11 len tooley representation cahr
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The document summarizes research analyzing the representation of men who have sex with men (MSM) in abstracts presented at the Canadian Association for HIV Research (CAHR) conferences from 2007-2011. The key findings were that only 7% of abstracts were exclusively about MSM, while 87% made no mention of MSM. A focused analysis of 2010-2011 abstracts found very few addressed specific MSM populations or their unique experiences. The research suggests current HIV research in Canada reflected at CAHR does not adequately represent or understand the diversity of MSM communities.
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11 len tooley representation cahr
- 1. Where are the gay men?! Representation of Men Who Have Sex With Men in CAHR Conference Abstracts: 2007-2011 Len Tooley Thursday, November 3rd, 2011 2011 BC Gay Men‟s Health Summit Vancouver, BC
- 2. Going to the CAHR Conference...
- 3. Gay/Bi/Queer/2-Spirit Men & HIV in Canada • “According to 2008 national estimates, sex between men may have accounted for the HIV infection of an estimated 33,360 MSM. This represents 51% of all people living with HIV.” • “Based on national HIV estimates...47% of all new cases of HIV in Canada in 2008 were in men who have sex with men.” Public Health Agency of Canada. HIV/AIDS Epi Updates, July 2010, Surveillance and Risk Assessment Division, Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, 2010.
- 4. MSM Global Forum Report: Coverage of Four Key Populations at AIDS 2010 • Quantified program coverage of MSM, people who use drugs, sex workers and transgender people • Revealed “a gross underrepresentation of MSMGF. (2010). Coverage of Four they key populations Key Populations at the 2010 International AIDS Conference (p. across the 2010 conference program” 25). Oakland, CA: MSMGF. Retrieved from http://www.msmgf.org
- 5. MSM Global Forum Report: Coverage of Four Key Populations at AIDS 2010 4.5% People who use drugs MSM 3.0% Sex Workers 2.6% 1.1% Transgender people “Program coverage of key populations at each IAC must seriously and respectfully reflect the epidemiological burden and on-the-ground needs”
- 6. If the MSMGF can do it...
- 7. • Held annually for the past 20 years • > 600 participants per year • Self-declared advocate for HIV research “The Voice of Canadian “The history of HIV/AIDS CAHR is Researchers” synonymous with the history of HIV Canadian Association for HIV Research. (2011). Mission - History. About CAHR. Retrieved from http://www.cahr- research in Canada” acrv.ca/about/vision-mission-history/
- 8. CAHR... • Resembles the scientific program of the International AIDS Conferences, though on a much smaller scale • Four disciplinary streams: • Basic Science • Clinical Science • Epidemiology • Public Health • Primarily oral and poster abstract presentations (~300/year) with satellite events, social events
- 9. So many questions... • How many abstracts (oral and poster) actually addressed/included gay/bi/MSM men? • Within those abstracts, what were the main topics addressed? • How were gay/bi/MSM men‟s populations portrayed?
- 10. Why do this research? • Without good-quality research, evidence- based practice is impossible • Underrepresentation can perpetuate and exacerbate injustices • In other words: it is unjust that gay/bi/MSM men suffer so heavily from HIV. Part of addressing that injustice is ensuring that there is enough high-quality research to direct our efforts. • To encourage discussion within the HIV sector, and among gay/bi/MSM men, about what we think research should look like • “Disciplinary reflection” or “taking stock”
- 11. What I did (Methods) • The Canadian Journal of Infectious Diseases & Medical Microbiology publishes all CAHR abstracts presented at CAHR conferences on-line. • 1,605 abstracts, representing all poster and oral presentations from five years of CAHR conferences (2007-2011) were reviewed.
