Thus, in order to appropriately address the issue
of AIDS and HIV prevention such messages must be presented within the framework
of the sexual, psychological, and social needs of the individual. For homosexual
males, this means discussing prevention within the context of the needs
and concerns that are specific to their identity and lifestyle.
In order to address the specific needs and concerns
of homosexual males it is important to lay out the basis for how they differ
from other groups of people. What must first be realized is that the sexual
activities of homosexuals differ from that of heterosexuals. This may seem
intuitive but it is a biological fact that is often neglected by psychologists
and doctors. This particularly becomes a problem when trying to understand
the sexual concerns of homosexual males. Perhaps the most overriding physical
sexual concern of homosexual males is that of painful receptive anal sex.
Nevertheless, this is a concern that has not been taken seriously by the
science world.
"Currently, DSM-IV does not recognize this as a
dysfunction ... Lack of diagnostic recognition has direct implications
for homosexual men seeking treatment, as well as for research on sexual
dysfunction. Research investigating the nature, etiology, and severity
of painful receptive anal intercourse is warranted" (5).
Just because receptive anal sex is a sexual activity
that is predominant in homosexual male populations and not in heterosexual
populations does not mean that the concern should be dismissed. Rather,
by addressing such concerns that are intrinsically connected to the identity
and lifestyle of a specific group of people, only then can HIV prevention
be successful.
Another important aspect to be considered is the
psychological needs and concerns of homosexual males. Like heterosexuals,
one of the fundamental psychological concerns is the concern of "normality",
which is defined as the "reassurance that ... concerns are common" (5).
While this is something that both groups encounter, the specific concerns
of homosexual males in this search for normality differ greatly from the
general heterosexual population.
The reason why normality concerns differ among the
two groups of people is correlated to the
different experiences and psychosocial obstacles that they face. Perhaps
one of the greatest psychological concerns specific to homosexual males
involves the often difficult process known as "coming out."
"Coming out" as gay is a developmental process that takes please on
several levels: first, telling oneself that one is gay; second, telling
others in a gay-affirmative environment; and third, telling the wider and
usually "straight" society of family, friends, an colleagues" (6).
The process is by no means an easy one.
"Since socialization experiences are absent for most gay men early on in their development positive roles which could counter stigmatization and isolation are not available to gay adolescents. As adults, the tasks of coming out are often complicated by identity diffusion, fear of exposure, rejection by significant others, and stigma. And further complicated now by the stigma associated with AIDS" (3).
While this indicates a wide variety of the anxiety
experienced felt when "coming out," there are still many other factors
not mentioned (e.g. ethnicity, family, community, and fear of rejection
by both the heterosexual and homosexual community) that may make the transition
even more difficult than it already is. Whatever the situation may be,
however, the most difficult and most important struggle dying this development
process is for the individual to accept the reality that he is gay and,
in effect, to feel comfortable about this part of his identity. Often this
integral part of the coming out process is identified as getting rid of
one's own internalized homophobia, which describes the "internalize[d]
negative feelings about being gay based on his exposure to these views
in others ... A vital role of the coming out process is to heal this narcissistic
injury and restore integrity and strength to the injured self" (3). While
much of the coming out process will depend on the individual there are
numerous things that the society can do to provide the individual with
a supportive environment: first, providing more affordable or even free
counseling to deal with gay-related issues and concerns; second, providing
greater assessability for homosexual males to meet up with each other and
thus feel more secure about their identity; and third, helping to create
a more tolerant, gay-friendly environment so that homosexuals do not feel
ostracized on account of their lifestyle. In sum, the goal should be one
of eradicating homophobia on both ends so that homosexual males are in
a more conducive environment towards addressing their needs and concerns.
