A discussion paper based on a Canadian project that invited HIV-negative and HIV-positive gay men to discuss anti-HIV stigma and sexual risk-taking concludes that ideas of “individual responsibility” and “looking after one’s health” are flawed as models of how to deal with the risk of HIV in the gay community.
They argue that the idea that “everyone is responsible for their own health” tends to create a situation in which responsibility is either passed to the other person in a sexual encounter, especially between partners of different HIV status, or is interpreted as a rigid exclusion of certain people or behaviours from the sexual repertoire.
These strategies may keep gay men physically free from HIV and STIs but can also paradoxically increase risk and entrench stigma within the gay community.
The authors – and some of the respondents in the discussion project – urge the revival of a more community-centred, mutual and dialogue-based approach to HIV risk that does not leave gay men to deal, or fail to deal, with HIV alone and which involves honest and respectful dialogue about sexual risk and HIV, both between couples and within the community.
The HIV stigma campaign was financed by the AIDS Bureau of the Ontario Ministry of Health in Canada in collaboration with local AIDS service organisations. Canada, and Ontario in particular, has particularly stringent laws on HIV transmission, exposing partners to HIV, and non-disclosure of status and has ruled that people with HIV only have a defence against non-disclosure if they both use a condom and have an undetectable viral load – not one or the other.
The HIV stigma campaign ran in 2010 and was publicised by adverts on billboards, in the gay press and on online meet websites that asked: “If you were rejected every time you disclosed, would you?” The campaign’s own website attracted 20,844 visitors, 4384 of whom visited it more than ten times.
Details of the outcomes and effects of this project appeared in a report on aidsmap.com in 2011.
The current article is a qualitative analysis of themes that emerged during moderated web discussion on www.hivstigma.com, the website attached to the project which, among other facts, points out that 30% of gay men with HIV in Ontario are undiagnosed.
One big theme emerged from these discussions: personal responsibility and, in particular, the idea that sexual risk is a solely individual matter. Researchers found that the men they talked to felt not only solely responsible for their own health but also, and paradoxically, solely responsible for the sexual health of their partners too.
As the writers of the article comment, this avoids the ordeal of disclosure but leaves gay men alone: “Protection from risk,” they comment, “is a contract, not between sexual partners, but a contract with oneself in order to be free from harm.”
When this individual responsibility does not ‘work’ – when men end up acquiring HIV or have sex that violates this code – many blame the other person for not being individually responsible, rather than pondering how lack of communication on HIV status, condom use, or sexual preference may have led to the situation. The result is a situation in which members of the gay community reflexively blame other gay men for the continued spread of HIV.
This theme – the burden of personal responsibility – plays out in many different ways. The starting point for many respondents was the individual responsibility each man has for his own health:
“Anyone who engages in risky behaviour and then seeks to blame someone for their conversion is not carrying his weight”
“If you are going to live recklessly, don’t blame others”
“Who is liable in this situation? Me, of course. I knew it was a risk. I did not know this guy. Why did I trust him? It was all my decision and my responsibility.”
Yet mixed into these comments, sometimes in the same sentence, is the complementary notion that the main reason for continued HIV transmission is because other gay men are not taking responsibility rather than the writer.
The first writer goes on to say: “Basically, it takes two to tango. The weight of the situation is in truth shared, but...gay men often like to paint the poz folks for stopping everything, even if a negative guy will bareback with anyone that says he is neg.”
The “two to tango” metaphor is also used by the second writer, who goes on to say: “Yes, it takes two to tango and this [i.e. HIV infection] is what happens when assumptions get made.”
The researchers comments that the “two to tango” metaphor is not being used here to suggest that gay men share or negotiate responsibility in sexual safety but rather that they should both take individual responsibility, as isolated, self-determined human beings: “The responsible actor is assumed to be fully knowledgeable and exclusively responsible for himself, rather than a participant in...practice that emerges between sexual partners.” In other words, it is not taking responsibility that is problematic, it is failing to share it.
When 'responsibility' equals silence
One consequence of exclusive personal responsibility is, the authors say, that it can “foreclose discussion about serostatus”. One respondent explicitly opposes discussion of serostatus with condom use, saying the first is unnecessary if the second is observed:
“I also try to educate people by saying ‘No I am not HIV positive, but you shouldn’t be asking the question. You should instead be protecting yourself as I do. I feel that’s the best way and you take responsibility for your actions not leave the onus on someone else to volunteer information.”
There is no need, in short, to ‘negotiate’ safety if you completely succeed, as the authors put it, “In closing off your body to risk”.
The problem with this is that if this strategy fails then one is left with nothing but blame, either for oneself or for the other person, as epitomised in this poignant passage from someone who did acquire HIV. At first he blames himself:
“I should not have had sex with a random person. I should not have trusted someone I don’t know. I should not have had unsafe sex. Period.”
