Ethnic minority gay men: Redefining community, restoring identity

This report presents the results of one of three studies investigating how social and cultural factors shape gay male identity and influence gay male social life in London today (see also Keogh, Dodds, Henderson 2004a; Keogh, Dodds, Henderson 2004b). These studies aim to problematise monolithic and (we believe) unhelpful concepts such as ‘gay community’ or ‘gay scene’ and show how the population of gay men in London is riven with cultural, political and social differences. It has often been said that ‘the gay community’ or the ‘gay scene’ is an essentially White, middle-class concept which excludes men from other classes or ethnic backgrounds. This research shows that this is not the case. Numerically, the population of gay men in London is disproportionately White and mainly British (as is the population of London), but it is also as multi-ethnic and multi-cultural as the broader London population. Although we regularly celebrate the multi-culturalism of the capital, we rarely, if ever describe the gay community in this way. This is unfortunate because the many facets of the gay community which should otherwise be acknowledged or represented in health or social policy for gay men are obscured. As a consequence, social and community services for gay men remain woefully impoverished. Moreover, by speaking the language of exclusion, we are condemned to always consider weakness as opposed to strength. There is an implicit assumption in nearly all research and policy work on gay men that to be within the charmed (White, middle-class) circle of the gay community is to be ‘included’ and therefore without need. It follows that, those outside of it are automatically ‘excluded’ and therefore, disadvantaged, weaker or more needy. These three reports will show that there is no paradigmatic gay experience or group. Rather, there are many ways of being gay, all of which are imbued with strengths as well as weaknesses. The three reports which emerge from this collection of studies can each stand alone, but are best read in relation to one other. One examines the relationship between being less well-educated, working class and having a gay identity. Another examines the experiences of gay adult migrants to London. This report investigates ethnic minority identity and gay identity specifically concentrating on the experience of British-born Black Carribean men and White Irish immigrants to London. Our aim in carrying out these studies is to change the way that health promoters and policy makers conceive of the gay male population. We want to replace the dominant ‘centre vs. periphery’ construction with a conception of the gay population of London as a composite of a range of different experiences; as fractured, antagonistic and constantly changing. Moreover, the factors which account for these differences amongst gay men are larger social and structural factors: ethnicity, religion, education, class, income etc. To put it simply, no gay man is simply gay, he also has a class background, an ethnicity, an employment history, a family and probably a religious affiliation. On a policy level, we hope to take gay men’s health and social concerns out of the policy ‘ghetto’ that is HIV. Gay and HIV community organisations should be broadening their policy objectives. We feel they should be seeking to transform the education of all boys as well as increasing the capacity of all families to live with and enjoy their gay children. We feel they should be challenging all services to meet the needs of their gay users and of all communities to capitalise on the presence of their gay members. In seeking to do this, we can all learn from the experiences of gay men from ethnic minorities, gay adult migrants and working class gay men

