Sunday, December 10, 2006

Campaign for condom use globally is failing to work with gay men - Rose Mangle

The AIDS epidemic was reported first in June 5, 1981. A brief article published by the CDC in its Morbidity and Mortality weekly report describing a strange new pneumonia in five otherwise healthy gay men. Even before that, the virus was first mentioned in may 8 issue in New York Native, a gay newspaper, AID was first detected in gay population. It was initially considered as “gay plague”. Almost from the beginning there was this message that HIV is transmitted in bodily fluids. The way to prevent HIV is to prevent transmission of bodily fluids by the use of condom. Even though safe sex and use of condom prevent the transmission of the world most deadly virus, still there is rising number of cases of unsafe sex in gay community. Studies have repeatedly shown a major problem with the condom and its consistent use efficacy (7). Since 2001, HIV is increasing by 1.6 percent each year globally. A recent study shows that one in 20 gay men were HIV positive in 2001 in North America and Europe. (1)

Stigma and homophobia

Since, any disease takes importance culturally and historically depending on how its interpreted and presented. The people respond according to the disease how it’s framed. (8) Aid is a plague of guilt and blame. It was labeled as gay plague, “GRID” [GAY RELATED IMMUNODEFICIENCY DISEASE]. Kaposi Sarcoma was called the “Gays Cancer”. Aids associated with gays further aggregated the stigma and homophobia of already stigmised group. (7)

Even today, the largest number of AIDS cases in the western world is homosexual and bisexual males and drug abusers. Majority of the people reject these forms of behavior and consumption. This rejection always results in negative feeling. Due to the stigma and homophobia, the preventive measures were minimal in early eighties due to social rejection and indifference. The initial efforts to fight the epidemic and creation of safer sex were exclusively developed by gay community. The government and media were uncooperative and did not made much effort in fighting AIDS. Addressing homosexuality was embarrassing for them. Death of homosexual was indifferent for them and they were not willing to discuss the possibility that how could gay men continue to have sexual fulfillment in the midst of sexually transmitted epidemic. (7)

The common social reaction to infectious disease is to blame them on some body else. The spread of AID was an opportunity for the people to point out fingers to its victim. Aids had created a clear division between innocent and guilty. The homosexuals denying the sexual order, threatening the pillars of family institution were regarded guilty and sinners and considered to deserve punishment such as AIDS. Clergy and religious leaders to advocate social reaction used AID as a tool. They also used it as tangible proof of god’s existence and his rage at sinners. The early era of aids being a gay disease played a great role in the spread of the disease. World faced a very political epidemic. Many heterosexual were left with the denial that they are not affected by AIDS/HIV and considered themselves non susceptible. By doing this, they placed themselves at increase risk of contracting virus. (7)

Most young gay teens were victim of stigma and have high level of dropouts, physical violence, drug abuse, and social isolation. High level of harassment that range from word taunting to physical violence lead to family stress to ejection from the home, lack of financial support. This has led to loneliness, the feeling of guilt. Homophobia can also be internalized causing low self-esteem among gay community. This indifferences and negative feelings have made them lose control of their lives and resulted in self-hatred and deep down they accepted HIV as a punishment of being gay. The self-hatred has lead to unsafe sex behaviors (i.e., not using a condom and having sex with an HIV-infected partner).

This example best fits the social learning model theory by Albert bandore in which he explains that self-efficacy can be influential in performing a health behavior. Self-efficacy means self-confidence that could only come from loving oneself and encourage forbidden behaviors. The social construction of HIV disease as a deserved punishment leaves gays with feeling of self-hatred resulting in low self-esteem, poor body image, depression and isolation. Others getting the aids such as donated blood and the drug abuser are considered the victims of the culprit. So it’s not paranoid for homosexuals to feel themselves blamed. (8)

The self-hatred and loss of self-confidence due to the internalized homophobia can lead to sense of fatalism and the belief that they will eventually be infected. HIV is being accepted as punishment. Some engage in unsafe sexual practices or injecting drug use putting them at risk of contracting HIV. This internalized homophobia may also lead to delay in seeking medical attention, thereby increasing the progression of HIV disease (9)


The argument would be different if unsafe sex automatically and instantly lead to HIV infection, illness and death.

First of all, the unsafe sex is not followed by instant and swift penalty of infection. One can expect that in order to get infected, you have to have unsafe sex at least several dozen times even with infected person to get infected. as long as the odds are with you many people decide to take the chance.

