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 Enhancing Sexual
Health, Self-Identity
and Wellbeing among
Men Who Have Sex
With Men
A GUIDE FOR PRACTITIONERS

RUSI JASPAL, PhD

Forewords by Professor Dame Glynis Breakwell and Dr Laura Waters
 Enhancing Sexual Health, Self-Identity and
Wellbeing among Men who have Sex with Men
of related interest

Counselling Skills for Working with Shame

Christiane Sanderson
ISBN 978 1 84905 562 8
eISBN 978 1 78450 001 6
Part of the Essential Skills for Counselling series

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ISBN 978 1 78592 741 6
eISBN 978 1 78450 481 6
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Morgan Potts
ISBN 978 1 78592 342 5
eISBN 978 1 78450 663 6

Counseling Transgender and Non-Binary Youth

The Essential Guide
Irwin Krieger
ISBN 978 1 78592 743 0
eISBN 978 1 78450 482 3

Improving Mental Health through Social Support

Building Positive and Empowering Relationships
Jonathan Leach
ISBN 978 1 84905 518 5
eISBN 978 0 85700 932 6

Queer Sex
A Trans and Non-Binary Guide to Intimacy, Pleasure and Relationships
Juno Roche
ISBN 978 1 78592 406 4
eISBN 978 1 78450 770 1
 Enhancing Sexual
Health, Self-Identity
and Wellbeing among
Men who have Sex
with Men
A GUIDE FOR PRACTITIONERS

RUSI JASPAL
Foreword by Professor Dame Glynis Breakwell
Foreword by Dr Laura Waters

Jessica Kingsley Publishers

London and Philadelphia
First published in 2018
by Jessica Kingsley Publishers
73 Collier Street
London N1 9BE, UK
and
400 Market Street, Suite 400
Philadelphia, PA 19106, USA
www.jkp.com
Copyright © Rusi Jaspal 2018
Foreword copyright © Glynis Breakwell 2018
Foreword copyright © Laura Waters 2018
All rights reserved. No part of this publication may be reproduced in any material form
(including photocopying, storing in any medium by electronic means or transmitting) without
the written permission of the copyright owner except in accordance with the provisions
of the law or under terms of a licence issued in the UK by the Copyright Licensing
Agency Ltd. www.cla.co.uk or in overseas territories by the relevant reproduction rights
organisation, for details see www.ifrro.org. Applications for the copyright owner’s written
permission to reproduce any part of this publication should be addressed to the publisher.
Warning: The doing of an unauthorised act in relation to a copyright work
may result in both a civil claim for damages and criminal prosecution.
Library of Congress Cataloging in Publication Data
A CIP catalog record for this book is available from the Library of Congress
British Library Cataloguing in Publication Data
A CIP catalogue record for this book is available from the British Library
ISBN 978 1 78592 322 7
eISBN 978 1 78450 636 0
 Contents

Foreword by Professor Dame Glynis Breakwell . . . . . . . . . 7

Foreword by Dr Laura Waters . . . . . . . . . . . . . . . . 11
Acknowledgements . . . . . . . . . . . . . . . . . . . . . 15

Part I: Introduction
1. Social Psychology for Practitioners in
Sexual Health and Wellbeing . . . . . . . . . . . . . . . 19

Part II: Theory and Research

2. Self-Identity, Psychological Wellbeing and
Sexual Health among MSM. . . . . . . . . . . . . . . . 35
3. Social Psychological Approaches to
Promoting Health and Wellbeing . . . . . . . . . . . . . 61
4. Identity Process Theory: Social Representation,
Identity and Action . . . . . . . . . . . . . . . . . . . . 85

Part III: Practice

5. Promoting Psychological Wellbeing among MSM . . . . 117
6. Developing Effective Sexual Health
Interventions for MSM . . . . . . . . . . . . . . . . . . 139
7. Integrating Tenets of Identity Theory into HIV Medicine 161
Part IV: Conclusion
8. Integrating Theory into Practice . . . . . . . . . . . . . 185

