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A Guide to A
AIDS
Research and and Counseling Counseling
Frustrated Desire, HIV Prevention, and Gay Culture Terry Trussler, EdD Since its beginnings, much of HIV prevention research has focused on individual attributes to account for the behavior of “risk takers.” Even while rates of unprotected sex among gay men have steadily increased over the past five years, the focus on the characteristics of individuals has continued to dominate explanations of risk taking.1 Now that rates of HIV transmission are also beginning to climb, new perspectives are urgently needed. The Community-Based Research Centre in Vancouver has always been skeptical about the “flawed personality” theory that underlies the individual risk-taker model.2 The term “barebacking,” for example, caught fire in gay discourse, because talking about unprotected sex became as fashionable as tattoos and piercings. Talk may not equal action but it begs a question: is doing the “cool” thing a more potent inducement for unprotected sex than the traits of individual risk takers as favored by the prevailing wisdom? In theorizing about HIV risk, the Community-Based Research Centre has long emphasized social over individual factors, noting that social environments play an important role in governing individual health.3 This conception is founded on two theoretical models in the health literature. First, Jonathan Mann’s vulnerability theory strongly suggests that individuals are at risk due to their status within their societal context.4 Although his theory has rarely been applied to gay men, Mann observed that HIV found routes of least resistance through communities of those most discriminated against in society. Second, population health theory, a relatively new policy framework in Canada, suggests that
social status is a stronger factor than individual behavior in determining disease.5 This theory also has yet to see much application to research on gay men. Anecdotally, it does seem that the way gay men approach sex is determined as much by what they believe is acceptable to others as by what they know about their risk of infection. For a period of time, that cultural phenomenon—the power of community norms to make unprotected sex unacceptable—may have actually been responsible for the achievement of HIV prevention goals among gay men. But not any more, it seems. Recent studies of gay men in Vancouver have tried to grasp the relationship between increasing rates of unprotected sex and cultural change in gay life. The most compelling interpretation of what has emerged so far is that social status, rank, or position—the place of gay men in the societal scheme of things—may play a significant role. In a city like Vancouver, dubbed “lotus land” by people in other parts of Canada, the good life seems abundant, but ultimately, it is truly available only to a few. What impact does the “frustrated desire” that many gay men experience as they arrive in this city and try to live their dreams have on HIV prevention? Could the effect of exposure to social boundaries explain the slow disintegration of safer sex?
Alienation among Young Gay Men In early attempts to understand what was happening, the Community-Based Research Centre first focused on young gay men whose attitudes about safe sex appeared increasingly cavalier. This attitude seemed to suggest that young men were in the process of reinventing a “post-AIDS” gay life for themselves.6 Could unprotected sex be catching on like a youthfully defiant fashion statement? A series of focus groups with 72 self-identified gay men between the ages of 18 and 30 found the opposite to be true: safe sex appeared to remain a valued pro-
Editorial: Status Symbols Robert Marks, Editor It is easy to be seduced by the idea that the truth is an either/or proposition, that risky behavior is influenced by what goes on inside a person’s head—or even within the DNA of his or her cells— rather than what goes on outside his or her body. It seems just as likely that internal and external forces work concurrently, sometimes amplifying each other’s effects, other times minimizing them, always influencing them. The nature of much scientific research today is to specialize, to not simply focus but to focus tightly on a theory or an approach. While this close study— a form of myopia—serves to clarify and test specific factors related to risk, it can sacrifice a broader view that may be particularly beneficial at a time when many are reevaluating fundamental HIV prevention approaches. Personal actions are more easily influenced than societal forces, and HIV prevention has been effective over time by con-