- 12. Methods Cont’d... 1. Identified abstracts • Reviewed Abstract titles • Keyword searches
- 13. Methods Cont’d... 2. First Coding: Abstract Classification • Three tiers of representation/inclusion • Breakdown by conference stream • Terminology used Exclusive Abstracts Non-Exclusive Abstracts Demographic Mention
- 14. Methods Cont’d... 2. Second Coding: Exclusive Abstracts from CAHR 2010 & 2011 • Nvivo Qualitative Analysis Software • Description of sample characteristics • Methodological information • Major topics & themes
- 15. • Abstracts don‟t necessarily tell the whole story • CAHR is not necessarily completely reflective of all HIV/AIDS research in Canada
- 16. FINDINGS: The Numbers 87% 7% 3% 2%
- 17. Findings (Cont’d) Total Number Non- Demo- Year of Exclusive Exclusiv graphic No Mention n (%) e Mention n (%) Abstract n (%) n (%) s 2011 376 25 (7%) 13 (3%) 13 (3%) 321 (85%) 2010 284 20 (7%) 9 (3%) 7 (2%) 247 (87%) 2009 325 30 (9%) 8 (2%) 13 (4%) 272 (84%) 2008 305 29 (10%) 7 (2%) 5 (2%) 260 (85%) 2007 315 15 (5%) 4 (1%) 2 (1%) 292 (93%) Totals 1605 119 (7%) 41 (3%) 40 (2%) 1,392 (87%)
- 18. Of the 119 exclusive abstracts... • 2% (n = 2) were in the Basic Sciences • 7% (n = 8) in Clinical Sciences • 51% (n = 61) in Public Health Sciences • 40% (n = 48) Social Sciences
- 19. Terms used to describe populations of MSM Number of Abstracts Term % Using Term MSM 92 77 Gay 56 47 Bisexual 23 19 Homosexual 7 6 Trans 2 2
- 20. From the focused analysis... (CAHR 2010 & 2011) • 45 abstracts were reviewed in detail Frequency of Mention of Demographic Characteristics Demographic Characteristic n % Sexual Orientation 44 98 Age 17 38 Race/Ethnicity 13 29 Education 7 16 Income / Socio-economic Status 6 13 Place of birth 4 9 Rural/Urban 1 2
- 21. From the focused analysis... (CAHR 2010 & 2011) • Six abstracts (13%) exclusively focused on specific populations of MSM: • Latin-American MSM New Immigrants (2) • Asian MSM (1) 1.2% of all abstracts over 2 years • MSM Sex Workers (1) exclusively addressed • Young Black MSM (1) the population that comprises 51% of the • Ethno-Racial MSM (1) HIV epidemic. • 4 abstracts mentioned Aboriginal or Métis men, none exclusively • Eight abstracts focused exclusively on HIV-positive MSM • Three abstracts focused exclusively on HIV-negative MSM
- 22. From the focused analysis... (CAHR 2010 & 2011) • No abstracts mentioned: • East Asian MSM • Middle Eastern MSM • MSM labelled/living with disabilities • Refugee MSM • Queer trans men
- 23. From the focused analysis... (CAHR 2010 & 2011) • Thematic Analysis Thematic Area n % Individual risk behaviours 26 58 Strategies for prevention 16 36 Testing patterns 14 31 Factors explaining vulnerability to HIV 13 29 Environments 13 29 Contextual & social issues 10 22 Individual protective factors 7 16 Recommendations for moving forward 4 9 Other topics 3 7 Attitudes, Opinions, Beliefs 2 4 Service Provision 2 4 STI & HIV prevalence/incidence 1 2 Biology of HIV transmission 1 2 Strengths and resiliencies 1 2
- 24. Concluding Thoughts... • Based on the research reflected by CAHR, it is hard to imagine evidence-based holistic health promotion programs that approach gay/bi/MSM men as whole people with cultures, values, communities, families, professional lives, etc. • The dearth of complexity and volume in research among gay/bi/MSM men prevents a nuanced understanding of the dynamics of HIV, STIs and other health disparities in our lives and communities • We are a diverse group: we need research that reflects our diversity rather than blurs it.
- 25. Caveat • This is not necessarily a commentary on CAHR abstract selection. Many factors could be influencing these numbers: • Funding dollars, research priorities of academic institutions, interests of academics, a dearth of „actualized‟ gay men doing HIV-related research who are willing/able to advocate for increased MSM research
Editor's Notes
- This presentation is based on a field research paper I have been working on as part of my Masters in Public Health at the University of Toronto. I’d like to start by premising the presentation with the fact that it is a work in progress and to beg for forgiveness of any seriuos shortcomings!
- So, I will admit that this year I was lucky enough to attend my very first CAHR conference. In many ways I am new to gay men’s health in particular and am only starting to understand the political, academic, organizational and interpersonal complexities of the national HIV and gay men’s health movement. PREMISE with appreciation for the two decades of work that has been put into the CAHR conference, etc. I was amazed by the quantity and quality of Canadian research on HIV that is undertaken each year. <Click>There were may powerpoint presentations, <click> more presentations, <click> and lots and lots of posters. There were also some pretty swanky lunches, if you were open to sitting through a pharma presentations. But....I went there with a specific lens in mind: to seek out and absorb all of the research that had to do with gay/bi/MSM. In the end, I ended up asking myself...<click>Where are all the gays men!?!
- Now, I must admit, I was slightly biased by some of the statistics I have become very familiar with. For instance, <Read first quote>, gay/bi/MSM men represent around 51% of all people living with HIV....and 47% of new cases in 2008. So, I figured, it would stand to reason that this conference would be...well....pretty gay. But I didn’t leave feeling that way!
