Risk, Stigma, and Pleasure:
The role of PrEP and Bareback Sexual Behavior among
the Men who have Sex with Men in Amsterdam
Kevin Singh (10870555)
MSc Medical Anthropology and Sociology Universiteit Van Amsterdam
Master Thesis 2016 Supervisor: Dr. Rene Gerrets Second Reader: Dr. Eileen Moyer
Acknowledgements
First and foremost I would like to thank all the respondents who participated in my research, their willingness to open up about such sensitive topics gave me the courage to continue
through some of the harder days of my writing.
Next I would like to thank my supervisor and mentor Dr. René Gerrets, whose wisdom and encouragement kept me going through the worst of it.
Last I would like to give thanks to my loving Mother and beloved Brother for their continued love and support, I could not do this without them.
Table of Contents
Table of Contents 2
Chapter One: Introduction 3
1. Problem Statement 3
2. Literature Review 4
1.3 Theoretical framework 7
Chapter Two: Research Methodology 9
2.1 Introduction to Methods 9
2.2 Ethnographic Methods 9
Ethnographic Field sites 9
Interviews 11
CyberEthnography 12
Informal Conversations 12
2.3 Ethical considerations 13
2.4 Data Analysis 13
2.5 Obstacles and Reflexivity 13
Chapter Three: Risk and Health, Sexual Behavior of PrEP 15
3.1 Introduction to Risk 15
3.2 Risk Compensation 16
3.3 Risk Compensation vs Disinhibition 18
3.4 Risk and Biomedical Technology 19
3.5 Risk Behavior and Change 20
3.6 Conclusions and Reflection 22
Chapter Four: Stigma, Sexual Beliefs and Behavior 24
4.1 Introduction to Stigma 25
4.2 Stigma and HIV 26
4.3 Anticipated Stigma and HIV 26
4.4 PrEP and Stigma 26
4.5 Data: Experiences with Stigma 27
Chapter Five: In the Pursuit of Pleasure? 34
5.1 Introduction to Pleasure 34
5.2 Sexual Morality and Pleasure 34
5.3 Sexual Health Behavior and Condom Fatigue 36
5.4 PrEP and Pleasure 38
5.5 Conclusion: Pleasure 39
Chapter Six: Conclusion-Final Thought and Discussions 41
Bibliography 44
In conventional wisdom it holds that risk taking in sexual behavior can play a role in the high rates of sexually transmitted disease (STD) and the continued spread of the human immunodeficiency virus (HIV). Despite years of research, the psychosocial mechanisms that lead to risk-taking behavior are still not completely understood. Prior research has often assumed that sexual decision making depends on rational thought processes and has not adequately addressed the role that other factors, such as emotional state, attraction, arousal, personality, substance use, as well as social and cultural influences, may have on behavior (Bancroft., Janssen., Strong., Carnes., 2003; Watkins-Hayes 2014). More recent work has shifted to answering these deficiencies, however with mixed results (Watkins-Hayes, 2014).
Understanding sexual risk behavior becomes even more essential when considering the role it plays in safe sex practices. In their annual epidemiological report 2014, the European Center for Disease Prevention and Control (ECDC), indicate that sexual transmitted infection (STI) continue to pose a threat to the public health in Europe. Many sexual behaviors increase an individual’s risk of STI contraction. Having sex without a condom, having sex with many partners, and having sex for pay or paying for sex are
especially risky (Campsmith et al., 2008; Workowski & Berman, 2010). In the Stitching HIV Monitoring (SHM) monitoring report 2015, sexually transmitted infections (STI), in
particular HIV continue to pose a threat to public health in the Netherlands. At the end of 2014 19,773 people have tested positive for HIV in the Netherlands, of whom 18,355 are in care. It is estimated that there are around 2,800 people who are HIV-Positive and living in the Netherlands, but don't know it. Understanding the mechanisms around the negotiation and assessment to have safe versus unprotected sex is essential in high-risk populations, such as gay and bisexual men in whom nearly two-thirds of new HIV infections occur (Workowski & Berman, 2010; Parsons, Grov, Golub, 2012).
Despite the implementation of behavioral preventive interventions and technologies designed to slow the transmission of HIV, as well as the coverage of antiretroviral therapy (ART) among HIV infected men who have sex with men (MSM), HIV continues to spread among high risk populations of not only the Netherlands, but other countries throughout the world (WHO, 2013)(Parsons et al., 2012). In response to this, a new biomedical approach has been created to offer HIV negative individuals a chance to reduce their risk of HIV through the usage of low intensity ART, it is the hope of researchers that the usage of pre-exposure prophylaxis (PrEP) will act as a preventative form of treatment against the continued spread of HIV. The multinational iPrEX study has reported a 44% reduction in HIV acquisition among MSM using daily PrEP, when compared to placebo controls. They also found a 92% reduction in HIV infections among MSM who remained adherent to the usage of daily PrEP (Grant., et al., 2010). Overall the usage of PrEP represents a new tool within the arena of HIV prevention. However, while many researchers are optimistic about the role PrEP will play in diminishing HIV transmission, there are many who argue against the availability of PrEP and the subsequent consequences, such as the potential increase in high risk sexual behaviors (i.e. condom-less sex).
Bareback sex is a slang word for a form of sexual activity, commonly penetrative sex, done without the usage of a condom. The term originates in the gay community and comes
from the equestrian term bareback, which refers to the practice of riding a horse without a saddle (Berg R., 2009). Overall, the practice of barebacking is usually referred to as conscious choice to not use condoms during penetrative anal sex. As the potential sexual health repercussions of such a phenomenon are exponential, it is imperative we critically examine the nature of such a practice in order to better understand how we may better improve sexual health efficacy. As stated above very little has been done to understand how culture, society, and even individual factors shape the sexual risk taking subculture. To these ends we must ask the question of how intersectionality of so many factors shapes the practice of this phenomena, and how the introduction of PrEP as a new biomedical technology may shift the overall culture of sexual behavior for MSM, and in turn change the nature of this practice among the MSM of Amsterdam. To these ends, I aimed to conduct an ethnographic field study surrounding the MSM culture of the greater Amsterdam area. In doing so my fieldwork has been guided by the following research question:
How does PrEP as a biomedical technology, shape the psychosocial and cultural landscape of MSM who practice bareback sex behavior in Amsterdam, the Netherlands?
Literature Review
In order to understand the potential influence of PrEP on the bareback subculture, it is imperative to understand the individual and ecological (socio-environmental) motivations to have bareback sex. As stated above, bareback sex is a form of penetrative sexual activity forgoing the usage of condoms. As such, it is important to understand how condoms play a role in the individuals’ assessment to partake in bareback sex. Condoms, initially used for contraceptive purposes, quickly came to be used to limit or prevent sexually transmitted diseases. As the AIDS epidemic emerged and the transmission factors of HIV became known, the usage of condoms became even more prevalent as the principal tool in the prevention of infection. This was more so true for MSM who engaged in anal sex, the importance of the usage of a condom in HIV prevention helped to shape the role of sexual health and interventions in the fight against HIV, thus establishing its usage as a norm for sexual behavior. However, the choice to forego the usage of condoms itself is a complicated one with many factors, many studies have focused on this particular issue with various results.
