Research in Cape Town, South Africa, by Andrew Tucker and colleagues shows that HIV prevention is imperiled by homophobia.[i] Men who have sex with men were asked if they had personally experience stigma as a result of being known as a man who has sex with other men. Had they been called names, threatened with or experienced violence, or perhaps had lost friends, accommodation or work? The men were also asked to respond to a set of questions used to establish if they were experiencing depression. Another set of questions related to what is called self-efficacy, their sense that they have meaningful control over their life. Finally, they were asked about the sexual risk taking in the form of unprotected anal intercourse. The results are striking. The men who reported most exposure to homophobia, were more likely to be depressed, less likely to think they had effective control over their life choices, and more likely to have engaged in unprotected anal intercourse during the previous six months. These are important findings. By inducing depression and low self-efficacy, homophobia makes it less likely that men who have sex with men with take good care of themselves. They are thus more likely to engage in sexual acts that carry a risk of HIV infection. We may speculate that depression and low self-efficacy may affect the likelihood of men following other health-promoting behaviours, such as seeking an HIV test, or following treatment regimes if they o become infected. Figure 1 is a representation of some of these relationships, with depression being made more likely by homophobia and self efficacy being reduced from the same cause. Depression is shown as making risk-taking more likely, HIV testing less likely and treatment compliance less likely. Self efficacy has the opposite result. Tackling homophobia must now be considered essential for improving the health prospects of men who have sex with men.
Figure 1. The relations between homophobia and HIV vulnerability [click on diagram for larger version]
Now, let’s consider these matters from an Irish point of view. When in February this year, TheJournal.ie asked readers for personal experiences of homophobia, it was ‘inundated with correspondence.’[ii] One gay man in his forties described a catalogue of abuse from ‘[n]ame calling and physical attack in a Catholic-run school while the principal ignored my complaints and told me to act more like a man,’ ‘[b]eing asked to stop coaching kids in GAA after I came out,’ to ‘[h]aving a friend punched in the face and his nose broken when set upon by thugs shouting ‘fucking faggot’ outside a local chipper.’ Another reported that ‘[s]chool was hell on earth for me. Every single day for probably 10 years I was mocked, verbally abused and, in some cases, physically abused.’ Another man told the story of a gay friend who ‘couldn’t handle the negative stereotypes and society judging him and looking down upon him for being gay. Eventually, he had enough of all that and [hanged] himself. His 12-year-old brother found his body.’
Among European countries, Ireland has the highest level of suicide for female teens (2.09 deaths by suicide for every 100,000 females aged under 20; against an EU average of 0.84) and the second highest level for male teens (Ireland: 5.12; EU: 2.39).[iii] Depression, an experience of being bullied, and the use of alcohol or other drugs are important predisposing factors. One online survey of Lesbian, gay, Bisexual or Transgender Irish people found 86% had ‘experienced depression at some point in their lives’ and from qualitative interviews, over 60% of LGBT individuals reporting a history of this affliction attributed their depression ‘directly to social and/or personal challenges connected with their LGBT identity.’[iv] A survey of LGBT young people (16-24 years) found that psychological distress (anxiety, depression, and suicidal thoughts) was strongly associated with exposure to ‘identity-related prejudice and discrimination’ (heterosexist experiences), with expectations for rejection on the basis of sexual identity (stigma consciousness), and with the ‘internalisation of society’s negative attitudes (sexual identity distress)’.[v] One survey of fifth-year Irish school children (c.16-17 years of age) found that 32.9% of heterosexual males reported having been bullied in the last couple of months, compared to 62.5% of non-heterosexual males.[vi] For females, 20.1% of the heterosexual students in the sample reported bullying during the previous two months, and the figure for non-heterosexual females was 66.7%. Another web-based survey of LGBT youth (18-26 years) found 65% had taken drugs other than alcohol and 21% systematically used them.[vii] This survey also found that 46% had unprotected sexual intercourse when under the influence of drugs, and 11% had suffered sexual assault when incapacitated. Ireland has a problem with teen suicide. It is failing its young people and it would seem that it is particularly unheedful of the needs of its young LGBT people. Homophobia is hurting Ireland’s young people.