Perhaps the greatest success in accomplishing such
a task has been the movement that has occurred in San Francisco. Consequentially,
by providing both a gay-friendly and gay-supportive environment, the city
has effectively been able to lower the incidence of AIDS, particularly
among homosexual males. While by 1992, "AIDS had become the most common
cause of death among men of all ages in San Francisco ... the epidemic
has also been more effectively contained in San Francisco than anywhere
else" (2). Since 1992, in fact, the AIDS incidence among men who have sex
with men (MSM) has been cut by over fifty percent (2). What is interesting
about this phenomenon is that this decline is specific to the MSM population.
Thus in contrast to the decreasing AIDS-related incidence among MSM, "the
number of persons dying of AIDS in other risk groups [in San Francisco]
continued to increase in 1993 and 1994" (2). See Appendix 1.
The success is not merely coincidence. Much of the
success in the significant decline of AIDS-related incidence among MSM
in San Francisco is directly related to the city's success in its prevention
efforts. Before most other cities:
"public health officials and members of the gay community [in San Francisco]
began discussing ways to reduce the rates of infection. In the early 1980s,
most information about AIDS was exchanged through one-on-one and group
discussion. Gay men, in pairs and larger groups, discusses the alarming
illness and its relationship to sexual practices. Because of other STDs
they were common among gay men ... there was a context for these discussions,
and many gay men were familiar with such concepts as asymptomatic carriers,
incubation periods, and immunity ... Although until 1984 it was not determined
for certain that AIDS was caused by a virus, HIV prevention [in San Francisco]
actually began in the early 1980s" (2).
The success of these early prevention prevention
was substantial. In fact, "on the basis of the AIDS incidence curves, we
can assume that the peak years of HIV seroconversion [in San Francisco]
were between 1981 and 1983, with a subsequent decrease" (2).
Using the success of San Francisco as a model for HIV prevention, a
couple of things may be concluded. First, "prevention works: Small studies
show that prevention interventions such as small groups discussions and
counseling can decrease the rate of HIV prevention" (1). "The success of
this HIV prevention effort is objectively confirmed by the decreasing incidence
of AIDS, and in the reduction of gonococcal proctitus, and in the reported
rates of anal intercourse" (2). Second:
"Community mobilization is a cost-effective method of dramatically
decreasing infection: San Francisco's gay community has been a driving
force for HIV prevention. Although the effort is supported financially
and politically by the San Francisco government, especially the Public
Health Department, it is led by members of the gay community" (2).
While in most cases it is impossible to imagine a
movement as influential or powerful as the one in San Francisco, it nevertheless
can be concluded that community mobilization does work. Thus, by having
a strong and vocal movement mobilized with specific concerns in mind, goals
(such as obtaining adequate government and private funding for HIV prevention
efforts) can be accomplished.
While San Francisco has indeed been successful in
its prevention efforts to reduce the AIDS incidence in the city, there
are still challenges that future prevention efforts need to address. Most
importantly:
"Prevention efforts must be ethnically, culturally, linguistically,
and age appropriate: The early prevention efforts worked, in part, because
gay men were talking to other gay men. However, until the late 1980s, many
persons of color perceived HIV as a disease that affected white gay men.
Perhaps infections among MSM of color could have been prevented but were
not. Similarly, until 1992 very few campaigns targeted young MSM because
youth were not recognized as a distinct group that required specific prevention
efforts" (2).
The diversity of different needs and concerns, therefore,
within the gay community cannot be put aside when addressing HIV prevention.
This is particular relevant when considering that the epidemic has increasingly
targeted young MSM of color rather than adult white MSM which was traditionally
believed to be the focal point of the epidemic. Such information, however,
requires that the prevention efforts address the needs and concerns of
the entire gay community in a way that is appropriate to the individual.
In sum, future prevention efforts need to be both more expansive and
more specific towards addressing the needs and concerns of the individual
in order to effectively go about such efforts.
"Prevention efforts must go beyond knowledge to include skill building,
treatment of substance abuse, and assessment and management of mental health
issues ... knowledge is a necessary but not a sufficient condition for
HIV prevention" (2).
