Transcript Powerpoint - Sandyford

Preparation module:
This session is to be completed before attending any of the topic based Masterclass sessions.
Please take about 45/50 minutes.
Each slide provides information and throughout the presentation there are questions
posed during which you are asked to take some time to reflect.
In preparation for your participation in any of the MSM Masterclass sessions it may be useful to
note down your responses to the questions.
This preparatory session draws on many sources of information but a significant amount
of input to this module and the MSM Masterclass itself is the HIV Prevention Needs
Assessment conducted by NHS GGC and NHS Lothian and funded by Scottish Government.
There will be more about how to find out about findings in detail at the end of this session.
Introduction
By the end of this session you will have:
1.
Good levels of background information which will help you engage fully with the
forthcoming MSM Masterclass.
2.
Recognised the disproportionate burden of ill-health experienced by the population
of interest: gay, bisexual and men who have sex with men (MSM).
3.
Understood some of the cultural and political reasons, as well as some key concepts
and ideas, which explain the health inequalities experienced.
4.
Considered further how, as a professional working with gay, bisexual and MSM you
might use this learning to influence the relationships you have with individual men.
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Terminology
used
These terms will be used in this session:
Gay Men
A term to describe men who are romantically and sexually attracted
to men.
Bisexual
A term to describe women or men who are romantically and or
sexually attracted to both sexes to some degree.
MSM
The term “men who have sex with men” (MSM) is used by sexual
health services to encapsulate the complexity of male behaviours
and identities. MSM is not a term that a man would use, nor would it
be used as a term in discussion with an individual.
These MSM Masterclass materials do not provide a glossary of
terms. Generally, we would suggest that when a practitioner hears a
term used by a man using their service, they ask the individual to
explain the term to them.
Population
estimates
There is no definitive or consistent way to measure how many men
in the population are gay or bisexual. The census and most large
scale surveys do not include categories to describe LGBT identity.
The UK government best estimate based on synthesising survey data
is that between 5-7% of men identify as gay or bisexual. It is known
that many gay and bisexual men migrate towards cities therefore
although the 5-7% can be used at NHS Board level; this number will
likely be higher for urban areas.
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Times have
changed
Attitudes to gay and bisexual men have changed rapidly in the UK.
The British Social Attitudes and Lifestyles survey has captured
some of these changes, but they have also been reflected in
changing legislation.
• In the 19th century male homosexuality had been a capital
offence.
•
It wasn’t until 1980 that Scots law reflected the changes on
legality brought about in England and Wales in 1967.
• In 1987 two in three respondents to the British Social Attitudes
and Lifestyles survey thought that homosexuality was “always
wrong”; nowadays that is one in three people.
• At the other of the scale presented in the BSA survey in 1987
only 1 in 10 people thought that homosexuality was “not wrong
at all”, nowadays that is nearly half of all people.
Please consider
Have your attitudes towards male homosexuality changed over
time? Do you think the gay or bisexual men you meet in services
have different experiences in society than their predecessors?
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Coming out
Men who are gay or bisexual go through a process called coming
out which is where they disclose to others their sexual identity.
This self-realisation mostly coincides with puberty.
The average gap between a young man realising their identity and
disclosing it to others is 3 years. During this time young people can
be very concerned about whether their families and friends will
have adverse reactions to their identities. Sadly for some young
men these adverse reactions do occur resulting in fractured
supportive networks at a time when they are most needed.
Some gay or bisexual never disclose their identities, or do so much
later in life either because they were so concerned about the
consequences of doing so or because they were not sure about
their identity.
HIV and STI
infection
Gay, bisexual and men who have sex with men are a population for
whom HIV and STI infections are of major concern.
• The number of diagnosed HIV-infected persons living in
Scotland is 4785.
• New diagnoses have averaged at 400 per annum.
• In terms of HIV infection the largest proportion of transmission
is between men who have sex with men.
• Late and very late diagnosis of HIV infection remains a problem
and has significant impact on outcomes for individuals
diagnosed late.
• MSM are the population most affected by infectious syphilis.
• Rates of rectal gonorrhoea amongst MSM, a marker of
condomless anal sex, are the highest recorded in recent years.