If the relationships identified in the South African study hold firm for Ireland, then we would expect to see failures of HIV prevention associated with this homophobia. In a report on long-term trends in sexually transmitted infections (STIs), the Health Protection Surveillance Centre gives data on the age specific incidence of new infections for STIs (excluding HIV) for the period 1995-2012. The incompleteness of the data (with a report of age missing for about half the notifications in the period 1995-2002) means that we can only look at trends from 2003, but even so the picture is bleak (see Figure 2).[viii] In 2012, the incidence of new infections among the age-group 20-29 was 59.1% of the total and even those aged under 20 accounted for 11.3% of new infections.[ix] If anything, over the past decade, there has been a deterioration of sexual health among young Irish people. The picture for HIV highlights the specific vulnerability of men who have sex with men. Whereas there has been a decline rate of new HIV infections where the probable route of transmission is sharing needles while injecting drugs (see Figure 3), and whereas there has also been a decline in the rate of new infections among heterosexual people, there has been a steady rise in infections among MSM who now make up about half of all new HIV infections.[x] This is a very depressing finding. Even in European terms, the Irish picture is unsettling. For the EU as a whole the average annual rate of new HIV infections in the period 1986-98 was 2.82 per 100,000 living, and in Ireland it was 3.22 (see Figure 4).[xi] During the period 1999-2012, the EU rate was 5.75 (about a doubling of the earlier rate) but for Ireland it was 8.13, which is two-and-half times the earlier figure.
Figure 2. Age-specific notification rates for STIs (excluding HIV) in Ireland. Source: Sarah Jackson, Derval Igoe and Kate O’Donnell, Trends in sexually transmitted infections in Ireland, 1995 to 2012 (Dublin: Health Protection Surveillance Centre, 2013) 5. [click on diagram for larger version]
Figure 3. New HIV diagnoses in Ireland. Source: Annual Report 2012 Health Protection Surveillance Centre (Dublin: Health Protection Surveillance Centre, 2013). [click on diagram for larger version]
Figure 4. New HIV infections (per 100,000 living), Ireland and the EU. Source: European health for all database (HFA-DB) (Copenhagen: World Health Organization Regional Office for Europe, 2014). [click on diagram for larger version]
Might homophobia be operating in Ireland in the way identified in South Africa? Might this help explain the particular vulnerability of MSM in Ireland? We have some evidence that it might. One study of the factors that dissuaded young people from coming for Chlamydia testing, another STI particularly prevalent in Ireland, concluded that: ‘The most important barrier reported by young people to seeking or accepting a STI test was the stigma associated with chlamydia and other STIs. The fear of stigma was greater among young women, especially those from rural backgrounds and in urban working class settings, who feared the consequences of being publicly exposed through asking for a STI test.’[xii] In a study of how people responded to an HIV diagnosis, Patrick Murphy and David Hevey found that people who internalized social stigma were least likely to have made lifestyle and attitudinal changes that would be beneficial to them in staying well.[xiii] These changes might involve healthier eating, lesser use of alcohol, increased exercise, and adherence to anti-viral medication regimes. Internalised stigma follows from broadly accepting society’s designation of certain people living with HIV as having essentially brought the disease upon themselves by their guilty behaviour. Such people feel that perhaps they deserved the disease. Cormac O’Brien’s studies of the representation of gay men in Irish culture shows that HIV is generally shown as fatal to gay men, reinforcing the idea that within the logic of the drama, gay men deserve to die.[xiv] It would be relatively easy to reduce the stigma of an HIV diagnosis for MSM were there to be more prevalent media representations of people living with HIV and flourishing due to the medication that controls their viral load.
In their study, Murphy and Hevey found that internalized social stigma was more likely among MSM than among people who were infected by heterosexual sex, and in turn this same group were the least likely to have adopted healthier attitudes and behaviours. Important among these is treatment compliance. Treatment compliance lessens the likelihood of hospitalization and by lowering the viral load in a person’s blood reduces a person’s infectiousness. These are significant benefits and thus clinicians have a clear interest in helping people living with HIV to avoid the impress of social homophobia and society has a clear interest in addressing the toxic relations that so clearly harm infected individuals.
Why is homophobia so stubborn and pernicious in Ireland? Well, it certainly hasn’t helped that the agency that controls the majority of the schools in Ireland has repeatedly advocated that homosexuality is an objective evil. In 1986, the future Pope Benedict, then Joseph Ratzinger and Prefect of the Congregation for the Doctrine of the Faith, issued an instruction on the pastoral care of homosexual persons. He noted that in a document of 1975, authored by himself, it had been advised that homosexual acts, being sexual acts that would not result in conception were thereby ‘described as […] “intrinsically disordered”, and able in no case to be approved of.’[xv] But Ratzinger felt that in distinguishing between the homosexual condition and homosexual acts, he had perhaps encouraged ‘an overly benign interpretation [… of] the homosexual condition itself.’ In 1986, Ratzinger insisted that homosexual inclination ‘must itself be seen as an objective disorder.’ In one study of how homophobic bullying develops in schools, James O’Higgins-Norman asserts that: ‘Given the religious ethos of so many of Irish schools I would argue that for the most part Irish schools reproduce a great deal of the heteronormativity that is found in the churches and wider Irish society.’[xvi] Teachers wee found to be very aware of the Catholic ethos of the schools run by the Catholic Church and policed themselves so that they might not offend religious doctrine. More narrowly, teachers would never ‘try to promote a gay or lesbian way of life as a valid option among the students.’[xvii] Can a gay child become a sexually confident and emotionally mature adult in the face of such closeted silence or explicit hostility? Can bullying be addressed effectively when the lifestyle is stigmatized alike by bullies and by church doctrine? O’Higgins-Norman has serious doubts: ‘[C]onsidering the problematic nature of homosexuality as an issue within the Catholic Church and the Church’s role as the major patron of schooling in Ireland, it seems unlikely that it will be possible to deliver a programme on sex education that includes a positive approach to homosexuality as an acceptable way of life for some.’[xviii]
[i] Andrew Tucker, Jose Liht, Glenn de Swardt, Geoffrey Jobson, Kevin Rebe, James McIntyre and Helen Struthers, ‘Homophobic stigma, depression, self-efficacy and unprotected anal intercourse for peri-urban township men who have sex with men in Cape Town, South Africa: a cross-sectional association model,’ AIDS Care 26:7 (2014) 882-889. http://dx.doi.org/10.1080/09540121.2013.859652
[ii] ‘In Your Words: Experiencing homophobia in Ireland,’ TheJournal.ie (23 February 2014); http://www.thejournal.ie/homophobia-1329801-Feb2014/
[iii] Morag MacKay and Joanne Vincenten, National Action to Address Child Intentional Injury – 2014: Europe Summary (Birmingham: European Child Safety Alliance, 2014) 18; http://www.childsafetyeurope.org/archives/news/2014/info/ciir-report.pdf.
