Bipolar Mania, Sex and HIV Prevention: Untangling the Threads of Shame and Ignorance
A few years ago, when I was 21, my former psychiatrist recommended that I abstain from sex until my bipolar condition "stabilized." Increased sexual activity, he cautioned, is a common symptom of the manic stages of bipolar disorder. Working his way down a checklist in an indifferent style, he asked whether I had recently exchanged sex for money, had sex with strangers or done so while using drugs. Not noticing that my hesitancy was due to disbelief and probably embarrassment, my doctor nodded knowingly, refilled my prescriptions and sent me off with a pat on the back and an instruction to "stay safe." Great, I thought, being bipolar meant I had to deal with the illness's draining symptoms, forgo margaritas due to medication contraindications and, now, live a sexless and single life.
As a person of color living with bipolar disorder who also is gay, I'm basically in the highest "at-risk" demographic. Later that year, the Centers for Disease Control and Prevention estimated that, if current diagnosis rates continued, one in four Latinx men who have sex with men (MSM) would be diagnosed with HIV in their lifetime, with black MSM facing the dismaying prospect of one in two. I don't know how much my queerness, my Latinidad or the community I come from impacted the recommendations I received from my physician. But I know that, at the time, it was the shame, not the diagnosis, that led me to give up on the prospect of dating, sex and a "normal" career.
Assumptions I Can't Take Control of My Life
What I remember most about my interactions with this doctor and many other health care providers is the assumption that I did not have the capacity or potential to take control of my life, whether it pertained to sex or my career. To be clear, sexual health and "hypersexuality" is indeed a real concern for individuals living with bipolar disorder. It is estimated that 5.7 million adults in the U.S. are living with bipolar disorder, with research suggesting that 25% to 80% of these individuals who experience mania have periods of "hyper sexuality." The problem with the way my doctor dealt with sex was not that he recommended "safe" behavior, but rather that he associated sex with illness and shame and dismissed the possibility that healthy sex could promote wellbeing and emotional growth. The problem with clinically injecting fear into sexuality and sexual behavior is that it breeds shame, and shame is a known enemy of health and recovery.
This is to say nothing about the bias queer and transgender individuals, especially those of us of color, face when receiving any type of medical care. We are often already presumed to be non-compliant with medication, promiscuous and prone to criminal behavior. In fact, recent studies have shown that in areas of medical care ranging from primary care to HIV treatment, patients of color consistently receive lower quality care, subpar medication regimens and, as a consequence, experience poorer health outcomes. How can I not be impacted by consistent messaging -- from doctors, media and society -- that people like me are sexually immoral, irresponsible and dangerous? These messages sink into us until we begin to see them reflected back in the mirror. This shame engenders secrecy, which in turn can implode into addiction, mental health issues or, worse, an acceptance of these messages.
Shame-Based Approaches to Health Don't Work
Shame for me has meant exploring the boundaries of my sexuality in strangers' cars for fear of being disowned by family; shame for me has meant hiding to take my bipolar medications when dating because some people don't know whether "they can handle that right now"; shame for me has meant explaining to my white health care providers that, yes, I have had sex with multiple partners and would like to discuss pre-exposure prophylaxis (PrEP), but, no, I am not currently a sex worker or using crystal meth. (And if I were, what difference would that really make in this matter?) You see, shame-based approaches to health, whether with regard to mental or sexual wellbeing, do not work because they encourage concealment and reckless abandon. These approaches stigmatize the very bodies professionals claim to protect. In mental health, the brain becomes an unreliable and deceitful organ in need of close supervision; in sexual health, the body becomes either a sexual weapon or a potential victim of sexual irresponsibility. In both areas, stigma is highly gendered and racial.
For those of us living with mental illness while seeking to combat HIV stigma and pursue sexually affirming experiences, it is necessary to embrace the vulnerability that comes with "coming out," whatever that might mean for us. This process, for many of us, will begin with finding competent health care providers who see us as individuals and not as diagnoses. This means providers that affirm our identities and potential to live healthy, independent and, yes, sexual lives. For those of us who can do so safely, we must share our experiences kept captive by shame -- not only for the sense of relief we encounter when we are met with a "me too," but also because there are groups of individuals spreading information in clinical or stereotypical terms that are grounded in racist tropes, homophobia and HIV stigma.
Reclaiming Agency Over My Body and Mind
Shame is a universal emotion that, at its core, perpetuates a belief that we are not good enough. It is a feeling highly correlated with suicide, addiction, depression, eating disorders and uninformed sexual decisions. One of the most powerful tools for combatting shame is confiding our deepest secrets -- all of the "nasty" and embarrassing things -- to people we trust and who can reflect back to us a version of ourselves that we fail to see sometimes. While addressing shame involves hard reflection and a personal journey, and perhaps therapy, it also involves realizing that the biggest culprits are intolerance and ignorance. This means that the main threats to my health, both mental and sexual, do not emanate from within but rather from misinformed health care providers and our society's investment in racial and sexual stereotypes. This realization is important not because it absolves me of responsibility but precisely because it allocates it fairly.
My continued recovery rests heavily on my ability to thwart fear by reclaiming agency over my body and mind and confronting ignorance and stigma regardless of the source. Recently, this has involved remaining compliant with my bipolar medication and PrEP. It has also involved firing and filing complaints against two doctors, one who assumed I might be a crack-cocaine user without knowing anything about me, and another who refused to prescribe PrEP because she believed condoms to be a more "practical" HIV prevention tool.
Most importantly, I have come to be weary of labels like "at-risk" and "susceptible." These terms present circumstances as facts and health disparities as situations isolated from systems of discrimination and disenfranchisement. If anything, addressing shame by embracing the entirety of my experiences has taught me that it is often medical professionals and prejudiced individuals who are most "at-risk" and "susceptible" to compromising my emotional and physical wellbeing. Their lack of caution and "safety" threatens my ability to live a healthy life -- not my identity as a gay man of color or my sexual practices.
As individuals with marginalized identities, we often become receptacles for ignorance and shame that do not belong to us. