Connecting The Dots: Male Sexual Abuse/Assault and HIV

by Rick Goodwin, MSW, RSW

In 2000-2001, I was commissioned by Health Canada to research and write a guidebook for counsellors working with men who have experienced childhood sexual abuse and/or adult sexual assault. I arranged a leave of absence from my agency to plow through the stacks of research articles and current analysis of HIV risk in regard to male survivors. Like many things in this business, a similar document had been created by Health Canada for women survivors (see: http://www.hc-sc.gc.ca/hppb/hiv_aids/you/sex_violence/index.html) - the first published document in the world on this topic.

Like many stories concerning government, the Male Sexual Abuse/Assault and HIV guidebook was never published. The final draft is no doubt sitting on a shelf somewhere, gathering dust. The reasons why were never truly articulated, and it remains today a sad story on issues of concern for male survivors. Given that gay men still constitute nearly 50% of all new infections in Canada, HIV prevention initiatives concerning the male population are still scant.

In preparing for this article, I am making many presumptions about you, the reader, and your knowledge base on male sexual abuse and male sexual assault (this is not an assumption I make at any workshop, however, our good editor will be governing this article with a word count cap). As we all know, it happens more than we think, and sexual abuse can take on many types of assault, from fondling to oral penetration to anal rape.

AIDS 101: WHAT ARE THE RISKS OF HIV TRANSMISSION?

I will also be brief about HIV/AIDS, and assume the knowledge base also exists in you, gentle reader. Suffice to say, unprotected sexual and drug use activities can put anyone at risk for HIV. Several factors must be considered when assessing risk. These factors include the following:

The behaviour involved - some sexual and drug use activities are higher risk than others.
How often the behaviour is repeated - repeated exposure to HIV can increase the risk of transmission.

In the case of sexual activities, other factors must also be considered:

The presence of open cuts, sores, burns, lesions and abrasions -- particularly to the anus, genitals or mouth -- which can provide a more efficient route for HIV transmission.
The presence of sexually transmitted diseases (STDs) can increase the likelihood of transmission of HIV. Persons infected with an STD are three to five time more likely than persons not infected to acquire HIV if exposed to the virus though sexual contact. A history of repeated STDs may also increase the risk of HIV infection.

WHAT ARE THE LINKS BETWEEN HIV AND MALE SEXUAL ABUSE/ASSAULT?

Okay, if you are still with me, I need to say that research on this connection is limited, complex, and only recently understood. Much of our knowledge in this field, as we know, has been based on research on women, not on men. As well, we know more about male sexual abuse (the term for those abused up to age 18), than male sexual assault (the term for men abused as adults).

Read this next sentence carefully: MSA/A can be both a cause and a consequence of HIV. The links can be defined as direct and indirect. To make sense out of this sentence, let's take the indirect connection first (where abuse causes risk behaviour). It looks kind of like this:

INDIRECT CONNECTION:

Sexual abuse => Post traumatic risk-taking behaviours => HIV infection

A general example of this would be a man, who was sexually abused as a child, engages in riskier sex as a consequence (e.g., intercourse without a condom) as a consequence, and by doing so, he gets infected.

Now compare this sequence to when HIV is a consequence of sexual abuse and assault:

DIRECT CONNECTION:

Sexual assault => HIV infection

A typical example of this connection that as a result of anal assault, the offender passes on HIV to his victim through the transfer of semen and mucosa to the victim.

POTENTIAL INDIRECT CONNECTIONS BETWEEN HIV AND MALE SEXUAL ABUSE

This section and the one that follows are titled "potential" connections because there is currently no research evidence proving that transmission occurs by either of the two connections. This being said, there is some anecdotal reports of such transmission, and to say that it is not yet evidenced in research is not to say it does not happen.