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Looking beyond
Looking beyond STIs/HIV, gay, bisexual and MSM bear a
STIs/HIV
disproportionate burden of ill-health when compared to
heterosexual men. Stonewall Scotland report as follows:
“Gay and bisexual Scots have high rates of attempted suicide and
are more likely to self-harm and have depression than their straight
peers. They are also more likely to smoke and take illegal drugs. It
ill-serves our gay and bisexual communities when these
uncomfortable truths are ignored.”
www.stonewallscotland.org.uk/documents/sw_gmh_scotland_low
_res_web_2.pdf
In the HIV Prevention Needs Assessment one interviewee said the
following:
“The bulk of my friends suffer from depression, but won’t do
anything about it. It’s common for gay men, a lot of us suffer. Its
peaks and troughs, it’s my trough. Occasionally I need help, I know
what to do. Some men will hide away, smoke, drink too much. You
can see it in your friends.” (Gay, 45+, HIV positive)
Please consider
Is this ‘disproportionate burden of ill-health’ something you are
aware of? Why do you think the Stonewall Scotland report refers
to the health problems identified as ‘uncomfortable truths’?
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Why a
disproportionate
burden?
If there are differences in the health experiences and outcomes
for gay, bisexual and MSM we need to ask why. In doing so we
can begin to understand underlying causes, and then address
disparities.
This presentation now asks you to consider the meaning and
importance of influences such as homophobia, stigma, stress,
vulnerability and health inequalities. Throughout, reflective
questions are asked about your understanding and your role
in consideration of these factors.
Please take time to pause and reflect.
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Homophobia
Put simply homophobia is dislike of or prejudice against
homosexual people. In a recent European wide poll 1 in 4 lesbian
and gay respondents said they had experienced attacks or violent
threats in the past 5 years. As reported earlier there are still a
significant minority of people who think that same sex
relationships are always or mostly wrong. Such attitudes are
captured in these quotes from author Robin Reardon and
author/broadcaster Stephen Fry:
“The only thing wrong with being gay is how some people treat
you when they find out.” Robin Reardon
“The concept that really gets the goat of the gay-hater, the idea
that really spins their melon and sickens their stomachs is that
most terrible and terrifying of all human notions, love. That one
can love another of the same gender, that is what the homophobe
really cannot stand.” Stephen Fry
But homophobia is also experienced in more subtle ways. This
LGBT Youth short film (7 minutes) describes the impact of isolation
and lack of acceptance for young people.
Link to film from LGBT Youth: Silence/homophobia
https://www.youtube.com/watch?v=XQKGigb5l28
Please consider
What do you think about the issue of homophobia? In your
personal or professional life have you ever been aware of how it
impacts on gay, bisexual and MSM?
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Stigma
Homophobia is a short hand term to help us recognise that LGBT
people can be treated poorly by others, but that perhaps it is not
enough of an explanation for some of the health disparities that
exist for gay, bisexual and MSM.
The idea of stigma captures more clearly that homosexuality might
be considered as bad, immature, sick or inferior to heterosexuality.
In the not too distant past homosexuality was considered a mental
disorder or pathology.
The experience of stigma and the important impact it has on
wellbeing is explained here by Professor Gregory M. Herek.
He writes that stigma:
“…engulfs the entire identity of the person who has it. Stigma does
not entail social disapproval of merely one aspect of an individual,
as might be the case for an annoying habit or a minor personality
flaw. Rather, it trumps all other traits and qualities. Once they
know about a person’s stigmatized status, others respond to the
individual mainly in terms of it. Finally, the roles of the stigmatized
and normal are not simply complementary or symmetrical. They
are differentiated by power. Stigmatized groups have less power
and access to resources than do normal... Homosexual people,
their relationships, and their communities are all considered sick,
immoral, criminal or, at best, less than optimal in comparison to
that which is heterosexual. ”
www.glbpsychology.net/html/Herek_2004_SRSP.pdf
(Continued on next slide)
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Stigma
Continued
The HIV Prevention Needs Assessment has addressed HIV stigma,
reflecting the emphasis that has been given to it by the NHS and
3rd sector partners over many years. However, the idea of stigma
as it applies to gay, bisexual and MSM also needs to be considered
so that we can understand hostility and oppression based on
sexual orientation and, ultimately, eradicate it.
