Critiquing the Condom Code: How The Public Health Approach To HIV Prevention In Men Who Have Sex With Men May Be Doing More Harm Than Good
Since the beginning of the HIV epidemic in the 1980s, the public health effort to prevent new cases of the disease among men who have sex with men (MSM) has been largely predicated on the message of “a condom every time”, or the “condom code”. The failure of these campaigns is illustrated in recent data, which indicate that, despite critical advances in the prevention and treatment of HIV, the disease remains a critical health issue among men who have sex with men (MSM) in the United States. This population accounts for more than half of all new cases annually and are the only risk group in which the number of new cases is rising(1).
This paper will utilize social science theory in an attempt to explain the failure of the condom code approach to HIV prevention in men who have sex with men in the United States. Among other things, it will argue that the approach makes unfair assumptions, ignores core values, encourages reactance, and does not consider the extremely complicated and largely homophobic environment in which gay men live. It will then outline a more suitable approach, arguing that men who have sex with men should not just be passive recipients of public health programs designed to reduce HIV incidence. The public health community has to engage and empower MSM to take control in the face of this crisis. It has to strive to make MSM feel respected, supported, accepted, meaningful, and worthy and make them feel that they are responsible for their decisions.
THREE FAILURES OF THE PUBLIC HEALTH APPROACH TO HIV PREVENTION IN MEN WHO HAVE SEX WITH MEN
1.) The condom code assumes rational behavior and ignores social context/the impact of homophobia
Assuming Rational Behavior
The earliest social behavior models emphasized the rationality and invariability of human behavior, assuming that people exercised a significant level of control over their actions. There was little weight given to the social contexts in which people lived, worked, and made decisions. Many public health interventions designed to change the way people act were predicated upon these theories. The “condom every time” approach to reducing HIV incidence in men who have sex with men is one example.
The condom code assumes that, if educated about the modes of transmission of HIV and safer sex, men who have sex with men will disengage in risky sexual behavior. However, as one gay advocate notes:
“We have been ‘educated’ to death. We have been directed, instructed, commanded, suggested, harangued and manipulated – all by people who believe that if you tell people
repeatedly what to do or not to do with their sex, they will comply.(2)”
This statement is illustrative of the fact that men who have sex with men are well informed of the risks of unsafe sex. A public health message that assumes they are not is not only unlikely to be heeded, but is also probably insulting. However, that is not the fundamental problem when considering rationality. The problem is that this knowledge has clearly not translated into action. Gay men know that using a condom reduces their likelihood of acquiring and transmitting HIV. But they engage in risky sexual behavior anyway. This is not rational behavior, and the public health approach clearly needs to change in order to attempt to understand what draws men to engage in these behaviors in spite of the known risks.
There are two social science arguments that lend themselves to explaining why it is MSM act irrationally despite understanding the potential negative outcomes that could be associated with their behavior. The first emphasizes the importance of visceral influences on behavior. Nordgren and colleagues found that when people were in a hot state (e.g., sexually aroused), they attributed their subsequent behavior primarily to visceral influences. This was in contrast to findings that when people were in a cold state, they underestimated the influence of visceral drives and attributed their behavior primarily to other factors(3). The implications of these findings are that when people are in hot state, they have no self-control. The implications with regard to condom use among MSM is that lack of a condom will probably not preclude a man from engaging in sex, as the desire to engage in sex when given the opportunity to do so will overwhelm the knowledge that an unprotected sexual encounter will increase the likelihood of transmission or acquisition of HIV.
A second consideration is optimism bias. Oftentimes people are well of the negative repercussions of a particular behavior but engage in it anyways because their perceived level of risk is low. With regards to MSM, this has been well documented through data demonstrating a disproportionate number of MSM whose perceived risk of acquiring or transmitting HIV is low, despite the fact that they regularly engage in unprotected intercourse.
Deemphasizing social context
Newer behavioral models have emphasized the importance of the role of social context in considering why people act the way they do. However, the public health community’s assumption that MSM can, and should, use a condom every time they have sex reflects a lack of regard for situation and environment.
The problem with disregarding context is marvelously summarized by Walt Odets in a conversation he had with Jesse Green:
“If you say to a man, 'In order not to get H.I.V. you are never going to have sex again without a condom,' his response would be that that seemed impossible. But there's a difference between going out with a guy you've never met whose status
you don't ask about, and a friend you've known 10 years who tells you he's negative. Education has refused to allow gay men even to think about that difference. It's like telling people that if they want to be safe drivers, they must always drive 35
miles per hour without regard to when, where or road conditions. Which any sane person will instantly reject(4)”.
Odets is right, and furthermore, public health practitioners would never dream of delivering this same message to the heterosexual community. This well-intentioned approach to limit the spread of HIV among MSM by promoting condom use every single time a MSM engages in sex is thus illustrative of an underlying prejudice. Generally speaking, our society greatly respects the importance that heterosexuals place on long-term commitment, love, and marriage(5). Unfortunately, the same cannot be said with regard to homosexual relationships. Many gay men interpret this as a dismissal of the value of sex and relationships between men. From a public health perspective, this has very important implications.