centrating on the individual, or more broadly, the way individuals interact in social groups. But, as we face more intractable prevention challenges, neglecting broad societal forces may undermine much of this success. Both of the articles in this issue of FOCUS attempt to synthesize findings about individual behavior within the larger context of society. Applying population health theory, the dominant model for health policy in Canada, Terry Trussler defines social factors as “first-order” determinants of health. Primary among these is social status. He suggests that the high cost of living in Vancouver, the presence of anti-gay violence, and the difficulty of sustaining long-term relationships converge in a “frustrated desire” that threatens social rank and the motivation to remain HIV-negative. Rodrick Wallace also considers the importance of social status, in particular, the communication of status through behavior. He
tective strategy in the culture of young gay men.7 But these focus groups also uncovered a wide assortment of other frustrations young gay men encountered in Vancouver, frustrations that these men, themselves, suggested were linked to the rise of unprotected sex. Chief among them was the experience of alienation. Focus group participants described Vancouver as a “passing fantasy” for many young men, who come for “the rest of their lives” but leave in a year or two still looking for a job. Many doubted the existence of “gay community.” They complained about a lack of venues for contact with gay culture outside of bars. Many expressed a deep desire to have a lifelong relationship with another man, but the cold realities of Vancouver’s sexual marketplace made fulfillment of this desire seem impossible. These narratives described an initial excitement about connecting with “out” gay culture in a big city that was quickly eroded by encounters with the local gay scene and an urban 2 FOCUS
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proposes that when a behavior that communicates status within a marginalized community becomes destructive, it may be difficult to change the behavior if the conditions that caused it to become an effective communicator do not also change. For example, if unprotected sex becomes central to a gay male identity formed in the crucible of discrimination, violence, and fear, protected sex may be an unachievable goal for some men—even in the face of HIV— unless the societal forces that marginalize gay men change. Society is at best a compromise: the social forces that marginalize and impede some advance others. It is unrealistic to expect society to change so dramatically as to eliminate the oppressive conditions that incubate what might become destructive behaviors. Acknowledging the role of broad societal forces— beyond the current use of social marketing to influence group norms—is crucial both in prevention planning and in psychotherapy, if for no other reason than it paints a more vivid and comprehensive picture of the truth.
society that still has difficulty embracing its gay residents. Intrigued by these findings, the Community-Based Research Centre used the population health model—which now governs health policy in Canada—to design a questionnaire probing the relationships between society, gay culture, and HIV prevention.
Population Health Population health theory proposes a set of determinants, over and above specific diseases, that influence peoples’ health.5 The term “determinant” holds an uneasy but crucial place in the theory, because it suggests that there are inevitable factors affecting health beyond individual volition or control. Listed here in order of what is thought to be their influence, population health determinants include: income and social status; social support networks; education; employment; social environment; physical environment; personal practices; child development; biological and genetic endowment; gender; and culture.8
References 1. Stall R, Hays R, Waldo C, et al. The gay 90’s: A review of research on sexual behaviors and HIV risk among men who have sex with men. AIDS. 2000; 14(Supp 3): S1–S14. 2. Strathdee S, Hogg R, Martindale S, et al. Determinants of sexual risk-taking among young HIV-negative gay and bisexual men. Journal of Acquired Immune Deficiency Syndrome and Human Retroviruses. 1998; 19(1): 61–66. 3. Labonte R. Population health and health promotion: What do they have to say to each other? Canadian Journal of Public Health. 1994; 86(3): 165–168. 4. Mann J, Gostin L, Gruskin S, et al. Health and Human Rights. Health and Human Rights: An International Journal. 1994; 1(1): 6–23. 5. Evans R, Barer M, Marmor T, eds. Why Are Some People Healthy and Others Not? The Determinants of Health of Populations. New York: Aldine De Gruyter, 1995. 6. Gubrium J, Holstein J, Buckholdt D. Constructing the Life Course. New York: General Hall Press, 1994.
