MSM, HIV and behaviour change ssha

MSM and HIV: Behaviour change
models and psychological therapies
Dr Phil Henshaw
Consultant Clinical Psychologist
Sussex Partnership NHS Foundation Trust
[email protected]
The erotics of internal ejaculation
Ok. but how about in your mind? Fluid exchange is part of the erotic
imagination isn’t it?
…Sometimes it does feel horny, the fact of cumming in somebody or
cumming in me, does feel erm just that bit more special, intimate
connected and also (pause) illicit. It must be said, that’s part of it as
well. So I think that in terms of certain kinds of sex and certain
situations, it is probably the more not necessarily rough, but the more
intense. The more erotic, the more kind of full-on sex sessions. Or
sometimes the much, much more intimate, when it is with somebody I
care about a great deal. The sensation of wanting everything – of
wanting all of them. So it works two ways. It is either the intensity of
love or the intensity of horny passionate, sometimes dirty sex – kind of
go for the whole lot. [p5]
H E A LT H B R I G H T O N & H OV E C I T Y C O U N C I L 2 0 1 4
In The substance misuse section: Sex & Drugs
 An area of significant concern over the last decade has been the growth in the use of
drugs such as crystal meth, GBL and Mephedrone by HIV positive men at sex parties.
 These parties, openly advertised on social media, can last for several days.
 Participants stop their HIV medication and have unprotected sex with many different
partners, putting themselves and others at risk of sexually transmitted infections
including gonorrhoea, syphilis, hepatitis and HIV.
 The prevalence of these parties is not fully understood, although sexual health and drug
services now work closer together compared to 10 years ago.
 Nevertheless, the persistence of high rates of HIV in the city after three decades of
health advice and widespread understanding of disease spread is an avoidable and
expensive public health failure.
In the Sexual Health Section: STI’s A story of success and failure
 …the adoption of new technology such as smart phone GPS /satellite applications, has
meant that potential sexual partners can be easily located for immediate meetings. Coupled
with the wider availability of certain recreational drugs like GBL - gammabutyrolactone, the
city has seen a small group of men who have sex with men (MSM) engage in very high-risk
sexual behaviour.
 Domestic drug and sex parties are just as popular as they were back in the mid 2010s when
they first received media attention. The continued high rates of HIV infection, of syphilis
and of drug resistant gonorrhoea in MSM are all testament to this social sexual phenomenon
 …the harder to reach sub-group of MSM with high risk-taking behaviour continue to present
with repeat infections, and syphilis is an infection that remains largely confined to the MSM
community…85% of local patients in treatment acquired the infection through sex with men.
 However, there continues to be a small core group of people in the city, in the main a subgroup of the MSM population, who remain resistant to behaviour change. if we could only
achieve it - would take us much further and the cost would be substantially lower.
Theories of behaviour change
NICE bases recommendations on KABP paradigm
(Knowledge, Attitudes, beliefs & Practice). Examples include
Health beliefs model
Theory of reasoned action
Motivational interviewing
Classical learning theory
Transtheoretical Model
Relapse prevention
Conner M, Norman P (eds.) (2005). Predicting health behaviour.
Maidenhead: Open University.
Motivational interviewing highly emphasised in implementation
Stages of change
preRelapse contemplation
Implications of NICE/Prevention
• Not much money with the recommendations
• No spare capacity in services
• Attempts made to teach clinic staff to implement
• One-off work-shops or 2 day training package
• Lack of ongoing supervision
• Some parts of population are “anti-contemplative” (my
phrase) and actively resist attempts to change behaviour
• Sub-group of MSM prioritise sex over health
• Very “targeted”
• Need to keep understanding of social processes
Foucauldian notion of public
health & Governmentality
 Public health is seen as one of the governmental techniques
under which externally imposed authority and domination
have been progressively replaced by techniques for
governing internal life (Bartos, 1993. p.82).
 Governmentality involves two key processes:
 Objectification: (Othering): processes such as scientific
classification and social dividing practices that separate off some
people from the rest of population with implications for identity
and action.
 Subjectification: Processes of active self formation by which a
human beings turns themselves into subjects. Associated with
reverse discourses in which dominant processes of
objectification can be turned on their head.
