Community effort no substitute for government inaction on MSM HIV

The Sunday Times article on the alarming increase in HIV infections among men who have sex with men (MSM) quoted me a little too briefly and I fear that readers may not fully grasp what I was trying to say. I think I shall have to expand on those words here.

What was quoted?

But activist Alex Au from gay movement People Like Us believes rallying the gay community to protect themselves will not be easy, not when they are treated like 'second-class citizens'.

They are pessimistic about being able to change things.

"Many gay people are suffering not just from condom fatigue but also from activism fatigue."

In fact, he thinks the recklessness in the community can be traced to a "certain nihilism" or self-destructiveness because of the discrimination they face.

"It's hard to tease out the threads but pessimism leads to fatalism which leads to nihilism. It's almost like the gay community is saying, 'Let's party while we can because Rome is going to burn'."

-- Sunday Times, 7 December 2008,
Surge in HIV cases among gay men

That itself is clear enough, but much of the preceding contextualisation, I think, was lost.

 
On the up and up

First, let's set the scene. On 30 November, the Ministry of Health reported that in the first ten months of 2008, there were 382 new cases of HIV infection. "In comparison," its press release said, "there were 423 HIV cases notified for the whole of 2007. It can be expected that the total number of notified HIV cases in 2008 will exceed that of last year."

Based on data from the first six months of this year, where there were 153 new infections, 32 percent of them were through homosex, similar to 2007, when homosexual transmission constituted 34 percent, and a big increase from the 16 percent in 2001.

As Sunday Times journalist Wong Kim Hoh noted in his article, the disproportionate increase of HIV infection among gay men mirrors a similar trend in the West, and in other Asian countries.

Even so, could we have done better? Of course, we could. But what? How?

 
Letting the government off the hook?

I got the sense, in my phone conversation with the journalist that he was asking me what the gay community should be doing about it. I told him I disagreed with the implied premise.

In my view, if we're looking to gay people alone to deal with this problem, we'll never succeed. Not when the government sets such ridiculously impossible boundaries that virtually nothing that has been proven to work in other countries can be tried. The government has a huge role and responsibility. To excuse the government from that responsibility on the basis that "they are conservative", as if that is an uncontestable given, and to expect the gay community with no resources and no legal space to do the job in its stead, is laughable.

The government is a big reason why there is activism fatigue; why community leaders make no headway. For years, the government has stubbornly refused to decriminalise homosexuality or subsidise treatment (though the latest news is that it will finally change, but no details yet), and as long as anyone can remember, it has maintained a highly moralistic tone in matters of sex, especially gay sex, evident from its censorship policies, etc. If after twenty years of effort, gay HIV campaigners have so little to show for being able to change the government's position on anything, it should hardly surprise you that they lose credibility in the eyes of the community.

And once that happens, however hard they keep repeating the safer sex message, it won't get anywhere.

Why is it necessary for the government to change its position re homosexuality and gay people, and do it publicly? Because intervention strategies must be realistic, and they cannot be realistic without first acknowledging the manifold ways in which MSM have sex, and jettisoning its kneejerk moralistic disapproval.

 
Subsets

The most vulnerable people, whether gay or straight, are those who have multiple partners. In that sense, "gay" or "MSM" is unhelpful, because it blurs the focus. The ones that need to be most targetted in outreach are the subsets of the gay and straight populations who have a high frequency of sexual activity with changeable partners, for among them, the networking effect is most pronounced, with the virus spreading very quickly from one to many.

In my view, the "frequent sex, multiple partners" subset among gay men is much larger relative to the total gay population than the similar subset among heterosexual men, and that is why it appears as if the gay community as a whole is more vulnerable.

Why is the subset relatively larger among gay men? Very simply, it is because for a straight man to have sex, he needs to find a straight woman. It is harder for him to find a willing straight woman than for a gay man to find another willing gay man. Some straight men have said to me, "But it *is* easy". Perhaps in tiny niches it is, but even then, I don't think their idea of "easy" is anywhere close to the gay man's experience of "easy". 

Very few straight men have any inkling how really easy it is to get gay sex without having to pay, because they have never experienced such a situation, and so there is a certain blindness, except among professional epidemiologists, that such conditions exist. Add to this the moralism that cannot allow for such "promiscuity" (bad, bad -- in Singapore's puritanism) and you have a national policy built upon denial or disapproval.

 
Shedding moralism

Come back to the subsets. For the individuals in them, whether gay or straight, Singapore's preferred message -– the stress on abstinence -– is utterly pointless. Their lifestyle, by its very definition, specifically does not include abstinence. Especially for gay men, it makes no rational sense. Abstinence has no meaning when there is neither legal marriage ("Save yourself for marriage." What?) nor the risk of pregnancy. Even faithfulness is problematic. How can that work when many (most?) gay men are not in long-term relationships? How can that exhortation work for those in the high-frequency subset?

For the gay man in the subset, frequent sexual activity with plenty of different people is a totally natural facet of his identity, as natural as the way Singaporeans consume different kinds of cuisine from breakfast to lunch to dinner. You tell him to eat only one kind of food at every meal, and he'll tell you to "go fly a kite", to use a colourful Singapore expression. Ditto, you confront the gay guy with a message that preaches against multiple partners, and you're just going to be mentally dismissed. A realistic intervention strategy for this subset must accept, with no value judgement, the fact that he is going to have sex with lots of people, and will continue to do so. Can the Singapore government do that?

Openly do that? Because if you insist on speaking with a forked tongue –- condemning promiscuity generally but trying to appear value-free in messages targetted only at certain vulnerable groups, then it is the same as conceding that you have not thrown off your moralism. No credibility again. If you have really thrown off your moralism, the audience would ask, why do you need to conceal that fact from the general public?

Moreover, years of resistance to decriminalisation and to offering subsidies for HIV treatment (which everybody reads as "if you're HIV-positive, you deserve it!") compounds the view that the government is preachy.

It's the gratification, stupid

Another difference between heterosexual activity and homosexual activity is that there is a culture that envelopes heterosexual sex within romantic love, or at least the pretence of love. I'll tell you this: 95 times out of 100, homosexual sex occurs outside the framework of love. It is sex for the sake of sex. Very often, they don't even know each other's names.

This being the case, gratification is of paramount importance. The orgasm, the high, is what matters. Some guys think that the rubber condom gets in the way of the "feeling" (some straight guys do too) and so they choose to bareback. Moreover, the focus on gratification means it's a short hop to chemically-enhanced sex -- yes, recreational drugs -- because that's what makes a higher high. The problem is that drug use induces more impulsive behaviour and condom use becomes erratic as a result.

I'm not sure what intervention strategies would work in such situations, but I can tell you when they will definitely not work: When one brings in a puritanistic disapproval of gratification and a punitive approach to drugs. That kind of judgementalism closes the door on engagement.

There have been times when I wonder how long it will take before someone invents a drug-coated condom. Then, if you want the mother of all orgasms, you'll have to put it on. I think that might work, but it would send our anti-narcotics people into a tizzy.

* * * * *

 
To cut to the chase, my view is that it's already so difficult given the nature of gay sexual activity, it would be impossible to make progress so long as the government insists on keeping the door closed to viewing things and doing things differently. Yes, the community and its organisations have a role to play, as partners to government-led and funded programs, but so long as the government stands aloof and forbids this and that, no civic group, no "gay community" can do what the government will not.

© Yawning Bread 

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