Monday, August 31, 2015

Community or Population: Gay and Bisexual Men differ from Men who Have Sex with Men

By Sean McShee

In the last ten years new, HIV infections have only increased in gay and bisexual men, among all groups at risk for HIV infection. Part of the problem may be an incoherent approach to cultural competence for gay and bisexual men.

People use two phrases, “gay and bisexual men” and ”men who have sex with men (MSM)” to describe the group on which HIV has had the most impact. Some people use these phrases interchangeably, assuming they refer to the same entity. Others use the phrase ”men who have sex with men (MSM)” believing it to be the more inclusive phrase. Neither of these usages suggests any awareness of cultural differences.

The updated National HIV/AIDS Strategy of 2015, however, uses the phrase “gay and bisexual men” much more often (50 times) than the phrase or its acronym “men who have sex with men (MSM)” (7 times). It also calls for cultural competency for gay and bisexual men in HIV service delivery. These two phrases refer to different things. While the phrase ”men who have sex with men (MSM)” refers to a population, the phrase “gay and bisexual men” refers to a community.

How do populations and communities differ?

Professionals define a population to serve their professional ends. As a result, a population has very clear boundaries. A population lacks any subjective awareness of its “group-hood”, as well as its shared norms, values, customs, and meanings. Without shared norms, values and customs, no need exists to socialize new members.  As these comprise some of a culture’s defining features, cultural competence has no relevance for a population.

People in a community, however, have a subjective self-awareness of their “group-hood”.  They share norms, values, customs, and meanings. A community transmits these norms, values, customs, and meanings to its new members when it socializes them into the community. These factors define a culture and require cultural competence.

Like other social processes, a community grows organically and has “fuzzy” boundaries. Unlike a population’s strict definitions and rigid boundaries, a community includes “others” within its “fuzzy” boundaries. For example, the gay and bisexual male community includes “fag hags” (straight women who like to hang out with gay men). People may vary in their integration into a community. Some gay-for-pay hustlers, porn stars, and strippers may be more integrated into the gay and bisexual male community than their exclusively gay, but closeted, “Johns” are integrated.

Epidemiologists defined the phrase “men who have sex with men (MSM)” to describe men at risk for HIV through anatomical male on male sexual activity. They defined “MSM” to ignore self and community identification and to have physiological and epidemiological validity.  Once we move into HIV program design, delivery, and evaluation, however, social processes occur. When those social processes occur, culture becomes paramount. This raises two critical questions:  1) Do effective HIV delivery programs require cultural competence for gay and bisexual men? and 2) How can we tell if a program has succeeded in reaching non-gay or bisexually identified MSM?
Question 1:
Do effective HIV delivery programs require cultural competence for gay and bisexual men?

Cultural groups parallel to gay and bisexual male culture

Given its binary focus on gender, transgender people become invisible in HIV data. When transgender women become visible, they have very high rates of HIV infection.  Non-op transgender women have the same anatomical sexual options (oral or anal sex) as gay and bisexual men have. Generally, they are counted among MSM. This may be the most glaring example of cultural incompetence since the Northern European “flesh” colored crayon.  At least that crayon had the excuse that it pre-dated the concept of cultural competence.

The phrase ”men who have sex with men (MSM)” includes several cultures based in ethnic groups: same gender loving (African American), two-spirit people (Native American), and Mahu (Polynesian), etc. Others no doubt exist.  These cultures exist parallel to gay and bisexual male culture and require cultural competence. No one can be globally culturally competent. People may be globally culturally sensitive, but cultural competence always refers to a specific culture.

Cultural competence for gay and bisexual men’s services

While cultural competence has become central to service delivery, it remains an elusive concept, difficult to define or measure. In practice, programs declare the problem “resolved”, when program staff matches program recipients on one demographic variable. While people can match on one demographic variable, they can differ in other key cultural/identity variables: race, class, ethnicity, gender, sexual orientation, etc. A perfect match on all variables of identification may not be possible. This simplistic understanding of cultural competence mystifies cultural competence as something that only people in that culture can possess. This understanding of cultural competence precludes the identification and transfer of cultural competence to people outside of that culture.

We should probably distinguish cultural competency from the marketing imperative of having a staff that matches the clients, and the justice/meritocratic imperative of hiring minorities.

It probably does help to have matching demographic profiles on the most visible of these key identifiers. People, however, should be able to identify, describe, and learn how to work with cultural differences. Some cultural differences, such as Sign Language, are more easily identified and learned than others are. Once identified, people from outside that culture can learn about them, increasing cultural competence in a pluralistic society.

How gay and bisexual male culture differs from mainstream cultures

Despite the difficulties in defining or measuring cultural competency, certain differences between gay and bisexual male culture and the dominant culture do stand out.