References . . . . . . . . . . . . . . . . . . . . . . . . . 197
Subject Index . . . . . . . . . . . . . . . . . . . . . . . . 209
Author Index . . . . . . . . . . . . . . . . . . . . . . . . 213
About the Author . . . . . . . . . . . . . . . . . . . . . . 215
 Foreword
Professor Dame Glynis Breakwell

This book is about the role of identity processes in shaping the

sexual health and wellbeing of men who have sex with men
(MSM). It explores the complex reasons, rooted in culture and
context, which underlie behaviours that might be misunderstood
by observers or simplistically labelled reckless or self-harming. This
is a book addressed to practitioners working to support the health
and wellbeing of MSM. The book seeks to equip practitioners with
methods derived from social psychological theories for explaining
the behaviour of individuals, groups and communities who are at risk
and who are asking for support. It argues that, used systematically and
with common sense, these methods will enhance the effectiveness of
the support that practitioners can offer and may result in enduring
change for those in need of help.
Readers should be warned this is not a book that offers simple
recipes for action by practitioners. It offers no ‘one size fits all’ mantras
or solutions. It does not strip down the social psychological theories
that it presents to their bare skeletons in order to make them palatable.
The introductions it offers of these theories are accurate and cover what
is necessary to make them really useful to an experienced practitioner.
Getting the best out of this book requires readers to reflect on their
own practice and think through how they would have intervened
differently in some of their past cases if they had used the methods
suggested by Jaspal.
The book does not restrict itself to solely discussing social
psychological models for practitioner intervention, the succinct
summaries of current biomedical methods are also useful. However,
Jaspal, not surprisingly given his eminence as a social psychological
theorist, is particularly effective in describing the sources of stress

7
8 Enhancing Sexual Health, Self-Identity and Wellbeing among MSM

experienced by MSM and the nature of the threats to identity that

they generate. He uses identity process theory (IPT) extensively in
this analysis. When I originally proposed the theory in the 1980s
it was primarily as a way of understanding how people develop and
deploy coping strategies when they are faced with a threat to their
identity. Strangely, most researchers who have used IPT have been
concerned with testing the model of identity structure and principles
that it proposes. They have not focused on the analysis that it offers of
the coping strategies that people use when threatened. In this book,
Jaspal has used that analysis of coping strategies in a way that few other
theorists attempted to do. For that I am personally grateful. It is about
time that the emphasis turned to thinking about coping strategies.
Without doubt, understanding and anticipating coping strategies is of
prime importance to practitioners.
An essential ingredient in understanding coping strategies is to
recognise that they can be very complex. They can reside in cognitive
or emotional responses in the individual and they can be vested in
the dynamic interactions between individuals and within and across
groups in a community. This is probably why Jaspal argues that
interventions to support people who face threats to identity should
not always be individualised. His proposal that social representations
theory can be used in concert with IPT to understand how sexual
health and wellbeing among MSM might be enhanced is founded
upon the argument that interventions can be better targeted if they
take account of the communities in which the individual lives.
Jaspal recognises the importance of communities in moderating the
impact of practitioners’ interventions. He encourages practitioners to
understand how those communities can be brought to bear upon the
enhancement of interventions. One interesting exemplar he uses is
the role of virtual, internet-based communities in the creation and
maintenance of identity for MSM. Identity in these cases is embedded
in an extended community which is digital – a community which can
be both a source of threat and of coping.
The approach towards the enhancement of sexual health and
wellbeing suggested in this book is not only relevant to MSM. It is
an approach which can inform any practitioner who is attempting to
understand how to help any person facing identity threat. Threats
to identity come in many, many forms - from physical injury to
memory loss or from social stigmatisation to job loss. The lessons
 Foreword by Professor Dame Glynis Breakwell 9

to be learned from this book are relevant to many contexts. A person’s

identity is a dynamic, evolving system – being created over a lifetime.
Supporting and channelling that evolution is often a most valuable
task of a practitioner.