Adam et al. (2010) also found that among many MSM who report unsafe sex
scenarios, many involved the concept of being lost in the “heat of the moment”. As in many other studies, a common theme reported is the role of condoms and erectile difficulties, as well as the reported urgency of passion and opportunity to connect with a particular desirable partner accounts for some unsafe sexual encounters (Calabrese et al., 2012). In addition many studies have found a connection to the usage of drugs or alcohol as a facilitator for these heat of the moment scenarios (Berg et al., 2011; Grov et al., 2007; Watkins-Hayes et al., 2014). Furthermore, heat of the moment situations may further become compounded upon by trade-off scenarios, in which men may feel at a disadvantage with a particular partner, be it in terms of age, ethnicity, or attractiveness. There is a fear of not wanting to offend or insult the
desirable partner, thus leading to a trade away of safer sex implication in case it leads to an obstacle in having sex with this desirable partner (Adam et al., 2010).
The role of sexual compulsivity has also been associated with increased sexual risk behaviors among MSM. Often characterized as sexual fantasies and behaviors which interfere with an individual’s personal and often inter-personal well-being, these fantasies and behaviors can occur in both men and women and continue increase over time, leading to further disruption in an individual’s life (Kalichman & Rompa, 1995; Parsons, Kelly, Bimbi, Muench, & Morgenstern, 2007; Parsons et al., 2012). When comparing MSM without sexual compulsivity to MSM who do, researchers have found that those with signs of compulsivity report higher rates of unprotected anal intercourse, an increase in numbers of sexual partners, more instances of sexual intercourse under the influence of drugs, and higher incidence of HIV and STI. (Grove, Parsons, & Bimbi, 2010; O’Leary, Wolitsky, & Remien, 2005; Parson et al., 2012).
While there are numerous theories for why MSM may engage in unprotected sex, one constant among the research among MSM who self-identify as gay men, is the theme of feeling alienated from the overall gay community, or conversely strongly identifying with it (Adam et al., 2005; Adam et al., 2008 ). It is here that alienation from a community you feel you should belong to, can bring on an internal feeling of loneliness, researchers have argued that it is this need to be accepted into the community that sometimes drives men into taking unsafe sexual risks. The same could be argued to play a role among MSM who do not identify as gay. This also plays into the perception of intimacy, not only with one’s sexual partner, but with a community in of itself (Frasca et al., 2012). While it can be argued that various psychological factors as well as social factors shape these concepts, the possibility of an internal construct of these social values placed on community and intimacy help to shape the overall field of bareback sexual behavior(Adams et al., 2005).
Lastly, as stated before, the need to answer the loneliness in the individuals’ self may drive the intent of not using condoms in a sexual situation. Yet decision-making is a
cognitive process in which a course of action is selected among many alternative
possibilities. Every decision-making process should produce a final choice that may or may not prompt an action. The decision of whether or not to pursue a sexual encounter has intrigued many researchers. What can appear to be a simple choice of yes or no often
involves a complex balance of short- and long-term potential benefits and costs , to both self and others. In answer to the question of how MSM weigh and out-weigh the risks and benefits of bareback sexual behavior may be tied to the final internal factor to be discussed, inevitability. Previous research has found that small portion of MSM have a preconceived sense of inevitability in that becoming infected with HIV is just a matter of time in the MSM community (Balán et al., 2013 ).
It has long been known that social factors such as race, and socioeconomic factors contribute to disparities in health. To this degree it can also be argued that sexuality can as well. At the widest level of social influence, factors such as heteronormativity may play a role in the alienation and rejection of MSM as a sexual minority. To this extent researchers
have viewed barebacking as a phenomenon which exists in an oppressive heteronormative society (Riggs, 2006). It is further argued that barebacking is a result of MSM asserting their expression of sexuality in an attempt to protest the homonegative views of sex (Holmes & Warner, 2005). The expression of homonegativity in society overall may act as
environmental stressor, which in turn may be preventative in HIV reduction behaviors. The internet has the capacity to provide a social network and environment to a unlimited assortment of social phenomena , thus providing endless opportunities. Yet how it does so is not yet clearly understood. While not having a hand in the creation of the bareback subculture, it has certainly has facilitated it. The internet serves as a medium in which MSM who bareback may be able to locate one another more easily. In research by Grov et al. (2006) it is estimated that there are about half dozen websites which exclusively target men who bareback seeking partners. According to cybercartography work on these websites and other bareback related sites, barebacking behavior was encouraged as an “expression of masculinity, courage, freedom and intimacy” (Carballo-Diéguez et al., 2006; Berg, 2009). Other research has shown that MSM find the internet as an easy medium in which to find partners who want to bareback (Halkitis & Parsons, 2003). Overall, research has found that with the rise of the internet as a sexual venue, the emergence barebacking related websites has potentially contributed to barebacking in of itself (Elford et al., 2007; Grov et al.,2007; Blackwell, 2010 ).
The role of community activism has also shaped the landscape of the bareback
culture. Research has found that MSM who practice bareback sex have found themselves in a changed cultural climate, which was shaped by a sense of complacency and normalcy. A lack of social responsibility and reported fatigue with the AIDS epidemic and condoms, has resulted in the normalcy of bareback behavior (Carballo-Diéguez & Bauermeister, 2004; Halkitis et al., 2003 ). The assumption of bareback sex as a norm continues as men who practice it report lower perceptions of safer sex norms in their community, suggesting that in certain groups, the act of bareback sex has already shifted to a form of social structure which as affirmed and normalized bareback sex (Berg, 2008).
In general, with the improvements of HIV treatment and the increase in longevity of individuals living with HIV, as well as improvement of quality of life, there has been a shift in the perception of HIV infection. With these advances in treatment and medical technology it is possible to argue that the perception of HIV as a chronic debilitating death sentence has been shifted to one of a simple chronic disease manageable by daily medication. Many research studies have found that this view has contributed to MSM’s decision to bareback in decreasing their concerns of infection (Berg, 2013; Elford et al., 2007). In one particular study men reported the knowledge that fewer men were developing AIDS due to improved medical technology lead them to have more unprotected sex (Mansergh et al., 2002). In addition research done by Halkitis et al. (2003) found that nearly half of the MSM in their sample felt that barebacking increased in New York City due to advances in medical treatment of HIV. In London, Elford et al. (2007) found that barebackers where much less worried about HIV infection due to the availability of HAART.
