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Risk, Stigma, and Pleasure: the Role of Prep and Bareback Sexual Behavior Among the Men Who Have Sex with Men in Amsterdam

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Risk, Stigma, and Pleasure: the Role of Prep and Bareback Sexual Behavior Among the Men Who Have Sex with Men in Amsterdam Risk, Stigma, and Pleasure: The role of PrEP and Bareback Sexual Behavior among the Men who have Sex with Men in Amsterdam Kevin Singh (10870555) MSc Medical Anthropology and Sociology Universiteit Van Amsterdam Master Thesis 2016 Supervisor: Dr. Rene Gerrets Second Reader: Dr. Eileen Moyer Acknowledgements First and foremost I would like to thank all the respondents who participated in my research, their willingness to open up about such sensitive topics gave me the courage to continue through some of the harder days of my writing. Next I would like to thank my supervisor and mentor Dr. René Gerrets, whose wisdom and encouragement kept me going through the worst of it. Last I would like to give thanks to my loving Mother and beloved Brother for their continued love and support, I could not do this without them. Table of Contents Acknowledgements 1 1 Table of Contents 2 Chapter One: Introduction 3 1. Problem Statement 3 2. Literature Review 4 1.3 Theoretical framework 7 Chapter Two: Research Methodology 9 2.1 Introduction to Methods 9 2.2 Ethnographic Methods 9 Ethnographic Field sites 9 Interviews 11 CyberEthnography 12 Informal Conversations 12 2.3 Ethical considerations 13 2.4 Data Analysis 13 2.5 Obstacles and Reflexivity 13 Chapter Three: Risk and Health, Sexual Behavior of PrEP 15 3.1 Introduction to Risk 15 3.2 Risk Compensation 16 3.3 Risk Compensation vs Disinhibition 18 3.4 Risk and Biomedical Technology 19 3.5 Risk Behavior and Change 20 3.6 Conclusions and Reflection 22 Chapter Four: Stigma, Sexual Beliefs and Behavior 24 4.1 Introduction to Stigma 25 4.2 Stigma and HIV 26 4.3 Anticipated Stigma and HIV 26 4.4 PrEP and Stigma 26 4.5 Data: Experiences with Stigma 27 Chapter Five: In the Pursuit of Pleasure? 34 5.1 Introduction to Pleasure 34 5.2 Sexual Morality and Pleasure 34 5.3 Sexual Health Behavior and Condom Fatigue 36 5.4 PrEP and Pleasure 38 5.5 Conclusion: Pleasure 39 Chapter Six: Conclusion-Final Thought and Discussions 41 Bibliography 44 Chapter One: The Introduction 2 In conventional wisdom it holds that risk taking in sexual behavior can play a role in the high rates of sexually transmitted disease (STD) and the continued spread of the human immunodeficiency virus (HIV). Despite years of research, the psychosocial mechanisms that lead to risk-taking behavior are still not completely understood. Prior research has often assumed that sexual decision making depends on rational thought processes and has not adequately addressed the role that other factors, such as emotional state, attraction, arousal, personality, substance use, as well as social and cultural influences, may have on behavior (Bancroft., Janssen., Strong., Carnes., 2003; Watkins-Hayes 2014). More recent work has shifted to answering these deficiencies, however with mixed results (Watkins-Hayes, 2014). Understanding sexual risk behavior becomes even more essential when considering the role it plays in safe sex practices. In their annual epidemiological report 2014, the European Center for Disease Prevention and Control (ECDC), indicate that sexual transmitted infection (STI) continue to pose a threat to the public health in Europe. Many sexual behaviors increase an individual’s risk of STI contraction. Having sex without a condom, having sex with many partners, and having sex for pay or paying for sex are especially risky (Campsmith et al., 2008; Workowski & Berman, 2010). In the Stitching HIV Monitoring (SHM) monitoring report 2015, sexually transmitted infections (STI), in particular HIV continue to pose a threat to public health in the Netherlands. At the end of 2014 19,773 people have tested positive for HIV in the Netherlands, of whom 18,355 are in care. It is estimated that there are around 2,800 people who are HIV-Positive and living in the Netherlands, but don't know it. Understanding the mechanisms around the negotiation and assessment to have safe versus unprotected sex is essential in high-risk populations, such as gay and bisexual men in whom nearly two-thirds of new HIV infections occur (Workowski & Berman, 2010; Parsons, Grov, Golub, 2012). Despite the implementation of behavioral preventive interventions and technologies designed to slow the transmission of HIV, as well as the coverage of antiretroviral therapy (ART) among HIV infected men who have sex with men (MSM), HIV continues to spread among high risk populations of not only the Netherlands, but other countries throughout the world (WHO, 2013)(Parsons et al., 2012). In response to this, a new biomedical approach has been created to offer HIV negative individuals a chance to reduce their risk of HIV through the usage of low intensity ART, it is the hope of researchers