Working class gay men: Redefining community, restoring identity

This report presents the full results of one of a suite of three studies investigating how a range of pre-existing social and cultural factors mediate the development of gay male identity and shape the many forms of gay male social life in London today. These studies aim to problematise monolithic and (we believe) unhelpful social categories such as ‘gay community’ or ‘gay scene’ and show how the population of gay men in London is riven with cultural, political and social differences. It is common to talk simplistically about ‘gay men’ or ‘the gay community’. Commentators have unsuccessfully attempted to undermine such simplistic concepts by asserting that these identities and communities are restricted to White, middle class men. However, we believe that this position on its own is unhelpful because it fails to articulate the broader impact of such sweeping terminology. It serves to obscure the myriad ways of being gay that are not currently being described or represented in health or social policy or interventions for gay men. It implicitly robs anyone who is not White and middle class of a gay identity and sociality. It therefore uses the rhetoric of exclusion to ensure that so-called excluded groups are never considered in mainstream health and social policy for gay men because they are somehow not ‘properly’ gay. In addition, it is reductionist in relation to White middle class gay men. It is always well to be suspicious of any notion of the ‘default’ group which is considered powerful, wealthy etc. Such groups are usually one of two things: an aspirational ‘brand’ created by marketeers to sell us certain lifestyles (a quick review of the commercial gay media supports this suspicion) or a conceptual construction which everyone else uses as a benchmark to establish their own ‘individuality’ or ‘difference’. In short, we are asserting that, in policy terms, the White middle class ‘mainstream’ gay community is a useful political fallacy. In short, our representations of gay men and gay sociality remain woefully impoverished and simplistic. There is one additional over-arching effect of the White middle class fallacy. That is, by speaking the language of inclusion and exclusion, we are condemned to always consider weakness as opposed to strength. There is an implicit assumption in nearly all research and policy work on gay men that to be within the charmed circle of the White middle classes is to be without need. Thus, other experiences of being gay and other groups of gay men are described as automatically disadvantaged and weaker. These three reports will show that there is no paradigmatic gay experience or group. Rather, there are myriad ways of being gay, all of which are imbued with strengths and weaknesses. To this end, we have conducted a suite of qualitative studies into gay men resident in London. One of the others examines the relationship between ethnic minority identity and gay identity and the other investigates the lives of gay migrants in London. This report examines the experiences of blue collar or working class gay men. We aim, with all these studies to change the way that health promoters and policy makers conceive of the gay male population. We want to challenge the construction of the gay male population as having a centre which is privileged – White and middle class – and a periphery of excluded ethnic minorities, migrants, bisexuals and working class men etc. Instead, we present a conception of the gay population of London as a composite of a range of different experiences. As fractured, antagonistic and constantly changing. Moreover, the factors which fracture that population, which create the flux and antagonisms are larger social and structural factors such as ethnicity, religion, education, class, income etc. To put it simply, no gay man is simply gay, he probably also has a class background, an ethnicity, a job, a family, and a religious affiliation or history among other things. It is these differences that animate the gay population of London. Therefore, in all these reports we talk about things rarely considered in policy-oriented research on gay men. We talk of the importance of biological family and heterosexual forms of sociality for many gay men. We talk of the centrality of spirituality and organised religion. We talk about education and the passage from school to work. We talk about masculinity and health. We talk about nationalism. We talk very little about HIV and AIDS and sexual health. We have a transparent aim in doing so. We are hoping to take gay men’s health and social concerns out of the service and policy ‘ghetto’ that is HIV. We are reasserting a particularly sociological perspective that gay men’s health (sexual and otherwise) and the HIV epidemic are fundamentally influenced by broader social factors. In short, if we were to recommend one practice outcome as a result of these studies it would be to produce less community interventions telling gay men what to do (or how to be). Rather, we should be seeking to transform the education of all boys and to increase the capacity of all families to live with and enjoy their gay children; of all services to meet the needs of their gay users and of all communities to capitalise on the presence of their gay members. This is not as socially transformative an agenda as it sounds. We have much to learn from the experiences of working class gay men, gay men from ethnic minorities and gay migrants. Such interventions are, properly speaking, HIV health promotion