With current public health and HIV prevention movements aiming to implement PrEP to the Netherlands in the near future, there continues to be concern over how such a
biomedical technology can shape the lives of those it was intended for. Before
implementation it will be necessary to assess how such technology can shape the already existing culture of bareback sexual practice. Recently work undertaken by Bil and colleagues (2015) attempted to examine the role of PrEP awareness and intentions among the MSM in Amsterdam, the Netherlands. They found that despite indications of an overall low intention to use PrEP among their sample, MSM who indicated a high degree of sexual risk taking were more inclined to be interested in the usage of PrEP. Similarly Golub and colleagues (2010) found parallel results among MSM of New York Cityas well as reported a decreased usage of condoms with intentions to use PrEP as well as an increase in sexual risk behaviors. Further research by Golub et al. (2013) later attempted to identify potential facilitators and barriers to PrEP acceptability as well as motivations for adherence among MSM and
transgendered women in New York City. They found that while over half their sample were willing to take PrEP, the most common barrier to PrEP use were health concerns, including both long term and short term side effects, the impact on future drug resistance, and the overall concern that PrEP does not provide complete protection against HIV. Facilitators to PrEP were free access, followed by support services such as regular HIV testing, sexual healthcare/monitoring, as well as access to counseling. One of the most interesting findings of this study was that participants of color were more likely to rate barriers and facilitators of PrEP highly when compared to their white counterparts, due to social factors associated with disparities in access to prevention and care among MSM as well as disparities in access to or acceptability of PrEP. Based on these studies it is clear that the advent of PrEP usage among the MSM community will have an impact on sexual behavior and health practices. To these ends I have attempted to identify potential barriers and facilitators to use PrEP among the bareback MSM population in Amsterdam, Furthermore I have endeavored to observe the potential influence PrEP may have on long standing high risk behaviors. Finally, my overall goal has been to understand the psychosocial nature of bareback sexual practices as well as the psychosocial motivation to use PrEP.
Theoretical Framework
In an attempt to explore the dimensions of bareback sex as a sexual subculture among MSM we must first identify what forces shape the practice of bareback sex, and how it may be conceived as a sexual subculture. In using Bronfenbrenner’s ecological systems theory, which identifies ‘environmental’ systems in which an individual may interact. I will attempt to provide a framework in which I can critically examine the relationship of the individual with the surrounding community and overall society. In using the Ecological systems theory, I approach bareback sexual behavior from a multi systemic perspective. This theory
emphasizes the reciprocal relations among multiple systems (the self, cultural, economic, and societal) of influence on a person’s behavior (Bronfenbrenner, 1979).
According to this approach, an accurate and comprehensive understanding of MSM sexual risk behavior must include knowledge of both the personal and environmental factors which may contribute to the decision to practice bareback sex. The overall goal will be to focus on
the social ecological influences, as well as psychosocial barriers and motivations, which may or may not play a role in the formation of this subculture/sexual practice. Very little has been done to understand how factors from multiple systems of influence can interact and/or combine with each other to shape a behavior. In using a multi-systemic perspective it is possible to identify the relationship between each system of influence, and how each may interact with the other, each playing a role in both direct and indirect effects on behavior. In a sense, one system may serve as a mediator of the effects of other systems/factors in terms of the behavior in question. Additionally, in accordance to this model, sexual behavior in of itself may hold some influence over each system in a form of feedback mechanism which continues to shape and reshape the interaction and relationships of each system(Kotchick, Shaffer, Miller, Forehand, 2001).
Conversely, using the Ecological Systems Theory in the study of PrEP’s influence on the established subculture of bareback sex will also provide a potential map of barriers and facilitators to its usage and implementation. Thus providing a map of what forces may play a role in the implementation among MSM in the Netherlands.
Chapter Two Research Methodology
Introduction
To begin my study of MSM sexual practices in Amsterdam it was necessary to plan how to introduce myself to the community. Originally, during the initial planning stages of my thesis I had hoped to attach myself to a larger project aimed at examining the barriers to HIV prevention strategies (such as PrEP) among people from HIV endemic countries (PEC) living in the Netherlands. In doing so it was my hope to intersect with members of the MSM
community, however as time went on it became clear that the needs of my research were shaped by access to the MSM community in Amsterdam. In order to understand how a biomedical technology such as PrEP can shape the psychosocial and cultural landscapes of MSM in Amsterdam, it would be necessary to systematically observe the culture in question. This is especially important in the study of bareback sexual practice, which in of itself can be seen as a subculture within the larger subculture of MSM. To do so would require an
ethnographic approach, so as to immerse myself within that community.
A central tenet in ethnographic methods is that human behavior can only be understood within the context of which it occurs. In relation to understanding sexual practices,
researchers often find themselves relying on self-reported data which may or may not carry certain biases. In the practice of a behavior (such as bareback sex) an individual’s behavior is linked to the context of the situation, this infers that people cannot always be studied
independent of a situation (Baillie, 1995). In order to understand how bareback sex is practiced and shaped as a subculture I had to go where MSM practiced this behavior.
The first stage of my fieldwork involved identifying sites of interest. This involved identifying key stakeholder and informants within the overall MSM community in
Amsterdam. Using various internet search engines, as well as social networking sites I
identified various areas in which MSM congregated both socially as well as sexually. Each of the sites visited during my fieldwork was selected carefully based on areas of high MSM populations. My fieldwork officially began on the 29th of February 2016 to the 8th of May 2016.
Ethnographic Methods Ethnographic Sites
The following sites where used as places for ethnographic participant observations as well as data gathering through the usage of conversations with patrons and key informants (such as bartenders or managers). Through participant observation I was able to interact with various people. In doing so I managed to identify key actors which in turn became key informants. By immersing myself in a site I managed to establish a presence, which in turn facilitated establishing rapport with key actors in the community. Site visits spanned the months of March and April, with at least one site being visited daily. A majority of the data used in this thesis are based on field notes taken while visiting each site.
Field site A is a gay bar with a large darkroom area in its basement. The basement consist of a maze/labyrinth type of design with various types of cabins and corners for men to have sex. The bar opens at 13:00h to 01:00h/3:00h, activity in the bar gets very busy in the early evenings during after work hours (17:00). This bar also provides free condoms and lubricant from dispensers in the bar area.
Field Site B
Field Site B is a gay bar, similar to Field site A literally around the corner. Like the Field Site A, Field site B opens at 13:00 to 01:00/03:00. The ground floor consist of a bar, smoking lounge, coat check, and toilets. The upstairs of Field site B offers a sexual play area, with a dark room, multiple cabins and cubicles, as well as a sling and various glory hole areas. Like Field site A, activity will pick up after working hours, as well as weekends. Additionally, you can find free condoms and lube in the bar area.
Field Site C
Field Site C is a gay cruise bar located in central Amsterdam, on a street well known for it leather scene (as well as leather wear stores). Field Site C itself is well known for its gay leather scene as well as various sexual fetish scenes. Split into two floors, the upstairs holds something of a rest area as well as bathrooms, a few dark corners for sexual activity as well as a sling and area for a DJ. The downstairs portion holds multiple darkroom areas, a smoking area, as well as a sling, glory holes, and a few cabins/cubicles. Field Site C has a late night opening times, from 22:00 to 04:00/05:00. According to key informants, Field Site C is most active on weekend nights, as its late night hours make it hard for many besides tourist and well known patrons from frequenting on weekdays. Solely a men’s bar. It is necessary to ring a door bell and be viewed by the bartender from a camera in order to gain entry.
Field Site D
Two doors down from Field Site C (Owned and managed by the same people), Field Site D is a self-proclaimed “sleaze” bar for men.. Open slightly earlier than The Eagle, 20:00 to
03:00/04:00, many men will frequent this spot before moving next door to Field Site C for one of their themed fetish parties. Two floors for sexual activity, once past the bar you will find multiple glory holes as well as dark rooms and stalls for sex, fetish-themed furniture such as a sling and St Andrews Cross, there is also an area set up for golden shower play. Upstairs is completely a dark room with a few more glory holes and a ‘shower fall’ for golden shower themed nights. Fetish-themed, this bar offers many different parties appealing to various fetish themes. Similar to Field Site C only doorbell access to the bar.
