Queering SRHR: Breaking Down Gay and Bisexual Men’s Healthcare Barriers
Editor’s note: Inspire launched a series of articles called “Queering SRHR” with the goal to dive a little deeper into the various specific ways that SRHR relates to LGBTIQ people.
In June 2019 the Inspire Team launched a series called “Queering SRHR” in the hope of raising awareness on current sexual and reproductive health and rights’ struggles, goals and achievements related to intersex, queer, gay, lesbian, bi and trans people. With this series, the goal is also to challenge the binary and heteronormative narratives around sexual and reproductive health and rights, and to encourage colleagues, partners and others to make SRHR discussions all-inclusive.
This is the sixth article of the “Queering SRHR” series.
Here, you can read our previous articles:
“Queering SRHR: LGBTIQ Families” click here
“Queering SRHR: Homo-Bi-Trans-Phobia No More” click here
“Queering SRHR: De-pathologizing Trans-people: WHO removes transgender as mental disorder from the ICD” click here
“Queering SRHR: The need for a trans-specific focus within SRHR” click here
“Queering SRHR: Lesbian women, Bisexual women and SRHR: the conversation we need to have.” click here.
Queering SRHR: Breaking Down Gay and Bisexual Men’s Healthcare Barriers
A vast majority of sexual and reproductive health programs and policies have been hetero-normative and women centric. Partially due to an initial lack of focus on men’s SRH, rigid gender norms and a variety of social factors that over time have defined SRH as a “woman issue”, have excluded men and adolescent boys from the SRH conversation. In particular, gay and bisexual men’s health and wellbeing have been significantly impacted by this exclusion, being both men and members of the LGBTIQ community (IPPF, 2012). As readers will be able to extrapolate from this article, most of the research and data readily available on gay and bisexual men sexual and reproductive health and rights mostly focuses on curbing the HIV epidemic. When the SRHR community addresses gay, bisexual men and SRHR, it mostly does so in relation to HIV treatment and prevention at times overlooking other sexual and reproductive health needs of gay and bisexual men that start with the lack of access to and availability of SRHR services specialised in men’s physical and mental healthcare.
Just like women, men and boys have specific and substantial sexual and reproductive health needs, which include the need for contraception, prevention and treatment of sexually transmitted infections, sexual dysfunction, infertility and male cancers. However, their needs are often unfulfilled due to a lack of service availability, SRH health facilities not considered ‘male-friendly’, and a lack of healthcare seeking by men (IPPF and UNFPA, 2017).
Most of the existing statistics display a worrisome trend of gay and bisexual (GB) men’s lack of attendance of SRH specific services (IPPF, 2012). This is generally caused by both a lack of GB men’s specific health care services and general SRH clinics and hospital been viewed as female spaces (IPPF, 2012). The wide majority of SRH services focus on female-oriented facilities such as ante, post-natal and maternal care (IPPF, 2012). In a variety of environments service providers miss the opportunities to create “male-friendly” SRH services and especially non-hetero male-friendly SRH services (IPPF, 2012).
Those who have tried to seek help have often endured negative experiences in the health system, by encountering unskilled staff or by learning about the unavailability of men-specific treatment, which has consequently reinforced their lack of willingness to seek help again. The overall lack of training and ill treatment of GB men in health care settings has led to inadequate diagnosis and treatment of men’s SRH illnesses. Since GB men also avoid attending health-care services due to fear and discrimination, it is important to create confidential, friendly and welcoming spaces for them, especially because, as data shows, significant health disparities between GB men and heterosexual men are consistently observed (The Global Forum on MSM & HIV & OutRight Action International 2017).
The goal of this article is to put under the spotlight the many barriers that stand between GB men and adequate access to healthcare, and the extensive negative impact they have on GB men’s sexual, mental and social health. By diving in depth on issues such as STIs, Cancer, Violence, Mental Health and discrimination, it will become clear that there is an urgent need to address and invest on the accurate healthcare measures to ensure GB men’s overall wellbeing.
STIs and Cancer
The most common sexually transmitted infections that concern gay and bisexual men are HIV, Syphilis, Gonorrhoea, Hepatitis A and B and Human papillomavirus (HPV). Because of poor healthcare measures, many among the MSM population, suffer disproportionately from health problems especially in the areas of mental and social health.
