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MSM and HIV: Behaviour change models and psychological therapies

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1 MSM and HIV: Behaviour change models and psychological therapies
Dr Phil Henshaw Consultant Clinical Psychologist Sussex Partnership NHS Foundation Trust

2 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]

3 Annual Report Of The director of Public health Brighton & hove city council 2014
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.

4 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 sub-group 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.

5 Sexual Health In Southeast

6 Theories of behaviour change
NICE bases recommendations on KABP paradigm (Knowledge, Attitudes, beliefs & Practice). Examples include Health beliefs model Theory of reasoned action Cognitive-behavioural 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

7 Stages of change pre- contemplation Relapse maintenance contemplation
Enter here pre- contemplation Relapse Permanent exit maintenance contemplation decision action Temporary Exit

8 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

9 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, 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.

10 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, p101).

11 Overview 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

12 Results: Five Discourses
Dominant Discourses Criminals Sex vectors Madmen Dissident Discourses Lovers (essentialist) Dissenters (anti-essentialist)

13 The criminal Objects HIV as a dangerous possession
Sex & onwards transmission as crime Active male desire more criminalised/predatory Any sex without disclosure as deceit Subjects 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

14 The disease vector Objects
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 Subjects 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

15 The Insane & Perverse Objects
UPAI & casual sex as psychopathology: Thanatos, mad love, perverse desire, grief, rage, addiction and loss UPAI & HIV+ status as deficiency or defect Subjects 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)

16 Dissidence: Lovers Objects 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 Subjects 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

17 Dissidence: The Outlaws
Objects Condomless sex as just one type of pleasure being framed as a new perversion 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 Subjects 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

18 Combined effects of dominant discourses
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

19 Conclusions 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 targeting

20 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

21 What could we do differently?
Drug policy- Prof Knut Proper debate about transmission responsibilities 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 health

22 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)

23 Psychology/sex therapy in SH
Non-pathological Sex skills Overcoming sexual anxieties Sexual life-coaching Happy sexual control Problems with sexuality Substance-use and sex

24 Sex therapy/psychology
Diagnosable problems Substance-use and sex Depression and sexual expression Social anxieties and sexual development Sexual addiction/compulsion Sexual impact of CSA/sexual violence Sexual dysfunction/psychosexual problems

25 Metaphor for mind Moral/Superego Chair/Executive - integrating
Doves/Positive qualities Relating Caring/empathic Flowing/absorbedness Spiritual/higher meaning Optimism Mindfulness Hawks/Primitive states Depressive Anxious Angry Paranoid Psychotic Bonding Emotions: Sex and Romantic states of mind Metaphor for mind

26 Modalities of therapy CBT Sex Therapy Systemic Psychoanalytic
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 interventions

27 Key elements of formulation
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 desires 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

28 Complexity of sexual control
Expect no other animal to control sexual behaviour As a culture, we still have many unresolved conflicts about our sexual natures and desires Values of sexual hedonism and anti-essentialism can be pathologised as sexual addiction and paraphilias Hedonism often temporary and need to offer pathways to rebalance when wanted

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