Field Site E
One of the more popular gay clubs in Amsterdam, Field Site E offers a popular dance and cruise scene. Field Site E offers an assortment of themed parties from fetish-themed to normal dancing and drinking scenes. Open from Tuesday to Sunday ranging from 20:00 to 01:00/04:00/05:00 depending on the night and party theme. Some nights have a very strict entrance requirements dependent on dress code. Some nights are about certain themed gay
fetishes or men only action, while other days are co-ed and themed for simple parties and drinking. The club is split into three parts, the ground floor holds the main bar and dance floor. The upper floor holds a balcony which overlooks the ground floor bar area, as well as a dark room/cruise area with sling and couches. Condoms and lube are available throughout the club, the basement holds toilets, some private cabins and dark rooms as well as showers where you can rent towels. Field Site E has been the site of a few sex themed party to which I have volunteered at.
Field Site F
Field Site F is a relatively new sauna to the gay scene of Amsterdam. Opened since the end of 2013, Field Site F is operated and managed by the same management of Field Site E. In the Sauna there is a capacity for about 260 men (260 lockers). The sauna has a large bar area with couches and lounges, there is smoking room right off the lounge/bar area. Next to the lounge is a hot tub, near a set of showers and a dry sauna. The sauna also holds a large steam room set up as a labyrinth. In the sauna itself there are 10 private cabins, A TV room, a sling room and a few open/ dark room spaces for sexual play. Overall the sauna represents a mix of both casual sex and relaxation. Open from 12:00 to 06:00 on weekdays and open 24 hours on weekends, the sauna attracts various types of men depending on the time and day. Free condoms and lube are distributed throughout the sauna, and safe sex is openly encouraged.
In my ethnographic approach I attempted to place myself as a man who has sex with men in an environment in which topics surrounding my research question would come to light. Often in anthropology, the researcher becomes a tool or actor in the very subject of study. My role as a researcher was well established among the various field sites well before my initial attempts at formal data collection, however it was well know that I was also a gay man, with a healthy sex drive and curiosity about practices taking place in these sites. While I will not denie the fact that I have been approached for sex on many different occasions, I have done my best to keep any such contact out of my data collection. I feel that it would be unethical of me to use any information gathered through sexual contact for the purpose of my research. All respondents be they formal or informal are men who I have not had any sexual contact with during the scope of my fieldwork. In addition all field notes where written down by me either in a journal after visiting a site or in a smartphone, as to disguise my note taking to potential respondents. It should also be noted that the primary language of my field sites is Dutch, yet due to the international character of Amsterdam, the widespread use of English, also by Dutch speakers, I encountered no difficulties communicating with respondents. In some cases I would say some native Dutch men had better grammar skills then myself.
Interviews
In addition to ethnographic field observations, 20 men who identified themselves as having sex with men were recruited for audio recorded interviews on the topics of PrEP and sexuality from the greater Amsterdam area. Participants were recruited using various
methods such as Internet based (Facebook and other social sites) as well as internet based dating apps (Growlr, Scruff, PlanetRomeo) On average interviews would take place in the place of the participants choosing, either their own home, a cafe, or bar. On average
interviews took about 1 hour to complete, leading to over 20 hours of recorded interviews. Topics covered included demographic/cultural background, opinions on sexuality among gay and bisexual men in Amsterdam, conversations about the participants own sex life,
knowledge of sexual health information (access to, std’s and HIV), knowledge and opinions on PrEP, and finally attitudes and opinions on bareback sexual behavior. For the purpose of this thesis, most of the data from these interviews where rarely used due to their complex nature, length of interviews, and time constraints in terms of transcription and analysis. Future research opportunities will be used to analyze the data closely.
CyberEthnography
The final addition to my data collection was around conversations and discussions generated among various social media groups surrounding the issues of PrEP here in the Netherlands. Using certain Facebook groups, as well as the internet hookup sites such as BullChat, I generated conversations on PrEP by posting requests for comments or interviews. Overall I have collected 10 short conversations about feeling and concerns to PrEP usage on BullChat, as well as observed posting on PrEP advocacy on the PrEPNu group on Facebook. Additionally, data was generated in my attempt to recruit participants for in-depth interviews through various dating apps. While not interested in meeting for a recorded interview, many men were willing to share their opinions on the topics of interest with me, thus providing additional insights into the role of PrEP here in Amsterdam. Many of these quotes where recorded in my field notes for analysis later on.
Informal Conversations
Apart from my ethnographic work and formal interviews, I also managed to collect data from various Key informant and stakeholders within the MSM sexual community. Most of these conversations took place in informal settings, such as bars or clubs, or even over lunch and coffee. Most held positions among various research groups either within the GGD or other sexual health related organization. Some also included conversations with bar owners and managers, and even activists among the PrEPNu movement here in Amsterdam. Being as these conversations where informal, there is no audio recording of these discussions, all I have are essentially notes taken after each conversations. Overall I would have had the opportunity to speak informally to at least 10 Key informants, in which we covered topics about PrEP expectations and attitudes as well as gay and bisexual sexuality and MSM sexuality, and overall MSM sexual scene here in Amsterdam. A majority of my data present are based off of these informal conversations, as many came from a total of 52, men ages ranging from 22-68.
Practical and Ethical Considerations
Potential risks to human subjects include breach of confidentiality which could occur if private and sensitive information regarding sexual health or use of HIV prevention
strategies could be linked to an individual research respondent and if this information was obtained by person(s) outside of the research project. A breach of confidentiality could possibly lead to psychological discomfort or distress on the part of the research respondent. Decisions over sexual health and the use of HIV prevention strategies (eg. condom use) are
emotionally charged and may lead to conflict within relationships, MSM are at risk of being stigmatized by community members if they chose an HIV prevention strategy which does not conform to local societal norms. Participants who have jobs may lose their job if they
articulate views about HIV, sexual health or HIV prevention strategies which are not considered acceptable from a normative perspective.
Steps have been taken to protect participants against potential risks posed by their participation in this research. No personal identifying information has been collected through the ethnographic, qualitative and participatory exercises. After data collection, only I had access to the recorded MP3 data and field notes. All files were password protected. Any person participating in my research has been informed of all risks and protections in the verbal consent script. Participants, including both formal and informal have been informed of their right to withdraw from the study and to not answer any questions they did not feel comfortable answering. All respondents have been provided my contact information in case there are any follow-up questions concerning my research or their participation in it.
All data based on this research has been reported in unique identify codes
(methodology, participant category, interviewer, date). No individual respondents can be identified. The interviews have been conducted in either the privacy of the participants’ homes or in a location of the participants choosing. If other people were present in the interview space during the interview, permission was sought from the respondent to conduct the interview in a private part of the location.