Glynis Breakwell
January 2018
 Foreword
Dr Laura Waters

As a clinician working in sexual health and HIV, the disproportionate

impact of sexually transmitted infections (STIs) on MSM, particularly
from Black and Minority Ethnic (BME) communities, is an issue I face
daily. Public Health England’s 2017 report highlighted that MSM and
BME groups, along with young heterosexuals, experience the greatest
impact of STIs. MSM form a small proportion of the UK population,
yet account for the majority of syphilis and gonorrhoea cases. 2016
syphilis figures showed the highest rates of infection since 1949, and
almost doubling since just 2012, mostly in MSM. This yielded many
headlines. The same report illustrated the highest population STI rates
amongst Black individuals, particularly those of Caribbean origin,
and attributed this to a “complex interplay of cultural, socio-economic
and behavioural factors”. Recent years have seen outbreaks of other
STIs in MSM including the enteric infections Shigella and hepatitis A,
the latter compounded by shortages of hepatitis A vaccine. Yet there
was also some good news. The “undetectable =untransmissible” or
“U=U” message, that is, individuals taking HIV drugs that render
the virus undetectable on a sustained basis cannot transmit HIV to
their sexual partners, really gained hold with even the Centres for
Disease Control and Prevention (CDC) in the US supporting the
message. Additionally, dramatic declines in new HIV diagnoses in
MSM in England highlighted that better testing, earlier HIV treatment
and targeted prevention (including PrEP) provide us with the tools
to ultimately stop new HIV infections. However, eradication of HIV
can be achieved only by diagnosing the 13% of people currently
living with undiagnosed HIV in the UK. Barriers to testing related to
ethnicity and self-identified sexuality are significant.

11
12 Enhancing Sexual Health, Self-Identity and Wellbeing among MSM

Having admired the work of Professor Jaspal on sexual risk-taking

and the experiences of people living with HIV, and his awareness-
raising related to the issues faced by BME MSM, it was an honour
to be asked to write a foreword for this book! His publication on
polarised press reporting related to HIV pre-exposure prophylaxis
(PrEP) was particularly pertinent to someone who spent many months
contributing to a subsequently abandoned NHS England policy – an
unfortunate triumph of fear of risk (and spending) over hope. I hope
the PrEP Impact trial, borne of the original policy, will answer some
of the ongoing questions related to PrEP use in BME communities.
This book describes, in an eloquent and approachable manner, the
relationships between identity, sexual risk and wellbeing. The three
cases summarised in Part 1 will be all too familiar to professionals
engaged in sexual health care and STI prevention. As a doctor well
versed in biomedical aspects of our specialty, this book was a sobering
reminder that my knowledge and use of psychosocial questioning is
limited. Part 2 highlights the psychological impact of social stressors,
particularly the section on homonegativity, and, in the same chapter, a
description of potential benefits of geospatial apps (so often associated
with negative STI and drug use connotations) related to sexual
identity and negotiation of condom use. The summary of counselling
psychology was highly informative and the author’s linking of
different approaches back to the Chapter 1 cases particularly helpful.
Similarly, the linkage of the section on theories of behaviour change
to the same three cases puts the three models in a context that, for me,
rendered the descriptions far more meaningful. Having established
the importance of psychosocial factors with regards to MSM sexual
health outcomes, identity and wellbeing, Chapter 4 describes social
and identity theories and, crucially, the relevance to sexual health
practitioners; I was inspired by the benefits of intergroup strategies,
particularly as my local service uses a group work model for sexual
dysfunction, coping with an HIV diagnosis and risk-reduction for
people with hepatitis C. Finally, Part 3 describes practice. In Chapter 5
we learn about promotion of psychological wellbeing through two
case studies: self-identity in British Pakistani Muslim MSM (I found
‘religious representations of sexuality’ particularly enlightening)
and the psychosocial challenges surrounding a new HIV diagnosis
(especially the evidence-based reminder about stigma). Chapter 6
uses more case studies to describe the development of effective sexual
 Foreword by Dr Laura Waters 13