Chronological Age vs. Coming-Out Cohort.  HIV programs report data with chronological age ranges. Within gay and bisexual male culture, the coming out cohort (the time in which someone came out) could have as much importance as chronological age. For example, let’s assume the following coming-out cohorts:  1) Pre-Stonewall, (before 1969); 2), the Golden age of Promiscuity (1969-1980); 3) the frAIDS (1981-1987); 4) ACT UP/Queer Nation (1988-1996), and 5) Anti-Retroviral Treatment and Normalcy (1997-present)    Those people who came out in different cohorts came out into very different gay and bisexual male cultures.

Someone who became HIV infected in 2015 at age 65 could belong to anyone of these cohorts. If he belonged to the ARVs and Normalcy Cohort, he would have had a very different life experience that someone belonging to the Golden Age of Promiscuity Cohort.  He would lack memories of the worst of the epidemic and may never have encountered, as a gay or bisexual man, any HIV prevention messages specific to gay or bisexual men.

Narrow vs. Broad Definitions of Sex. In mainstream culture, sex means penis-vagina intercourse with the rest as foreplay, and maybe deviance. Many gay and bisexual men define sex much more broadly to include mutual masturbation, oral sex, anal sex, water sports, multiple fetishes, and leather. Each of which has a different risk level for transmitting HIV and other STDs. This makes answering questions about “how many sexual partners have you had in the last six months”, difficult to answer and meaningless to interpret. Yet, HIV test sites ask these questions, leaving it up to the respondent to define “sexual acts” and “sexual partners” as they wish.This violates a key requirement of survey question design.

Contact tracing vs. norms of frequent testing.  Contract tracing for STDs makes sense for cultures with a courtship/dating pattern. While the dominant culture has an ideological standard of monogamy (its practice is another matter entirely), gay male culture differs drastically. Gay and bisexual male culture accepts a plurality of relational styles:  anonymous, semi-anonymous (screen name or first name known only), short-term, open, and closed relationships. Long-term partners may no longer have sex with each other, but each partner may have sex outside the relationship. No one in a gay bar, gym, or sex club has a last name. While this probably originated as a protective factor during the time of bar raids, it has continued to this day. People who “hook-up” on line may only know each other’s screen name. For this community, contract tracing has minimal utility; norms of frequent regular testing schedules for STDs for all sexually active people have much more utility. 

Disclosure and hook-ups/anonymous sex.  Disclosure of HIV status also makes most sense in a courtship model of a relationship. Some gay and bisexual men have a rather “abbreviated” courtship period. For a hook-up to work, the parties involved have to create a mutually erotically charged atmosphere rather quickly, but few people find that discussions of HIV enhance an erotic atmosphere. For many, HIV is an erotic turn off. This type of situation encourages perfunctory assumptions and discussions about status.

Some gay men have a fetish for anonymous silent sex where verbal disclosure violates the norms for that situation. Culturally appropriate HIV prevention messages would recognize this fetish and problems with disclosure in these situations. These messages would emphasize that people should assume their partner’s HIV status differs from their own. 

If double-consciousness characterizes African American culture, as DuBois suggested, respectability/flaunting dichotomy may characterize gay and bisexual male culture, both at a collective and at an individual level. Some gay or bisexual men, heavy on the respectability side, have consistently used HIV to push for a standard of monogamy rather than monogamy as one fetish among many. 

Some gay and bisexual men will object to these last points, but internal conflicts define living cultures. In order to serve communities with internal cultural conflicts, a program cannot take sides, but has to be able to serve all sides. This emphasis on respectability further complicates culturally appropriate HIV messages. It defines cultural differences as problems to eradicate rather than an as opportunities for prevention.

In addition to the internal conflict, these last points describe a major political conflict. Serious value conflicts exist between gay and bisexual male culture and the dominant culture about relational pluralism vs. ideological adherence to the standard of monogamy. 

Question 2:
How can we tell if a program has succeeded in reaching non-gay and bisexually identified MSM?
HIV reporting uses the phrase ”men who have sex with men (MSM)” which, counter-intuitively, obscures the program’s reach to non-gay and bisexually identified men. In order to tell if a program has reached non-gay and bisexually identified men, it has to collect data on that population. That program has to collect data on how clients identify at intake, at pre-determined intervals while they remain in the program, and at outcomes. This will show if the program has any disparities in reach, retention, or effectiveness between gay and bisexually identified men, same gender loving men, two-sprit men, non-op transgender women, and non-culturally identified MSM. When programs fail to record and report this data, and use the phrase ”men who have sex with men (MSM)” that phrase hides rather than includes non-gay and bisexually identified men.
Whether greater gay and bisexual male cultural competence might cause the high numbers of new HIV infections among gay and bisexual men to begin to decline is an open question. We should, however, ask that question.

Next month Intersectionality.

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