The recruitment and consent process ensured that the study participants understood the purpose of this study. If a respondent expressed any discomfort or stress during an interview or data-collection process, I would remind him that he did not have to answer questions which may make him uncomfortable and would give the respondent time to recover before proceeding with data interview. If a respondent expressed any mental or emotional anxiety, I offered to terminate the interview.
Data Analysis
Due to the ethnographic nature of my research most of my data stems from my field-notes as well as informal conversations both in person and online. During fieldwork I digitalized all hand written field notes for analysis. Using the program NVIVO, I began to systematically code for themes using a grounded theory approach (Glaser & Strauss, 2009). Through coding and classification of my data, specific themes began to emerge. The most prominent theme to emerge from analysis was stigma followed closely by risk, and then pleasure. Other themes such as drug and alcohol usage, sexual health knowledge, health behavior, and health care dynamics also emerged. However, due to my own experience in the field of HIV prevention, I chose the three most prominent themes which I felt reflected not only psychosocial factors, but also held value to myself. As noted in many ethnographic based research, the role of the researcher holds sway over many aspects, including data interpretation. Thus, the themes reviewed in this thesis are a reflection of my own interpretations of the data, which are colored by my own experiences and perceptions. Segments of data used to support my claims came from multiple sources. Triangulation of these data granted more validity to my findings. However, as with the nature of such research
the validity of such statements is in question to how I as the researcher interprets them. This leads to greater subjectivity and is a limitation of this thesis.
Obstacles/Reflexivity
Overall during fieldwork I encountered few obstacles in terms of accessing sites, however few informants permitted recording of interviews. Another issue that was my ability to be self-aware of my biases, while maintaining a professional line while interacting in sexual themed places. While neither of these required much work to deal with, it did provide me with times of stress and worry about the way I collected data and the validity of such data.
As an openly identified gay man I tried to be actively reflexive in my approach to this study. I kept a diary during my time in the field, which aided in controlling potential bias during data collection and analysis. When approaching potential informants, I did my utmost to clarify the intent of this study, especially that I was not looking for sex. It is also important to consider how I as a gay male, may have unwittingly influence the responses of my
participants, while peer to peer dialog may reveal hidden themes, it may also hinder them. I have attempted to be self-reflexive during the entire process of data collection through the usage of a diary, as unwitting biases could have been reflected in my tone or manner of speech. Lastly, questions posed to me about my own opinion on the subject matter of the interviews were handled with care and I have attempted to maintain a neutral ground in my responses to the best of my abilities.
Chapter Three
Risk and Health, Sexual Behavior of PrEP Introduction
The ability to take risks is a hallmark of human nature. When facing uncertainty, humans often begin an internal calculation of various outcomes, which scholars define as risk (Baral et al., 2013). Risk is the consequence of an action taken in the face of uncertainty. In taking risks one has the potential of losing or gaining something of value. The values themselves are subjective to the individual, as each individual differs in the dimensions of social, interpersonal, and individual factors. Values such as physical/emotional health, social standing, and financial wealth are just few of the facets in which risks can influence. When it comes to the domain of sex, we can be faced with the consequences of contracting a sexually transmitted infection and/or experiencing unintended pregnancies through the uncertainty of risky sexual behaviors. To define sexual risk, we must first understand unsafe sex. Going into my fieldwork, I was already well aware of what I wanted to look at. Bareback sexual
behavior, is often epitomized by sexual health care workers as one of the most unsafe forms of sex. Yet, apart from the biological associative risks involved with condomless sex, it was important for me to reflect on what constitutes risk. The uncertainty that a sexual partner carries a STI remains a pivotal factor in the definition of unsafe sex, the risk is the action, or choice to refrain from condom usage. To these ends, I began field work hoping to understand the pathways in which an individual may choose a given action or choice. Surely there must be more to the reasoning in the practice of bareback sex than simply making a choice in the face of uncertainty. As one respondent commented over a beer at Field Site A:
“Bareback sex is fantastic! I have only gone bare with partners in a long term relationship. I trusted him, but it’s still a risk.” “We play with other guys, but I trust that he doesn't go bare with them. I’ve had mistakes before, and you have to deal with the anxiety and fear that you may get something, you don’t ever know, right?” Chuck 32, 08-03-16
“You don’t ever know, right?.” This statement sums up the uncertainty that exist
among MSM and condomless sex. An individual cannot know for certain that their sexual partner is without a STI. For MSM, the most important uncertainty currently faced among MSM is that of HIV and AIDS (Watkins-Hayes, 2014), although other types of uncertainty ranging from other STI are also relevant. The influence of the HIV/AIDS pandemic has had a collective effect on sexual health practices and beliefs worldwide. In the face of this
uncertainty, the decision to eschew condoms during sexual intercourse remains somewhat a mystery. Previous research has attempted to understand the individual and situational factors that play a role in this risk behavior. Factors such as attitudes towards condom usage
(Appleby, Miller, & Rothspan, 1999), as well as drug and alcohol usage (Grove, Parsons, & Bimbi, 2010) are but a few of the many factors which have been investigated, and some of which I came across during my time in the field. Examples of these can be seen in some of the responses to my question: What are your views on condoms?
“Well, I know that you should use condoms to prevent HIV, but I just can’t stay hard with them on.”
“Condoms don’t feel good.” -Third, Grindr, 20-03-16
“Do you use condoms for oral sex? No, right? So why would I use it when fucking?” -Mac, unknown age, Field Site D, 04-04-16
These responses where similar to others I received during my time in the field. Many of the men I talked to who practiced bareback sex shared similar views as the ones above. Conversely among informants who self-identified as inconsistent barebackers (men who indicated condom usage with only some partners), condom attitude was indicated as a factor, yet, the usage of party drugs, as well as alcohol consumption was in some cases also a factor.
“Usually I use condoms when I meet a guy, but sometimes I get so horny that I just need to feel the guy inside, feel him as I fuck him, nothing between us.”
“Sometimes when I am high I forget to use a condom. The E [Ecstasy] sometimes gets me so hot I just want to connect with the guy” -Bart, 34, Field Site D, 17-04-16
“A little Speed and I get so horny, I’ll just fuck raw.” -George, 51, Field Site B, 22-03-16 “I always use a condoms, except, maybe I’ll be partying with some friends, and I’ll get high or really drunk, and, I like have sex with them, without a condom, but I’m not too worried, I know them, they get tested all the time, so do I, so I’m not worried about getting fucked without a condom by them, but I know better.” -Dan, 57, Field Site C, 12-04-16
“I know I know, its risky, but I just can’t stand condoms. I can always tell the difference when A guy is fucking me with one, it doesn't feel right”
“…..Have you ever taken MDMA with some G [GHB]? It feels so good getting fucked, You can feel everything, even the guys heartbeat. If he is fucking with a condom you can’t feel anything, it sucks.” -Jelmer, 31, Field Site E, 24-03-16
These respondents indicated an awareness to the risks they were partaking in Yet it could be argued that their attitude towards condoms and their drug usage played a role in their risk assessment. Obviously these responses are but the tiniest indication of a larger theme, and further research will be necessary. Based on the responses above, I would posit that instead of being factors that enable risk behaviors, such as attitude towards condoms as shown by Bart, or drug/alcohol consumption as seen by both George and Dan, that it could be that these factors where simply in addition to the risk assessment of bareback sex. While I do not try to presume that these factors do not play a role in sexual risk taking and bareback sexual behavior, I believe the question should be asked - Why do they? Most importantly, with the advent of additional HIV preventative technologies in the fight against HIV these questions become increasingly important. However, the way we asses risk is also important, how do we compensate for things we know are risky, or protected, and how do we handle risk situations once we know they are not as risky?