Research has found that the loneliness born out of negative societal perceptions of homosexual relationships is a cofactor for long-term risk for unsafe sexual behaviors (6) and that negative attitudes towards homosexuality result in high levels of psychological distress. Acceptance and comfort with sexuality are associated with increased condom use. Conversely, feelings of guilt are associated with decreased use(7). This research is illustrative of Maslow’s Hierarchy of Needs. According to this particular behavioral theory, people need to feel a sense of acceptance and belonging. They need to love, and in turn, be loved by others. They need to be respected, have self-esteem, and self-respect. In the absence of acceptance, love, belonging, and respect, people become likely to suffer from anxiety, depression, low self esteem, loneliness, and a feeling of helplessness(8).
Understanding that men who have sex with men often find themselves feeling alone, ostracized, and rejected as a consequence of their sexuality, it is easy to see why sex is such “core component(5)” of the gay identity. Sex confers a feeling of being loved, accepted, and needed, if only briefly. For many gay men, these feelings justify and even motivate high-risk sexual behavior. Negative emotional states and general urges to simply engage in sex have been shown to precede violations of safe-sex goals(6).
Ignoring the role the homophobia plays in HIV prevention in the U.S. means “ignoring an element of the disease as important as biology”(4). The refusal of our society to acknowledge and celebrate homosexuality in the same way we do heterosexuality has unwittingly encouraged the continued engagement of MSM in risky sexual behavior. According to the social research and theories outlined above, the importance of social context in designing a public health intervention cannot be overstated.
2.) The condom code sells health (A critique based on marketing theory)
The condom code message sells good health. In most regards, it sends a simple, clear, rational message: if you use a condom every single time you have sex, you will not transmit or be infected by HIV, and you, your partner, or both of you can avoid this dreaded scourge. It assumes that men who have sex with men want to be healthy. However, this fallacy is one of the failures of the public health message about HIV prevention to MSM.
Traditional public health interventions have relied on intuition about what people want, need, and desire. But, marketing theory suggests that intuition about what people want is often off the mark, and thus leads to inefficient interventions. Marketing theory says that in order to create a successful product, the wants of your target population have to be fulfilled. Public health practitioners need to identify the needs and desires of the target intervention group and design products, or interventions, that meet this demand(9). The key is to abandon the traditional approach of deciding what people want and then trying to sell it to them. In order to obtain this information, formative research about your group is needed.
There has been remarkably little formative research done into the hearts and minds of men who have sex with men living in the United States(5). However, based on the experience of the gay community in the 1970s and an examination of some of the grey literature, some of the core values of this particular population can be gleaned. Gay men struggled against a backdrop of fear, hostility, and discrimination throughout the 1970s to achieve some degree of self-determination, empowerment, and equality (2). The arrival of HIV changed all that. According to Eric Rofes, “It was as if a bomb had been dropped…and ground zero was gay men’s sex” (2). From that time forward, with regards to their sexual behavior, gay men have been told what to do and when and how to do it by an HIV prevention community that by and large does not understand what it means to be gay in the U.S.
Based on marketing theory, one of the problems with the condom code is that it sells health. Though public health professionals see health as something people should want, it is generally not a basic human value. Public health interventions designed to reduce HIV incidence in MSM communities have to sell the values that these men fought so hard to achieve throughout the 1970s. Sex, freedom, equality and independence are all likely to be valued more by MSM than health. Though it is counterintuitive to the public health community, the promise of good health does not meet the wants of MSM in the way that these values do. The problem with the condom code is not that it is ill-intentioned or unfounded. The problem is that, for a variety of reasons, some of which are outlined above, it doesn’t appeal to MSM living in the United States. Public health professionals have to present a position or a policy that is consistent with the core values, desires, and needs of men who have sex with men. As difficult as it is for the public health community to grasp, health is not one of these values, in this community, or in most others.
3.) The condom code may increase resistance to condom use: a critique based on Psychological Reactance Theory
Reactance occurs in response to threats to behavioral freedoms. It asserts that if a person is told not to engage in a behavior that they become motivated to do whatever it is they are being told not to. The degree to which an individual feels pressured, manipulated, or angered by being told what to do determines the likelihood of their reactance. Reactance increases resistance to persuasion, and is thus considered by social scientists such as Miller to be a risk factor for harmful behaviors. Psychological reactance theory is the most violated behavior model in all of public health. The public health community’s HIV prevention campaign is an example of how the ill-delivery of the message to wear a condom every time promotes reactance.
The theory argues that trust of the source of messages regarding one’s health is an important indicator of whether or not those messages will be heeded. This has been a failure of the “condom every time” message delivered by public health campaigns to the gay community. As Rofes noted: “A population with a long history of victimization by government, medicine, scientific research, and the media will not easily and quickly see these sectors as trustworthy partners in [HIV] prevention”(10). Unless gay relationships are accepted and celebrated in the same way that heterosexual relationships are, it is unreasonable to expect gay men to take messages about safe sex, stable relationships, and decreased promiscuity seriously(5). Especially when these messages are coming from the exact people who have historically discriminated against them. In order to reduce reactance, the messenger should be similar, or at the very least relatable, to the target intervention group. A man who engages in sex with men will be much more likely to consider a message about the importance of condom use if it comes from someone like him.