In this scheme of health, social factors are first-order determinants, taking precedence over personal practices and even biological endowment. Theoretically, those people, communities, and nations that rank higher have better health. Social rank—defined by confidence, authority, and power, even more than wealth—is the most important social status variable. Given the uncertain place that gay men continue to occupy in North American society, what might the “social status” determinant mean for gay health? The Vancouver survey recruited a sample of 620 men over three weeks. Participation was open to all, and recruitment drew from a wide variety of venues, events, and media. Ultimately, the sample in many ways resembled any gay gathering in Vancouver. While the sample included a wide range of ages— from 18 to 70—the mean age was 38. There was a complete spectrum of ethnic groups, and education and income levels. About 15 percent of the sample was HIV-positive. Taken as a whole, the data seemed to point in another surprising direction. Little in the aggregate findings suggested a crisis in gay health. For example, in terms of unprotected sex— which the survey defined as instances of either receptive or insertive anal sex without a condom during the previous six months—about 63 percent of the sample said they had none, about 23 percent said they had it with one man only, and about 14 percent said they had it with more than one man. The extent of unprotected sex in relationships during the period before the study was unknown, but it was somewhat reassuring that multiple-partner unprotected sex was less popular than it seemed it would be given widespread talk about barebacking. There was also evidence to suggest that, in many respects, social support was stronger than expected. As many as 80 percent of men in the sample thought they had a strong network of friends. On the other hand, when it came to finding new male friends, 54 percent said they found it to be quite difficult. Findings such as these were perplexing, implying perhaps that the survey ques-
tions were not precise enough or that the effort to relate social status to safe sex was too ambitious for a survey. A deeper look into natural groupings in the gay community—HIV-positive, HIV-negative, and unknown status; single and partnered; young, middle, and older age—began to uncover important differences within these groupings. It also revealed further hints of the underlying frustration that accompanies gay men’s experience of their ascribed social status.
City of Broken Dreams Frustrated desire, often seen as a root cause of conflict, anger, and violence, is an age-old concept. Freud proposed psychoanalysis as a process of recovering unconscious desire to find a way out of depression. Thus, to discover and know one’s desire was the goal of psychoanalysis. But when the object of desire is found to be unattainable, the resulting frustration may bring about a cascade of negative emotions and unpredictable consequences. What happens if frustrated desire is operative as a cultural condition of an identifiable population due to its apparent rank in the social scheme of things? Do gay men suffer subtle effects of the social position afforded them that goes beyond blatant discrimination? Frustrated desire does help explain the alienation apparent among Vancouver’s young gay men, especially men under 30 years old. It was expressed in three realms in the Community-Based Research Centre findings: cost of living, violence, and relationships. Here in a city full of gay men seeking paradise, insurmountable barriers to attaining it are everywhere. As many as 70 percent of the Vancouver sample said what they really want is a lifelong partner, but far fewer have actually attained anything close to that. While it may seem counter to gay mythology, among young gay men in the sample this percentage rose to 88 percent. But what are their chances of achieving this goal?
Population health theory holds that social factors are first-order determinants, taking precedence over personal practices and even biological endowment.
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7. Trussler T, Perchal P, Barker A. Between what is said and what is done: Cultural constructs of gay men’s HIV vulnerability. Psychology, Health and Medicine. 2000; 5(3): 295–306. 8. Health Canada. What is population health? Health Canada. 2000: http://www.hc-sc.gc. ca/hppb/phdd.
Authors Terry Trussler, EdD is a co-founder and Director of the Community-Based Research Centre (CBRC) in Vancouver, a gay health thinktank that, in addition to its own research, supports the general involvement of community HIV organizations in prevention research. The CBRC facilitated an International Consensus Statement on Community-Based Research, which is available at www.hiv-cbr.net.