In the health sciences, we see new technologies emerging in the fight again disease and disorders. In the realm of sexual behavior, new biomedical technologies in the fight against HIV/AIDS and other STI’s are imperative in our struggle to curb the ongoing spread of such diseases. With advances in such technology there is speculation about the possibility of unintended consequences, some of which are potentially damaging. In many preventive technologies and methods we find that these consequences unintended or otherwise stem from what is known as risk compensation (Hogben & Liddon, 2008).
When defined, risk compensation is a theory which holds that an individual will change his or her response to a level of risk by becoming more careful in a more risky situation, while being less careful in situation which has less risk. It can also be
operationalized as ones feeling of being protected against something, an individual may engage in other risky sexual behaviors. As it follows, in the realm of health, to be protected from a health related risk, it is possible that you may engage in risk taking behaviors which may put you at risk for the same or other problems (Cassell et al., 2006; Hogben & Liddon, 2008). Throughout health care history we can see various patterns of such thinking. For example, during the introduction over the human papillomavirus vaccinations for young women in the United States, There was fierce debate over concerns that once protected, young women would be more incline to have unprotected sex with more partners at an earlier age (Lo, 2006; Kapoor 2008; Kahan, 2010). Similar arguments were made with the
introduction of condom distribution programs in the fight against HIV/AIDS (Cassell et al., 2006). Osorio and colleagues (2015) did a study which revealed that adolescents who believed sex with condoms are 100% safe, had a higher chance of having earlier sexual initiation, something of which is correlated with risky sexual behaviors later in life (Cassell et al., 2006). Furthermore, risk compensation in the form of increased sexual risk taking has been indicated among participants in HIV vaccine and microbicide trials (Chesney,
Chambers, Kahn, 1997; Roddy et al., 2002), as well as among men living with HIV and on ARV therapy (Crepaz, Hart, Marks, 2004). To support these arguments I will attempt to explain how such a phenomena has occurred during my field-work.
My first run in with the concept of risk compensation came during a visit to Field Site F in central Amsterdam. An all-male sauna openly advertising to gay men, was one of my key field sites during my fieldwork period. Relatively new, having been opened at the end of 2013, the sauna has a capacity for 260 men. The sauna provides a rich environment for not only participant observation, but informal discussions, the sauna provides a spacious bar and smoking areas, as well as hot tubs and dry sauna (Further description in methods), as well as dark rooms and private cabins, Field Site F provided on of the optimal locations for my research questions. During my initial days there I struggled with myself and my ability to open up to members while being completely naked. Often when discussing my choice of field sites with colleagues, there would be some light banter about the sexual nature of the sites. A common misconception, while sexual contact and behavior does occur frequently at such sites, there are often times where in-depth discussions and debates may occur in common social areas. During my time at this sauna I was lucky enough to encounter an open discussion about sexual health risk among three members, this enabled me to drop my ‘shyness’ to the naked situation and quickly entered into dialogue with the men. One of the
discussions was about the seriousness of current STD’s such as chlamydia , gonorrhea, and hepatitis C. During this conversation I openly discussed with the men, my research interest in bareback sex and PrEP, and asked what concerns they may have regarding STD’s besides HIV, this was their response:
“I’m not all that worried [risky sex], you basically get an injection for everything nowadays.”
“Yeah, I’ve had it before [gonorrhea], but it wasn't a big deal, I found out and got an injection. It hurt like a bitch though.”
“They aren't a big a deal as HIV, but nowadays even that isn't so bad anymore. Guys are living a lot longer with new meds. I don’t want HIV, but its not the end of the world if I get it.” -Adam, Field Site F, 12-03-16
“I do bareback once in a while…[laughter] I did it just before you got here” “I only have sex with guys I know awhile, and it’s not that I worry, one guy he is
undetectable so I can’t get it from him, He didn't come in me, you know? If I got something else they have medication for it. The GGD.” -Barry, Field Site F, 12-03-16
“I come here often, almost every week. It’s a nice place, you always meet new guys, it’s so close to Central there are always tourists or guys who live farther out stopping in.” “I always use condoms when I bottom [laughter] and I bottom a lot, but not when I top, I rarely use condoms then”
“Topping is safer[seropositioning, you are less likely to get AIDS when you top. There are medications for STD’s too.” -Cade, Field Site F, 12-03-16
From the aforementioned quotes, we can postulate that the risk taking behaviors mentioned by these men (e.g. condomless sex, anonymous sexual encounters,
seropositioning) are in relation to the premise behind the risk compensation theory. With the current ability to treat bacterial STI’s with antibiotics, respondents indicated very little worry in the possibility of infection. This line of thought is also coupled with the concept of anti-retroviral treatment, removing the ‘death sentence’ associated from the earlier history of HIV. The concept of taking a pill every day for the rest of one’s life seems to be mitigated in the face of sexual pleasure and disinhibition. The assumption that HIV viral load at an
undetectable level creates a perception of protection enabling the practice of condomless sex with openly HIV positive individuals, without fear of HIV infection, despite the risk of other STI’s. To quote another man at the sauna, “I can’t get it if its undetectable” is just another concept of risk compensation.
Risk Compensation vs Disinhibition
There are contextual differences between risk compensation and disinhibition, and it is important to conceptually understand them in relation to an individual’s interaction with risk. Overall, risk compensation is a cognitive perspective (Hogben & Liddon, 2008), a perspective which applies to the diminished susceptibility due to a preventive measure which
permits an individual to increase their other risk behaviors. As mentioned above, preventive measures such as condoms or medical treatment can create the perception of diminished risk, thus enabling the increase in similar or other risk related behaviors. Conversely, the concept of disinhibition is rooted in the foundations of psychological theory. To be inhibited is to have a mental restraint due to feelings of self-consciousness or unconscious restraint. When applied to risk, inhibition can be seen as ones restraint against a risky behavior. Such restraint can be conscious or unconscious. Thus, disinhibition is implied to make one less inhibited. In terms of risk, disinhibition occurs when an individual will stop trying to avoid risk either to themselves or others (Hogben & Liddon, 2008). When it comes to sexual behavior, examples of disinhibition can be seen in the effects of drugs and/or alcohol. As indicated in the quotes above, drug and alcohol consumption are frequently associated with increased sexual risk behaviors. It should be noted that the individuals constant interaction with their social environment will shape and influence their disinhibition in any given situation. Intra and interpersonal relationships will also play a role in how an individual may or may not respond. For example, when inebriated, a person may become sexual incautious and more inclined for risk and sexual exposure. Yet if in a situation surrounded by people who they may not feel sexually inclined they may not proceed to act on such feeling, or such feeling will not manifest. The following comment from a man whom contacted me through an gay internet dating app known as Growlr provides an example of disinhibition:
“ I don’t bother with condoms, honestly at this point I’m probably already positive. If not, It’s inevitable.” - Second, Growlr, 07-03-16
The respondent was responding to an open-ad I had made online for individuals to discuss motivations of bareback sex. His response is one example of many which reflects another aspect to disinhibition; when an individual feels that he or she cannot avoid a harm, then they no longer attempt to do so (Hogben & Liddon, 2008; Balán et al., 2013). From this quote I was quickly drawn to his indication of inevitability, something of which has been often reported on in previous research. As posited by researcher Balán and colleagues (2013), the sense of inevitability, that becoming infected with HIV is just a matter of time in the gay community. These responses along with the aforementioned alcohol and drug use are good examples of how two different factors can play a role in disinhibition. While previous research and literature has used the terms of risk compensation and disinhibition interchangeably, the lack of caring indicated in disinhibition is the primary difference between the two.
