Risk refers to the possibility of a negative outcome such as harm, injury, or loss. There are many kinds of risk that we all encounter, from social risks to financial and professional risks to health and safety risks. In the lives of gay men, one source of risk is pervasive heterosexism and homophobia that create exclusion, discrimination, and violence – all of which are linked to health and social inequities (1, 2). As Chris Bartlett writes, generations of gay men have lived amidst risk day in and day out: living in the context of risk includes the possibility of negative outcomes, but also opportunities for creativity and resilience. Bartlett writes, “My own experience of risky gay men leads me to celebrate the role of risk and risk-taking in gay culture, and to grieve that risk has been pathologized and demonized as a result of the virus” (3). Risk is one of many forces that shape gay men’s lives, and a force that public health efforts seek to minimize – but, what risks are being addressed? In this blog, I consider the ways sexual risk is understood and the ways gay men and health promotion responds to risk.
What is risk?
While there are many types of risk, the risks that come with sex have occupied the gay men’s health sector for decades. While gay men celebrate sexual pleasure and freedoms, these aspects of sex also come along with risk, and gay men have led initiatives to provide information about risks and ways of managing it to their communities (4) since before the earliest reports of what we now know as Human Immunodeficiency Virus (HIV).
Recently, risk of HIV has been quantified in objective measures of biological per-act risk. The Canadian AIDS Treatment and Information Exchange (CATIE) (5) and the Canadian AIDS Society (CAS) (6) have recently produced resources summarizing current evidence of factors that impact transmission risk. In educational resources, risk has been categorized on a lower to higher risk scale (7). However, these scientific quantifications are not exhaustive and can be tricky to translate into gay men’s daily lives (8), but they recognize that risk of HIV differs based on the sexual act and many other biological factors.
Some prevention efforts portray all people living with HIV (PHAs) as a risk to all those who are HIV-negative, and pay less attention to the specific sexual act and biological factors involved (9). For example, in Canada, the criminalization of non-disclosure is one strategy that adopts this approach. In fact, Canadian HIV researchers have called on the judicial system to recognize the scientific evidence that documents HIV risk, rather than the current approach that equates non-disclosure as HIV risk (10). PHAs and scholars alike have rightly criticized these discourses, which needlessly pit individuals against each other based on HIV status, and deny the ways in which PHAs care for people who do not know their HIV status or are HIV-negative (9, 11).
In these examples, risk is primarily conceptualized at the interpersonal level, and is understood by accounting for factors in a specific interaction. Yet, these concepts of risk – and many others – do not account for the many structural factors that we know impact how gay men experience the world. As such, many people have articulated that current concepts of risk are framed in omnipresent neoliberal ideology which focuses on individual accountability and downplays societal forces (12, 13). This is not to say risk is an irrelevant concept, but that it must be understood as only one part of gay men’s sexual decision making, and that risk is produced, in part, by structure (9-14). Further, while these examples – and many prominent discourses of risk – focus on HIV, sexual risks extend beyond HIV and include other biological outcomes, such as STIs, and also include social and legal risks.
Taking sexual risks and sexual decision making
Risk is commonly seen as something to be avoided. For example, syndemics theory is often used to help gay men’s health practitioners recognize and respond to risk factors in men’s lives, with the goal of reducing risk (14). Yet, gay men’s sexual decision making extends beyond the latest information about sexual risk, and includes sexual desire, intimacy, interpersonal relationships, and community participation (15-18). Further, the ways in which gay men experience sexual risk extend beyond HIV status alone, and include the possibility of acquiring or transmitting any number of sexually transmitted infections, changes to interpersonal relationships, and personal safety and wellbeing (9). Flowers and coauthors (2000, p. 286) use the term ‘HIV-risk management’ to “incorporate the multiple and changing HIV risks that gay men experience” and highlight the ongoing changes in the risk environment, including those related to changes in medical knowledge, prevention options, psychosocial needs, and the legal landscape (9). This concept counters the commonly used neoliberal concept of risk, in which the focus is almost exclusively on the individual and their personal decisions.
Kane Race (2003, p. 371) highlights the ways HIV risk management occurs among “homosexually and scientifically active” men (17). These communities of men incorporate knowledge of emerging HIV prevention research (e.g. findings that HIV treatment lowers the amount of the virus in the blood to a point that the possibility of transmission is decreased) into their sexual decision-making. These groups of men – many of whom are HIV-positive, integrate scientific evidence with their own sexual experiences to derive “scientifically plausible” prevention strategies. In many places, these strategies are being adopted in the absence of public health guidance, where the focus remains on condom-only messages (17).