Second of all, HIV has a long incubation period. Illness is postponed for many years even if the infection occurs, even for decades. A teenager get infected would probably have the illness in his late thirties. Which is further delayed by drug treatment (8)

The cultural shift in perception of HIV among gay men is that Aid is now considered as a ‘manageable ’ and curable syndrome, rather being considered as a life threatening disease. The belief among gay men is that if you have HIV, you can live with it as long as you take the medication. This shift in the perception of the disease has led to risky behavior. Another notion has been spreading in gay community is that this is their fate to live with aids for the rest of their life. (3)

This argument is backed by social learning model theory in which two variables play important role, self-efficacy and outcome expectancy. The outcome expectancy variable in this case is that the taking of medication as prescribed would lead to longer and realistic life. A person is more likely to change his or her behavior if the outcome expectation is desirable. As the gay perceive the outcomes of medicine manageable, ultimately it changed their behavior towards preventive measure. The other factor is self-efficacy. The belief on oneself is that if one has aids, one can cope with it as its manageable. Gays accept it as a reward and spend more meaningful life without fear and precautions. This has further aggregated risky behavior and risky attitude. (5)


In the beginning the gays and lesbians were bombarded with the message that they are sick and disgusting. Polls consistently showed that 75% of Americans believe that homosexuality is in words in one poll ‘always wrong’’. (7)

The picture changes completely once you contract HIV. Government that refuses to give the basic civil rights to homosexual often provide housing, income support, and health cares to those with AIDS. Companies that often discriminate against the homosexual are often forbidden and sued by law to discriminate against those disabled by HIV. Families, who literary throw out their sons for being gay, embrace and take them back when they are dying. Clergymen who condemn homosexuality often turn around and take up a stand for the HIV and provide care. Its almost as if society is saying to HIV positive gay men that “Now that you are infected, you are forgiven’’. (8)

People and institution are compassionate towards those homosexuals dying of AIDS then for those who are struggling to live healthy sexual life. If you are merely gay than message is “you are always wrong”. If you get sick. People will love you again. You find meaning and community who care for you. You will be mourned. Its not illogical for the gay men to conclude at least they are better off, if not dead at least dying. They are rewarded more by society being infected then healthy. (9)

Another aspect of the rewardful life of being HIV positive is misapprehended within the gay community themselves. Some articles in gay magazines were filled with stories of the successful life of healthy young infected men having a rewardful life. The message is that one can have meaningful personal growth only after they were infected just to avoid the image of wasting, illness and gruesome deathbed scenes. (7)

High self-esteem and solved long-standing psychological problems could be seen as a sort of reward to a stranger to a gay community. Messages aimed towards infected inevitably reach the uninfected as well, creating an impression that the penalty of unsafe sex is really not so bad.

The theory of reasoned action in which the health behavior is result of two determents people’s attitude towards the behavior whether the behavior is good or bad and the person perception of social pressure to perform or not to perform an act. In the second determinant, its person’s belief about what others think will influence their perception. Which is called normative belief. If the social contribution in forgiving gays is so strong and influential after they contract HIV. Then the gays would be less hesitant to practice safe sex. The benefits awarded to gays who contract HIV are far more and out weigh then just being a gay.

Our behaviors are also attributed to the rewards and benefit which one get after a particular behavior. The reward behind being HIV positive and the boosterism is one of the factor encouraging gay men to practice unsafe sex. Even some gays do not consider themselves enough gay until infected with HIV.

Bare Backers and Partner Coercion

There is a minority group among the gay community who are called “bare backers”. The exact definition varies but ”bare backers” are generally considered to be gay men who are involved in sex without the use of condom and without caring about the HIV status of sex partners.

Bare backers are usually victims of loneliness and insecurity. The needs of intimacy and being loved have made them take riskier decisions by not using condom. They have difficulty being intimate while using condom. This bare backing attitude of gays reflects their feeling of loneliness. (6) Although there is small minority of this group in this community but they have the potential to shift safer sex norms within the gay community.

This attitude of the bare backers could be explained by the theory of Reasoned Actions, in which the attitude towards the behavior and the perception of the social norm that is if you are bare backer, you consider your partner as clean loved and wanted which leads to an intention of a behavior that is unsafe sex. Sexual intimacy is a way of creating a community, a source of psychological meaning. In the gay world in which sex itself provide the sense of meaning and community that children and marriage provide for others. Within gay community those who have occasional unsafe sex are acting in full accord with the total reward system that they find themselves. Men in this group define unsafe sex ‘an expression of love, affection or acceptance. Many define this behavior as a sacrifice made for their partner. (8)

There is a group of men who claim that that have been involved in unsafe sex due to pressure of their partners. Some claim that their partners saying that they are using condoms deceive them.

Human behavior in groups is one of the concentrations of social psychology. Many aspects of our behaviors are outcomes influenced directly or indirectly by others. Even some aspects inside us are influenced by our surroundings. For example self-concept is formed and reformed in interaction with others. Our attitude and decision are shaped and reshaped through discussion and interchange with other people. Indeed we are social animal who live in groups.

Health decision model that include variables beyond those related to the individuals view. Some decision is made jointly involving two or three person. The decision about Use of condom involves two people and it’s basically the decision of two people at one point in place and time. The conflict should be resolved if one person favor the use of condom and the other person does not.

The health decision model focuses on the social variable of experience, and interaction, in addition to the variables of severity, susceptibility and evaluation of action. This model suggest that the decision of an individual to change the health behavior is based on individual experience with other people in the past who are important to him or her and the knowledge of others view and opinions and individuals current interaction with others.

