HIV Endgame: How can we express vulnerability?

OHTNEngagement, HIV Endgame Conference, Men who Have Sex with Men, People who use Drugs, Prevention, Substance Use

Speaking at the HIV Endgame conference in November, 2016, David Stuart, of Dean Street Health, talks about the ways social networking apps such as Grindr have changed the sexual landscape for gay men, and how interventions can address topics such as vulnerability, communication, masculinity, and rejection.

Descriptive Transcript

The HIV Endgame conference logo appears. Titles read: David Stuart, How can we express vulnerability? David Stuart stands alone on the Endgame stage. On-screen graphics identify him as the Substance Use Lead at 56 Dean Street. Throughout his presentation, Stuart occasionally refers to slides that do not appear on screen.

David Stuart: These things like Grindr, and some of these other apps that gay men and others used for finding sex, really changed the way our patients and local populations are experiencing sexual well-being. Trying to commun — first of all being aware or understanding of their own sexual and emotional needs in the bedroom or in a relationship, and being able to communicate that on an app, with an avatar, with a limited number of characters, with no, sort of, facial bonding that happens when you connect with somebody in real life. And we’re finding they’re really, really struggling with that, and it was manifesting as sexual health problems, it was manifesting as rejections, racial rejections, masculine rejections, camp feminine rejections, body shaming rejections. It was a whole new world for a whole population of people, and they were really struggling with it. It was absolutely translating to poor sexual health.

Also, although HIV care was getting so much better, HIV prevention was getting way complicated. As I mentioned, we prescribed 800 PEP courses to our patients, so our populations very much know that PEP is available and an option for HIV prevention. They come in in high numbers for it. They also know, I think they’re coming to understand, that undetectable viral loads mean uninfectious, and they also — they all know that condoms that are an option, too. It doesn’t mean that — their being well informed doesn’t make it easier for them. Being well informed in some cases can make it much more complicated. Because, do you trust the person in bed with you that they are undetectable? Or is it just something they said on that app, in that very short introduction? Do you bring up that conversation?

So, I think, it’s just simply saying, although HIV care has been getting so much better, HIV prevention is getting really complicated. We’re asking our gay men to be so well informed on so many levels, with so many technologies and interventions, and medicines, and communication skills in these — in the bedrooms. We really needed to understand the kind of anxieties that our patients are experiencing out there, outside of the clinic, in their bedrooms, on their gay scenes. And, of course, scenes are changing, too.

Technology’s changing, taking it out of the traditional bar and club and making more online social networks, and communication skills about how to befriend, how to communicate our politics, our emotional needs, how to understand our emotional and sexual needs, and form relationships through communication skills that we learned online. And it’s a whole other — you know there is trolling and there is lots of — it’s a whole different world. And our changing scenes and, of course, cultural and societal homophobia are changing a lot over the last 30 years. And, of course, the AIDS epidemic of 30+ years that’s kind of traumatized this community.

So, we were less looking at the historical, geographical, economic, socio-economic, or these kind of factors. We were looking at the changing seasons of risk that our patients were experiencing just today, given modern-day trends. And, we thought, how do we protect them to be… or support them to be more resilient with all of these changes?

Just to give you some examples, one of our clinics is called Dean Street Express. It’s a very, very busy clinic, of course. So a nurse, a young nurse, she might be working, if she was working a double shift, she might see 20 to 30 gay men one after the other after the other in a double shift on one day. It’s a very busy clinic.

And as an example, the first guy might come in, and he might say, “Hi, I was at a sauna. I was doing loads of chems or drugs, having sex with loads of people, having a really good time. Well, I even passed out from some of the drugs for a few hours but there were still some people in the cubicle, but I think I had a good time. But I’ve got gonorrhea, I think. There’s something going on here. Give me medicine please.”

And the nurse’s thinking, “Goodness me, there’s so many things I want to talk about, here. Like, is this the kind of sex life that they wanted? Do they feel informed to acknowledge the risks that are happening there and navigate their way through them? Are drugs something they want to be doing? Are they well informed about the drugs? Was consent to sex an issue?” that she wanted to talk to about that patient in that situation, but, you know, there are 40 other people waiting outside and he is saying, “Please don’t judge my gay life. It happened last month, it’ll happen next month, too. I don’t know the names of these guys. Son’t judge me, just give me my medicine please.”