Please consider
What do you think about the suggestion that stigma impacts on
the lives of gay, bisexual and MSM?
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Shame and
disgust
Healthy sexualities need to be devoid of shame, guilt and disgust.
Yet with a long history these views of homosexuality persist in
their influence.
In his opposition to the Wolfenden Report (1957) that
recommended decriminalizing private consensual homosexual acts
Lord Devlin argued that that such things would "disgust the
average man.”
Some faith groups seek to promote the idea of shame and disgust:
“Normal people will be shocked and saddened that fellow human
beings, made in the image of God, could fall so low”.
(Christian Voice online)
The Archbishop of Canterbury has recognised this: “Christians need
to confront feelings of embarrassment, shame and disgust over
homosexuality”.
In her work philosopher Martha Nussbaum reminds us that
‘It is not surprising that sexuality is an area of life in which disgust
often plays a role. Sex involves the exchange of bodily fluids, and it
makes us bodily beings rather than angelic transcendent beings. So
sex is a site of anxiety for anyone who is ambivalent about having
an animal and mortal nature, and that includes many if not most
people…. What inspires disgust is typically the male thought of the
male homosexual, imagined as anally penetrable.’
(Continued on next slide)
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Shame and
disgust
Continued
In their contributions to the HIV Prevention Needs Assessment
men also reflect on the view that their family might have of their
homosexuality: “I probably never subscribed to the approach my
mum and dad would, that it's perverse.” (Gay, 26-35, HIV
negative)
Where gay, bisexual and MSM are exposed to messages about
shame and disgust it is unsurprising that these can be internalised
and impact on wellbeing through feelings of internalised
oppression.
Please consider
Do you think that gay, bisexual or MSM are viewed through this
lens of shame or disgust? Does this happen in your service?
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The idea of
minority stress
This preparation activity, before you attend any of the Masterclass
sessions, is suggesting that homophobia, stigma or messages about
shame or disgust are factors (background or foreground) that
impact on the health and wellbeing of gay, bisexual and MSM. But
how?
One idea is that this collection of negative factors and influences
can be understood as causing minority stress.
Minority stress describes chronically high levels of stress faced by
members of stigmatised minority groups. It may be caused by a
number of factors, including poor social support and low
socioeconomic status, but the most well understood causes
of minority stress are interpersonal prejudice and discrimination.
Numerous scientific studies have shown that minority individuals
experience a high degree of prejudice, which causes stress
responses (e.g., high blood pressure, anxiety) that accrue over time,
eventually leading to poor mental and physical health. Researcher
and academic Michael P. Dentato writes about this as follows:
“The minority stress perspective adds significant insight into the
critical application and evaluation of theory regarding the impact of
homophobia and correlates of HIV risk among gay and bisexual men
and other sexual minorities. Continued understanding of the role
that stigma, prejudice, heteronormativity, rejection and internalized
homophobia play in fuelling HIV and substance use among gay and
bisexual men is also necessary.”
www.apa.org/pi/aids/resources/exchange/2012/04/minoritystress.aspx)
From one HIV Prevention Needs Assessment contributor:
“All the way through school I'd been called homo and gay and got
really picked on… I had no support and couldn't talk to teachers. It
felt very alone basically. I wouldn’t have dared ask anyone.”
(Gay, 36-45, HIV negative)
Please consider
What do you think about the idea of minority stress? How might it
apply across various populations? In your professional experiences
have you seen how it impacts on gay, bisexual and MSM?
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Vulnerability
The Adult Support and Protection (Scotland) Act 2007 says that an
adult at risk of harm is defined as a person aged 16 or over who
may be unable to protect themselves from someone harming
them, or from exploitation or neglect, because of a disability,
mental disorder, illness or physical or mental infirmity.
In addition to this formal understanding of vulnerability, from the
HIV Prevention Needs Assessment it was identified that nearly 1 in
3 men newly diagnosed with HIV were experiencing a number of
problems which, acting together, were impacting on their sexual
health outcomes. This included problematic alcohol use, low self-
esteem, mental health problems or experience of violence or
childhood sexual abuse. Having a high risk of STI acquisition,
infrequent HIV testing, or never being tested for HIV also appears
to be associated with social deprivation and with not accessing
MSM specific services.