Many gay men come to Vancouver with expectations that their education and skills will lead to fulfilling jobs, comfortable lives, and improved social status. While these men are often well-educated and earn relatively high incomes, such achievements turn out to be a condition of basic survival. Rents are so prohibitive, new city residents are forced into less desirable roommate relationships, and disposable incomes are inadequate to take full advantage of the recreational and cultural opportunities of a large, cosmopolitan city. The result is that gay migrants to Vancouver— and perhaps other large North American cities as well—must confront largely hidden social boundaries they were not expecting to encounter. Forty-eight percent of respondents reported having experienced “gay bashing” at least once in their lives. Anti-gay violence may well frustrate attempts to “live the good life,” but when it involves nearly half the community, the aggregate suggests a much more significant effect. This finding raised a red flag. Is anti-gay violence an indicator of diminished social rank, that first-order determinant in population health theory, and does its prevalence have an impact on HIV risk? The Vancouver study found that those who had been gay-bashed were more than twice as likely to have engaged in high risk sex than those who had not. Finally, the differences in responses between single and partnered men uncovered another pattern. Overall, half of the younger men in the sample participated in unprotected sex, but most of it was with only one partner. This suggests that serial monogamy may be a central HIV prevention strategy for these men. Could access to “safer” unprotected sex be one of the reasons so many young men want a relationship? If so, is the difficulty of forming
relationships under Vancouver’s conditions having an impact on HIV risk, and is this ultimately a consequence of frustrated desire? Among single men, another piece of evidence emerged: an underlying frustration that was not as apparent among gay men in general. Single men turned out to be less satisfied with Vancouver’s living conditions, found it more difficult to meet new men, and were more likely to have sought care for mental health or relationship issues. They were also more likely to be engaged in multiple-partner unprotected sex, perhaps a barometer of frustrated desire. Considering only the single men who engaged in multiple-partner unprotected sex, the barometer rose much higher: they were also more likely to have been gay bashed, to have experienced relationship violence, and to use party drugs such as crystal.
Conclusion Further exploration of these issues may begin to answer the question of how frustrated desire operates within the day-today construction of gay life and what it may mean for the future of gay culture. From the perspective of population health theory, frustrated desire seems a natural by-product of the social status, rank, and position afforded gay men. In gay culture itself, social status seems currently to be vested most in relationship status. Those in relationships have more of what most gay men desire: more income, more satisfaction with living, and more optimism about their own futures. For young gay men today, the desire for the good life is the desire for a stable partner, but the risks involved in achieving this may include violence and HIV infection. This suggests that the struggle for human rights for gay men may well be as important for HIV prevention as individual sexual health.
Clearinghouse: Culture and Norms References Amaro H, Raj A, Reed E. Women’s sexual health: The need for feminist analyses in public health in the Decade of Behavior. Psychology of Women Quarterly. 2001; 25(4): 324–334. Carmona JV, Romero GJ, Loeb TB. The impact of HIV status and acculturation on Latinas’ sexual risk taking. Cultural Diversity and Ethnic Minority Psychology. 1999; 5(3): 209–221.
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Fishbein M, von Haeften I, Appleyard J. The role of theory in developing effective interventions: Implications from Project SAFER. Psychology, Health and Medicine. 2001; 6(2): 223–228. Flowers P, Smith JA, Sheeran P, et al. “Coming out” and sexual debut: Understanding the social context of HIV riskrelated behaviour. Journal of Community and Applied Social Psychology. 1998; 8(6): 409–421.
Herdt G. Stigma and the ethnographic study of HIV: Problems and prospects. AIDS and Behavior. 2001; 5(2): 141–149. Hou S, Basen-Engquist K. Human immunodeficiency virus risk behavior among White and Asian/Pacific Islander high school students in the United States: Does culture make a difference? Journal of Adolescent Health. 1997; 20(1): 68–74. Kelly JA, Sikkema KJ, Winnet RA, et al. Factors predicting continued high-risk behavior among gay men in small cities: Psychological, behavioral, and demographic characteristics related to unsafe
Behavioral Coding and HIV Risk Rodrick Wallace, PhD Marginalized communities have internal structures that reflect economic, social, historical, and even geographic constraints imposed upon them by the oppressive societies in which they are embedded. For these subgroups for example, the African American and gay and lesbian communities— the forms of and limits to education and economic opportunity, the controls on where community members are allowed to reside, the conditions of that residence, even life expectancy, are highly structured by mainstream societal forces.1–3 These forces shape subpopulations and the symbolic value of behaviors within these groups, potentially so distorting communication that destructive behaviors substitute for more affirmative ones as ways of conveying status and self-worth. This article describes the ways in which the value of behaviors may be determined by outside forces, how destructive behaviors gain currency, and the implications of these dynamics for HIV prevention.
