Tailoring tobacco smoking reduction and cessation interventions with gay men living with HIV

Kevan (name changed) participated in one of two participatory focus groups held in Victoria and Vancouver in the spring of 2013 to provide advice on helping create services for men living with HIV who smoke tobacco products. During the focus group he learned that smoking rates among gay men and persons living with HIV (PLWH) are 2 – 4 times higher than the general population. Smoking is a major modifiable determinant of health associated with significant comorbidities (e.g., cardiovascular, neuropsychiatric, pulmonary, renal diseases) and HIV disease progression. Among gay and bisexual men, heavier tobacco use is associated with more severe illness symptoms and higher smoking rates are associated with comorbid illness. Previous smoking reduction and cessation (SRC) interventions used generalized (one-size-fits-all) approaches that have limited success with gay men. Tailoring SRC interventions to the unique needs of gay PLWH may improve the success of SRC with these men. Working with gay men living with HIV who smoke, the BC Lung Association’s QuitNow Program, and researchers from the Schools of Nursing at the University of British Columbia and the University of Ottawa are exploring the use of personas and empathy mapping to develop a tailored SRC web-assisted tobacco intervention (WATI).

Kevan and his peers were invited to become researcher-participants in the development of personas representing the typical gay man living with HIV who smokes. Personas are used in marketing to develop “detailed descriptions of imaginary people constructed out of well-understood, highly specified data about real people.” Personas help people who do not belong to a target market understand the needs of people like Kevan and how their culture influences health promotion and smoking behaviors. During participatory design sessions, Kevan and his peers generated a name and demographic information for their ‘persona’ and ascribed unique thoughts, feelings, and behaviors to each persona.  Four personas emerged from the design sessions, Joe Average, Biff Barista, Riley Homo, and Joe Schmo.

Joe Average, for example, is an HIV positive gay man living with his partner in a mid-sized city. He works full time He is a pack-a-day smoker who often smokes with his partner, co-workers, or friends. He is strongly goal oriented and he strives to manage his HIV. He makes sure that he eats right and gets plenty of exercise. Often under deadlines for his job, he finds himself smoking to relieve stress. He smokes as part of his many routines, including taking medications and vitamins, activities of daily living (e.g., showering), socializing with co-workers, smoking marijuana with his partner, and he sometimes smokes cigarettes after getting high on marijuana. Although concerned with his health, he hasn’t been able to quit smoking.

The four personas created by Kevan and his peers were analyzed using ethnographic and thematic analysis techniques to understand the collective needs of HIV positive gay men who smoke and how culture influences their SRC efforts. The first theme that emerged was navigating life and HIV, followed by triple stigma (i.e. gay-related stigma, HIV-related stigma, smoking-related stigma), immunity to public health messages, complexity of managing HIV, complexity of managing identity, benefits of smoking, anxiety about life, and apathy about life. Our goals with Kevan and his peers are to engage with gay men living with HIV who smoke as researcher-participants. This approach affords gay men living with HIV who smoke the opportunity to collaborate with each other, policy makers, researchers, and clinicians in the development of a WATI that includes input and collaboration from all stakeholders.

Authors:

CPhillips_web

J. Craig Phillips, PhD, LLM, RN, ARNP, PMHCNS-BC, ACRN, Associate Professor, School of Nursing, University of Ottawa

Jack Boomer

Jack Boomer, MPA, B.Ed., Director, QuitNow, BC Lung Association, Principal, Context Research

Leanne M. Currie, PhD, RN, Associate Professor, School of Nursing, University of British Columbia

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC

Advertisements

Sex & Substance Use Among Transgender Gay, Bisexual & Other Men Who Have Sex with Men

Gay, bisexual and other men who have sex with men (GBMSM) make up over 50% of new HIV infections in British Columbia, as well as almost half of those living with HIV in the province. Despite up to two-thirds of transgender men identifying as gay, bisexual or queer, the presence of transgender GBMSM within the largely cisgender (people whose gender identity is consistent with their sex assigned at birth) gay men’s communities is often invisible. While the link between substance use and HIV sexual risk is well-documented among gay men, little is known about trans GBMSM’s relationship to this culture of substance use with sex.

