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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
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Counseling Transgender and Non-Binary Youth

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 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
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