Thus, "in terms of HIV prevention, research is warranted
if researchers are to achieve a comprehensive understanding of sexual behavior
and behavioral change" (5). Not only is this beneficial in terms of saving
lives, but it also helps in reducing medical costs.
"Under most reasonable assumptions, the incremental costs of the skills
training (prevention awareness) were outweighed by reducing the medical
costs saved. Thus, not only is skills training effective in reducing risky
behavior, it is also cost saving" (4).
Considering the benefits of HIV prevention it is
important that these programs are constructed effectively. As I have mentioned
throughout this paper, HIV prevention should always be based on the needs
and concerns of the individual. Thus, "sexual health aimed at homosexual
men should go beyond behavioral interventions to encourage safer sex behavior
and should also address the wider sexual functioning, emotional fears,
and cognitive concerns of those men" (5).
References
1. Choi, K.H., Coates, TJ., "Prevention of HIV infection." AIDS, 1994, 8(8): pp. 1371-1389.
2. Katz, Mitchell H., "AIDS epidemic in San Francisco among men who report sex with men: successes and challenges of HIV prevention." Journal of Acquired Immune Deficiency Syndromes and Retrovirology, 1997, 14(2): pp. S38-S46.
3. Paradis, Bruce A., "Multicultural identity and gay men in the era of AIDS." American Journal of Orthopsychiatry, April 1997, 67(2): pp. 300-307.
4. Pinkerton, Steven D., Holtgrave, David R., and Valdiserri, Ronald O., "Cost-effectiveness of HIV-prevention skills training for men who have sex with men." AIDS, March 1997, 11(3): pp. 347-357.
5. Rosser, B.R. Simon, Metz, Michael E., Bocktin, and Buroker, Timothy, "Sexual difficulties, concerns, and satisfaction in homosexual men: an empirical study with implications for HIV prevention." Journal of Sex and Marital Therapy, Spring 1997, 23(1): pp. 61-73.
6. Weiss, Jeffrey J., "Psychotherapy with HIV-positive gay men: a psychodynamic perspective." American Journal of Psychotherapy, Winter 1997, 51(1): pp. 31-44.
Appendix 1
Relationship of Sexual Functioning Concerns to HIV/AIDS and Safer
Sex
"When asked [among 197 homosxual men who had attended a health seminar]
if HIV/AIDS had any negative on the participants' sexual functioning, 43%
(n = 83) said Yes, and 57% (n = 111) said No. Of those who indicated a
negative impact, 65% (n = 54) reported the major impact to be an increase
in fear and distrust. Relatively few, however, stressed a fear of HIV/AIDS
itself. Most stated that HIV/AIDS had made them more fearful of sex, and
many stressed that it made them fearful of not just the physical aspects
of sex but the emotional and intimate aspects as well. Others indicated
some form of behaviorial restriction, including 11% (n = 9) of participants
who stated HIV/AIDS had curbed their freedom, 7% (n = 6) who said that
it caused them to be less "promiscuous," 6% (n = 5) that it prevented or
made problematic the forming of relatioships, 5% (n = 4) that it caused
sexual disfunctions, 5% (n = 4) that it made them deny themselves sexual
expression, 4% (n = 3) that it was a turnoff, and 1% (n = 1) each that
it made them less aggressive, dislike condoms, feel constrined by safer
sex, feel dirty, and grieve lost behavior" (5).
Figure below: AIDS incidence by risk group and year of diagnosis,
San Francisco, 1980-1995 (n = 22,602). From the San Francisco Department
of Public Health (2).
Appendix 2: Solution Outline
Gay Male Counseling Program
I. Overriding objective: To address the specific psychological, physical,
and sexual needs and
concerns of homosexual males as a means to effectively foster greater
HIV prevention.
II. Several factors to be considered in addressing needs and concerns
of clients.
A. Diversity of needs and concerns within the gay community.
III. Design of program
A. Counseling