Trans people are generally left out of epidemiological surveillance and the collection of other public health data, sometimes explicitly excluded from research studies. What we do know about the size of the population and their health profile is largely based on small convenience samples, with the recent exception of theTransPULSEstudy conducted in Ontario which used respondent driven sampling (RDS) to recruit 433 trans people across the province. Further to the lack of data, research with transgender people has generally focused on gender identity, leaving the experiences of trans GBMSM not well documented.

The Momentum Health Study is a new opportunity to learn more about the health of GBMSM. A five-year bio-behavioural longitudinal study, Momentum is open to HIV-positive and HIV-negative cisgender and transgender men who are sexually active with other men in the Greater Vancouver Region. Following participants in the cohort over the study period Momentum will produce quantitative clinical, behavioural and psychometric data and provide a deeper understanding of some of the complexities around sexual health, gender identity and sexual orientation, sexual risk and decision making through qualitative interviewing.

In preliminary quantitative analysis, almost half the trans GBMSM in Momentum used at least one substance (primarily alcohol and cannabis) as did their partners, during one of their most recent sexual encounters while one-quarter did not know the HIV status of their sexual partner prior to sex. Overall, transgender GBMSM in the study appear to be engaging in lower HIV sexual risk behaviours than their cisgender peers as well as employing more HIV risk reduction strategies, despite not testing for HIV as frequently.

As a longitudinal bio-behavioural study, Momentum will provide an opportunity to gain a picture of the clinical and behavioural sexual health of trans GBMSM over time, adding to the limited knowledge on these men’s health. The initial take away is that public health prevention and harm reduction interventions targeting gay, bisexual and other men who have sex with men need to acknowledge the inclusion of trans men within these communities and ensure they are inclusive of trans gay men.

ashleigh

Author: Ashleigh Rich, Research Coordinator, Momentum Health Study, BC Centre for Excellence in HIV/AIDS in Vancouver

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC

Trans Language Awareness

Increasingly in the field of addiction research, we are seeing a commitment to acknowledging and understanding the “relevant contours” of addiction for people from different social locations. We often seek to understand the cumulative advantage or disadvantage that can occur at distinct intersections of human experience, based on such factors as socioeconomic status, age, geographic location, race, ethnicity, sexual orientation, and of course gender. Most researchers now acknowledge that gender does not exist within a neat binary (i.e., “women” versus “men”), and is likely to shift over the lifecourse. More and more we are seeing the inclusion of trans people in research, and in some rare cases, people who identify as “gender fluid” – i.e., those who do not readily identify with normative gender categories. While this trend signals a commitment to understanding a rich diversity of experiences, researchers’ interest in gender issues, and trans issues in particular, is not always up to speed with the evolving language and politics of being trans*.

Given the power of language to reduce people to labels and in the process, stigmatize them (as is the case with terms like, “drug addict”, “HIV positive” and “prostitute”), it is important for us to think carefully about how we use it. When it comes to speaking about trans people there are a few issues to consider. First, we often inadvertently use incorrect grammar. People often refer to “transgendered” women or “transgendered” men. This is akin to calling someone a “younged woman” or a “younged man”. As such, the correct language would be “transgender woman” and “transgender man” or more simply, “trans woman” and “trans man”. In many cases, people prefer the term “trans*” as it includes those who identify as transgender and/or transsexual.

Another term sometimes used in popular discourse is “transgenders”. This kind of language constitutes a form of “othering”, which is the process whereby people draw a distinction between themselves and “others” based on perceived differences. These others often become defined by, and reduced to, a fixed set of assumed characteristics. This process inevitably leads to bias and stereotyping. Many trans people experience this kind of language, and the actions that go along with it, as deeply discriminatory in the same way that racist language is experienced.

Similarly, there can be a tendency among researchers to write about trans people’s experiences as if they are homogenous. Because of our desire to better understand how gender shapes addiction in our research we attempt to separate the experiences of men, from women. Sometimes we create a third category of trans people. However, just as there is no universal experience of being a cisgender¹ man or a cisgender woman, there is no singular trans experience. What’s more, some trans people do not want to be seen as a distinct group as they aspire to more general gender categories. For instance, many trans people wish to “pass” and simply be called men or women, or boys or girls as the case may be.

