Attitudes towards HIV risks and education

Readers of Yawning Bread may recall that I was doing an online survey a little while ago. Thank you for your participation.

First, a summary of the chief conclusions:

1. A big minority of net-savvy, relatively young, current-affairs-aware (and therefore presumably correlated with being better-informed) Singaporeans still do not see HIV and Aids as serious threats to Singapore.

2. A large majority of heterosexuals in this stratum of society do not exhibit traits and views that are associated with conservatism, with respect to sexuality. Only a small slice of them showed homophobic bias in their opinions.

3. While nearly everyone sees HIV/Aids as a sexual disease calling for sex education and condom dispensing, why many also think moral education would help the fight against Aids is unclear.

4. Just under the surface, there is a tendency to see HIV/Aids as a threat from the "other" person, rather than as a consequence of one's own behaviour; this segues into a tendency to xenophobia.

5. Heterosexuals in the set have a poor understanding of how anti-gay laws and policies lead to an undergrounding of the disease; this must be explained with greater specificity in public education.

 
Publicity and reach

Being an online survey, it meant that the sample was not controlled. Hence, I make no claim that the results are representative of any population; at most, the results are merely suggestive of the population that the online survey managed to reach.

The survey was advertised on this site, as well as on Singabloodypore and Mr Wang Bakes Good Karma -- my thanks to them. It might have also been advertised on other sites which I am unaware of -- again, thanks to those webmasters.

Yawning Bread, Mr Wang Bakes Good Karma and Singabloodypore are sites that focus mainly on social and political issues. They generally adopt a liberal point of view. One should therefore expect that the regular readers of these websites would be those who are keen on current affairs, critical and generally liberal in outlook.

However, I also sent emails to quite a few friends with a request to forward my request further. There was likely to have been some snowballing, but how much, I can't tell.

My guess is that the survey basically reached the population that is served by the 3 websites, and those whom I and my friends tend to know. I would believe this population to be characterised thus:

• net-savvy
• more politically-aware than Singaporeans in general
• more liberal and critical than Singaporeans in general

No one would claim these to be "average" Singaporeans. For sure, as we will see further down, they are younger than the "average". Naturally, I was aware that this would be the likely population the survey would reach, but that was what I wanted, not merely what I had to content myself with.

I wanted to know whether the Singaporeans at this end of the Gaussian bell-curve, who have access to infinite information from the internet, who are au courant with current affairs and able to think critically, are equally able to apply their minds to the question of HIV and Aids. To what extent are they still ignorant and bigotted? To what degree does misinformation and over-generalisation still resonate with them?

Do they exhibit any of the tell-tale signs of "conservatism", which in the matter of sexually transmitted disease, is usually associated with 

• treating the subject as a moral issue
• discomfort with open discussion, due to sex-phobia
• tendency to see minorities (gay men, sex workers, foreigners) as scapegoats?

If even this better-informed, younger subset of Singaporeans are "conservative" by these measures, then indeed the government's claim that Singapore is a conservative society must be a solid one, justifying all sorts of laws and measures that make fighting HIV and Aids harder, not easier.

If they are not, then there is hope that as this generation takes charge and this net-savvy set become the opinion leaders, we may see a more enlightened approach to battling the epidemic.

 
Responses received

In the one month period that the survey was open, 13 Oct to 13 Nov 2006, a total of 727 responses were received. A fairly good balance of gay and straight was obtained. The male-female balance was not so good however; males outnumbered females about 2:1, probably reflecting the readership profile of the three websites.

From the beginning, it was not my intention to take aggregate readings from the total response base; rather, I wanted to segment the results by sex and sexual orientation to see how each group's attitudes compared with others'. I was interested in knowing how gays thought, how straights thought and whether men and women saw things differently.

However, this also meant I had to be quite brutal in excluding some responses from the analysis if the participant did not fall neatly into any group. Thus, out of 727 responses received, 156 were excluded. Only 571 were kept for analysis.

To be included, the participant had to meet all 4 criteria:

• Be a Singapore citizen or Permanent Resident, and
• Be living in Singapore for at least 50% of the time in the last 3 months, and
• Be either male or female, and
• Be either heterosexual or homosexual/bisexual.

Singaporean citizens living abroad were excluded. Foreigners living in Singapore were excluded. The 4 transgendered persons who responded had to be, unfortunately, excluded since they were too few to make a category of their own and I couldn't quite fit them into either the "male" or "female" categories. There were 19 persons who answered the sexual orientation question with "none of the above"; they didn't fit anywhere either.