The deconstruction of HIV prevention
and social construction of Bareback?
 In the 20th and 21st century a whole series of discourses on
the species and sub-species of gay men who practice unsafe
sex, HIV positive gay men, sex addicts and barebackers
made possible a strong advance of social control into this
area of “transgressive sexuality”; but it also made possible
the formation of a reverse discourse. Barebackers began to
speak on their own behalf, to demand that their legitimacy
or “naturality” be acknowledged, often in the same
vocabulary, using the same categories by which they were
radically disqualified.
 This is an adaptation of a quote from Foucault concerning
the social construction of Homosexuality (Foucault, 1979,
 Increases in condomless sex amongst gay men
are thought to relate to the bareback
phenomenon; an eroticising gay vernacular for
condomless anal sex.
 This study explores the meaning and relationship
of this vernacular to the social and scientific
discourses of HIV prevention by exploring the
different meanings of condomless sex to gay
men living with HIV.
 The Study uses a Foucauldian epistemology
Results: Five Discourses
 Dominant Discourses
 Criminals
 Sex vectors
 Madmen
 Dissident Discourses
 Lovers (essentialist)
 Dissenters (anti-essentialist)
The criminal
 HIV as a dangerous possession
 Sex & onwards transmission as crime
 Active male desire more criminalised/predatory
 Any sex without disclosure as deceit
 Criminalised desire & Internalised judiciary
 Insertive penetration as reckless even with
condoms – condoms flimsy mitigation factor
 Fear and risk of corrupting the innocent
Coherent Meaning & Power
 HIV Positive men differentially imbued with
responsibility to police sex
 Consensual transmission not an option
The disease vector
 Desires, acts & people as a hierarchy of bio-risk
 Anal and penetrating acts as most dangerous
 Internal ejaculation as like injecting the infection
 No biological purpose for condomless anal sex
 No such thing as safe sex
 Sense of contagiousness, contamination and toxicity
 Constant internal medical surveillance
 Wounded masculinity: safer to be a bottom
Coherent meaning & power
 Anal sex equated with disease (older discourse)
 Male/anal physical intimacy as dangerous and dirty
The Insane & Perverse
 UPAI & casual sex as psychopathology: Thanatos,
mad love, perverse desire, grief, rage, addiction and
 UPAI & HIV+ status as deficiency or defect
 HIV positivity as profound attack on identity/soul
 Reduced sense of control in sex & love
 Disclosure of HIV as confession of madness
 HIV- men wanting UPAI as irrational & vulnerable
Coherent meaning & power
 Preserves Christian sexual values (essentialism)
 HIV a result of mad & perverse desires (gay plague)
Dissidence: Lovers
 Sex as deep physical and spiritual union
 Love as the realisation and liberation of the deeper self
 Sex talked about in universal terms (pan sex/gender)
 Condomless sex as natural & Condoms as unnatural
not true sex, interferes with symbolic roles of tops/bottoms
Prevent true physical and spiritual union
 Lovers, souls and deeper selves
 Safer sex is like wrestling against nature
 Seroconcordant love as the liberation of desire and identity
 Serodiscordant love as tragic and thwarted
 HIV transmission as the destroyer of relative identities (corruption)
Coherent meaning & Power
 Condomless sex as natural in love and symbolic of spiritual union
 Desire for condomless sex as an overwhelming force of nature
 Internal ejaculation as a potent symbol of physical and spiritual union
 Condoms as barriers – keeping souls apart
 Rationality not a currency of romantic love
Dissidence: The Outlaws
 Condomless sex as just one type of pleasure being framed as a new
 HIV prevention as an extension of sex regulation
 HIV diagnosis as a transgressive liberation
 Drugs as a vehicle to transgression
 STI/HIV as valid risks and dangers in sexual lifestyle choices
 Perverts, sexual outlaws, willing devils and sinners
 HIV as a club or brotherhood
 Multiple selves and contradictions allowed
Coherent meaning & power
 HIV dx offers new sexual possibilities free from fear of infection
 HIV prevention an extension of political regulation of transgression
 Negation of sole responsibility for HIV transmission
 A return to the pantheon - progressive and anti-conservative,
subversive and challenging.