Furthermore, the message about safe sex and condom use has historically been serious, judgmental (though not outrightly so), and driven by scare tactics about the dismal outcomes associated with HIV. It is an overtly negative message, one that is delivered by people removed from HIV and the realities of life as a gay man in a homophobic society. A respectful, reflective approach is more likely to inspire change than is a strong, disciplinary, and reproachful message, as feelings of pressure, irritation, and manipulation that result from being told what to do all increase reactance.
As Green wonders, in a world where financing for AIDS research keeps increasing but agencies that serve gay populations are chronically underfunded, should we really be surprised if gay men wonder whether the disease itself matters more than they do? In cataloging the failures of the public health campaign to decrease incidence of HIV in men who have sex with men, it becomes clear that a new approach, one that affirms and celebrates their sexuality, is needed.
Recommendation: Application of the Sexual Health Model to Existing HIV Prevention Programs
Health promotion campaigns that combine personal freedom and personal choice with a practical response are more likely to be effective than those that inhibit desires or prohibit desired activities(11). Sex is a core value for gay men, and given that the current public health policy is essentially directed at restricting sex practices, it is easy to understand why it has not met with much success.
As a result of these failures, numerous researchers have recommended the use of more targeted HIV prevention efforts, so as to increase the relevance and effectiveness of the intervention for the particular at-risk population(12). With regards to MSM, HIV researchers have recognized the need to address sexuality and relationships when designing HIV prevention programs(6), especially in the face of evidence that suggests the incidence of new cases in this population is rising.
The Sexual Health Model is a behavioral model that offers a holistic approach to sexuality. The model promotes a sex-positive, culturally specific, multi-faceted approach to sexual health informed by both qualitative and quantitative research. Grounded in sexological theory, the model takes into account the need for sexual fulfillment, intimacy, and affirmation of self and identity(12).
Underlying the Sexual Health Model is a belief that HIV interventions need to encourage participants to think for themselves, to identify their sexual needs and desires, to develop their own sexual morality, and to make informed choices about their sexual behavior(6). The Sexual Health Model posits that sexual health cannot be obtained without personal awareness and self-acceptance. The assumption is that sexually healthy persons, that is, people who are sexually literate, comfortable, and confidant will make healthy choices when it comes to sexual behaviors (6). These choices include, but are not limited to: condom use and non-penetrative safer sex practices; strategies that focus on sexual relationships, such as developing rules for primary and casual partners; reserving penetrative sex for more intimate relationships; and agreeing that condom use is not necessary if both partners test negative and practice monogamy (6). Based on these principles, it is clear that the Sexual Health Model, unlike the current public health approach, emphasizes the importance of context or situation, and relays the understanding that there are circumstances in which condom use is not necessary. It also acknowledges the difficulties MSM face with regards to awareness and self-acceptance within a largely homophobic and unequal society.
The application of the program begins with an acknowledgement of the importance of the background of the target population(6) and focuses on the importance of exploring and celebrating sexuality. HIV prevention is an integral part of that emphasis, but the approach is positive and empowering, focusing on strengths rather than weaknesses (6). Rather than selling health, the model sells sex, empowerment, independence, and control, the values that the MSM community prioritizes. In addition, this shift in focus to a positive, affirming message reduces the kind of reactance that the current campaign elicits. Already, it is clear that the Sexual Health model eliminates most of the breakdowns of the current model.
Though the data supporting the use of the Sexual Health Model in HIV prevention programs is limited, initial evidence is encouraging. In a randomized control trial assessing the theory’s effectiveness, MSM who attended intensive two-day seminars designed to promote sexual health and explore sexuality reported an 8% increase in condom use, while the control group reported a 29% decrease. In addition, a significant reduction in internalized homonegativity was found in the experimental group (6). In the face of the failures of the current public health approach, it seems prudent to recommend that existing HIV prevention programs targeting MSM consider incorporating the types of seminars, focus groups, and educational campaigns that the Sexual Health Model advocates.
This is not to downplay the importance of condom use as a means of preventing HIV transmission in men who have sex with men. Safer sexual practices should undoubtedly at the core of any intervention designed to reduce HIV incidence among men who have sex with men. The Sexual Health Model supports this. However, the message as it is being relayed now is both unfeasible and unfair. Thus far, most public health programs designed to prevent HIV in men who have sex with men have demonstrated a total failure to seek to understand the reality of sex and relationships for gay men. Public health interventions designed to change the sexual behavior of gay men must include efforts to improve sexual awareness and sexual well-being. They must validate the legitimacy of homosexual relationships, and must empower men who have sex with men to make their own decisions. The Sexual Health Model provides an ideal framework by which the public health community can finally begin to do this.
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