Next person coming in might be needing PEP and the nurse, again, wants to ask about the status of or infectiousness of the person involved in the possible transmission. “Is the person in the waiting room so we can find out?” And the patient will go, “Gosh, no. I don’t know the name. I might know the grinder name. Could have been one of ten guys. I need my PEP. Please don’t judge me. I did it three months ago, I’ll be needing PEP probably next month. Medicine please.” Next, next, next.

Okay, I’m exaggerating a little bit but it is a very high-risk group of people who aren’t acknowledging that they’re high-risk. People that we might be perceiving who have a poor sense of sexual well-being, but they don’t have any idea about it themselves. It’s just become a norm for so many of them. And how do we support these guys to be resilient through these changes that have become so normalized for a lot of them that they don’t even acknowledge that this is very poor sexual well-being.

Well we can’t just lecture them in the busy clinic. So, we thought, well, perhaps one of the best ways is really to support them with their cultural needs. One of them would be, certainly, app use support. And to give you another kind of example, this is the kind of — a lot of us in the room; I’m trying to look at the age of people out there, and a lot of them are kind of my age, but a lot of us do remember meeting people in a bar and having a 20-minute face to face drink with someone before the decision, the commitment, to have sex with someone happens. For a lot of our guys, the commitment happens on an app before they even get there, and that change of mind might not be very welcome.

Stuart refers to an image off camera.

This guy, for instance, I kind of like this guy, because you can all read, he’s masculine, which is good, I guess, he’s got manners — I like manners — he’s got morals — I like that too. He wants no weirdos. He says no drugs. Good, I like that this guy’s trying to communicate his boundaries; he doesn’t want to do drugs. No slags. I don’t even know what that means. He says no camp. He says no BB, no bareback, which is good; he’s also trying to communicate that he wants to use condoms. No scene queens, no one unemployed, no one over 35, and then he asks, “Is anyone left?”

Which for me is kind of an indicator of how difficult it is. It’s kind of — it’s an indictment of the times, I think. Now, this guy is trying to communicate his boundaries. He’s trying to be safe. He doesn’t want to use drugs. He wants to use condoms. But gosh, he’s doing it badly. He needs our help. Now, is he talking to his best mates about this? Is he talking to his lovers about this? Is he talking to his mum and dad or his big brother about this? Probably not. He’s only talking, we find, to us in clinic about it. And so, that comes with a huge responsibility to support that.

But it also raises the other issue — if they’re not talking to us about — if they’re not talking to each other, their lovers, their friends, their communities about their own sexual needs, emotional needs around sex and relationships, if it’s only us, that’s not good enough. That’s dreadful. How do we support our local populations to have a dialogue within their own communities around this?

And that gave birth to our Dean Street Wellbeing Program, which is really — we thought we wanted to hand the dialogue back to the communities. There had been this tradition of The Sexual Health Clinic — so, I’m going to say it again, the clap clinics — sort of, on one side of this huge gulf, which is usually the National Health Service — government services — sort of wagging their finger at the naughty gay men who have naughty bad sex all the time, spreading this disease. I know it’s not really like that. But it can be can be perceived that way. And on the other side of this gulf was the naughty gay men misbehaving. And the two were kind of not at ease with each other. That was kind of the climate that, when I started to work at Dean Street, that we were aware of.

If we did focus groups, we would invite the gay men to come into our building, and we would talk to them with our presentations and take some notes and send them away and make a decision about what they needed after they’d left the room. We would segregate HIV-positive people into groups and we would therapy them towards understanding them. Segregating them from the HIV-negative people or the newly diagnosed people, forgetting that out there in the real world the HIV-negative people and the HIV-positive people and those on PrEP and those who are undetectable are all talking to each other on Grindr and in real life about their needs. They’re not segregating themselves, it’s only us doing that.

So, we thought, well, we have to really support our local communities. What we were hearing is, a lot of the guys, the choice of gay scenes in many big cities around the world is places of intoxication, saunas, bars, nightclubs, places you do drugs, places to drink, and places to hook up or find sex. Now, I know a lot of cities have a lot more than that, but they’re the easiest things to find when a person goes to a big city, and in London, it just — it did seem the case that our scenes were places where guys could hook up, become intoxicated, and have a lot of fun, but not in environments where it was conducive to their well-being. And the only space they would come and talk about their sexual and emotional needs was to professionals like us. So, really it was starting all our our support groups.

