Presentation on theme: "MSM and HIV: Behaviour change models and psychological therapies"— Presentation transcript:
1 MSM and HIV: Behaviour change models and psychological therapies Dr Phil HenshawConsultant Clinical PsychologistSussex 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 & DrugsAn 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.
6 Theories of behaviour change NICE bases recommendations on KABP paradigm (Knowledge, Attitudes, beliefs & Practice). Examples includeHealth beliefs modelTheory of reasoned actionCognitive-behaviouralMotivational interviewingClassical learning theoryTranstheoretical ModelRelapse preventionConner 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 herepre-contemplationRelapsePermanent exitmaintenancecontemplationdecisionactionTemporary Exit
8 Implications of NICE/Prevention Not much money with the recommendationsNo spare capacity in servicesAttempts made to teach clinic staff to implementOne-off work-shops or 2 day training packageLack of ongoing supervisionSome parts of population are “anti-contemplative” (my phrase) and actively resist attempts to change behaviourSub-group of MSM prioritise sex over healthVery “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 OverviewIncreases 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 DiscoursesCriminalsSex vectorsMadmenDissident DiscoursesLovers (essentialist)Dissenters (anti-essentialist)
13 The criminal Objects HIV as a dangerous possession Sex & onwards transmission as crimeActive male desire more criminalised/predatoryAny sex without disclosure as deceitSubjectsCriminalised desire & Internalised judiciaryInsertive penetration as reckless even with condoms – condoms flimsy mitigation factorFear and risk of corrupting the innocentCoherent Meaning & PowerHIV Positive men differentially imbued with responsibility to police sexConsensual transmission not an option
14 The disease vector Objects Desires, acts & people as a hierarchy of bio-riskAnal and penetrating acts as most dangerousInternal ejaculation as like injecting the infectionNo biological purpose for condomless anal sexNo such thing as safe sexSubjectsSense of contagiousness, contamination and toxicityConstant internal medical surveillanceWounded masculinity: safer to be a bottomCoherent meaning & powerAnal 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 lossUPAI & HIV+ status as deficiency or defectSubjectsHIV positivity as profound attack on identity/soulReduced sense of control in sex & loveDisclosure of HIV as confession of madnessHIV- men wanting UPAI as irrational & vulnerableCoherent meaning & powerPreserves 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 selfSex talked about in universal terms (pan sex/gender)Condomless sex as natural & Condoms as unnaturalnot true sex, interferes with symbolic roles of tops/bottomsPrevent true physical and spiritual unionSubjectsLovers, souls and deeper selvesSafer sex is like wrestling against natureSeroconcordant love as the liberation of desire and identitySerodiscordant love as tragic and thwartedHIV transmission as the destroyer of relative identities (corruption)Coherent meaning & PowerCondomless sex as natural in love and symbolic of spiritual unionDesire for condomless sex as an overwhelming force of natureInternal ejaculation as a potent symbol of physical and spiritual unionCondoms as barriers – keeping souls apartRationality not a currency of romantic love
17 Dissidence: The Outlaws ObjectsCondomless sex as just one type of pleasure being framed as a new perversionHIV prevention as an extension of sex regulationHIV diagnosis as a transgressive liberationDrugs as a vehicle to transgressionSTI/HIV as valid risks and dangers in sexual lifestyle choicesSubjectsPerverts, sexual outlaws, willing devils and sinnersHIV as a club or brotherhoodMultiple selves and contradictions allowedCoherent meaning & powerHIV dx offers new sexual possibilities free from fear of infectionHIV prevention an extension of political regulation of transgressionNegation of sole responsibility for HIV transmissionA return to the pantheon - progressive and anti-conservative, subversive and challenging.Highlights social power structures -Valid critiques of HIV preventionHarm 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 perverseSex with condoms becomes dangerous and riskyNon-positive men relieved of responsibility for HIV transmissionGhettoising and excluding effectssex & love made very difficult in serodiscordanceJust 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 containDissident positions highlight the difficulties of living in these discourses but also the hypocrisies of the dominant discourses
19 ConclusionsBareback 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 ConfessionalCalls 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-essentialistSexual hedonists are the objects of intense governmental scrutinyLegal, biomedical, mental healthSame old binary remains between essentialism and anti-essentialismServices compelled to try and persuade them to change
21 What could we do differently? Drug policy- Prof KnutProper debate about transmission responsibilitiesAs opposed to Victorian law to criminaliseCommunity engagement/service designWhat do “bare-backers” want from SH services?Harm minimisationDifferent service goalsDifferent interventionsMore investment in the psychology of sexual health
22 Psychological Interventions No single recipe intervention to reduce sexual risk behavioursComplexity of sexual controlMSM struggle to access bespoke therapies until they are HIV positiveSocial & psychological meaning of PREP (pre-exposure ARVs)
23 Psychology/sex therapy in SH Non-pathologicalSex skillsOvercoming sexual anxietiesSexual life-coachingHappy sexual controlProblems with sexualitySubstance-use and sex
24 Sex therapy/psychology Diagnosable problemsSubstance-use and sexDepression and sexual expressionSocial anxieties and sexual developmentSexual addiction/compulsionSexual impact of CSA/sexual violenceSexual dysfunction/psychosexual problems
25 Metaphor for mind Moral/Superego Chair/Executive - integrating Doves/Positive qualitiesRelatingCaring/empathicFlowing/absorbednessSpiritual/higher meaningOptimismMindfulnessHawks/Primitive statesDepressiveAnxiousAngryParanoidPsychoticBonding Emotions:Sex and Romantic states of mindMetaphor for mind
26 Modalities of therapy CBT Sex Therapy Systemic Psychoanalytic Motivational (SMS)Anxiety and sexSex therapies (a form of graded exposure)New sex therapies – work with individualsSex TherapySystemicCouples/relationship therapyPsychoanalyticObjects relations approachSocial constructionist and narrativeCritical framework useful for adjusting traditional approachesNarrative particularly useful in adjustment and building esteem and generation of novel goals and ideasUse all to generate clinical psychology formulations and interventions
27 Key elements of formulation Motivational ModelsTry to help patient build a model of mind/bodySex as a state of mind/body (primitive bonding gear)Anxiety as another good primitive defence gearWork towards acceptance of desires while trying define what limits they really want to operate withinExploration of positive functions of substances on expressions of desiresCondomless sex as naturalSex & substance use as old as the hillsIdentify sexual problems that can be solved in different waysRealistic discussions about continued use of substancesEducation around sex, substances and brain chemistryBuilding a good and trusting relationship between executive control and the sexual selfUsing the dog whisperer analogyKey elements of formulation
28 Complexity of sexual control Expect no other animal to control sexual behaviourAs a culture, we still have many unresolved conflicts about our sexual natures and desiresValues of sexual hedonism and anti-essentialism can be pathologised as sexual addiction and paraphiliasHedonism often temporary and need to offer pathways to rebalance when wanted