limited for individuals within marginalized communities. Examples abound: gay men may be openly homosexual only in certain refuges of a few cities, notably New York and San Francisco. In suburban areas or small cities, they are often restricted to a few social clubs or similar facilities. Openly homosexual men may be blackballed from certain occupations or steered into others, and even privacy and discretion may not be enough to prevent discrimination or physical assault. The rigidity of acceptable appearance and behavior in many places is so great that straight men may mistakenly be attacked if they are perceived as gay. Ethnic minorities in the United States, particularly African Americans and Hispanics, face analogous constraints.2,3 Under such pressures, the evolution of distinctive ingroup versus out-group norms and behavior patterns is inevitable for a great variety of reasons, not the least of which may be the unavailability of educational, professional, and employment status to group members. For example, within physically devastated minority urban communities, the sudden fragmentation of social networks— the virtual community meltdown that routinely occurs in the face of decaying
Within devastated urban communities, the sudden fragmentation of social networks may interrupt traditional channels that guide the socialization of adolescents into the adult world.
Acquiring Self-Worth Opportunities for acquisition of symbols of worth from the larger society are
sex. Journal of Consulting and Clinical Psychology. 1995; 63(1): 101–107. Miller JE, Guarnaccia PJ, Fasina A. AIDS knowledge among Latinos: The roles of language, culture, and socioeconomic status. Journal of Immigrant Health. 2002; 4(2): 63–72. Norris AE, Ford K. Moderating influence of peer norms on gender differences in condom use. Applied Developmental Science. 1998; 2(4): 174–181. Page JB. Needle exchange and reduction of harm: An anthropological view. Medical Anthropology. 1997; 18(1): 13–33.
Pryor JB, Reeder GD, Landau S. A socialpsychological analysis of HIV-related stigma: A two-factor theory. American Behavioral Scientist. 199; 42(7): 1193–1211. Schiller NG, Crystal S, Lewellen D. Risky business: The cultural construct of AIDS risk groups. Social Science and Medicine. 1994; 38(10): 1337–1346. Svenkerud PJ, Singhal A. Enhancing the effectiveness of HIV/AIDS prevention programs targeted to unique population groups in Thailand: Lessons learned from applying concepts of diffusion of innovation and social marketing. Journal of Health Communication. 1998; 3: 193–216.
Contacts Terry Trussler, EdD, Community-Based Research Centre, 2023 West 4th Avenue, Suite 2, Vancouver, British Columbia, V6J 1N3, Canada, 604-7369150, 604-736-9120 (fax), ttruss@telus.net (e-mail). Rodrick Wallace, PhD, PISCS Inc., 549 West 123rd Street, Suite 16F, New York, NY, 10027, 212-865-4766, rdwall@ix.netcom.com (e-mail).
See also references cited in articles in this issue.
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References 1. McCord C, Freeman HP. Excess mortality in Harlem. New England Journal of Medicine. 1990; 322(3): 173–177. 2. Massey D, Denton N. American Apartheid: Segregation and the Making of the Underclass. Cambridge, Mass.: Harvard University Press, 1992. 3. Wallace D, Wallace R. A Plague on Your Houses: How New York Was Burned Down and National Public Health Crumbled. New York: Verso, 1998. 4. Wallace R, Fullilove M, Flisher A. AIDS violence and behavioral coding: Information theory, risk behavior and dynamic process on core-group social networks. Social Science and Medicine. 1996; 43(3): 339–352. 5. Fullilove R. Focus Group, Violence and Recovery Project, December 1994. 6. Fullilove M. Focus Group, Women and Trauma Project, July 1992. 7. Fanon F. The Wretched of the Earth. New York: Grove Press, 1966. 8. Aggleton P, O’Reilly K, Slutkin G, et al. Risking everything? Risk behavior, behavior change and AIDS. Science. 1994; 265(5170): 341–345. 6 FOCUS
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housing, high unemployment, inadequate schools, and an overall sense of futility— may interrupt the traditional channels that guide the appropriate socialization of adolescents into the adult world of work and family responsibility.3 This might, on the one hand, trigger an extended adolescence and the formation of youth gangs, which later develop into drug-marketing posses steeped in high levels of competitive violence. On the other hand, the interruption of appropriate socialization might force very young people into inappropriate adult roles and responsibilities without adequate training, resulting, for example, in childhood pregnancies. More generally, within subgroups suffering significant discrimination, frequent anonymous sexual contact may constitute an expression of self- and communityworth as a direct reaction against oppression. This may be particularly true for young people if their pathways to education and professional career status are blocked. In this way, depriving marginalized people of “conventional” routes to status and worth may lead them to embrace behavioral repertories that include what would otherwise be defined only as ”risk behaviors” but in this new context acquire value. These repertories comprise “typical” sequences of behaviors—including but not limited to spoken language—as codes for the rapid communication of norms, personal statements, and other information. This communication travels throughout highly interactive and geographically focused social networks.4 They will change over time, evolving like adaptive genetic attributes, so as to remain an efficient means for communicating group norms or individual needs within these networks.