Risk and Biomedical Technology
As mentioned earlier, the role of biomedical technology on risk behavior has been well studied in the realm of HIV preventive technologies. From the initial concerns of the HPV vaccines on increased protected sex among young women (Lo, 2006; Kapoor 2008), to the role of condom distribution programs enabling increased sexual partners and possibly increased risk behaviors with the intention of condom usage (Richens et al., 2000;Starks et al., 2014; Mullan et al., 2016). Previous research has also found indications of risk
compensation among various HIV vaccine and STD microbicide trails (Chesney et al., 2000; Roddy et al., 2002). With the advent of PrEP and its impending introduction to the
Netherlands and other parts of Europe, it has become increasingly important to understand how PrEP as a biomedical technology may play a role on the risk assessment of its users. A key point of debate among public health researchers is the concern that PrEP may lead to risk compensation, thus leading its users to engaging in more risky sexual behaviors. While there is evidence of risk compensation with the usage of preventive biomedical technologies in previous literature. There is little evidence among the various PrEP clinical trials to indicate risk compensation (Baeten et al., 2012; Liu et al., 2013; Guest et al., 2008; Marcus et al., 2013). On the contrary, researchers from the IPrEx and Partners PrEP studies found evidence that condom use increased and diagnosis of STI’s decreased during follow-ups (Baeten et al., 2012; Marcus et al., 2013). These findings are echoed by the few men whom are currently enrolled in the AMPrEP study As one participant indicated informally- “Instead of having
more bare sex, I think I’m actually more aware of who I'm having sex with, and just more aware of using condoms.” This thought is echoed among the few men I had an opportunity to
speak to enrolled in the current study.
The impact of PrEP on the sexual practice of users outside of the clinical trials continues to be understudied. While researchers in the Partners PrEP study found no substantial change in risk practices (Mugwanya et al., 2013), It should be noted that such findings could be regulated by social desirability biases. That social desirability can shape interactions is illustrated in the following explanation by Johnny:
“I don’t talk about my sexual practice with my GP[General Practitioner], he knows I’m gay, he is gay himself, but I don’t tell him I fuck bare.”
“Its hard to explain, I know I should let him know, I think its because I'm embarrassed.”
Johnny, 38, Field Site B, 23-03-16
We could infer from this statement that individuals may self-report socially
desirablabl outcomes to the respective clinical trials, thus creating inconsistencies or weak associations between risk compensation and PrEP.
Overall, the degree to which risk compensation plays a role in the individuals risk taking decisions, as well as the role of biomedical technologies on behavior continues to remain understudied, however there continues to be indications that risk compensation varies as a function of perceived risk, dependent on the technology being perceived as well as the individual in question. As indicated by researchers in the San Francisco US PrEP Demo Project, risk taking behavior seemed to fluctuate among participants. Researchers found that sexual decision making was influenced by various factors including individual, psychosocial, and health related. They also found that risk behaviors were also associated with factors relating to personal relationships, substance abuse, and psychological distress. They
concluded that the risk compensation may also be influenced by such factors, and that further research was necessary (Hojilla et al., 2015).
Among the theoretical models of risk compensation and PrEP users, researchers predict that an individual may only increase their sexual risk taking when there is opportunity and a perceived meaningful value in doing so, such as in creasing sexual pleasure or
relationship satisfactions (Eaton & Kalichman, 2007; Hedlund, 2000). What this implies is that risk compensation will not increase sexual risk taking among individuals who lack opportunity or motivation. For example, among individuals who exclusively practice bareback sex, will not further increase their practice. Furthermore, it is unlikely that individuals who have already calculated their sexual risk in terms of decision about, frequency of sex, sexual positioning partner selection, or number of sexual partners, will increase their risks along those factors. Yet among my time in the field I came across many individuals who self reported this not to be the case:
“ I do not know if this is such a good idea. PrEP can lead to guys fucking around more, all the other diseases, and its not completely safe, what if you forget about taking it?” -Sixth,
BullChat, 13-03-16
“Have you seen guys who say they use PrEP in their profile? All they want to do is bareback!” - Second, Scruff, 14-04-16
“My friend is taking PrEP and now all he does is go bare.” -Second, Grindr, 08-04-16
Conversely, others indicated less concern about risk:
“I don’t think guys are gonna just start having bareback sex, I mean you're gonna do it if you want to do it.”-Teddy,62,Field Site A, 31-03-16
“I think its a great idea [PrEP], some people are worried its gonna make guys have more sex. Then all the other STD’s will rise. Or some say that men will just become more promiscuous than they already are. But I don't think so.” First, BullChat, 08-03-16
These initial comments simply reflect the anticipation of PrEP usage among men in the Netherlands, yet when we take a look at the men already using PrEP, whether or not as a part of the AMPrEP study we find very distinct views. On participant of the AMPrEP study indicated how his involvement in the clinical trial has increased his own awareness of his sexual behaviors.
“In the study we have to use this calendar app to indicate when we take the pill, when we have sex, and what kinds of sex we have, that sort of thing. I notice the more I do it, the more aware I am of what I'm doing when I hook Up with someone, If anything I think I’m being safer than I was before.”
This AMPrEP participant’s views are similar to findings as reported above, that in some cases, PrEP usage has shown to decrease sexual risk taking practices. Conversely, one of my key informants, a well-known key figure in the LGBT community who I will refer to
as Jake, met with me multiple times over the course of my fieldwork. We began a dialog about his own impressions of PrEP and his feelings about it:
Jake: “So PrEP is now starting a big thing here in Amsterdam, there is already a movement to push it for release now instead of waiting for the study.”
Kevin: “How are you're feeling about it?”
Jake: “I think its a good thing, It feels like we are moving in the right direction.” Kevin: “Any concerns?”
Jake: “No, not really. I’ve heard the guys say that guys using it don’t want to use condoms, so I guess people are worried about that. Maybe I could see it being a problem if there are guys on PrEP who only fuck without condoms, and won’t sleep with a guy who wants to use one, but no, honestly I doubt its gonna make that much of a difference, apart from the protective aspect.”
Kevin: “Do you think guys will be more inclined to choose condoms if using PrEP?” Jake: “I think they will use it if they want to use it, I really don’t think PrEP will change my mind if I want to use a condom.”