As you can see from the pie above, there were a reasonable number of gay male, straight male and straight female participants. 

Lesbians were a little too few for my liking, though, so the usual caveat (small sample, thus treat with caution) applies. However, as you will see below in the detailed discussion, the responses from the lesbians are quite consistent with those from the other subsets, thus one can invest some credibility in their answers too.

I mentioned above that age-wise, the respondents were definitely untypical. Here is Singapore's age pyramid (left) compared with the survey respondents' age pyramid (right).

Note: The Department of Statistics defines "Singapore residents" to mean Singapore citizens and Permanent Residents, living in Singapore. The survey uses the same filter for deciding which responses to include in the analysis.

263 respondents (46%) were in their twenties; 153 respondents (27%) were in their thirties. 
  

The opening question simply asked participants how serious a threat to Singapore they saw HIV to be, assuming the current level of intervention continued.

Percentages 3 38 47 10 1 25 56 17 1 32 54 9 4 33 48 15

Note: Respondents who gave "Don't know" as their answer are not shown in the percentages table, nor in the colour bars.

41% of straight males (green and café latté in the uppermost bar) rated HIV to be either "not significant threat" or "no threat at all".

Even among gay men, 27% felt the same way, despite their own community being one of the most vulnerable.

The figures for both the female subsets were somewhere in between.

Personally, I am rather disappointed by these numbers. I would have thought that these better-informed segments of our population were aware of how explosive the rise of Aids has been in Africa and neighbouring Asian countries, and how much human misery and economic loss it has caused.

If so many of these better-informed Singaporeans are still complacent about the threat, then what about other Singaporeans who are less interested in current affairs?
 

The second question was a six-part question, positing 6 different factors, and asking the participants whether each factor increased or decreased the risk of exposure. It was intended to provide some insight into how informed this segment of our population was about risk factors, but more importantly, about how rational they were in assessing risk.

The first factor presented to them was "Being married." Does this increase or decrease one's risk? 

Percentages 17 35 42 3 1 7 33 54 3 1 12 30 43 15 1 2 33 53 8 4

42% of heterosexual men said it would make no difference (purple band), 35% said it would decrease one's risk somewhat (lilac) and 17% said it would decrease one's risk greatly (light blue). Thus, 52% of the straight men seemed to have quite a sanguine view of marriage as a protective factor.

What was interesting was seeing how some straight women had a more jaundiced view. 15% of them thought that marriage increased the risk of being infected (crimson band in the third horizontal bar).

In a way, these were rational responses, albeit informed by seeing things from perhaps a personal perspective. Men might think that marriage imposed a burden of fidelity, and with less casual sex, would decrease their risk exposure. While 42% of women agreed with them, the 15% who did not might see conjugal relationships as a route to being infected by the germs that the husband brings home from his trysts outside.

The relatively high percentages going for the "makes no difference" response (purple bands) tells you what the largest group of these participants think of fidelity in marriage: They don't believe it. They don't expect people, in the main, to remain faithful.

If Singaporeans don't expect married couples to be always faithful, then the "Be faithful to your partner" arm of the safe sex message must be seen as less than sufficient as a solution to the threat of Aids.  What more of the call for abstinence?

*

The next factor presented in the questionnaire was "Being homosexual". Would this increase or decrease the risk?

Percentages 0 0 34 41 22 1 1 50 44 5 0 0 39 38 22 0 4 58 33 4

A majority of heterosexual respondents said it increased the risk. 22% of them said it "greatly increased" it (the paprika orange bands).

The truth of course is that homosexual men are more vulnerable to HIV/Aids than heterosexual men (see incidence data in box on the right). In my opinion, to say that being homosexual "somewhat increases" the risk is probably the most accurate assessment.

However, to say it "greatly increases" the risk is an exaggeration. That 22% of heterosexuals saw it as such indicates to me that even among the better-informed, thinking Singaporeans, some of the heterosexuals there continue to associate HIV with homosexuality more than may be rationally justified.

*

The third statement was "Avoiding sex with Caucasian tourists". Would this increase or decrease the risk?

Now, rationally, the answer should be "no difference". There is no reason to believe that Caucasian tourists have a much higher prevalence of HIV than local Singaporeans, so why should the risk change?