Morality, responsibility and risk: Gay men and proximity to HIV. London

Network analysis and network theory have emerged in various strands of research on HIV. Epidemiological research has used network analysis to map and predict the course of the HIV and STI epidemics among Gay men (Doherty et al. 2005; Piqueira et al. 2004). It constitutes an advance on cruder epidemiological models of random mixing (see Keeling & Eames 2005). Social network analysis and social attachment have been important concepts in informing more recent HIV prevention interventions (see Fernandez et al. 2003; Latkin and Knowlton 2005) and have had specific applications in the case of disadvantaged communities such as injecting drug users and sex workers (Latkin et al. 2003; Rhodes et al. 2005). Moreover, network analysis has been useful in understanding social support of disadvantaged groups living with HIV such as African migrants and ethnic minority women (Hough et al. 2005; Asander et al. 2004; Sivaram et al. 2005). Considering a Gay man as part of a social network involves engaging with the social and cultural factors that shape his experience. Rather than thinking of his relationships as essentially random, we characterise them as being profoundly influenced by his social environment; an environment made up by other individuals who share common understandings and social norms. This social network is generally self-perpetuating and limited. Individuals come into contact and hence derive friends and partners from this finite network. Network analysis is especially valuable when examining a population that is highly heterogeneous and made up of individuals who enter that population as autonomous adults. Gay men are such a population being made up of socially mobile individuals deriving from a range of social, ethnic and geographical backgrounds. Social networks are central to our understanding of the dynamics of HIV risk among Gay men. The nature and density of social networks have been found to be connected to sexual risk practices and susceptibility to HIV infection in Gay men (Smith et al. 2004). Moreover, networks influence Gay men’s perceptions and understandings of the HIV epidemic (Grierson 2005). In addition, social networks may have a role in influencing an individuals’ knowledge and understandings of, and access to new technologies such as PEP (see Dodds & Hammond 2006; Korner et al. 2005). Social norms have been found to be important in influencing Gay men’s attitudes towards safer sex and risk-taking especially among groups that have been traditionally disempowered or marginalised such as young Gay men (see Amirkhanian et al. 2005a) and Black/ethnic minority Gay men (see Wilson et al. 2002; Peterson et al. 2003; Zea et al. 2005). Finally social network analysis has been useful in describing social support for Gay men living with HIV and their carers (Shippy et al. 2003; White and Cant 2003; Cant 2004; Zea et al. 2005). A range of HIV prevention interventions have been based around social networks and innovation diffusion theory (see Amirkhanian et al. 2005a). Such interventions would seem to have most salience with disadvantaged groups of Gay and Bisexual men and have achieved some success (see Amirkhanian et al. 2005b). Other authors point out the limitations of network interventions in reaching men at relatively low risk or stress limitations in their efficacy over time (see Martin et al. 2003). Findings from the 2003 Gay Men’s Sex Survey (GMSS) highlight the importance of proximity to HIV. That is, men in certain social and cultural networks had limited experience of HIV in their social network and these men tended to have greater HIV prevention need (see Reid et al. 2004). GMSS 2003 established a range of indicators to measure personal and social proximity to the epidemic. These included: • Having tested for HIV. • Not having tested positive, but believing you are or could be infected. • Being in or having had a sero-discordant relationship. • Personally knowing someone with HIV. At the population level proximity to HIV was mediated by a range of demographic factors. • Area of residence: Men resident in London had greater proximity than men resident elsewhere, although men with low proximity to HIV were present in every city and town and in every area of the UK. • Age: Men in their 30's and 40's had greater proximity than either older or younger men. • Ethnicity: Black men and White men of ethnicities other than British had greater proximity than men in other ethnic groups. • Education: Better educated men had greater proximity (even though less well educated men were more likely to have HIV). • Income: Men in higher income brackets had greater proximity than men in lower income brackets. • Gender of sexual partners: Exclusively homosexually active men had greater proximity to HIV than men who were behaviourally bisexual. • Numbers of male partners: Men with greater numbers of partners had greater proximity than men with fewer partners. While these differences are important it is essential to note that they denote difference at the population level. In fact, there are men with low proximity to HIV in every city and town in the UK (including London); in every age group and ethnic group; with every level of formal education and at every income level; and with a range of sexual identities and sexual practices. These population differences in proximity to HIV present an interesting health promotion dilemma. Those men with greatest proximity have less unmet needs but are more likely to be involved in HIV exposure. Those with less proximity have the greatest unmet need and will therefore be vulnerable if they do come into contact with HIV (either knowingly or unknowingly) but they are probably less likely to do so. In response, the original research recommends “a diverse portfolio of interventions that are encountered by men with a wide variety of relationships to HIV” (Reid et al. 2004). The study presented in this report is in response to these findings. That is, a qualitative examination of social proximity to the epidemic among Gay men. However, we must start with a caveat. Neither GMSS nor this study measures actual proximity to HIV, that is the numbers of social and sexual contacts an individual has who are actually HIV positive, or the percentages of a social network who are actually positive. Rather, GMSS sets up a range of proxy markers to indicate proximity (such as testing history, beliefs about one’s own status and beliefs about the HIV status of social and sexual partners). Likewise, this study measures perceptions of proximity to the epidemic rather than actual proximity (to study actual proximity would require an ambitious network analysis where we recruited all the social and sexual contacts of respondents and asked them about their actual or known HIV status). Studying men’s perceptions of their proximity to the epidemic allows us to examine the ways in which men’s perceptions of their social surroundings influence how they experience and negotiate sexual risk. Moreover, an individual’s perception of the world around him influences the types of information and messages he is likely to notice. The purpose of this study is to inform the nature of interventions targeting men based on their perceived proximity to the epidemic. We will do so by exploring how their perceptions of proximity influence management of HIV-related sexual risk among men who assume or know themselves to be HIV negative