 Highlights social power structures -Valid critiques of HIV prevention
 Harm minimisation philosophy
Combined effects of dominant
Desires of HIV + gay men constructed in much the same way as before
decriminalisation – criminal, unhygienic, mad and perverse
Sex with condoms becomes dangerous and risky
Non-positive men relieved of responsibility for HIV transmission
Ghettoising and excluding effects
sex & love made very difficult in serodiscordance
Just as the catholic confessional and psychiatrisation of sex led to
proliferation of language and knowledge of unnatural sex, so it appears
that HIV prevention results in a proliferation of language and eroticisation
of the very desires it seeks to contain
Dissident positions highlight the difficulties of living in these discourses
but also the hypocrisies of the dominant discourses
 Bareback can be understood as a reverse discourse
to the oppressive dominant discourses of HIV
prevention and their differential impact on those
living with HIV (subjectification)
 The anti-essentialist voice of the bareback
phenomenon can in fact be viewed as a valid
deconstruction of HIV prevention – it frames in
similar terms that Foucault frames the Confessional
 Calls into question the validity of criminalisation of
transmission and of the public health practice of
Bareback & Chemsex
 Both represent the same phenomena
 …
Sexual Hedonism/anti-essentialist
 Sexual hedonists are the objects of
intense governmental scrutiny
 Legal, biomedical, mental health
 Same old binary remains between
essentialism and anti-essentialism
 Services compelled to try and
persuade them to change
What could we do differently?
 Drug policy- Prof Knut
 Proper debate about transmission
 As opposed to Victorian law to criminalise
 Community engagement/service design
 What do “bare-backers” want from SH services?
 Harm minimisation
 Different service goals
 Different interventions
 More investment in the psychology of sexual
Psychological Interventions
 No single recipe intervention to
reduce sexual risk behaviours
 Complexity of sexual control
 MSM struggle to access bespoke
therapies until they are HIV positive
 Social & psychological meaning of
PREP (pre-exposure ARVs)
Psychology/sex therapy in SH
 Sex skills
 Overcoming sexual anxieties
 Sexual life-coaching
 Happy sexual control
 Problems with sexuality
 Substance-use and sex
Sex therapy/psychology
Diagnosable problems
 Substance-use and sex
 Depression and sexual expression
 Social anxieties and sexual
 Sexual addiction/compulsion
 Sexual impact of CSA/sexual violence
 Sexual dysfunction/psychosexual
Chair/Executive - integrating
Doves/Positive qualities
Spiritual/higher meaning
Hawks/Primitive states
Bonding Emotions:
Sex and Romantic states of mind
Metaphor for mind
Modalities of therapy
• Motivational (SMS)
• Anxiety and sex
• Sex therapies (a form of graded exposure)
• New sex therapies – work with individuals
• Sex Therapy
• Systemic
• Couples/relationship therapy
• Psychoanalytic
• Objects relations approach
• Social constructionist and narrative
• Critical framework useful for adjusting traditional approaches
• Narrative particularly useful in adjustment and building esteem and
generation of novel goals and ideas
• Use all to generate clinical psychology formulations and
• Motivational Models
• Try to help patient build a model of mind/body
• Sex as a state of mind/body (primitive bonding gear)
• Anxiety as another good primitive defence gear
• Work towards acceptance of desires while trying define what
limits they really want to operate within
• Exploration of positive functions of substances on expressions of
• Condomless sex as natural
• Sex & substance use as old as the hills
• Identify sexual problems that can be solved in different ways
• Realistic discussions about continued use of substances
• Education around sex, substances and brain chemistry
• Building a good and trusting relationship between executive
control and the sexual self
• Using the dog whisperer analogy
Key elements of formulation
Complexity of sexual control
 Expect no other animal to control sexual
 As a culture, we still have many
unresolved conflicts about our sexual
natures and desires
 Values of sexual hedonism and antiessentialism can be pathologised as
sexual addiction and paraphilias
 Hedonism often temporary and need to
offer pathways to rebalance when wanted

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