health interventions including a sauna project in Leicester and the

‘Selfie’ project, part of Public Health England’s BME MSM project.
Finally, Chapter 7 outlines how HIV practice can be enhanced by
identity theory, focusing on PrEP and HIV medication adherence;
the latter topic was a real wake-up for me that the advances in HIV
drugs do not necessarily negate the barriers patients experience when
expected to take the medication daily. Each chapter in Part 3 ends with
a must-read section on ‘implications for practitioners’, with important
lessons that I intend to incorporate in my teaching and my practice.
As we struggle with rising rates of some STIs, it is our duty to
ensure our increasingly limited resources are utilised effectively, and
herein lies that evidence and how we can use this to best optimise
our interventions. This book summarises a wealth of evidence and
examples into a highly informative, even essential, read for all working
with MSM.
In England, recent years have seen marked reductions in public
health spending with a direct impact on sexual health services
including clinic closures. 2018 sees the launch of online STI services
and it remains to be seen how well these address not just disease
detection and management, but also tailored sexual health promotion
and risk reduction advice. However, despite the challenges we face,
I am proud to be part of a committed and multi-disciplinary specialty
and will be recommending this book to the doctors, nurses, support
staff, psychologists, health advisors, outreach workers, epidemiologists
and researchers who do so much to improve the sexual wellbeing of
MSM. I will end by suggesting that this book is also an essential read
for the commissioners who have to decide how best to spend their
constrained sexual health funds. Cutting psychosocial support and
access to interventions may seem a quick-win from a spending regard
but without understanding, and addressing, the drivers of poor sexual
health this may ultimately prove the falsest of economies.

Laura Waters
January 2018
 Acknowledgements

This book is the culmination of numerous research projects exploring

self-identity, wellbeing and sexual health among men who have sex
with men (MSM). I am grateful to my co-workers and PhD students
over the years who have contributed to these projects and without
whom the research described in this book would never have come
to fruition. I thank my PhD students Zaqia Rehman and Sebastian
Cordoba for their insightful comments on my original musings in
relation to this book. I am particularly thankful to Periklis Papaloukas
who worked as a research assistant on the Public Health England-
funded projects outlined in Chapter 6, to Dr Joann Griffith who
has been a constant source of valuable insight into the counselling
psychology models described in Chapter 3, and to Dr Barbara Lopes
whose clinical psychological expertise has been invaluable. This book
has benefitted enormously from Dr Jake Bayley’s meticulous and
constructive feedback, especially on Chapter 2, as well as his rigorous
critical evaluation of the role that social sciences research can play in HIV
medicine. I acknowledge the input of Professor Julie Fish and Dr Iain
Williamson, both of De Montfort University, who collaborated with me
on the Black and Minority Ethnic MSM Project, which is discussed in
Chapter 6. This book has indirectly benefitted from discussions with
fellow members of the Medical Board of NAZ Project London. I should
like to acknowledge the input of Tanya Edwards, my former personal
assistant, who provided impeccable administrative support during the
composition of this book and indeed the research projects that preceded
it. I am very grateful to De Montfort University (UK) and Åbo Akademi
University (Finland), my two academic homes, for providing stimulating
research environments for my scholarly activities. Finally, I would like
to thank Babak Hessamian, not only for his love, encouragement and
unwavering support in everything that I do, but also for his unremitting
patience with me during the writing of this and other books.

15
 Part I

INTRODUCTION
 Chapter 1

Social Psychology for

Practitioners in Sexual
Health and Wellbeing

Gay, bisexual and other men who have sex with men (MSM) can face a
series of psychosocial challenges during the life course. Some of these
challenges are transient and short-lived, while others persist over time.
Some are societal in nature, while others are psychological in origin.
Individuals may encounter homophobia, stigma, and rejection from
others. They may perceive aspects of identity (such as their sexual
orientation) to be problematic, internalise stigma, and experience
feelings of low self-worth, guilt and shame. The antecedents of these
social and psychological challenges are multifarious and include
the presence of particular stereotypes, images and representations
in our social context, as well as specific past experiences that shape
our perspectives on our identities and the world around us. The con-
sequences of these social and psychological challenges can be similarly
far-reaching and impinge on various dimensions of our lives, not least
on sexual health and psychological wellbeing. Some individuals may
come to experience shame, anxiety and depression, and engage in
behaviours that can put their sexual health at risk.
The tripartite relationship between sexual health, self-identity
and wellbeing constitutes the focus of this volume. The inter-relations
between these three components will be outlined and discussed in the
chapters that follow. The following three cases illustrate and exemplify
the social and psychological challenges faced by MSM, as well as the
ways in which wellbeing and sexual health may be affected:

19
20 Enhancing Sexual Health, Self-Identity and Wellbeing among MSM

Case 1: Mark, an HIV-negative gay man

Mark is a 27-year-old gay man who has recently moved from
a small town in Derbyshire to London, having completed his
studies. When he arrived in London six months ago, Mark
immediately took full advantage of his new life in the capital
and was keen to make new friends, to socialise and to explore
the gay scene in London. He rented a flat with three other
gay friends in an area with a large gay population. Given
that his hometown in Derbyshire did not have any gay bars
or clubs, he was particularly excited about exploring the gay
scene in London and was sure that he would enjoy it. Mark
downloaded Grindr1 on his phone and was delighted to see
that there were so many gay men in his neighbourhood. He
compared this to his experience of being gay in Derbyshire,
which had felt very lonely, and now felt elated to be in such
a gay-friendly city. Each time he opened Grindr on his phone,
he was propositioned by attractive gay men and ended up
meeting two or three new guys a week. He liked the fact that
there were so many guys on the application and he felt that he
was making up for the disappointing sex life he had had in his
home town. Mark also discovered that there were two gay
saunas in his area, which he began to frequent in order to meet
sexual partners. He had never had so much sex before. Mark
knew about HIV and that people could catch it from not using
a condom. However, given that the guys he was meeting did
not ‘appear’ to have HIV, he did not see himself as being at
risk. Although he had condoms at home, sometimes he did
not bother using them, especially if condom use was not
suggested by his sexual partners. On one occasion, he was
invited to a chemsex2 party in his neighbourhood. Although
slightly nervous at first, Mark went along to see what it was like.
Most of the guys at the party were taking drugs and eventually
Mark was offered drugs too and accepted. Suddenly, he felt
an enormous bout of confidence and felt able to approach

1 Grindr is a gay geospatial mobile social networking application (see detailed overview
in Chapter 2).
2 The term ‘chemsex’ refers to the use of psychoactive drugs in sexualised settings
(see detailed overview in Chapter 2).
 Social Psychology for Practitioners in Sexual Health and Wellbeing 21

guys that he found attractive. He greatly enjoyed the sex he

had that night. Since that night, Mark has regularly attended
chemsex parties, and no longer enjoys sober sex as much.
These days Mark goes to parties almost every weekend and,
while it was just a bit of fun at the beginning, now it feels as if it
is taking over his life. He no longer feels as able to concentrate
on other things in his life, like his friends, his job and his new
boyfriend. Many of the people who matter to Mark seem to
be distancing themselves from him and he feels increasingly
lonely. Recently, Mark noticed a white sore around his anus
and booked an appointment with his doctor who diagnosed
him with both syphilis and rectal gonorrhoea. Though he
tested negative for HIV, the doctor informed him that he was
at high risk of infection. This has made Mark reflect on his
life in London. He realises that he does not really enjoy the
casual sexual encounters he has been having and that he often
regrets them afterwards. He feels fearful of getting HIV as he
now realises that he is at significant risk. Mark wants to make
some changes in his life but does not know where to begin.
It feels as if a lot of things need to change but Mark wonders
what his life will be like if he makes these changes.

Case 2: Ahmed, a British Muslim gay man

Ahmed is a 25-year-old British Pakistani Muslim gay man.
He grew up in a conservative Muslim family in a large
Pakistani community in inner-city Bradford. Most of his
neighbours, family friends and school friends were, like him, of
Pakistani background, and he had almost no friends of other
ethnic backgrounds. From a very early age, Ahmed realised
that he was attracted to men but did not understand why
he felt this way and what this meant. He felt abnormal and
ashamed of himself and initially tried to fight his same-sex
attraction. When Ahmed went to the mosque and began to
read the Koran, he came to believe that his feelings were sinful
and that he must attempt to change them. As a teenager, he
convinced himself that his feelings were transient and that he
would eventually change and become heterosexual. At school,
other boys would tease Ahmed and call him gay because he
22 Enhancing Sexual Health, Self-Identity and Wellbeing among MSM