Modest serum creatinine elevation affects adverse outcome after general surgery

Modest serum creatinine elevation affects adverse outcome after general surgery.BackgroundModest preoperative serum creatinine elevation (1.5 to 3.0 mg/dL) has been recently shown to be independently associated with morbidity and mortality after cardiac surgery. It is important to know if this association can be applied more broadly to general surgery cases.MethodsMultivariable logistic regression analyses of 46 risk variables in 49,081 cases from the Veterans Affairs National Surgical Quality Improvement Program, undergoing major general surgery from 10/1/96 through 9/30/98.ResultsThirty day mortality and several cardiac, respiratory, infectious and hemorrhagic morbidities were significantly (P < 0.001) higher in patients with a serum creatinine>1.5 mg/dL. With multivariable analysis, the adjusted odds ratio for mortality for patients with a serum creatinine of 1.5 to 3.0 mg/dL was 1.44 [95% confidence interval (95% CI) 1.22 to 1.71] and for creatinine>3.0 mg/dL was 1.93 (95% CI 1.51 to 2.46). The adjusted odds ratio for morbidity (one or more postoperative complications) for patients with a serum creatinine of 1.5 to 3.0 mg/dL was 1.18 (95% CI 1.06 to 1.32) and for creatinine>3.0 mg/dL was 1.19 (95% CI 0.99 to 1.43). Further stratification and recursive partitioning of creatinine levels revealed that a serum creatinine level>1.5 mg/dL was the approximate threshold for both increased morbidity and mortality.ConclusionsModest preoperative serum creatinine elevation (>1.5 mg/dL) is a significant predictor of risk-adjusted morbidity and mortality after general surgery. A preoperative serum creatinine of 1.5 mg/dL or higher is a readily available marker for potential adverse outcomes after general surgery

Affected by HIV Stigma: Interpreting Results from a Population Survey of an Urban Center in Guangxi, China

We aimed to identify factors related to HIV stigma in Liuzhou, Guangxi province, a city in southwest China with high HIV prevalence. We used a multi-stage cluster randomized sample of the general population to survey 852 adults. We conducted ordinal logistic regression analyses to test factors associated with punishment and isolation stigma. Eighteen percent of respondents agreed that people with HIV should be punished, and 40% agreed that people with HIV should be quarantined. Punishment stigma was associated with age, having three or more sexual partners, and TV watching. Isolation stigma was associated with age, urban residence and a history of STI. HIV transmission knowledge was low, and having correct knowledge attenuated the association with punishment and isolation stigma. Despite programs in China to provide care and treatment for PLHIV, HIV stigma is common in this region. Targeted interventions need to focus on fears related to HIV and PLHIV

Population-Based Sexual Behavior Surveys in China: Liuzhou Compared with Other Prefectural Cities

Sexual behaviors in China are rapidly changing; simultaneously, STI/HIV prevalence is increasing in the general population. To investigate these major shifts, we examined sexual behaviors and self-reported sexually transmitted infections (STI) in one prefectural city in southern China, Liuzhou, and compared it to other prefectural cities throughout China. We used adults age 18-39 from two sets of population-based surveys that paralleled each other in both content and method. The first set was the Liuzhou survey conducted in 2008 (n=398). The second set consisted of two national surveys collected in 2006 and 2010 (n=2186). Liuzhou respondents reported more active social and sexual behaviors than their national counterparts, including more socializing, dancing, drinking excessively, sexual activity among never married men and women, purchasing commercial sex among men, one-night stands among men, multiple sexual partnerships and self-reported STI among both men and women. Women in Liuzhou reported greater sexual risk behavior than their national counterparts, although overall they reported less than their male counterparts; they were also more likely to have had an abortion than women in other prefectural cities. Our findings provide a comprehensive overview of the sexual context of Liuzhou among the general population, which may help explain the greater STI/HIV prevalence in Liuzhou

The Organization of Sex Work in Low- and High-Priced Venues with a Focus on the Experiences of Ethnic Minority Women Working in These Venues

Prior research on female sex workers (FSW) in China, and their risk for HIV and STI, neglects the nuanced experiences of ethnic minority FSW. We conducted participant observations and in-depth interviews with 33 FSW and six venue bosses to describe the experiences of FSW and management structures in high and low-priced sex work venues in Liuzhou, China. In low-priced venues, FSW had more autonomy and stronger relationships with their ethnic minority peers. Mid and high-priced venues had more formal management structures. Ethnic minority FSW working in higher priced venues experienced less support and kinship with their peers. HIV/STI prevention outreach activities occurred in all of the venues, but they were not tailored for different venue types or for ethnic minority FSW. Our findings provide guidance for tailoring public health programs that meet the needs of ethnic minority women working in different types of sex work venues