Finally, there is a tendency to conflate trans identity with sexual identity. For instance, researchers will often refer to “gay, lesbian, and trans” populations. While trans identity politics are often intimately tied to gay, lesbian and queer politics, a trans identity is not a sexual identity. Trans people may consider themselves “gay” or “straight”, or they may prefer to identify as “queer” to signal their resistance to heteronormative thinking and categorization.

Admittedly, all these issues can make writing up research results complicated. Even more so given that the language continues to evolve alongside gender politics. As researchers the onus is on us to evolve alongside these kinds of important social and political movements. In part this means acknowledging and including trans people and trans issues in our research. But it also means being attuned to the meaningful distinctions between, and the implications of, the labels and the categorizations we use. There needs to be an explicit recognition of the power of words to both empower and disempower people.

¹ The term cisgender refers to when a person’s biological sex (e.g., being born female) matches their gender experience (e.g., living as a girl or woman).

Leah Shumka

Author: Leah Shumka, sessional instructor,  Gender Studies, University of Victoria; doctoral candidate, Department of Anthropology, University of Toronto.

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC

Navigating the Risks and Rewards of Group Sex

 Queer and Questioning Men as Pleasure-Seeking Harm-Reduction Experts

Moving forward, particularly in HIV/AIDS prevention, and gay men’s health overall, we must not reduce members of our community to problems that need to be solved and thus rush to establish prevention strategies without any genuine grasp of our desires and sexuality.  -Charles Stephens

Group sex events (GSE) have been a social, albeit mostly secretive, phenomenon throughout history. From ancient Dionysian mystery cults to today’s commercial sex clubs, intense communal sex-capades have attracted segments of the populace. GSE may involve anywhere from five to many lovers in a variety of private and public settings. According to early data drawn from the Vancouver’s 2014 Momentum Health Study, a Canadian Institute of Health Research and National Institute of Health funded longitudinal study of Vancouver gay men’s health, nearly a quarter of gay/bisexual/question (GBQ) men participate in GSE. Of these, 74 percent of participants used anywhere from one to a combination of 12 substances with the intention to disinhibit, prolong and/or enhance pleasure; while the same number of participants of the same study expressed interest in safer sex parties. How do queer and questioning men negotiate seemingly competing needs between sexual pleasure and health?

Few would deny the known risks to GBQ men associated with group sex. Nearly 60 percent of all new HIV diagnoses here in BC are from within this population. Do we know enough about the potential rewards of sexual exploration? More nuanced, culturally sensitive information is needed to provide a richer understanding of what constitutes both “risk and reward” in areas of queer and questioning men’s health.

Resiliency Theory advocates for strength-based HIV programs for men who lust for men. A new study of GSE out of Vancouver in partnership with community organizations including Health Initiative for Men suggests such programs should be internally navigated from within the specific contexts of GSE.  Momentum Health Study data indicates a subculture of intensive sex partying associated with GSE, and importantly reveals evidence of personal harm reduction practices (e.g. always being the top in anal intercourse to reduce HIV transmission). The Momentum study seeks to determine what other indigenous prevention tactics are associated within this subculture. The mixed-methods study will gather more information about who attends GSE, what motivates participant’s risk-taking/reward-making choices, and their harm-reducing and pleasure-amplifying practices. Between 20 and 30 participants, interviewed twice over a three-month period will inform researchers and community practitioners about the cultural characteristics and intrinsic values GSE offer participants. Project participants will ideally recommend potential customized event-level sexual health concepts for implementation.