In addition to these groups of men who are able to navigate the emerging HIV research, there are groups of gay men who do not have access to basic information and prevention options (15, 18). Further, whilst some gay men have information, information alone is insufficient to impact behaviour. In some cases, assumptions rather than facts about a partner’s status or sexual health may inform gay men’s risk calculations (16).
Health promotion efforts tailored to gay men need to account for the different kinds of risk gay men encounter, and recognize that risk is celebrated and not universally demonized among gay men. Further, gay men pioneer and adopt new HIV risk management strategies as the informational, legal, and social landscape continues to evolve. Diverse health promotion strategies are needed, and these should include providing up-to-date information for “homosexually and scientifically active men,” supporting men’s efforts to build safer sex community norms, and building men’s capacity to act on information they know.
Current approaches to gay men’s health consider risk as something to be mitigated, avoided or managed. Yet, some forms of risk are valorized in society – those related to professional or financial gain, especially. While risk is often demonized, it will continue to be, in some cases, a celebrated part of gay men’s communities. First and foremost, health promotion efforts must continue to reflect the risk management needs and experiences of diverse gay men. Health promotion efforts must also seek to build communities and environments in which the legal and biological risks experienced by gay men are minimized, including through clear opposition to the criminalization of HIV non-disclosure and sex work.
(1) Christopher Banks, 2003 – The Cost of Homophobia: Literature Review on the Human Impact of Homophobia on Canada via http://www.usask.ca/cuisr/sites/cbrc.net/files/BanksHumanCostFINAL.pdf
(2) Sarah Chown, 2012 – ‘Homophobia is killing us’: Heterosexism and gay men’s health
(3) Chris Bartlett, 2012 – Levity and Gravity in M. Bernstein Sycamore (Ed.), Why are faggots so afraid of faggots? (p. 25- 32)
(4) News from the Front Publications, 1983 - How to have sex in an epidemic: One approach via http://richardberkowitz.com/category/4-how-to-have-sex-in-an-epidemic/
(5) Canadian AIDS Treatment and Information Exchange, 2012 – Webinar Series: Sexual Transmission of HIV via http://www.catie.ca/en/webinar-series-sexual-transmission-hiv/
(6) Canadian AIDS Society, 2013 – HIV Transmission Guidelines for Assessing Risk via http://www.cdnaids.ca/hivtransmissionguidelinesforassessi
(7) Canadian Public Health Association, 2008 – Safer Sex Menu for HIV Transmission via http://librarypdf.catie.ca/PDF/ATI-10000s/19667.pdf
(8) James Wilton, 2012 – Certainly uncertain: Challenges in communicating HIV risk via http://www.catie.ca/en/pif/summer-2012/certainly-uncertain-challenges-communicating-hiv-risk
(9) Paul Flowers, Barbara Duncan and Jamie Frankis, 2000 – Community, Responsibility and Culpability: HIV Risk-Management among Scottish gay men
(10) Mona Loutfy, Mark Tyndall, Jean-Guy Baril, Julio Montaner, Rupert Kaul and Catherine Hankins, 2014 – Canadian consensus statement on HIV and its transmission in the context of criminal law via http://www.aidslaw.ca/EN/lawyers-kit/documents/2014_Consensus-statement-ENG.pdf
(11) AIDS Action Now, 2011 - Poster Virus via http://postervirus.tumblr.com/
(12) Susan Kippax, N Stephenson, Richard Parker, and Peter Aggleton, 2013 - Between Individual Agency and Structure in HIV Prevention: Understanding the Middle Ground of Social Practice via http://www.ncbi.nlm.nih.gov/pubmed/23763397
(13) Barry Adam, 2005 - Constructing the neoliberal sexual actor: Responsibility and care of the self in the discourse of barebackers
(14) Sarah Chown, 2013 – Understanding Syndemics and Gay Men’s Health
(15) Ayden I Scheim, Syrus Marcus Ware, Nik Redman, Zack Marshall and Broden Giambrone, 2014 – Sexual health on our own terms: The Gay, Bi, Queer Trans Men’s Working Group. In D. Irving & R. Raj (Eds.), Trans activism in Canada: A reader (pp. 247-258).
(16) CIHR Team in the Study of Acute HIV Infection in Gay Men, 2014 – HIV-Negative Gay Men's Understandings of Sexual Safety without Condoms via http://www.acutehivstudy.com/Grace%20et%20al%20%202014%20CHS%20Fact%20Sheet.pdf
(17) Kane Race, 2003 – Reevaluation of Risk Among Gay Men
(18) Katrina Kubicek, Julie Carpineto, Bryce McDavitt, George Weiss, Ellen F. Iverson, Chi-Wai Au, Dustin Kerrone, Miguel Martinez, and Michelete D. Kipke, 2008 – Integrating Professional and Folk Models of HIV Risk: YMSM’s Perceptions of High-Risk Sex