Channels, Behavioral Codes, and Risk One theory holds that this flow occurs as information travels along “channels” and, specifically, “noisy channels,” that is, among people in a community. Information—including community norms and behaviors—will travel as quickly as the channel allows and only at the capacity that the channel allows. For example, dissemination of the quantum theory of physics through a word-of-mouth channel within a community of non-physicists will fail, because the capacity of this word-ofmouth channel is too narrow too handle the complexity of this highly technical information. But the channel may work well to communicate the meaning and value of sexual activity.
Channels communicate more than factual information, and they may carry more than words. A metaphorical statement like “I am a person of worth in a community of worth” may be expressed in a variety of ways determined by a subgroup’s behavioral code. But suppose that code, which has evolved in response to a historical pattern of externally imposed constraints and pressures, begins itself to damage the social network in which it is transmitted. A compelling example of this arose out of a series of discussions about the relationship between violence and status in the Harlem neighborhood of New York.5,6 Residents who were in recovery from heroin addiction said that revealing any sign of weakness signaled to others that a person was a “punk” and, therefore, a suitable target of victimization. The principle of ensuring personal safety by appropriate displays of one’s willingness to commit violent acts was considered fundamental to daily life. Safety came from being respected, and carrying oneself in a “manly” way earned respect from other men. “Punks” could be victimized at will: “men” were left alone. Confrontation, handled on each side in a “manly” fashion, was the foundation of friendship between men. In this way, a community that was denied other ways of attaining and communicating status adapted violence, an otherwise dysfunctional response, to the task. It was the introduction of guns into this situation that turned this adaptation from relatively healthy to destructive. Guns became widespread shortly after illegal drug marketing became the mainstay of the economy of disintegrating inner city communities. Prior to the gun era, the pinnacle of violent displays was a fist fight. The use of guns in the course of violent displays is a behavior that appears to conform to this traditional norm. However, the lethality of guns increases harm
Comments and Submissions We invite readers to send letters responding to articles published in FOCUS or dealing with current AIDS research and counseling issues. We also encourage readers to submit article proposals. Send correspondence to rmarks@itsa.ucsf.edu or to Editor, FOCUS, UCSF AIDS Health Project, Box 0884, San Francisco, CA 94143-0884.