- One notable exception is a recent report produced by the Global Forum on MSM & HIV (MSMGF, 2010) that analyzed “every abstract and session programmed” (p. 1) of the 2010 International AIDS Conference (IAC) to quantify “program coverage of men who have sex with men (MSM), people who use drugs, sex workers and transgender people” (p. 1). The report distinguished between exclusive abstracts and sessions (an entire abstract or session focused solely on one key population), and non-exclusive abstracts and sessions (which focused on, or mentioned, two or more key populations). The analysis determined that a mere 2.6% of all sessions from the entire IAC program exclusively focused on MSM (MSMGF, 2010, p. 1). They note that this is significantly lower than the proportion of HIV infections comprised by MSM in most parts of the world, ranging from 25% in Latin America and the Caribbean to 76% in parts of south-eastern Europe (MSMGF, 2010, p. 3).
- Session = affiliatedevents, bridging sessions, commercial satellite, cultural activity, global village sessions, non-commercial satellites,plenary, special session, symposium, community skills development workshops, leadership and accountability developmentworkshops, and professional development workshops. Sessions also include panel presentations where multiple abstracts arepresented together.They note that this is significantly lower than the proportion of HIV infections comprised by MSM in most parts of the world, ranging from 25% in Latin America and the Caribbean to 76% in parts of south-eastern Europe (MSMGF, 2010, p. 3).ALL HIV professionals and health workers must possess the skills to effectively respond to the HIV prevention, treatment, care and support needs of these populations- As a premier venue, the IAC can seve as a vehicle for change; it has the potential to influence knowledge production, policy and advocacy strategies, donor responses, research foci, industry behaviour and political scenarios
- In other words....why do I feel so unsatisfied??
- Justice:I asked myself, with the majority of the burden of the HIV epidemic falling on the shoulders of gay/bi/MSM men, what is a just amount of research that is reflective?Without good quality research, evidence-based practice is impossible: underrepresentation can perpetuate and exacerbate injustices in research and FURTHER MARGINALIZE VULNERABLE POPULATIONSDeviance:Schiller, writing on the cultural constructino of AIDS in 1994, noted that just at a time when scholars had been questioning the association“at a time when many scholars had begun to question the equation of homosexuality with social deviance or psychiatric disorder, the intimate sexual activities of gay men again became objects for scientific scrutiny” While this was a logical, reasonable line of inquiry, over time it contributed to the “continued concentration on the ‘deviant’ sexual behaviors of gay men,” which served to “distance both AIDS and gay men from the oft referred to ‘general population’” Biomedical:A more worrying concern is the constant focus on, and conceptualization of, ‘high risk behaviours’ that put gay/bi/MSM ‘at risk’ for HIV which can easily translate into a discourse that blames individual men, and ‘MSM’ as a population, for their continued inability to halt the spread of HIV.Sex and Danger:Crossley(2002) and others (Carballo-Diéguez et al., 2011), for instance, explored how risk, excitement and challenging cultural norms are in many ways culturally imbued in gay sex by the very fact that in most social contexts gay sex continues to be shamed and stigmatized. In other words, if sex is often/always socially ‘dangerous,’ ‘dangerous’ might be construed as inherently sexy. HIV prevention initiatives that focus too much on unprotected sex, then, run the risk of moralizing protected sex and equating unprotected sex with socially deviant, ‘bad’ sexual behaviour (Crossley, 2002)
- First, I identified all abstracts that made any mention of gay/bi/queer/2-spirit and other MSM Once I identified these articles, I retained any that referred to gay/bi/MSM men in a Canadian context in any way.The only exception was articles that addressed other populations exclusively but made passing reference to how HIV/AIDS is often associated with MSM.
- First, I identified all abstracts that made any mention of gay/bi/queer/2-spirit and other MSM Once I identified these articles, I retained any that referred to gay/bi/MSM men in a Canadian context in any way.The only exception was articles that addressed other populations exclusively but made passing reference to how HIV/AIDS is often associated with MSM. Exclusive abstracts were those that focused solely on a gay/bi/MSM population within Canada. Non-exclusive abstracts were those that focused gay/bi/MSM in addition to one or more other key populations. In order to be classified as non-exclusive an abstract not only had to mention gay/bi/MSM as a focus population but also had to discuss gay/bi/MSM-specific findings and, ideally, the relevance of these findings to gay/bi/MSM populations. demographic mentionwere ones that listed gay/bi/MSM populations when reporting the demographic characteristics of their research but in no other way made any significant mention to gay/bi/MSM men, such as gay/bi/MSM-specific results or how the results were relevant to HIV treatment or prevention with gay/bi/MSM men.
- Used the General Inductive Approach as elaborated by Thomas (2006)
- Average of 24 abstracts, out of around 300, per year, exclusively addressed gay/bi/MSM men and their issues.
- Given the fact that MSM account for 51% of HIV prevalence within Canada, the stark fact that MSM were only mentioned in 13% of all CAHR abstracts over 5 years is arguably problematic. This dearth of content related to MSM within the conference effectively means that important aspects of gay/bi/MSM experiences, communities and specific populations are effectively ignored.