Researchers also intend to meet with sex party hosts to better understand their needs and strategies for offering higher quality, safer and sounder sexual experiences to their guests. By engaging queer and questioning men in conversations about their chosen sexual practices and culturally explicit erotic spaces, future health strategies may more successfully evolve by both honouring men’s need for sexual adventurism while supporting their efforts for self and communal care. Your thoughts are most welcome.

robert birch

Robert Birch, MA is a doctoral student with the Social Dimensions of Health program at the University of Victoria, a new qualitative researcher with the B.C. Centre for Excellence Momentum Health Study for gay/bi men, and writes for the award winning national HIV/AIDS blog www.positivelite.com

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC

Gay Men, Sex(uality) and Crystal Meth Use

Drugs are people substitutes, people are drug substitutes¹

As a counsellor I prefer the term “drug use” rather than “addiction.” For many, addiction implies “bad behaviour” and can foster stigma and disempowerment for drug using individuals. One of the main characteristics of counselling is acceptance without judgment, especially when talking about sex with drugs. People use drugs for a reason, often to meet unfulfilled needs. Crystal meth was the most used illicit drug in the gay community during the 90s and early 2000s. While I am not an addictions specialist, about half of the gay men I see for therapy have current or past history of crystal meth problems. A common reason for gay men to use crystal meth relates to social and sexual inhibition and lack of connection to people.

Aspects of gay male subculture are dominated by sex. Within any medium size community, gay men can find sex within 10 minutes via phone apps. While such “hook-ups” frequently result in sexual release, they often do not meet their emotional needs. Many gay men struggle and cope with feelings of being different, or may have experienced various forms of abuse, and therefore question if they are lovable. Crystal may temporarily help users feel free of judgment, facilitate emotional connection with others and provide great pleasure with sexual partners.Crystal can also partially fulfill one’s sexual needs or fantasies, (i.e. engaging in “pig sex”), that otherwise might never be explored due to internal and/or external inhibitions. With reflection and support, these men often identify their desire for connectedness as the most important aspect of being high. Many report that without crystal, sex is boring because they are inhibited and cannot emotionally connect.

Crystal meth is not the problem but the symptom: the symptom of being unable to be free and spontaneous and therefore cannot connect with others. Thus, the primary goal of therapy is not to stop crystal use, but rather to assist the person in acquiring the skills needed to have uninhibited, drug-free and meaningful sex while feeling more connected with partners. This approach may require the therapist to be sexually open and sensitive to these topics in order to assist gay men to more intimately explore their sexual feelings and needs. As counsellors we need to lay the foundations of a nurturing therapeutic relationship that refrains from labels and judgments that disempower a person.  It seems with gay men and crystal use that, truly “drugs are people substitutes,” and with support, ideally “people can become drug substitutes.”

BillColeman

Author: Bill Coleman, counsellor

Biography: Most of Bill’s career has been working with criminals, primarily sexual criminals. He also works in the area of sexual health. Much of his work here has been with gay men at BC Centre for Disease Control, and many years in private practice.  He has also written for the LGBT newspaper, Xtra, on gay men and health. www.bcoleman.ca

¹  (Blachly, 1970) Seduction: A Conceptual Model in the Drug Dependencies and Other Contagious Ills, Paul H. Blachly, M.D., 1970, Charles C. Thomas, Springfield, Illinois.

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC

Rehabilitating Our Approach to Gay Men Who Use Drugs

Much of the writing on HIV prevention is loaded with punitive clichés about gay men that highlight psychological deficits, lack of self control, and prevention fatigue. Perhaps the most repeated one since the onset of the epidemic suggests that the majority of gay men are into drugs and couldn’t care less about becoming infected while enjoying their substances.

While these clichés have persisted throughout the epidemic, a closer look at statistics shows a more nuanced portrait of gay men. The Sex Now survey (Canada’s largest survey of gay and bisexual men) showed that the vast majority of gay men report no risk for HIV in the previous year (70 percent) nor did most report any use of party drugs over the same time period (85 percent), not even once.

One issue of concern emerging from the Sex Now survey, however, is that gay men who do use drugs are nearly twice as likely to report HIV risk. Other researchers have also demonstrated this relationship. But concluding that “drugs = uncontrolled gay men = risky sex ”, and that health professionals should focus their efforts on eradicating drug use among gay men to prevent HIV, ignores the complexity of gay men’s lives and the reasons they engage in both risky sex and substance use. For example, a recent UK study looking into the narratives of gay men who use drugs suggests that only a small minority were unable to control their behaviour when doing drugs. For others, risky sex was a decision made independently of drug use, while others enjoyed their sex lives and substances without any HIV risk.