and undermines the possibility that the encounter will function as it had as a way to bring men together. In addition, guns escalate violence to the point that begins to drive affected neighborhoods toward further physical and social decay. The same analysis might be used to look at the role of sex in the gay male community. Suppose frequent, unprotected sexual contact becomes an essential component of gay identity within a subgroup of a larger gay community. Suppose frequent sexual contact suddenly begins to transmit HIV, whose expression as HIV disease further shreds this marginalized community. In both cases, one possible outcome could be to evolve the optimal code so as to raise the level of the very behavior that is damaging the channel, causing the damage to reach even higher levels, and initiating a selfdestructive positive feedback. Thus having HIV itself might come to replace frequent sexual contact as a central defining character of gay identity, and deadly Hatfield-and-McCoy cycles of violence might become the expected norm within segments of disintegrating innercity neighborhoods.7
laws, relatively high levels of needlesharing or of frequent unprotected sexual contact among gay males may continue for fundamental reasons. Indeed, frequent unprotected sexual contact may be a fundamental behavioral statement within many marginalized groups—an affirmation of life and control in the context of circumscribed lives. This view has become a common currency in discussions of AIDS risk behaviors. For example, HIV prevention theorist Peter Aggleton considers a range of social, political, religious, and cultural influences as critical in defining the context in which risk behavior occurs, the risks individuals face, and the likely success of efforts to reduce these risks.8
Encouraging condom use will work as a prevention approach for many people, but for those for whom unprotected sex is central to gay identity, relapse may be inevitable.
Relapse and Prevention
Authors Rodrick Wallace, PhD is a Research Scientist in the Epidemiology of Mental Disorders Research Department of the New York State Psychiatric Institute, and Technical Director of the Public Interest Scientific Consulting Service, Inc. (PISCS), a nonprofit research organization.
This theory is relevant not only as a way of explaining the spread of HIV, but also to suggest ways in which it might, and might not, be prevented. The behavioral code of a subgroup, with proper translation by “native speakers,” might plausibly be used to communicate disease control information, as well as disease itself, along the group’s sociogeographic networks. This is the basis for many HIV prevention approaches that rely on the dissemination of information and norms for sexual and drug-using activity via peers, applying direct intervention at the site of activity, for example, in bars, in bath houses, and at shooting galleries. If, however, external factors conspire to structure the channel in such a way that “risky” behaviors must remain part of the accepted behavioral vocabulary, then “relapse” would seem inevitable. For example, if clean needles are not freely available to injection drug users, or if homosexuality is not protected under civil rights
Conclusion Seeking an alternative to encoding prevention messages in the “natural language” of a community, a mathematical modeling exercise suggests a more efficient approach: actually modifying the “channel” by which individuals communicate within a social network.4 This approach raises serious questions regarding the relative efficiency of “harm reduction” methods that accept existing behavioral coding when they are compared with structural changes to the transmission channel that may render “risk behaviors” obsolete. Encouraging condom use will work as a prevention approach for many people, but for those for whom unprotected sex is central to gay identity, relapse may be inevitable. Instituting gay rights laws and working on a large scale to change attitudes toward gay people—particularly in schools when many of these attitudes are formed—may alter the meaning of unprotected sex. While it may remain preferable because it is pleasurable, pleasure may no longer trump safety. 7 FOCUS
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A Guide to
AIDS
Recent Reports Research and Counseling
Executive Editor; Director, AIDS Health Project James W. Dilley, MD Editor Robert Marks Assistant Editor Alex Chase Founding Editor; Advisor Michael Helquist Medical Advisor Stephen Follansbee, MD Design Saul Rosenfield Production Carrel Crawford Jennifer Jones Gabriel Rabu Lisa Roth Circulation Carrel Crawford Jennifer Jones Interns and Volunteers Ateka Gunja FOCUS is a monthly publication of the AIDS Health Project, affiliated with the University of California San Francisco. Twelve issues of FOCUS cost: Individual: Paper–$48; Paper Outside U.S.–$60; Electronic–$36 (inside and outside U.S.); Both Formats –$58; Both Formats Outside U.S.–$70; Limited Income –$24 for either format and $30 for both formats. Institutional: Paper–$105; Paper Outside U.S.–$125; Electronic–$90 (inside and outside U.S.); Both Formats–$120; Both Formats Outside the U.S.–$140. Make checks payable to “UC Regents.” Address subscription requests and correspondence to: FOCUS, UCSF AIDS Health Project, Box 0884, San Francisco, CA 94143-0884. For a list of back issues and information about cost, write to the above address, call (415) 502-4930, or e-mail jejones@itsa.ucsf.edu. To ensure uninterrupted delivery, send new address four weeks before you move. Printed on recycled paper. ©2002 UC Regents: All rights reserved. ISSN 1047-0719
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Sexual Norms among Latina Women Ortiz-Torres B, Serrano-Garcia I, Torres-Burgos N. Subverting culture: Promoting HIV/AIDS prevention among Puerto Rican and Dominican women. American Journal of Community Psychology. 2000; 28(6): 859–881. (University of Puerto Rico.)