These were their responses:

Percentages 15 22 51 5 4 4 22 71 2 1 10 32 48 6 3 4 31 54 4 6

Quite a large minority of all groups felt that if they stayed away from Caucasian tourists, it would improve their chances of remaining HIV-free. 26% of gay men and as many as 42% of straight women thought so.

I had an inkling that some gay men thought like that, perhaps stuck with a picture from 20 years ago of gay Americans emaciated by Aids and falling like dominoes. What mystified me from the data was to see that even more of the lesbians and straight Singaporeans were prone to this stereotypical view.

Male heterosexuals here, when they think of "Caucasian tourist" as a sex partner, are likely to imagine a "white chick". Do they also see "white chicks" as disease carriers? When was this, objectively, ever the case? If there's no rational basis for this, then is it pure xenophobia?

I anticipated the possibility that this might be a leading question to some participants, skewing the result. Perhaps the participants hadn't thought like that until I posed the question. They might have thought, "Oh, if the researcher singles out Caucasians specifically, then it must mean something's wrong with them!"

To check that possibility, I threw in another red herring.

*

The fourth statement was "Consuming milk and milk products daily". Would this increase or decrease risk?

Percentages 1 0 92 0 0 0 0 92 0 1 0 0 91 1 0 0 0 90 0 0

All 4 subgroups were nearly unanimous that it would make no difference to risk (purple bands). On this question, they showed themselves to be perfectly rational, and not swayed by the tacit suggestion within the question.

So, in the earlier question about Caucasian tourists, the results showing a largish minority believing them to be a risk factor, were not an artefact of a leading question. They really believed that.

However, I should point out that this milk question gave one unusual pattern in the answers. About 7 - 10% of each subset gave "don't know" as their answer (not shown in the bars above). This was much higher than in the case of the other questions, where typically, "don't knows" were 2 - 4%.

This shows that up to 10% of this internet-savvy, current-affairs-interested group of Singaporeans had little confidence in their knowledge of HIV and Aids. What they thought they knew was easily destabilised by a tiny little suggestion that maybe milk might be of protective value.

* 

The next statement was "Being heterosexual". 

Percentages 2 9 76 9 4 1 9 82 5 3 1 3 83 9 3 0 0 83 13 4

There's not a lot of difference among the 4 groups. A huge majority in each group thought heterosexual orientation would no make difference to risk.

From a purely technical angle, this is inconsistent with the answers they gave to the second statement, "Being homosexual". Since they saw being homosexual as leading to an increased risk, they ought to see being heterosexual as the reverse.

Objectively too, it would be so. From the HIV incidence statistics in Singapore, we know that there is a disproportionately higher number of homosexuals being infected, and therefore a disproportionately lower number of heterosexuals.

The only way I can interpret this set of answers is to say that the respondents (gay and straight) see heterosexuality as a reference. Heterosexuals, in their subliminal view are, by definition, the reference risk; homosexuals have a higher risk when measured against the reference (rather than balanced against heterosexuals' lower risk).

Why do they see it like that? I don't know.

*

The sixth and last statement of Question Two was "using synthetic/party drugs". Would this increase or decrease the risk?

Percentages 0 0 27 41 30 1 0 13 37 47 0 1 22 44 30 0 0 17 48 35

Once again, opinion was consistent across all 4 subgroups. The gay men seemed to be most aware of this risk, probably because the prevention messages aimed at this community have put more stress into this aspect than messages aimed at other communities.

More generally, this shows that educational messages are definitely getting through to all subsets, at least insofar as this relatively information-rich segment of Singapore's population is concerned. I wonder though, what answers we'd get if we put the same question to less-educated segments of our population.
  

The third question was also a six-part question, seeking to fathom attitudes towards various known or supposed counter-measures that might be useful in the battle against Aids.

The first was "Increase moral education in schools". Would this help or hinder the fight?

Percentages 18 50 23 3 5 9 45 21 14 10 16 54 16 6 7 13 46 19 6 17

To my surprise, a majority in all 4 subsets said moral education would help (the two green bands). I cannot really explain this, though I believe that it may have to do with how people understand the term "moral education".

Personally, I'm of the view that too much moralising about sex and sexually-transmitted diseases drives sexual behaviour underground, and alienates those who are already sexually active and therefore most in need of information and support. 