Health decision model throws further light why someone may not follow a preventive measure such as use of condom. The health intervention programs could be more effective if more aspects related to health behavior change principles are incorporated. Special focus should be paid on behavior skill training and norm resetting related to sexual behavior. The skills should include the behavior principles related to negotiating condom use with the sexual partner.


The message of safe sex and use of condom and the fear of AIDS has been repeated so often that the people ignore or actively refuses to hear it. Efforts that are made to prevent AIDS but completely ignore its maintenance of safe sex have failed. There is need of strengthen activities in surveillance, intervention research and prevention. The health intervention should address the ways to sustainability and long-term use of condoms (5) Overhauling of these programs are desperately needed to keep HIV salient in the minds of MSM.

Some connection with personnel emotion can facilitate long term Change. Simply conveying message repeatedly to a person doesn’t change a behavior. Advertisement with an emotion with information can create a difference. Positive and negative emotions are generally used in health behavior change. Negative emotion such as fear can be used in health behavior change. We have to be careful with the particular emotions, especially fear. If we generate too much of a fear, the message is often missed and often backfired. (8)

The example of the use of condom has definitely been used so much that gays literary turned away from the message and others reject the information and decide that it’s too late to make a change. To know how much fear is appropriate and to learn which other emotions would be best to tap, we need to know and understand well the intended audience for our message


Effective health prevention not only involves social and cultural dimensions but also, technology and physical setting related to the target population. Law, technology and physical setting are considered the structural elements.

Proper use of condoms is effective and can minimize the risk of HIV contraction during the sex since condoms are widely advocated as good protection. It does not provide 100 percent protection. Studies has shown that condom sometimes break, fall off during or after, or are otherwise misused. 4.7% to 8% of condom failure reported by a survey published in American Journal Public Health. Condom being too small, too thin, the use of oil opposed to water based lubricant, physical stress on condom inherent to anal intercourse not designed for anal intercourse are factors that lead to failure of condom. The mechanical failure of condom has created different outcomes and confusion resulting in more condom free sex. The mechanical failure of condom use has also increased the unsafe behavior of the gays. It’s important to improve the Quality and efficacy of the condoms. Attention to the structural aspect is important. Which is one of the principles of health behavior.

The health belief model could further explain the structural and the loss of the credibility on the condoms. In which the third variable is person’s evaluation of the effectiveness of the recommended health promoting or illness preventing action. If the action is clearly effective, it is easier for the person to decide to undertake the action. Seat belt use in automobile is a good example. Seat-belt use saves life is proven by great data. More people have taken the action to start wearing seat belt due to their belief in the data. However, the outcomes of condom use are confusing and not 100 percent effective. Those who question the effectiveness of condom in preventing the spread of AIDS feel little or no pressure to use them, which explain why some people do not use condoms.


Friday, August 18, 2006 / 12:10 PM. Study warns of skyrocketing HIV rates.

Gus Cairns. 11/9/06. A Common Problem.

August 17, 2006. What Lies Ahead. /

G J Hart, L M Williamson. 01/10/05. Increase in HIV sexual risk behavior in homosexual men in Scotland, 1996 – 2002. Preventive failure.

Ron Stall. 9/17/94. “How to lose the fight against AIDS among gay men”.

Richard J Wolitski, MA. Ronald O. Valdiserri, MD, MPH, Paul H. Denning, MD, MPH, and
William C. Levine, MD, MSc. June 2001. Volume 19. “Are we headed for a resurgence of the HIV epidemic among men who have sex with men?” American Journal of Public Health.


Pollak Micheal “ AIDS A problem for sociological Research” 1992

Hung Y.Fan , Ross F.Conner, Luis P. Villarreal “ AIDS Science And Society” Fouth edition 2004


Anonymous Anonymous said...

Hi, Rose-Thanks for your interesting thoughts on HIV prevention efforts among gay men. I agree with you that self efficacy plays an important role in HIV prevention among gay and bisexual men. I don't really agree with your theory about gay men seeing HIV as a way of being accepted...although I know that theory is considered. I actually think that HIV is another reason that gay men are stigmitized. In other words, people don't get special attention for having HIV. Instead, many use HIV as another reason to stigmitize gay men (eg all gay men have HIV/AIDS).
I look forward to discussing more in seminar. Rodney

5:29 PM  
Anonymous Anonymous said...

That is a tremendous insight, a
tremendous insight, that "If you
get sick, people will love you
again" could be a hidden motivator,
an imagined reward which somewhat
balances-out the negative aspects
of contracting HIV/AIDS.

And people do treat you differently
when you're acting-up and in their
face, different from when you're
visibly just trying to survive.

It is a common fantasy in children
(not having done any research on this,
I state this just from my own imagination,
and memory of my childhood) that when
children are powerless and somebody is
giving them a hard time, they imagine
"boy, if I really were afflicted, then
you'd be sorry for treating me badly now."
And if it occurs in children,
you can't rule it out in adults.

2:16 PM  

Post a Comment

<< Home