But then bursts out in fury at the person who infected him:
“Even when I agree it is my responsibility, he reminds me of the kid that tears the wings off flies just for fun and when confronted with his cruelty says ‘Well, the fly should not have entered my room for starters.’”
The idea of individual responsibility is also problematic if (as is particularly the case in Canada) people with HIV are regarded as having the majority of, or all, the responsibility to avoid transmission.
Some respondents were quite happy about this:
“The best prevention of HIV is never to have sex with an infected person. This is my right. Any infected person has a moral and I hope legal obligation to disclose their HIV status before having sex. It is not up to you to decide how I should protect myself, it is up to me. There is an old saying ‘Your rights end where mine begin’.”
Some HIV-positive men agreed:
“I do consider that I have a higher level of responsibility to myself and others now I am poz than I did before.”
Others, however, resented the extra burden they felt was placed on their shoulders with their HIV:
“It’s easier for HIV-negative guys to avoid HIV-positive guys by saying ‘It’s the law for you to tell me’ so they don’t have to ask [or] take responsibility for any conversation, because they know it would ‘kill the mood’. So they think ‘It’s your problem, you do all the work’.”
Some thought avoiding talking about HIV was part of a general social attitude drive towards leading lives that were flawless on the surface or avoided complication:
“We live in pragmatic times and nobody wants to get involved with people with problems – they don’t want a sick guy with their Cheerios. They don’t want to risk their health..they don’t want to risk anything...they want to live paranoically safely.”
Others thought that avoiding dialogue was more due to the general failings of human nature:
“It’s not like poz guys are homicidal maniacs or neg guys are irresponsible dopes. Boys just want to have fun. And when being nosy or honest gets in the way, we make assumptions about each other that don’t work.”
Some respondents thought this isolated and isolating individuality was exacting a great price on the gay community:
“The outcome of all this fear and rejection is isolation. HIV-negative dudes are cutting themselves off from [HIV-positive] men who are wise, sexy, experienced and full of vitality. And HIV-positive men are being marginalised from a community they have equal claim to...HIV stigma literally sucks the life out of the community.”
What to do instead? The researchers, and many of the bloggers in the project, advocated for a much more communal and dialogic approach both to the business of safer sex and to talking about HIV in the community in general:
“What takes collective maturity is to say HIV has and continues to affect a vast number of gay men, with impact on our community and collective soul. Let’s face it, not turn our back on it.”
The researchers recommend an approach towards sexual risk that accepts:
- firstly, that risk cannot be eliminated from gay men’s sex lives;
- secondly, that understands how silence, blame and shame (“the structures of domination that risk discourse produces” in their words) increase rather than control risk;
- thirdly, that understands that the very nature of the gay community and being a gay man are dictated by the quality of the conversations we are able to have with each other about risk.
One respondent asked the question of where responsibility lies thus:
“What are the ways that we can highlight both the importance of individual responsibility for both HIV-positive and -negative men, and yet also speak to the importance of a concern for the collective responsibility for the physical and emotional health and wellbeing of our community? What would it look like tangibly?”
“A ‘look out for yourself’ mentality without a regard for the health of our neighbours doesn’t promote the idea of a healthy community, and that’s what ending stigma is all about.”
But he goes on to emphasise that he thinks there is a responsibility that older and more experienced gay men have within their community to have dialogues about safety:
“Sometimes even in this partnership of shared responsibility there requires a bit of mentorship by those with a clearer understanding of the issue. Where disclosure isn’t always an option, it can be as simple as ‘you should really always lay with a condom, let me show you how’.”
The researchers put it this way: “Silence may disadvantage those who may not know or understand the cues for sexual engagement in certain settings, such as men who are new to gay scenes, immigrants, or simply men in different micro-cultures with different shared understandings.”
Many men avoid talking about HIV because it can be painful, as one HIV-positive respondent with a younger HIV-negative boyfriend says:
“I don’t want to pressure him into an act he is not comfortable with...even though he loves me he gets upset because of my status and I get frustrated because I really want safe sex with him. But, he is afraid...”
Failing to talk about HIV, however, may be harming the gay community in a fundamental way, and may be ignoring some lessons from history, one respondent comments at the end of the article:
“HIV-positive people have a proud history. We changed the way medicine and research are practised. We developed services and support systems to keep ourselves healthy. We pushed governments and won programs to ensure everyone has access to treatment. We invented safer sex to protect each other."
The researchers comment that “early HIV activists were keenly aware of, and vocal about, the individualised moral subject, proposing instead community-oriented solutions that engaged with the state and the medical system.”
Another put it more personally:
“The cultural distinctions we wear upon ourselves like clothing do not stop us from loving, hating, hurting or holding out a hand to another – and as a human, it’s very easy to hurt. There’s only two things that help me get past the prejudices I accuse others of – the fact I know I’m as guilty as they are, and that I can love them if they are willing to be loved.”