HIV discrimination and Blood Deferral Policies
The human immunodeficiency viruses (HIV) that causes HIV infection and, over time, acquired immunodeficiency syndrome (AIDS), like other chronic diseases has been disproportionately affecting gay, bisexual men and other men who have sex with men (MSM) in all parts of the world (Advancing SRHR for MSM with HIV, 2010).
Historically, the global HIV epidemic has always been closely linked with Msm (Avert, 2019). Although the disease originated decades earlier, the outbreak of HIV and AIDS in the 1980s and early 1990s led to a general panic, which, combined with inaccurate medical diagnosis and irresponsible media sensationalism built up an homophobic narrative that singled out GB men as responsible for the transmission of HIV (Avert, 2019). A 1982 study from the US Center of Diseases and Control, suggested that the cause of the immune deficiency was sexual, and the syndrome was initially called gay-related immune deficiency (CDC, 1982). The general lack of information on HIV, fuelled by homophobia led to decades of stigma and discrimination towards GB men and HIV, a stigma that still permeates today. The great amount of focus and attention towards HIV and MSM, led the discourse around GB men’s sexual healthcare to have become HIV-centric, a phenomenon that has negative repercussions towards GB men’s health and rights.
Decades of stigma against GB men, led to a sexuality-based blood donation discrimination, where MSM have been classified as high-risk donors. Since the early 1980s, donor deferrals targeting men who have sex with men were implemented as a response to the outbreak of HIV/AIDS in countries like the USA, Germany, Switzerland, the Netherlands, Norway, Hong Kong, Denmark, Finland, France, Mexico, Slovenia, and Iceland. As of 2018, there are still deferral policies in place for blood donation based on a period of abstinence from Men who have sex with men (MSM), often of 12 months duration, in jurisdictions like Australia, New Zealand, Canada, the United States, Brazil and many Western European countries such as Finland, Belgium, Ireland, and the Czech Republic (Goldman, Shihm O’Brien & Devine, 2018). Following years of advocacy against blood donation discrimination by organisations such as Stonewall UK, in 2018, the UK’s 12-months deferral policy for blood-donation was finally turned into a 3 months deferral policy. France also recently reduced its 12-months deferral policy into a 4 months deferral policy. Nevertheless, some European countries, such as Denmark, Austria and Croatia, still hold a permanent-deferral policy in place.
Overall, MSM living with HIV face double stigma due to fear and ignorance surrounding HIV transmission. This double stigma can cause MSM – both HIV-positive and HIV-negative – to avoid or fear accessing health services, including counselling and testing, treatment, prevention and support (GNP+, 2010). Improving the current situation entails challenging criminalisation, discrimination, and stigma directed at all GB men and other MSM. Moreover, it entails building open, effective and sensitive delivery of information and services, which are tailored to their specific needs and priorities, even within political and cultural environments that are unwelcoming or hostile to GB men and other MSM (GNP+, 2010).
Gonorrhoea and Syphilis
According to a Public Health England report from June 2019, cases of gonorrhoea and syphilis among gay and bisexual men are surging in the UK. Syphilis and Gonorrhea are two bacterial infections that are transmitted through oral, vaginal and anal sex. According to the Public Health England report (2019), cases of gonorrhoea are the highest on record since 1978 and GB men account for 3 quarters of all syphilis diagnoses in England and nearly half for gonorrhoea. Public Health England argues that this increase may be “driven by behavioural changes” among men who have sex with men. Among these “behavioural changes” Public Health England addressed a specific concern towards the link between STI diagnosis and rise of condom less anal intercourse, ‘chem-sex’ and group sex facilitated by geosocial networking applications (GNas). A 2015 cross-sectional MSM Internet Survey Ireland (MISI) also supported the argument that STI diagnosis among MSM testing for STIs is associated with GSNa use, as well as sexual behaviours.
Chemsex and adressing STIs
Qualitative reports suggest that ‘chem-sex’ is becoming an increasingly popular practice among some gay, bi and other men who have sex with men (BMJ, 2016). Chemsex refers to gay and bisexual men using any combination of drugs that include crystal methamphetamine, mephedrone (and other cathenones) and/ or GHB/GBL specifically in the context of sexual encounters. These three substances are used in combination to make users feel relaxed and aroused (New Statesman, 2016). The particular inhibition provoked by the drugs can lead bisexual and gay men to have unprotected sex and to sharing needles, reason why public health authors have been increasingly concerned with the possible link between chem-sex and HIV and other sexually transmitted infection (STI) transmission like hepatitis (BMJ, 2016; New Scientist, 2017). However, attributing this directly to dating apps or changes in sexual practices is only speculative and more research needs to be undertaken in order to understand these interlinkages.