Moreover, the explanation for higher sexual risk among drug using gay men may not actually reside in drug use itself. In Sex Now, gay men who reported drug use were also likely to report an array of other psychosocial difficulties such as depression, anxiety, suicidality, experiences of violence and homophobia and episodes of binge drinking. All these factors are known in the HIV literature to increase one’s vulnerability to HIV.

Finally, it is important to consider how public health and community agencies have generally responded to the prevention needs of drug using gay men. A recent review of prevention activities in BC demonstrated that the gay drug-using population is largely ignored by prevention. Initiatives that have been implemented have tended to focus on warning gay men against the danger of mixing drugs and sex, while doing very little to empower more informed decisions. Again, this strategy does not attend to gay men’s needs – most men are familiar with the danger of drugs with sex. Fear-based campaigns ignore the co-occurring factors and health problems gay men may be experiencing in conjunction with drug use. A strategy that focuses on educating solely on the risks of drugs reinforces the cliché that gay men cannot make rational decisions.

Rather than blaming gay men, we need a more positive approach to sex and drug research that examines gay men’s experiences with substances beyond a statistical correlation with risky sex. This research needs to take into account the burden of other health issues in this sub-population. We should demand targeted health promotion initiatives that reflect gay men’s real needs and work to reduce the bias of the public health field which appears to have issues with both gay sex and substance use.

olivier ferlatte

Author: Olivier Ferlatte, Research Education Director at the Community-Based Research Centre for Gay Men’s Health, Vancouver.

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC

Straight to Work

Canada is a country of labourers; a nation of hard working loggers, fishermen, farmers, and miners, toiling away in remote rural environments. To Canadians, these men are deemed rugged, resourceful, and above all heterosexual. However there is something we tend to overlook: some of these heterosexual men are having sex with one another.

These men are working in majority male-only environments remotely perched in the corners of our most rural landscapes, and on Vancouver Island such men have existed for a long time according to the anecdotal evidence available. Some might suggest that anecdotes are little to go on as evidence, but I disagree. Sometimes, these narratives of lived human experience are all we have in the face of a research void. Through these narratives we are learning that there are men having sex with men in a “MSM Vacuum;” a sex space that exists in isolation from and without connection to the social and cultural norms and expectations of men’s sexuality. Studies have explored this idea of a stand-alone MSM vacuum, such as research around rural gay experiences, incarcerated men and their sex practices, and the sex practices of men in the military. However, no research seems to have been done about specific rural work-based male-dominated labour environments.

Instead, these moments exist in a vacuum where the activities taking place within it are not connected to the outside world, and therefore divided from social expectations on sexuality, gender roles, and societal norms. For many of these men the key to entering into this vacuum is through the use of substances, such as alcohol, marijuana, or other harder drugs. If consequence-free MSM sex is the box, then the use of substance is the key to unlocking it.

This substance use could be interpreted in many ways. Does intoxication provide freedom from consequences in the decision making process? Does it lower a guard around secret sexual preferences, or create a heightened state where impulse control decreases? Or is it the absence of available female partners? Without more formidable research into the topic, this might be something we are left wondering over for a long time. The two consistent pieces of this MSM vacuum that have been shared with me thus far are a) this vacuum occurs often after substance use, and b) the use of condoms or other prevention barriers are virtually non-existent within these spaces.

With that in mind, how do we in turn create approachable HIV/STI prevention programming for MSM when some of these men identify as straight, and the prevention messages are directed toward gay/bisexual identified men? Accessing and engaging the varied MSM populations has always been a challenge in HIV work, and looking at men in this MSM vacuum might offer some further insights into how we can implement sexual health programming that is approachable to any and all men that engage sexually with other men. Perhaps HIV/STI prevention work will go further if we explore how sexuality is something more internal and experiential than longitudinal; perhaps straight men having sex with other men are simply straight men having sex with men.

samuel salvati

Author: Samuel Salvati, Men’s Wellness Program Coordinator, AIDS Vancouver Island

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC