they are overly optimistic about the effectiveness of HAART (Yi, Sandfort, & Shidlo 2010).
In the aforementioned study about mental stigma in Brazil, an interesting point that was articulated was that being victims of stigma (e.g., being made fun of for being gay) and having a low self-image (e.g., not feeling sexy) do not necessarily lead to risky sexual behaviour. However, feeling that others will not find them attractive or will not want to be in a relationship with them led the individuals to unprotected sex and multiple partners. This is a key finding that can be applied to the gay population, because it addresses one of the reasons why gay males may not use condoms or be monogamous even though they may understand these risks for HIV. Part of the issue is again that stigma has forced many men to hide their sexuality and lose hope in ever having an open relationship with another man. This created a culture of substituting multiple-partner sex for relationships, and many gay males may find sex as the only form of validation for their attractiveness to other males – the extent of a relationship for many. Thus, when long-term relationships seem unattainable and sex becomes the highly valued substitute, it becomes difficult to negotiate safer sex. This is confounded by the low proportion of gay males in the male population to begin with.
The ability to negotiate safer sex as a vulnerability to HIV transmission is often a psychological barrier for homosexual males. For younger gay males, selecting older partners is common for many reasons, including because the proportion of males coming out increases with age group and because of personal partner preferences. Coburn and Blower (2010) describe how the selection of older sex partners is an important risk factor for HIV infection for young MSM because HIV prevalence is very age stratified, with prevalence in older men (over 30) almost twice as high as in younger MSM (less than 30 years old). However, young gay men with older partners are at risk for HIV not only because of the greater chance of encountering HIV, but because young men are at a disadvantage when negotiating safe sex. This could be because of trust for the older man in terms of sexual decision making, physical inability to refuse unsafe sex, a heightened desire to please his partner, and/or other reasons. This imbalance of power in decision making is reminiscent of a similar gender imbalance in many heterosexual couples.
3. Psychological Factors on Adherence
Unfortunately, stigma not only plays a role in how HIV is transmitted, but it affects treatment decisions, as well. For example, internalized heterosexism, or the internalization of societal anti-homosexual attitudes, are not only associated with unprotected receptive (but not insertive) anal intercourse with HIV-negative or unknown HIV status partners, but also with HAART non-adherence indirectly, through increased negative affect and more regular stimulant use (Johnson et al. 2008). Interestingly, this highlights the common conflict between internalized homophobia and being the receptive gay male partner. However, more importantly, it underlines the need for mental health experts to help address potential internalized heterosexism in HIV prevention and treatment with HIV-positive, and –negative, gay men.
Adherence in HIV-infected gay men is dependent on a complex and interrelated set of circumstances, including the availability of “MSM-friendly” health providers, cultural factors (such as fear of being deported or family/religious repercussions), concerns about physical appearance, practical considerations (like being able to remember to take the drugs), motivational prerequisites (believing in HAART and wanting to treat the HIV), and the availability of emotional support (Brion & Menke 2008). A key observation is that all of these factors influencing adherence is directly or indirectly related to the need to feel accepted and embraced in one’s community.
One successful method of maintaining adherence to HAART has been the practical support of gay male partners (Wrubel, Stumbo, & Johnson 2008). This support included reminders that were regular or situational; instrumental assistance, such as setting out medications at dose time and picking up refills; and coaching support, including situational problem-solving and shaping behaviour by offering affirmations. Unfortunately, the prevalence of long-term monogamy in gay males is low, in part due to the previously described stigma, thus limiting the practicality of partner support for many in the HIV-positive gay male population.
One type of counselling intervention administered prior to initiation of HAART and combined with follow-up phone support during HAART suggested cost-effective prolongation of the individuals’ lives, but only modest benefit for prevention of HIV transmission (Zaric et al. 2008). Such an intervention may be an avenue to explore, but the study also suggests the need to clarify how individuals view treatment versus transmission. Whether individuals see treatment as prevention or completely separate the two will help dictate future health policies and programs to educate and treat the public.
4. Conclusion: Implications for Change
Walch et al. (2010) looked at community attitudes toward homosexuality as a function of age, education, race/ethnicity, religious affiliation, political party affiliation, and personal contact with homosexual individuals and persons living with HIV/AIDS. All factors, besides race/ethnicity, were associated with homophobia, but a significant portion of the variance in homophobia was predicted by having personal contact with homosexual individuals. This finding is important because it suggests that eradicating homophobia simply requires getting to really know, and one presumes to like, a homosexual individual. This helps explain the importance of gay celebrities, like Adam Lambert and Neil Patrick Harris, in changing the tide of public opinion, and it also points to potential directions for government intervention, such as leveraging gay celebrities to have discourse with students in schools about homosexuality and homophobia. In Afraid to Be Gay, famous rugby player Gareth Thomas had a dialogue with students about how homophobic comments hurt him, and he was able to start helping students understand why their actions and words matter.
It is this author’s opinion that homophobia is the single most important underlying issue leading to the prevalence of HIV transmission in the gay male population. In order to change this, education about homosexuality, HIV, and homophobia needs to happen in high school, when students are starting to think independently from their parents and are starting to form lasting values and opinions about the world. This stage of life is where governments need to intervene to start eliminating homophobia from this generation on.”