[iv] Paula Mayock, Audrey Bryan, Nicola Carr and Karl Kitching, Supporting LGBT Lives: A Study of the Mental Health and Well-being of Lesbian, Gay, Bisexual and Transgender People (Dublin: Children’s Research Centre, Trinity College Dublin, 2010); https://www.tcd.ie/childrensresearchcentre/assets/pdf/15th%20Anniversary/LGBT%20Lives%20Poster_CRC%20Anniversary%20Event.pdf.
[v] Cathy Kelleher, ‘Minority stress and health: Implications for lesbian, gay, bisexual, transgender, and questioning (LGBTQ) young people,’ Counselling Psychology Quarterly 22:4 (2009) 373-379; http://arrow.dit.ie/cgi/viewcontent.cgi?article=1031&context=aaschsslarts.
[vi] Stephen Minton, ‘Submission to: Consultation on tackling bullying in schools, Department of Education and Skills,’ 25 June 2012; https://www.education.ie/en/Press-Events/Conferences/cp_anti_bullying/Anti-Bullying-Forum-Submissions/anti_bully_sub_academic_dr_minton.pdf.
[vii] Kiran Sarma, ‘Recreational Drug Taking Among LGBT Young Adults in Ireland: Results of an Exploratory Study,’ Youth Studies Ireland 2:2 (2007) 35-49; http://youthstudiesireland.ie/index.php/ysi/article/view/22/22.
[viii] Sarah Jackson, Derval Igoe and Kate O’Donnell, Trends in sexually transmitted infections in Ireland, 1995 to 2012 (Dublin: Health Protection Surveillance Centre, 2013); http://www.hpsc.ie/A-Z/HIVSTIs/SexuallyTransmittedInfections/Publications/STIReports/TrendsinSTIs/File,14375,en.pdf.
[ix] Ibid., 16.
[x] Annual Report 2012 Health Protection Surveillance Centre (Dublin: Health Protection Surveillance Centre, 2013); http://www.hpsc.ie/AboutHPSC/AnnualReports/File,14421,en.pdf. The data for 2013 show a slight drop in the MSM numbers and share of new infections, HIV in Ireland. 2013 Report (Dublin: Health Protection Surveillance Centre, 2014),
[xii] Chlamydia Screening in Ireland Pilot Study. Policy Brief (Dublin: Royal College of Surgeons of Ireland, 2012) 1.
[xiii] Patrick J. Murphy and David Hevey, ‘The relationship between internalised HIV-related stigma and posttraumatic growth, AIDS and Behavior 17:5 (2013) 1809-1818: doi:http://dx.doi.org/10.1007/s10461-013-0482-4.
[xiv] Cormac O’Brien, ‘Performing Poz: Irish Theatre, HIV Stigma, and “Post-AIDS” Identities,’ Irish University Review 43:1 (2013) 74-85; http://www.euppublishing.com/doi/abs/10.3366/iur.2013.0056.
[xv] Joseph Ratzinger, Letter to the Bishops of the Catholic Church on the Pastoral Care of Homosexual Persons (Rome: Congregation for the Doctrine of the Faith, 1986); http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19861001_homosexual-persons_en.html.
[xvi] James O’Higgins-Norman, ‘Still catching up: Schools, sexual orientation and homophobia in Ireland,’ Sexuality & Culture 13 (2009) 1-16, 7; http://link.springer.com/article/10.1007%2Fs12119-008-9030-1.
[xvii] Ibid., 14.
[xviii] Ibid., 14-15.