Especially in Singapore, moral education in schools -- even sex education -- is often hijacked by fundamentalist Christians, usually with the connivance of like-minded principals and teachers inviting those guest speakers into their schools. Their extremely sex-phobic views are problematic because they can be so judgemental and alienating. 

I would think that for this question, "hinder somewhat" would be the more rational, and more empirically-based answer.

You would have noted that a distinct one-quarter of gay men and women were negative about moral education as a counter-measure against the spread of HIV, rather more than the negatives among heterosexuals. They probably share my opinion about this being hijacked in schools (as did the audience at the Singapore Aids Conference 2006 who applauded my use of the word "hijack").

Yet, only 8 - 13% of heterosexuals felt that moral education hindered the spread of this disease. This cries out for further investigation.

Are Singaporeans indoctrinated to respond with an automatic thumbs-up each time "morality" is mentioned? Do they embrace the label "moral" unquestioningly, without looking into what values those so-called "morals" represent? If they do, then it may not be hard to see how anything labelled "moral education" is immediately seen as a good thing.

*

The second statement presented to participants was "Increase sex education in schools". Would this help or hinder the fight against Aids?

Percentages 51 41 6 2 0 60 36 3 0 1 67 29 4 0 0 54 40 6 0 0

Nearly all respondents felt that increased sex education would help. Interestingly, straight women were the most convinced of this, and straight men the least, relatively speaking.

Despite the cloudiness introduced by the answers to the moral education question, these answers make it very clear that this group of Singaporeans saw HIV as first and foremost a sexual disease, for which equipping youngsters with relevant life skills was essential.

*

The next statement was "Compulsory HIV testing before marriage".

Percentages 28 44 19 4 1 20 42 23 9 4 38 40 15 7 0 33 40 21 2 0

Three out of the four subsets demonstrated a rather similar spread of views. About 3 in 4 of heterosexuals and lesbians thought that compulsory testing prior to marriage would be a useful tool. Straight women in particular were a shade more enthusiastic than the rest.

This probably reflects their own perception of risk from their (non-virgin) husbands.

The views of the gay men are a little distinct from the rest. They seem to be a bit more sceptical about the usefulness of such a measure.

The fact that such a strong majority of the respondents believed in this measure suggests to me that just under the surface, even with this group of relatively well-informed, thinking, Singaporeans, there is a tendency to see HIV as a threat coming from the "other" person, rather than as a consequence of our own behaviour and our own powers of observation. This is consistent with the tendency to see foreigners (e.g. Caucasian tourists) as threats as well even when there is really no basis to do so.

As a consequence of seeing HIV in this way, embodied in the "other" person, there is likely to be a certain receptivity to the idea of mandatorily controlling the "other" as a means of protecting ourselves.

Besides potentially giving rise to various illiberal demands, it can also serve to excuse oneself from being watchful of one's own behaviour and one's partner's behaviour. This delegation of responsibility to third-party agencies, such as the State (e.g. expecting it to pass a law to make this and that compulsory!) may lead people to let down their own guard.

It therefore troubles me to see how eager people are to adopt a "compulsory testing before marriage" solution.

*

The fourth statement for consideration was "Repeal the law that makes homosexual sex illegal". Would this help or hinder the fight against HIV?

Percentages 9 16 60 6 7 40 30 22 2 5 11 15 57 9 5 25 19 48 2 4

This question brought out the biggest difference between gay men and heterosexuals. A majority of both male and female heterosexuals felt that repealing the law would make no difference to the battle against HIV (the olive bands in the first and third bars).

In this, they were not only at variance with gay men's opinion, they were also at variance with professional opinion. Worldwide, professionals involved in HIV, from the United Nations down, are quite adamant that criminalising homosexuality is a major hindrance to their objectives. 

Criminalisation, and the social prejudice and discrimination that it engenders, drive the disease in the gay community underground, making it harder for education, testing and treatment to reach those most in need. The underground gay community then becomes a festering reservoir, but not a water-tight one. Married homosexuals and bisexuals act as bridges bringing infection to women, and thence to the heterosexual community.

It is important to deal with the reservoir, but if there is a law on the books, government agencies and others who take their cue from the State find themselves in an antagonistic relationship with the gay community. There is neither trust, communication nor engagement. Such a situation impedes the aim of preventing a reservoir from developing.

Ditto with sex workers, both male and female. The more the police chase them down, the less likely the healthcare people will be able to reach them. The more they have to hide from friends and family due to shame and stigma for doing sex work, the more negative and fatalistic they may be about life. With such an attitude, why bother to take precautions and take care of oneself? What's there to live for?