- This lack of acknowledgement is particularly troubling in the basic sciences stream, in which only two abstracts over five years of CAHR conferences refers to gay/bi/MSM men. Other populations – for instance a cohort of Punwami sex workers from Nairobi – are mentioned far more frequently. Further, given that gay/bi/MSM men account for over half of the HIV-positive people in Canada it is largely their bodies that are providing the tissue samples and life specimens on which experiments can be conducted. The total invisibility of the sacrifices HIV positive men who have sex with men have made for their community and the broader population of people living with HIV is unfortunate.
- Language used to describe populations of MSM is extremely important in determining who within the broad category of MSM is actually at high risk of contracting HIV. This influences decisions such as language used in outreach and advertising campaigns and what sorts of environments outreach are done in. For instance, if the majority of MSM becoming HIV positive do not identify as gay or bisexual then campaigns, ads and messages that use gay linguistic and cultural references may be distancing and ineffective. If, however, the MSM most at risk for HIV identify as gay, generalizing messages that do not reflect their identities or cultures may not be effective. This, in fact, may reflect the dominant cultural trend of heterosexist health promotion programs that effectively erase GLBT identities. Table 2 demonstrates that MSM were referred to as gay in slightly less than 50% of abstracts referring to gay/bi/MSM men. Among the abstracts that refer to gay or bisexual men the majority determined this by asking study participants how they identified their sexual orientation; however this information was rarely used as a category for structuring results. In this situation bisexual men are most strongly erased, only being mentioned at all in 19% of MSM-focused articles. Moreover, only one abstract actually reported on data relevant to bisexual men as distinct from gay men and other men who have sex with men.
- Authors were generally slack in reporting the demographic composition of their study populations however, with only one exception, none reflected on the generalizability or validity of their findings. Due to the challenges of conducting randomized studies among hard-to-reach populations such as gay/bi/MSM men, samples are often small and unrepresentative (Phillips et al., 2003). Failing to accurately describe the population about which results are being discussed, and neglecting to discuss the generalizability of findings, CAHR abstracts overly-generalize gay/bi/MSM men and fail to pick up nuanced yet often stark differences between gay/bi/MSM men’s lives, experiences, behaviours and socio-cultural realities. Further, given that generalizability and internal/external validity was only mentioned in one abstract of the 45 coded, there seems to be a disciplinary lack of recognition/reflection of the diversity of gay/bi/MSM populations and the challenges implicit (and explicit) in generalizing findings of a small, non-representative population onto an extremely diverse group of people.
- Emphasize that this is in two whole years of research on HIV in Canada, in 2010 and 2011.For example: in 2010/2011, only 8 abstracts specifically addressed HIV+ MSM. Considering this population makes up the most sizable portion of the HIV epidemic (51%) (Public Health Agency of Canada, 2010), the fact that they are exclusively addressed in only 1.2% of abstracts over two years is alarming. IS THIS ENOUGH????
- Emphasize that this is in two whole years of research on HIV in Canada, in 2010 and 2011. IS THIS ENOUGH????
- With respect to the thematic analysis, the majority of abstracts reviewed focused on individual-level analyses that evaluated gay/bi/MSM men’s behaviour and consequent susceptibility to HIV. Even those articles which contextualized gay/bi/MSM men’s ‘vulnerability’ to HIV/AIDS often linked higher-level socio-ecological factors with gay/bi/MSM’s likelihood of having unprotected anal intercourse. Taken as a distinct body of research this perpetuates an almost inappropriate focus on gay men’s sexual lives and stigmatizes and judges their sexual practices based on externally-presumed priorities. Other than one abstract which referred to intimacy and pleasure as risk factors for unprotected anal intercourse, none of the abstracts analyzed evaluated the experiences, values and priorities around sexuality from the lived perspectives of gay/bi/MSM men. Topics such as love, desire for connection, sexual pleasure, sense of community, relationship between identity and sex, were effectively ignored. This portrays gay men’s decisions and behaviours around sex and sexual practices as solely focused on HIV and STI transmission and constructs them as hypersexualized creatures whose sexuality is stripped of culture, value, emotion, and meaning. Very few articles addressed factors external to gay/bi/MSM that might influence HIV incidence and prevalence in these communities. One hopeful set of research was that conducted by a coalition of organization in Montreal around a project called SPOT which aims to enhance and increase HIV testing among gay/bi/MSM in Montreal’s gay community. Beyond these abstracts very few actually questioned how other professionals such as medical doctors, researchers, politicians, public health professionals, and health promoters have adequately (or inadequately) prioritized and addressed the unacceptable disproportionate representation of gay/bi/MSM men in the HIV epidemic.