The success of HIV prevention programs among Latina women must go beyond an idealization of culture, according to a comprehensive review of the HIV prevention literature on Dominican women living in New York and Puerto Rican women living in New York and Puerto Rico. It must depend instead on the promotion of changes that both respect cultural diversity and foster participation in the development of new values, beliefs, and norms. Traditional Latino cultural ideals may undermine HIV prevention by reinforcing unequal power relationships. In particular, machismo, which idealizes men’s virility, independence, strength, and sexual prowess, and marianismo, which idealizes women’s chastity and obedience (and is modeled on the conception of the Virgin Mary), hinder women’s abilities to conduct safer sex negotiation and impede their access to education about their sexuality. Within this socially constructed framework, many barriers to safer sex prevail, including women’s discomfort initiating negotiation, their limited knowledge of safe sexual behaviors, their doubts about condom use, and men’s use of verbal aggression during negotiation. On the other hand, Latinas who had a “proactive” relationship with their dominant culture—for example, through bilingualism or work environments that included non-Latino workers—engaged more often in safer sex practices than did traditionally acculturated Latinas.
Adoption of HIV Prevention Interventions Miller RL. Innovations in HIV prevention: Organizational and intervention characteristics affecting program adoption. American Journal of Community Psychology. 2001; 29(4): 621–647. (University of Illinois, Chicago.)
A study of community-based organizations identified five criteria HIV agencies use to evaluate prevention approaches they are considering implementing. In order of importance, they are: degree of compatibility with organizational philosophy about HIV prevention, perceived relevance to local culture, evidence of efficacy, feasibility, and ability to fill gaps in local services. Researchers conducted qualitative interviews at 38 non-profit HIV prevention
service providers throughout Illinois. Three fairly evenly distributed groups emerged: low adopters, which had never adopted an external HIV prevention program; moderate adopters, which had implemented part of an external program; and high adopters, which had adopted one or more programs. The majority of low and medium adopters had less than five people devoted to HIV prevention and a primary mission focused beyond HIV. Most of the high adopters were HIV-specific organizations founded early in the epidemic. Half of these targeted gay, lesbian, bisexual, and transgendered populations, and nearly twothirds targeted youth. High adopters spent nearly half their budgets on prevention. Of the organizations under study, 68 percent of adopters reported incongruence with organizational philosophy as the primary reason for program rejection. Adherence to local cultural and community values was valued by 65 percent of the adopters. A majority of adopters required evidence to support the use of a program, including evaluation data, particularly regarding process. Reputation also held substantial weight, with 51 percent expressing a preference for programs they had seen people use and enjoy. Equally important was feasibility, dictated by limitations of money, resources, staff, and time. Finally, bolstered by a sense of responsibility to their community base and the desire to maintain their uniqueness, organizations also sought programs that filled gaps in local services.
Next Month Being infected with HIV, in and of itself, changes a person’s body image, and up until the late 1990s, many other HIVrelated body challenges were the result of opportunistic conditions such as Kaposi’s sarcoma and wasting syndrome. Today HIV treatment, as much as HIV illness, changes the shape of a person’s body and his or her conception of self. In the July issue of FOCUS, Elizabeth Chapman, PhD of the University of Cambridge discusses body image theory and describes the psychological component of lipodystrophy syndrome. In addition, Paul Kunsberg recounts his own experience living with HIV and the changes it has wrought to both his body and consequently, his emotional health.
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ABOUT UCSF AIDS Health Project Publications
The AIDS Health Project produces periodicals and books that blend research and practice to help front-line mental health and health care providers deliver the highest quality HIV-related counseling and mental health care. For more information about this program, visit http://ucsf-ahp.org/ HTML2/services_providers_publications.html.