To properly address STIs affecting GB men, there is an urgent need for targeted programs. Given existing differences in health-care access on a gender basis, a possible lack of male-centred knowledge regarding SRH issues, and higher feelings of embarrassment related to being seen at a health centre or discussing concerns about sex and sexuality, leads men to disclose their STI concerns differently. Many may initially refer to their symptoms as a general “headache” without addressing an STI concern (IPPF and UNFPA, 2017). Because of this, it is essential that healthcare providers receive adequate sensitivity training around working with GB men.
Studies have shown that gay men are at risk (and in some cases, increased risk) for several types of cancer, including testicular, prostate and anal cancer, with prostate cancer being the most present one found in men (Cancer network, 2010).
Prostate cancer is the most prevalent invasive cancer among men which generally occurs in men older than 50 and affects nearly one in eight men (Center for Disease Control, 2018). Despite prostate cancer being the most common cancer in GB men, prostate cancer in GB men is still very under-researched: as of 2016 there were only 30 published articles in English on this issue (a rate of 1.9 articles per year) and most of the literature was limited to case studies or anecdotal reports (LGBT Health, 2016). This is particularly worrying because of some evidence of a link between HIV-positive status and prostate cancer (LGBT Health, 2016). Based on this admittedly limited literature, GB men appear to be screened for prostate cancer less than other men and even though they are diagnosed with prostate cancer at about the same rate as other men, they have poorer sexual function and quality-of-life outcomes (NBC News, 2018). Men who have sex with men (MSM) are less likely to get regular prostate cancer screenings, and those who are diagnosed are less likely to have familial and social support (NBC News, 2018; American Cancer Society, 2019). Moreover, if their health-care provider is not culturally competent, gay and bisexual men are much less likely to understand how treatment will impact their lives (NBC News, 2018).
Although there are many ways in which these types of cancer can be prevented and treated when identified in time, researchers claim that gay and bisexual men get less routine healthcare than other men (LGBT Health, 2016). Fearing stigma, discrimination and culturally insensitive care, gay and bisexual men tend to avoid accessing both screening and health-care services. This has a significant impact on the health of GB especially in the case of anal cancer.
Anal cancer is predominantly caused by chronic or persistent human papillomavirus (HPV) infection. HPV infection can lead to the development of anal precancer which, if remains undetected or not adequately treated, may lead to anal cancer (The Conversation, 2017). To avoid being infected with HPV, GB men need to use protection such as condoms. Nevertheless, it is important to point out that HPV can be contracted through skin to skin contact (when the skin around genitalia or the anal area are not covered by condom).
In order to prevent HPV, HPV vaccines are strongly recommended up to age of 26 for men who have sex with men. Moreover, a simple and inexpensive anal Pap test could easily detect the virus (National LGBT Cancer Network, 2019). As a matter of fact, age-specific anal precancer management, including post-treatment HPV vaccination, can potentially lead to an 80 percent decrease in lifetime risk of anal cancer and anal cancer mortality among gay and bisexual men (The Conversation 2017).
Unfortunately, few physicians are performing anal screening exams and offering anal pap smears to gay men, resulting in anal cancer rates as high as those of cervical cancer before the use of routine Pap smears in women (LGBT Cancer Network, 2019). Observed increase in anal cancer is a concern for gay and bisexual men, who are at substantially greater risk for the disease than heterosexual men (Reed et. Al, 2010). Thus, increased screening could play a role in anal cancer prevention for gay and bisexual men regardless of whether they receive HPV vaccination. Statistical models suggest that regularly screening gay and bisexual men for anal cancer through anal Papanicolaou (Pap) testing (also called anal cytology) would increase life expectancy similarly to other accepted prevention measures, such as cervical cancer screening, and would be cost effective. However, few gay and bisexual men have undergone anal Pap testing (Reed et al. 2010).