did not like to play football and because most of his friends
were girls. These early experiences of teasing and bullying
caused Ahmed immense psychological distress and made him
feel inadequate. He became withdrawn at school and in other
contexts. After a while, rumours began to circulate about
Ahmed’s sexual orientation and soon several of his classmates
joined in and bullied him. Some even threatened him with
physical violence. These experiences, coupled with his early
belief that homosexuality was sinful, led Ahmed to believe
that he was right all along – that being gay was a terrible thing
and that the bullies were in fact right to treat him as they did.
Ahmed tried to immerse himself in religion as a means of
distancing himself from his sexual orientation but, as he got
older, he found it increasingly difficult to resist sexual urges. He
watched gay porn online but always felt awful about himself
afterwards – this made him feel confused, guilty and dirty. He
downloaded Grindr on his smart phone and began to meet
up with guys for sex. These experiences too contributed to
his sense of low self-worth and perceived immorality. One of
the men he met on Grindr invited him to a gay club in London.
Ahmed felt uneasy about going to a club where he might
be recognised and ‘outed’ to other people, but decided to
take the risk and accepted the invitation. In the club he felt
immensely uncomfortable and at times even feared that God
would deliver some form of divine punishment to him for
being in that environment. Now that Ahmed has completed his
degree at the University of Bradford, his parents have begun
to discuss arranged marriage and to introduce him to potential
spouses – the daughters of relatives and family friends. This
has made him feel very anxious and conflicted. On the one
hand, he knows he feels no attraction to women but, on the
other hand, he believes that an arranged marriage could be an
effective ‘distraction’ from his gay lifestyle. Sometimes Ahmed
refuses to discuss marriage with his parents, which has caused
them to become suspicious. Ahmed in turn is fearful of the
consequences – both for himself and for his family’s reputation
– if people in his community find out that he is gay. Ahmed
is feeling increasingly depressed, anxious and helpless. He
cannot imagine having a relationship with another man, even
 Social Psychology for Practitioners in Sexual Health and Wellbeing 23

though deep down he would like to. The idea of a relationship

scares him so he just meets other guys for sex. Ahmed’s use of
Grindr has increased significantly and he is now meeting more
and more guys for casual sex. He does not really understand
why he is doing this.

Case 3: Juan, a gay man living with HIV

Juan is a 33-year-old gay man from Spain. He was diagnosed
with HIV at a gay men’s health charity in his hometown during
the summer of 2014. As he did not view his sexual behaviour
as risky, Juan expected to receive a negative test result and
was thus shocked to learn that he was in fact HIV-positive.
The gay men’s health charity referred Juan to the local hospital
to confirm the reactive test result. Although his CD4 count
was still relatively high, Juan requested to initiate antiretroviral
therapy (ART) immediately. Still shocked at his diagnosis, Juan
viewed his medication as an unfortunate daily reminder of
his HIV infection. Moreover, days after initiating treatment,
Juan began to experience negative physical side effects. He
discussed his side effects with one of the doctors at the clinic,
who was dismissive and unhelpful. The doctor appeared to
be suggesting that this is what life with HIV is like and that
Juan should simply get used to it. Juan felt that the doctor was
unsympathetic towards him because he was gay and living with
HIV. This situation was further complicated by the fact that
Juan had a very difficult relationship with his family. As a child,
he suffered sexual abuse, and he felt let-down by his parents
who never acknowledged this. He felt unable to disclose his
HIV status to his family, with whom he was living at the time
of his diagnosis. In fact, given his strict Catholic upbringing,
he also felt unable to come out as gay and, thus, he felt that he
had to conceal both his sexual identity and his HIV status from
significant others. This made him resent his parents. Although
Juan did have a small group of HIV-positive friends from whom
he derived some social support, he viewed himself as different
from them and implicitly stigmatised his own friends, whom
he regarded as responsible for their infection. A year after his
diagnosis, Juan decided to move to London to distance himself
24 Enhancing Sexual Health, Self-Identity and Wellbeing among MSM