If we do look at the available research-based evidence, we do know many things. Compared to men who have not experienced sexual abuse as children, both gay and straight male survivors tend to have:

a greater number of sexual partners;
increased incidents of sex with someone they do not know;
initiated sex at an earlier age;
increased incidents of unprotected anal intercourse and other risky behaviour with steady and/or casual partners;
experienced more frequent use of sex clubs and/or bathhouses;
more self-reported incidents of "sexually compulsive" encounters;
a greater likelihood of having a sexual partner who has known HIV risk factors;
engaged more often in sexual activities with sex trade workers;
a greater likelihood of being under the influence of recreational drugs while engaging in sex;
a greater likelihood of injecting drugs and sharing needles;
a greater likelihood of working in the sex trade.

In reviewing this list, it is understood that these traits are known HIV risk activities, or are related to risk activities that can increase a man's vulnerability to HIV. Additionally, this list does not include post-traumatic stress symptoms like depression that may interfere with a survivor's ability to make healthy decisions in his life, including those related to sex.

POTENTIAL DIRECT CONNECTIONS BETWEEN HIV AND MALE SEXUAL ASSAULT

Just as we cannot prove that child abuse survivors have acquired HIV as a result of their childhood experience, there is no research that documents the rate of HIV transmission through sexual assault. Given that anal rape is the most common form of male sexual assault, we need to consider these risks seriously.

Given that both vaginal intercourse and anal intercourse without a condom are considered "high risk" sex (in Canada, there is no official recognition that anal intercourse without a condom is "riskier" than vaginal intercourse). Some researchers believe there could be up to a 10x greater likelihood in HIV transmission during anal sex given that significantly more micro-tissue damage occurs than in vaginal sex).

So let's now consider some of the factors associated with sexual assault that increases the risk:

Assuming the perpetrator(s) is HIV-positive, how infectious is he? The stage of HIV infection can increase infectiousness.
The type of sexual assault, i.e., anal penetration or oral penetration.
The victim has anal or oral contact with the perpetrator(s)' semen (cum), pre-ejaculatory fluid (pre-cum), or blood. The risk of HIV transmission is increased if the victim has cuts, sores, or burns in his mouth or anus prior to the assault.
The victim has injuries on his anus, genitals or mouth because of the assault. (One study concluded that two thirds of male victims have these injuries).
The victim suffers multiple assaults from one perpetrator or had multiple perpetrators.
Either the victim or the perpetrator(s) has a pre-existing STD, or a history of repeated STDs.

Some survivors of male sexual assault may also exhibit some of the same post-traumatic risk behaviours that have been documented with survivors of male sexual abuse.

AND SOME FURTHER CONCERNS…

As if the above is not worrying enough, in our work supporting male survivors of both child sexual abuse and adult sexual assault, there exists some further potential connections that are not even on the map in terms of research. Borrowing from some research about abused women, it could be surmised that in cases where a man is abused by his adult partner (e.g., a gay relationship), he may be sexually assaulted in this relationship; he may be unknowingly exposed to HIV through his partner's behaviour, or he may engage in post-traumatic behaviours related to the spousal abuse that lead to sexual risk-taking.

In another potential scenario (again, borrowing from feminist research), it could be that HIV+ men are at higher risk of being sexually assaulted. While the research on this has not been applied to men, some studies suggest that HIV+ women experience more sexual assault. We can understand this angle if we think that an HIV+ individual may stay in an abusive relationship longer than somebody who is HIV- (e.g., economic dependence, emotional vulnerability, physical limitations) or "places" himself in situations where he is at higher risk of assault (e.g., sex trade work).

SO WHERE DO WE GO FROM HERE:

That's hard to say. This accumulated knowledge is insufficient to formulate into safer sex public education messages to gay men or the broader men's community. As we know all too well, many of these behaviours are deep-seated, and require considerable therapeutic work for a survivor to articulate, let alone to change. It's a daunting task.

However, we must find ways of doing it. The AIDS movement and the male survivor movement have had very little overlap in either professional services or in grassroots activism. The AIDS movement has primarily focused on gay men (or as the debatable research term has it, "men who have sex with men"), while survivor work has been more inclusive in terms of men of different sexual orientations. As a movement, we need to affirm the common ground between us, while continuing to inform and instruct the powers that be on this troubling dynamic. If not, we will continue to loose our brothers.


TSO WEB

Tell Someone