In the meantime, they service God knows how many clients a month. So how?

That's why stigma, prejudice, and the laws and policies that support all that, matter a great deal.

What came out of this survey question is that the majority of heterosexuals fail to understand this psycho-social cycle, thus responding to this question with a "will make no difference" answer.

My suggestion to anyone involved in HIV is to be more specific in explaining to society at large how exactly an anti-gay law can give rise to a festering problem within the gay community, and how that boomerangs back onto the straight community. We must not assume that people are able to connect the dots on their own.

*

The fifth statement was just to confirm the findings from the previous. "Widen the ban on gay activities and websites" -- will this help or hinder?

Percentages 7 10 60 11 12 1 2 37 13 46 4 10 54 16 13 0 2 42 17 35

Once again, a majority of heterosexuals said, "will make no difference" (olive bands). On the other hand, a majority of gay men and women felt that a widened ban would hinder prevention efforts, a view supported by about a quarter of the heterosexuals.

*

The last of the 6 statements of Question Three was "Permit condom vending machines in shopping malls and entertainment outlets".

Percentages 32 49 14 2 2 38 52 6 3 0 29 48 17 3 1 35 46 15 2 0

A strong majority in all 4 subsets felt that having condom machines around would be a good thing. There was not a lot of difference among the different subgroups in the survey.

I was intrigued by the 2 - 4% of respondents who disagreed. They seemed to represent the constituency who feel that making it easier for people to have sex is not a good thing.

So there's a trace of sex-phobic conservatism among the net-savvy, politically-aware Singaporeans after all.
  

These two questions were based on hypotheses. The preamble explained that "Some people argue that for effective prevention, we need to talk openly about sex, and we should be specific about the do's and don'ts."

The hypothesis for Question Four was: "Suppose there was a talkshow on TV, after 10pm, that discussed heterosexual sex and HIV prevention." 

Then offered the statement: "I will be offended." Do you agree or disagree with this statement?

Percentages 56 21 11 7 5 70 13 12 4 1 54 25 16 3 1 65 17 17 2 0

As you can see, more than 3 in 4 said they would not take offence (yellow and dark mustard). 

Next, the hypothesis was tweaked slightly for Question Five: "Suppose there was a talkshow on TV, after 10pm, that discussed homosexual sex and HIV prevention."

"I will be offended." Do you agree or disagree with this statement?

Percentages 40 20 24 9 7 67 15 12 4 2 41 21 20 8 9 69 6 13 8 4

The shift in heterosexual opinion is striking. 4% more straight males and 13% more straight females would feel offended (i.e. more black and grey) when the topic was tweaked from heterosexual sex to homosexual sex. Another 13 - 16% shuffled back from being definitely not offended to "somewhat" not offended (changing from yellow to dark mustard in the first and third bars)

*

However, I felt I should allow for the possibility that whether or not they felt personally offended, they might still favour airing the program in the interest of public health.

So, an alternative, affirmative statement was offered for both hypotheses.

Thus, "Suppose there was a talkshow on TV, after 10pm, that discussed heterosexual sex and HIV prevention." 

Statement offered: "I am in favour of having such a program."

Percentages 52 32 12 2 1 72 22 5 1 0 52 33 14 1 1 58 35 13 4 0

It looks like a mirror image of the above, except that among the straight males, even though 12% had earlier said they would be offended, only 3% objected to having such a program. Perhaps they saw that public health interest was more important than their own queasiness.

Then the gay version, "Suppose there was a talkshow on TV, after 10pm, that discussed homosexual sex and HIV prevention."

Statement offered: "I am in favour of having such a program."

Percentages 35 29 25 5 5 69 22 8 1 0 40 32 15 7 6 69 17 10 4 0

The shift in the opinion is still there, in fact bigger. 

20% fewer straight males and 13% fewer straight females were in favour of airing the program if it talked about homosexual sex.

You could say these represent the latent homophobia in some people within the net-savvy, politically-aware section of the Singapore population, preferring censorship over the public health interest.

However, the overall picture is still an encouraging one. Over two-thirds of heterosexuals were still in favour of having such a  program on television. "Conservative", homophobic opinion is actually marginal in this group of Singaporeans. 

Jump back up to chief conclusions at the top of the essay.

© Yawning Bread 

Footnotes

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Addenda

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