from his family and in order to ‘be himself ’. However, he felt

lonely in London. Concerned about his declining health, Juan
registered as a patient at his local sexual health clinic. His HIV
consultant advised him to initiate ART immediately, reassuring
him that he would be well looked after and that any side effects
would be dealt with. However, Juan, still distrustful of medical
professionals following his experience in Spain, initially refused
treatment. This posed a dilemma for him because, on the one
hand, he was well aware of his poor disease prognosis in the
absence of medication but, on the other hand, he did not
wish to think about his HIV infection and feared further side
effects and indifference from his medical team. In view of a
significant drop in his CD4 count, Juan reluctantly began ART.
With his new drug regimen, he experienced no physical side
effects but did continue to experience psychological adversity,
including loneliness, depression and shame. Juan decided
not to attend support groups, partly because he did not wish
to disclose his HIV status to others and because he did not
think he would have anything in common with other support
group attendees. Indeed, he continued to deny that he had
engaged in sexual risk behaviours in an attempt to differentiate
himself from others living with HIV. As Juan’s mental health has
begun to deteriorate, he is missing doses of his medication,
which has increased the risk of drug resistance and of onward
HIV transmission to his sexual partners. He finds it difficult to
discuss these issues with his doctor and has also started
to miss appointments. To deal with his feelings of loneliness,
Juan is meeting sexual partners online and in gay bars. After
facing rejection from potential sexual partners to whom he has
disclosed his HIV status, he feels more ashamed and distressed
about being HIV-positive. He has started to attend chemsex
parties in London because nobody asks him his status there,
allowing him to forget about HIV and to experience a sense
of connection and intimacy with other men. Juan now has a
detectable viral load but is not consistently using condoms
with sexual partners of unknown HIV status.

This is not a book about chemsex in London, difficulties in adju-

sting to an HIV diagnosis among Spanish gay men, or the potential
 Social Psychology for Practitioners in Sexual Health and Wellbeing 25

incompatibilities between religion and homosexuality among British

Muslim gay men per se. Rather, this book is about the things that these
cases have in common, namely the role of identity in determining
sexual health and wellbeing outcomes among MSM. The cases
allude to changes in personal and social circumstances, the desire
to gain and maintain a sense of control and competence in complex
situations, and the impact that events and circumstances can have
on one’s sense of self-worth. They demonstrate that the reasons
underlying behaviours that some observers may perceive to be reckless
and irresponsible actually have more complex underpinnings that are
rooted in culture, context and identity. They emphasise the impact that
self-identity and sexual health can have for psychological wellbeing.
The cases also raise a series of challenging questions among
practitioners who may work with the individuals described in them.
How can HIV risk and HIV prevention be communicated to Mark in
a way that will lead to effective and enduring behaviour change? How
can he be supported to disengage from chemsex in a way that does
not stigmatise him and that does not disrupt his life narrative? Why
is Ahmed experiencing such distress in relation to being Muslim and
gay? Why does he not just distance himself from his religion if this
is deemed to be incompatible with his sexual orientation? Why does
he appear to be taking more sexual risks now that he has problems
at home? Despite his knowledge of HIV and of the effectiveness of
ART, why is Juan so reluctant to initiate and to adhere to ART? Why
does he actively avoid other people living with HIV? How can he
be retained in HIV care? More generally, how can practitioners be
better equipped to support Mark, Ahmed and Juan with their sexual
health and wellbeing needs? The overarching aim of this volume
is to draw attention to these challenging questions and to equip
practitioners with the social psychological tools for understanding
the tripartite relationship between self-identity, sexual health and
wellbeing; for developing effective clinical practice cognisant of this
tripartite relationship; and for constructing theory-driven public health
interventions. A central thesis of this volume is that a combination of
both individual and public health interventions is required in order
to address the aforementioned questions and to enact effective and
enduring change in patients.
In view of the multi-level nature of this project – focusing on
both individual health and public health – social psychology seems
26 Enhancing Sexual Health, Self-Identity and Wellbeing among MSM