that the usage of pre-exposure prophylaxis (PrEP) will act as a preventative form of treatment against the continued spread of HIV. The multinational iPrEX study has reported a 44% reduction in HIV acquisition among MSM using daily PrEP, when compared to placebo controls. They also found a 92% reduction in HIV infections among MSM who remained adherent to the usage of daily PrEP (Grant., et al., 2010). Overall the usage of PrEP represents a new tool within the arena of HIV prevention. However, while many researchers are optimistic about the role PrEP will play in diminishing HIV transmission, there are many who argue against the availability of PrEP and the subsequent consequences, such as the potential increase in high risk sexual behaviors (i.e. condom-less sex). Bareback sex is a slang word for a form of sexual activity, commonly penetrative sex, done without the usage of a condom. The term originates in the gay community and comes 3 from the equestrian term bareback, which refers to the practice of riding a horse without a saddle (Berg R., 2009). Overall, the practice of barebacking is usually referred to as conscious choice to not use condoms during penetrative anal sex. As the potential sexual health repercussions of such a phenomenon are exponential, it is imperative we critically examine the nature of such a practice in order to better understand how we may better improve sexual health efficacy. As stated above very little has been done to understand how culture, society, and even individual factors shape the sexual risk taking subculture. To these ends we must ask the question of how intersectionality of so many factors shapes the practice of this phenomena, and how the introduction of PrEP as a new biomedical technology may shift the overall culture of sexual behavior for MSM, and in turn change the nature of this practice among the MSM of Amsterdam. To these ends, I aimed to conduct an ethnographic field study surrounding the MSM culture of the greater Amsterdam area. In doing so my fieldwork has been guided by the following research question: How does PrEP as a biomedical technology, shape the psychosocial and cultural landscape of MSM who practice bareback sex behavior in Amsterdam, the Netherlands? Literature Review In order to understand the potential influence of PrEP on the bareback subculture, it is imperative to understand the individual and ecological (socio-environmental) motivations to have bareback sex. As stated above, bareback sex is a form of penetrative sexual activity forgoing the usage of condoms. As such, it is important to understand how condoms play a role in the individuals’ assessment to partake in bareback sex. Condoms, initially used for contraceptive purposes, quickly came to be used to limit or prevent sexually transmitted diseases. As the AIDS epidemic emerged and the transmission factors of HIV became known, the usage of condoms became even more prevalent as the principal tool in the prevention of infection. This was more so true for MSM who engaged in anal sex, the importance of the usage of a condom in HIV prevention helped to shape the role of sexual health and interventions in the fight against HIV, thus establishing its usage as a norm for sexual behavior. However, the choice to forego the usage of condoms itself is a complicated one with many factors, many studies have focused on this particular issue with various results. Adam et al. (2010) also found that among many MSM who report unsafe sex scenarios, many involved the concept of being lost in the “heat of the moment”. As in many other studies, a common theme reported is the role of condoms and erectile difficulties, as well as the reported urgency of passion and opportunity to connect with a particular desirable partner accounts for some unsafe sexual encounters (Calabrese et al., 2012). In addition many studies have found a connection to the usage of drugs or alcohol as a facilitator for these heat of the moment scenarios (Berg et al., 2011; Grov et al., 2007; Watkins-Hayes et al., 2014). Furthermore, heat of the moment situations may further become compounded upon by trade- off scenarios, in which men may feel at a disadvantage with a particular partner, be it in terms of age, ethnicity, or attractiveness. There is a fear of not wanting to offend or insult the 4 desirable partner, thus leading to a trade away of safer sex implication in case it leads to an obstacle in having sex with this desirable partner (Adam et al., 2010). The role of sexual compulsivity has also been associated with increased sexual risk behaviors among MSM. Often characterized as sexual fantasies and behaviors which interfere with an individual’s personal and often inter-personal well-being, these fantasies and behaviors can occur in both men and women and continue increase over time, leading to further disruption in an individual’s life (Kalichman & Rompa, 1995; Parsons, Kelly, Bimbi, Muench, & Morgenstern, 2007; Parsons et al., 2012).
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