Other Health Considerations: Mental Health, Suicide and Sexual Violence
Living in a homophobic and/or heteronormative society can impact both gay and bisexual men’s well-being and mental health (Link, Phelan & Hatzenbuehler, 2018). Overall, the existing literature offers convincing evidence of higher prevalence of mental health problems among LGBTIQ people (Kuyper 2011; Paul et al. 2011). According to a great amount of studies, gay and bisexual men experience higher rates of substance abuse, depression and suicide compared to their heterosexual counterparts (Paul et al. 2011). A new study published in July 2019 in the International Journal of Environmental Research and Public Health found that, in China, gay men 25 - 29 years old are eight times more likely to feel criticised, rejected, and lonely than younger men. The study found that men who were open about their sexual orientation and had partners were at less risk for these negative feelings than other men. To respond to the heightened loneliness found in gay men in China, researchers suggested that the government should encourage an open and inclusive social environment with counselling centres for mental health care for gay men (Jian et al. 2019). However, despite the great amount of evidence that the mental wellbeing of gay and bisexual men should be adequately addressed, the mental health of MSM, especially the one of those living with HIV is rarely analysed in depth or even talked about.
Depression is the most common neuropsychiatric complication for people living with HIV, affecting 42 percent of those living with the virus (Nanni et al. 2015). However, HIV is not a catalyst per se as suicide among HIV-positive gay and bisexual men is most likely associated with the stigma, rejection, violence and harassment associated with a HIV-diagnosis (Nanni et al. 2015).
Because of their sexual orientation both gay and bisexual men face higher rates of stigma, discrimination and violence, which usually leads to both a higher percentage of substance abuse among MSM and higher risks for depression (Psychology Today, 2018). Factors such as verbal and physical harassment, negative “coming out” experiences and lack of family acceptance, substance use and isolation of gay and bisexual men and youth all contribute in leading to higher rates of suicide among gay and bisexual men (Cancer network, 2010). A British survey of gay men found that 50 percent of those who experienced depression had contemplated suicide and 24 percent had already attempted to take their own lives because of low self-esteem or homophobic bullying (Paul et. al, 2011).
The high rates of depression, substance abuse, and suicide tendencies amongst gay and bisexual men are especially worrying because suicide itself has been considered the biggest killer of men under the age of 45 in several countries (BBC Future, 2019). Studies across the world have consistently shown that male suicide rates are several times higher than females (American Foundation for Suicide Prevention, 2019). Lack of public awareness around depression and suicide among men, lack of research on the issue and general reluctance of men in accessing health-services and seeking help, further emphasise the concern that mental well-being among GB men has yet to be addressed effectively (BBC Future, 2019).
Sexual and Intimate Partner Violence
Sexual and intimate partner violence is another factor that negatively impacts gay and bisexual men’s psyche and mental health. Sexual violence affects every demographic and every community including men. According to 1in6 (2019), one in six men has experienced or will experience some form of sexual violence assault in their lifetime. Historically, male sexual assault has been shrouded in secrecy and stigma, reason why many male survivors never report their assault out of fear of being blamed for their own attack, being disbelieved, ridiculed, shamed, accused of weakness or ignored (AASAS, 2019).
Besides experiencing many of the same feelings and reactions as other survivors of sexual assault, many men and boys who have been sexually assaulted or abused may also face additional challenges because of social attitudes and stereotypes about men and masculinity (AASAS, 2019). Additionally, there is a general lack of recovery services and support groups for male survivors and law enforcement and justice systems are often ill-equipped to deal with this type of crime when it is committed against men (AASAS, 2019). Because of this, the reporting rate for male survivors of sexual assault is even lower than the already-low rate of females. (AASAS, 2019)
Gay and bisexual men experience sexual violence at similar or higher rates than their heterosexuals’ counterparts (Human Rights Campaign, 2019; John Hopkins Medicine, 2019). However, gay and bisexual men rarely talk about their experiences of both sexual and intimate partner violence and are mostly hesitant to seek help because they fear discrimination from supposed support mechanisms such as the police, hospitals, shelters or rape crisis centres (Human Rights Campaign, 2019). Even in cases where violence survivors choose to report the assault experienced, intersections between systems of inequality, discrimination and absence of accessible LGBTIQ-affirming services, lead to most of these crimes going unpunished and to an increased marginalisation of gay and bisexual men survivors (NSVRC, 2012).
Besides facing the same amount of stigma and discrimination as gay men, bisexual men often endure specific prejudicial attitudes. As a matter of fact, there are several myths and prejudices that surround bisexual men. Many, deny bisexuality as a sexual orientation, rather defining bisexuality as a steppingstone before “fully” identifying as gay (Bustle, 2016). Others, believe that bisexual men are sexually greedy, confused, less inclined towards monogamous relationship and not able to maintain long-term relationships (Zivony & Lobel, 2014, Bustle, 2016, Pride, 2016).