And this is, I think, where I’m just going to give you some examples of some of those, some of the ones we do. But, hooking up online, as I mentioned before, communication skills, and workshops, so guys could communicate their vulnerability. My — I mean, if I wanted — if I had a Grindr profile — I don’t. Don’t go looking for me. — It would probably say I get nervous taking my clothes off with a complete stranger. I don’t want to be embarrassed to say that. I am vulnerable about my sexuality and I’m kind of proud of that. In fact, my vulnerability is one of the strongest, proudest, sexiest things about me. And I have boundaries about who I will go to bed with, because I need to protect this life and health and sanity that I’ve forged over the many decades. And one of those boundaries is I don’t go to bed with anyone unless they get that my vulnerability is one of those sexy things about me.

And I want — but if I’d said that on my Grindr profile I would get things like, “Butch up, dude” or “What site do you think you’re on?” Rejections. Which, fortunately, I can handle rejection quite well because I’ve been surrounded by an amazing health care profession and I’m lucky and I’m older. But not all of us are like that. In fact, a lot of us don’t have that kind of resilience. So we really want to support our communities to be able to manage the communication skills and rejections and everything that happens online to reflect on their sexual and emotional needs and communicate that the right way. Having profiles that reflect who they are and what they want. Not just stating what they don’t want.

Sober sex groups, again, led by the community, not led by us, not led by a therapist trying to change their behavior, just guys can come together and talk about sober sex. Forget that one. We’ve already talked about that, too. Other groups, Change of Scene, which happens every month with different topics. How to deal with Grindr and the racial rejections that happen on there and other rejections. Body image issues.

Discussion topics. We’ll get a porn star and a DJ and a club promoter to come and host a panel discussion about consent to sex when high on drugs. Something that a lot of our patients are experiencing. They’re not coming to us saying, “Help me, I was assaulted. Help me I was raped.” They were saying, “Yeah I was a bit unconscious and some people had sex with me. It’s my fault; I did too many drugs.” So, how do we talk about that as a community? And empower our local populations to talk about it amongst themselves rather than just educating them and therapying them after they’ve disclosed an assault.

And introducing our — I mentioned that the easiest thing to find are the bars and the clubs and the saunas and the sex clubs. There’s usually a gay chess club in every city. I know because I always look for one. I was greeted with those big chess pieces at the front, here, that was great. There’s also a gay Star Trek Club in most cities, too, I know that one because I go looking for them as well. But there’s usually a lot more for gay men to do if you just look a little bit harder. So we just wanted to make it not such a difficult find for our patients. So, we’ve got, we put an event together where we got kind of sexy charismatic representatives from all of them — I was the sexy charismatic guy from the Star Trek Club — and just to talk about all the other options there are for us to do in in our city or in cities.

Another thing that happened is a patient sent to me a picture — it wasn’t a patient. Just a person sent to me a picture — I didn’t know him — not this picture — a picture of two very sexy guys in leather harnesses injecting each other in a very intimate, sexy, hot fetish moment. And it was part of an exhibition he was hoping to do and he said, “David, I haven’t met you, but I kind of want your opinion. Is that wrong?”

I was like, “Goodness. It’s kind of fetishizing a very harmful activity, sexualizing it, and fetishizing it, and glamorizing it, even. If you can make 30 more of these pictures, we’ll put you in an art gallery and we’ll talk about the controversy of that with your community.” And we did, and it was one of the best events we did and it attracted not just gay communities to talk about the controversy of chems and sex and fetish and glamorization and risk with it amongst themselves — but it’s also also really helpful for clinicians to try to be involved in that dialogue, too.

We filmed some people — we didn’t film people having sex. The people went into a bedroom to have sex at — by their own choice and we waited outside. And, after they had sex, we interviewed them about the sex they just had. They still had that rosy glow of having just had sex, sort of beaming happy, and couldn’t stop touching each other. And we talked about the sex they had, and we did that twice.

One was to remind us that sex can be about intimacy, particularly in 2016, when it can be about casual hookups, risk, rejection, danger, camp shaming — all these other the kinds of things. That sex can be about intimacy and really sexy. It’s also really good for clinicians, too, who when someone catches gonorrhea for the second time this year, and a clinician thinks it’s because they had risky sex, to remind them that it’s also because they had great sex. Sometimes we catch diseases because we have great sex. It’s not just all about risk. So, these are — a lot of these services sort of function as both for the clinicians and for our communities.

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