What is interesting about this dialog is that at the time of this conversation, Jake expressed an interest in PrEP, yet was not enrolled in the study, and did not consider himself eligible for it. Working close to the sex club industry, Jake has come into many sexual encounters with patrons, yet always claimed to use a condom. It was only a few weeks later Jake managed to attain a prescription for Truvada from his GP. While Truvada usage for PrEP has not yet been cleared for usage in the Netherlands, it seems that his GP was willing to prescribe it anyway. Upon our next meeting he openly discussed its usage:
“Ive been on it for about two weeks now, and I can tell you, since you are interested. I haven't used a condom since. At least when I’ve been topping.”
“You wanted to know if PrEP changes behavior? Well I can tell you, it does, I’m taking it everyday, and I just don't worry anymore”
“I have had so much more sex since I’ve been on it. Its fun! I’m enjoying it a lot more, and I can just relax during a party.”
“My partner knows I’m on it, and I think it may be a relief for him as well.”
“I haven't really gone bare when I’ve bottomed, but definitely when I top.” -Jake, Key
Informant, Date Redacted
From these conversations I shared had with Jake, we can begin to see parallels with the situational factors which may contribute to behavior change with risk compensation. First let us address the setting, from our conversations Jake mentions his involvement with the sex
club party scenes, as of such he identifies it as one of the few places he tends to have
anonymous sexual encounters. Before his usage of PrEP Jake was always adamant about his condom usage in such liaisons, yet as we can see from his quotes, two weeks into PrEP usage and he reports condomless intercourse. Hojilla and colleagues (2015) reported that among the men in the San Fransisco PrEP Demo Project, that preventive decision making during an encounter was largely based on the context of said encounter. For example, bathhouse or online chat site. Additionally the assessment of a potential partner’s risk was also dependent on the context. These findings mirrored what I experienced in the field, not only from Jake but others as well. That the risk assessment and preventive strategies MSM use to reduce risk are complex and dependent on individual variation and context of the sexual encounter.
In addition to context playing a role in risk assessment and behavior we must also take a look at role of PrEP in conjunction with other risk reduction strategies. While Jake indicates condomless intercourse, he also mentioned his sexual positioning as a factor. This is mirrored by other informants thought my time in the field. The usage of topping or being the penetrative partner is well documented in studies on preventive risk behaviors among MSM (Seropositioning), especially when negotiating the risk in bareback sex (Halkitis et al., 2008; Van de Ven, 2002; Grace et al., 2014). This assumption is indicative of the argument that risk reduction strategies are not simply discarded in the usage of PrEP, but rather incorporated into an individual’s existing prevention methods (Hojilla et al., 2015).
Lastly, It should be noted the relief exhibited by Jake during our discussion about his being able to relax and enjoy the sex party more. Previous research on MSM sexual concerns has found that fears of HIV play a role in the physical and emotional aspects of sexual behavior and risk assessment (Rosser et al., 1997). From his statements and those of others I infer that PrEP usage provides some sense of relief against fears and stressors surrounding sex and HIV, and thus plays an additional role in how and individual may negotiate their risk assessment in the face of sex. Hojilla et at. (2015) found a similar result among the men of the San Fransisco PrEP Demo Project, in which they too suggest that PrEP plays a role in alleviating sexual anxieties, and enhancing intimacy among partners.
Conclusions and Reflection
The role of risk in sexual decision making behavior is a complex one. Research has shown the influence of social and structural level factors play a role in the assessment of sexual risk in the areas of social, economic, organization, and history of sexual risk taking and HIV acquisition (Baral et al., 2013). Yet it is important to understand the individual level forces at work in any new HIV preventive strategies for these to be successful. Sexual Risk taking is a complex phenomenon that should be examined at an individual’s risk threshold and sexual health goals. If we are to strive towards the goal of an HIV free generation it is imperative that we look at how individual factors shape the efficacy of PrEP not only for the individual, but for the community overall.
In writing this chapter, I often thought back to my own sexual encounters, both before fieldwork and after. As a gay man, living with the fear of acquiring HIV has played a large role in my own sexual initiation as well as behavior over the course of my adult life. The
longer I seem to work in public health, the more judgmental of certain things I become. My initial thoughts into the usage of PrEP mirrored those of some of my respondents, that PrEP was a dangerous tool. Ingenious, yet dangerous. I did not believe that our current societies where capable of using such a tool appropriately. That the goal of HIV elimination was fool hardy without a vaccine or cure. Yet the more I delved into the MSM party and club scene, the more I began to see the appeal of PrEP. The constant fear of HIV has long shadowed many lives since the initial onset of the epidemic, factors such as stigma hold sway over our sexual lives(See corresponding chapter). The advent of this biomedical technology has the power to change all that. Yet, are we as flawed social beings capable of using it properly? What does it mean to be proper? I have no answer to these questions, yet all I know is that my views on risk, and sexual behavior in the coming of PrEP have changed. Perhaps it would be nice to live and love without fear?
Stigma, Sexual Beliefs and Behavior Introduction
What is Stigma? I asked myself this question many times, over the course of my fieldwork. Yet when trying to put into my own words, often the definition seemed to allude me. Why do we place meaning on the actions of others? How do we brand those with differing behaviors in negative light? Originating in the late 16th century, this Latin term of Greek origins denoted a mark being made by pricking or branding (Merriam-Webster Dictionary). A stigma was commonly cut or burned into the skin of criminals and slaves, in order to mark them as polluted persons. These individuals were actively shunned and avoided, looked down upon, and lowered to the lowest of classes.
It is known commonly in the present that the word stigma, when used as a noun, functions to name a specific type of label of status. Stigma is often used to indicate a mark of disgrace, usually associated with a particular circumstance, quality, or even a person (Oxford Dictionary). Synonymous with words such as shame, disgrace, and dishonor, conversely the term stigma may also be used to identify visible signs or characteristics of disease.
In his book Stigma: Notes on the Management of Spoiled Identity (1963;2009), famed sociologist Erving Goffman describes stigma as “an attribute that is deeply discrediting” by other people and results in a degree of social rejection, often in the form of discrimination or disrespect; it exists when an attribute is linked to a negative stereotype. According to
Goffman, stigma may be categorized into both discredited and discreditable attributes such as behaviors, physical conditions, or reputation. A discredited attribute can be perceived by others, while a discreditable one is not as obvious. It is in this distinction that an individual may manage a stigma dependent on how noticeable the stigmatized attribute is (Goffman, 1963).
When applied socially a stigma can take many different forms. Often dependent on the cultural and societal sphere of influence, stigmas can be dependent on cultural values, gender, race, illness, and disease. Stigmas in today’s world can often occur in everyday settings, such as the workplace, educational institutes, within health care, the criminal justice system, and even with a family.
It is also possible to conceptualize stigma as a process of interrelated components. According to research by Link and Phelan (2001), these interrelated components include:
1) The labeling and differentiating of attributes prevalent among certain groups of people
2) The association of negative stereotypes to those attributes
3) Placing the individuals possessing the fabled attributes into a separate category from the group
4) Employing strategies against separated individuals to the extent that they experience social loss and discrimination.
It is through this process in which stigmatized individuals may experience the perceptual and social components to stigma.