Overall, bisexual men are constantly faced with both social stereotypes and public and political invisibility (McLean, 2007; Ochs, 1996; Rust, 2002; Eliason, 1997; Steinman, 2000). Denial of bisexuality as a sexual orientation combined with harmful stereotypes towards bisexuality and assumptions of one’s sexual orientation based on the gender of their current partner, leads to increased invisibility and marginalisation of bisexual men (Barker et al. 2012a, b; Diamond 2008; Eliason 1997; McLean 2008; Rust 2002). These marginalization processes often operate unintentionally in a “taken-for-granted world” and socially exclude people who are not part of the mono-normative world (Kitzinger 2005, p. 478; Robinson 2012). Bisexual men are rarely represented by the media and their issues remain relatively unknown to the general public, which eventually leads to even higher rates of health issues and inequalities (Barker, 2007; Miller, Andre, Ebin, & Bessonova, 2007). Compared to gay and lesbian-identified people, bisexual-identified people are less open about their sexual orientation to people in their social network, report more internalised homonegativity, report more mental health problems, score higher on suicidality, and show lower LGB community identification and community involvement (Barker et al. 2012a; Cox et al. 2010, 2011; D’Augelli et al. 2005; Herek et al. 2010; Kertzner et al. 2009).
The Right to Health and the Right to Education as cornerstones
In November 2006, 29 distinguished human rights experts met in Yogyakarta, Indonesia, to draft, develop, and redefine what are now called the ‘Yogyakarta Principles on the Application of International Human Rights Law in relation to Sexual Orientation and Sexual Identity’ (‘YPs’).
The YPs were issued to reflect the existing international human rights laws in relation to sexual orientation and gender identity considering the principles of universality and non-discrimination.
According to Yogyakarta Principle 17, the Right to the Highest Attainable Standard of Health “Everyone has the right to the highest attainable standard of physical and mental health, without discrimination on the basis of sexual orientation or gender identity.” YP 17 also stresses that: “Sexual and reproductive health is a fundamental aspect of this right.”
Because gay and bisexual men face even higher risks of contracting HIV, STIs or contracting cancer, as YP 17 stresses, States need to “ensure that all persons are informed and empowered to make their own decisions regarding medical treatment and care”, “ensure that healthcare facilities, goods and services are designed to improve the health status of all persons without discriminations and that medical records are treated with confidentiality” and “ensure that all sexual and reproductive health, education, prevention, care and treatment programmes and services respect the diversity of sexual orientation and are equally available to all without discrimination”.
In order to achieve this, there is an urgent need to create an environment that specifically addresses gay and bisexual men’s different SRH needs (IPPF, 2012). Both staff and SRH-care services providers should be trained to both be knowledgeable about gay and bisexual men’s needs and to create a safe and welcoming environment for them to access without the fear of stigma and discrimination (IPPF and UNFPA, 2017). Moreover, a wide range of SRH-related services should be offered to address issues from HIV and other sexually transmitted infections to positive prevention, noncommunicable conditions (such as male-specific cancers), sexual dysfunctions, family planning, and parenting choices. Moreover, in order to help gay and bisexual men attain higher standards of mental health, service providers should also be able to refer clients to related services, such as harm reduction, mental health and/or other social services (IPPF, 2012).
Finally, for both gay and bisexual men and healthcare service providers to be knowledgeable of GB men sexual and reproductive health and care, there is a need for radical change within the field of sexual education. Yogyakarta Principle 16 on “The Right to Education” sets forth that states need to: “ensure inclusion of comprehensive affirmative and accurate material on sexual, biological, physical and psychological diversity and the human rights of people of diverse sexual orientations, gender identities, gender expression and sex characteristics in curricula taking into consideration the evolving capacity of a child.”
It is high time to recognise that restrictive sexual and reproductive rights policies are just as harmful in practice to gay and bisexual men, if not even more so, since their access to these rights are a challenge to start with.
We would like partners and allies in the SRHR community to take these issues on board, and to fight for all, let’s work together on queering SRHR, to make it as inclusive as possible and to go beyond the binaries.
Together let’s work on Queering SRHR!
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