Please consider
In your professional experiences do you engage with men you
think are vulnerable? Are there men for whom a number of factors
act together to cause concern? Does this affect how you assess
risk or the service you provide?
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Health
inequality
Health inequality might be understood to be concerned with the
burden of ill-health experienced by some populations and also
how they access or experience services. The Scottish Government
has said:
“Reducing inequalities in health is critical to achieving the Scottish
Government's aim of making Scotland a better, healthier place for
everyone, no matter where they live…. While the health of the
country as a whole is improving, the fact is that some inequalities
are widening. That requires concerted action across government.
Health inequalities can be a matter of personal lifestyles such as
smoking or lack of physical activity. However, as important are
community, economic, cultural and environmental factors.”
www.gov.scot/Topics/Health/Healthy-Living/HealthInequalities/Equally-Well
Inequality in health is an aspect of wider inequality in society.
This session began with an identification of the disproportionate
burden of ill-health experienced by gay, bisexual and MSM.
When it comes to using services in recent research one in three
gay and bisexual men in Scotland report a negative experience
related to their sexual orientation. More than a third of gay and
bisexual men are not out to their GP or healthcare professionals.
www.stonewallscotland.org.uk/documents/sw_gmh_scotland_low
_res_web_2.pdf
Please consider
What health inequalities do you see in your professional practice?
What responsibility do you feel your service has towards
addressing inequalities? Specifically, what’s your role?
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What can we
strive for in our
relationship
The picture painted of gay, bisexual and MSM health and wellbeing
challenges us all to consider how best to meet needs. Undoubtedly
working with minority populations can make the professional
with gay,
bisexual and
MSM?
person anxious, especially if aspects of the individual or
community are unknown or unfamiliar, and complexity can seem
overwhelming.
The idea of cultural humility comes from health professionals
trying to understand the culture of an individual or group of
patients which they are not part of themselves. The term was first
coined by Melanie Tervalon and Jann Murray-Garcia in 1998 to
describe a way of bringing multiculturalism into their work as
healthcare professionals. There are three main components to
cultural humility:
1. Lifelong commitment to self-evaluation and self-critique,
2. An interest in fixing power imbalances,
3. A desire to develop partnerships with people and groups
who advocate for others.
The idea of cultural humility is important because it recognises
that it can be difficult to understand the experiences and culture of
another person or group. It recognises that learning and dialogue
are required to build a relationship with ‘the other’ person or
group and it understands that behaviours or symptoms of ill-health
can best be understood from the perspective of those affected and
seen in the context in which they live their life. Philosopher
Martha Nussbaum reminds us that:
‘Only by imagining how the world looks through that person’s eyes
does one get to the point of seeing the other person as a someone
and not a something’.
Continued on next slide.
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What can we
strive for in our
relationship
with gay,
bisexual and
MSM?
Continued
This all points to the importance of personal and professional
reflection and the quality of the conversation that practitioners
engage in with men.
These quotes from the HIV Prevention Needs Assessment
community engagement work help us understand how gay,
bisexual and MSM might phrase the need for cultural humility and
refreshed relationships. Men were asked:
What does a doctor, nurse or health advisor need to do or to know
to make you comfortable speaking to them?
Sincerity is the main thing. Any doctor I’ve encountered who made
the process easier it is because they are the type of people they
are. (Bisexual, 45+, HIV negative)
Don’t judge. Be knowledgeable. Offer advice but listen is the most
important one. Don’t just assume. (Gay, 16-25, HIV negative)
Smile. Be non-judgemental. Be open about sex and sexual acts,
talking about anal sex and you know, gay sexual practices. Be sort
of friendly. Be non-authoritarian and non-disapproving. (Gay, 45+,
HIV positive)
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Final
Please take some time to reflect on these questions in advance of
thoughts
your attendance at any of the Masterclass topic based sessions.
1.How do you feel about providing a service to gay, bisexual and
MSM?
2.When you reflect on your professional practice what is it that
concerns or worries you?
3.What do you need to know more about?
Please also complete the pre-session Reflection Sheet 1 which
you have been sent.
If you want to explore any of the findings from the HIV Prevention
Needs Assessment in advance of the Masterclass you will find it
here: www.gov.scot/Topics/Health/Services/SexualHealth/HIVMSMNeeds
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