HIV-positive gay men’s experiences of stigma and rejection by sexual partners strongly influence their involvement in casual sex and discourage them from practicing many risk-reduction strategies, report Sigma Research in their Relative Safety II report published this week.
The men they interviewed wished to balance their desire for sexual pleasure with a need to maintain their sense of moral integrity, but were often unable to avoid sex that could result in HIV transmission.
To follow up a similar study published a decade ago, Adam Bourne and colleagues interviewed 42 gay men with diagnosed HIV about their sexual practices and management of risk. The in-depth, qualitative interviews focused on recent experiences of unprotected anal intercourse (UAI), and to take part in the study, men had to have had unprotected sex in the past year. Therefore it’s important to note that the study does not reflect the experiences of the one-third of gay men with HIV who do not practice UAI in any given year.
The researchers attempted to include in the sample a mix of respondents from London and Manchester as well as lower-prevalence areas, and also ensure diversity in terms of age and time since diagnosis.
All respondents were aware that they could transmit HIV through unprotected anal intercourse, and almost all said that they would never want to be responsible for doing so. Men more recently diagnosed tended to be particularly preoccupied by this concern, often avoiding sex altogether for a period after diagnosis.
In terms of the other harms that unprotected sex could give rise to, men tended to feel that sexually transmitted infections were rarely serious, although a few were more concerned about hepatitis C. Whilst some recently diagnosed men felt that HIV superinfection was an issue, men who had been diagnosed for longer usually believed that clinicians had deliberately exaggerated its importance.
Of more concern, however, were the emotional, psychological and social harms that unprotected sex could lead to. If men failed to live up to their own ethical guidelines, this could lead to inner turmoil. Moreover, some respondents described the perceived irresponsible behaviour of other HIV-positive men in order to highlight their own moral integrity. Having unprotected anal intercourse posed a threat both to a man’s positive sense of self and to the way in which other gay men saw him.
The researchers argue that men’s concerns about rejection and stigma shape the way they manage risk. Disclosure leaves men vulnerable to significant harm, including violent reactions and anxiety about ex-partners using police investigations as retribution, as well as rejection leading to emotional upset and problems finding sexual partners. In a community that often remains hostile to people with HIV, men’s instinct for self-preservation often leads them to choose behaviours where disclosure is felt to be unnecessary.
For example, many men used saunas, not just because sex was readily available, but also because the men assumed that almost all other sauna users were HIV-positive. Like online chat rooms or HIV support group meetings, saunas were thought to be ‘HIV-positive spaces’ where men had implicitly announced their HIV status simply by being there. This allowed men to have unprotected sex there without an explicit discussion of HIV status, but leaving them with their sense of personal integrity intact.
In some settings, some men tried to avoid disclosure but maintain their sense of moral integrity by suggesting to sexual partners that it would be a good idea to use a condom. Nonetheless one man described how these suggestions prompted one sexual partner to ask directly whether he had HIV. When he said yes, the man became angry and left.
Another form of implicit disclosure that men tried was ticking ‘safer sex needs discussion’ on a Gaydar internet profile. Few men explicitly advertised their HIV status on their profile, but might mention it during private instant messaging. The respondents described ambiguities and misunderstandings in disclosure on the internet, but generally found that the internet enabled them to screen potential partners with less fear of disappointment or reprisal.
Nonetheless, the researchers found that men used risk reduction strategies to quite a limited extent. No respondents mentioned reducing the duration of anal intercourse or the impact that viral load or a sexually transmitted infection could have on the risk of transmission. Just a few men discussed the greater risk of infection for the receptive partner or the possible benefit of withdrawing before ejaculation.
Some men did practice some form of serosorting (seeking partners of the same HIV status) and respondents said that it allowed them to have uninhibited sex where HIV status did not remain the most salient concern throughout.
Nonetheless the researchers stress that very few men exclusively practiced serosorting in a way that could guarantee that both partners had the same HIV status. Disclosure was often implicit (by being in a sauna, for example) or was not reciprocal. The respondent may have made an upfront disclosure of HIV status, and assumed that if his partner was ready to carry on without condoms, then he must be positive too.
However, the majority of men actually rejected the idea of serosorting. It was associated in their minds with high-risk, esoteric practices, and in the words of one respondent, men who are “going spreading it round because they are shagging willy-nilly”. Many men were at pains to distance themselves from this behaviour. They were appalled by the idea that unprotected sex could ever be a regular or planned activity, and so rejected serosorting, strategic positioning, withdrawal before ejaculation and other risk-reduction strategies.
Nonetheless these same men had all had some unprotected sex. It tended to be described as an exceptional event, explained by circumstances such as substance use or a partner’s insistence. The researchers make it clear that a number of men lacked the self-confidence or negotiation skills to manage such situations. Many men aspired to use a condom every time, but were not able to fall back on risk-reduction strategies when, for whatever reason, condoms weren’t used.
In their conclusion the researchers note several consequences of HIV-related stigma: a reluctance to disclose and an encouragement to have anonymous sex; some interviewees' rejection of other HIV-positive men and their behaviour; a desire not to engage with the idea that HIV risk is an integral part of sex; and the reluctance to use risk-reduction strategies.
However they also note that, for many men, there are direct contradictions between their intentions and their behaviour. Many men construct systems of belief about risk that enable them to have the sex they desire, whilst feeling that they are ‘moral enough’. They believe they are behaving responsibly, but HIV transmission may well be taking place.
The researchers recommend tailored prevention interventions for diagnosed men which take account of the centrality of stigma, and discuss unprotected sex in credible and informative ways. Moreover, health professionals need to improve their skills in engaging men with these issues.