the ideal starting-point. Social psychology is essentially the study of

how the individual interacts with the social world – the individual’s
cognition, emotion and behaviour is understood to be shaped by
the social world (Jaspal and Breakwell 2014). Social psychology
thus focuses on individual cognition, social influence processes,
relationships with others and how people think, feel and behave as
group members. Social psychologists have a long-standing interest in
solving problems. They tend to favour methodological approaches,
such as experiments and interviews, to understand the ways in which
people think and behave and, crucially, to try to predict how people
will think and behave in particular contexts. Description is important
because it enables us to understand the past and present, but prediction
is equally as important because it enables us to foresee, with varying
degrees of accuracy, future events. While some social psychological
theories describe, others predict.
Given that the description and prediction of attitudes and
behaviour have constituted the principal focus of social psychology,
it is easy to see why social psychologists have made such important
contributions to the field of sexual health, self-identity and wellbeing
among MSM. After all, if one can understand how and why people
have engaged in risk behaviours in the past, one is better positioned
to develop individual and public health interventions for preventing
these behaviours in the future. For instance, Juan (Case 3) is clearly
experiencing significant psychosocial challenges in relation to his
HIV diagnosis, due in part to social stigma in Spain, his religious
background which he perceives to be homonegative, and fears of
rejection from sexual partners. These issues appear to be associated
with his decreased self-care and increased engagement in sexual
risk-taking behaviours. Furthermore, his poor experience of HIV care
seems to be related to his current disengagement from services. In
short, by understanding some of these psychosocial issues, practitioners
may be able to tailor HIV care in ways that acknowledge them and,
thus, maximise the likelihood of access to and retention in care. It
may be possible to predict engagement and retention in care and to
focus efforts on those less likely to be engaged and retained in care.
Moreover, this can provide scope for enhancing among practitioners
cultural competence in relation to patients.
Much social psychological research is grounded in robust theory that
has been tested and validated in other empirical contexts. It therefore
 Social Psychology for Practitioners in Sexual Health and Wellbeing 27

gives us a head start in terms of understanding what has worked and

indeed failed in analogous contexts. In Part 2 of this volume, relevant
theory and research from social psychology in relation to MSM is
presented. Overall, this volume constitutes an attempt to highlight and
discuss how social psychological theory and research can empower
practitioners in sexual health and wellbeing among MSM.

Some definitions
From the outset it is useful to provide some definitions. The title of
this volume refers to ‘men who have sex with men’; it points to three
concepts – sexual health, self-identity and wellbeing – each with
long-standing traditions of research, theory and commentary from a
multitude of disciplinary approaches; and it identifies a community of
beneficiaries, namely ‘practitioners’. Each requires commentary.
Identity is a complex construct. It is especially complex in the
context of sexuality due in part to the stigma that is often appended
to some sexual identity categories. Most same-sex attracted men in
Western, industrialised societies, such as the UK, self-identify as gay and
they may express great pride in their gay identity. A smaller minority
self-identifies as bisexual. However, it must be noted that some same-sex
attracted men reject these categories as inaccurate descriptors of their
sexual identity. They may attempt to eschew the social stigma appended
to gay and bisexual identities, which may be particularly acute in some
social and cultural contexts, as exemplified in Cases 2 and 3 above.
Some same-sex attracted men may in fact self-identify as heterosexual
and cite various reasons for doing so, such as ‘I only have sex with men
but feel no emotional attachment to them’ or ‘I am only top3 when I
have sex with men and so I’m not really gay’. Some may self-identify as
‘queer’, claiming that the categories ‘gay’ and ‘bisexual’ are restrictive.
It is also noteworthy that (sexual) identity categories only really
become available to people in particular social and cultural contexts. In
some Middle Eastern societies, sex between men has always occurred
but there has never been a category like ‘gay’ in public discourse, so
same-sex attracted men have never self-identified in those terms.

3 The terms ‘top’ and ‘bottom’ refer to insertive and receptive sexual partners,
respectively.
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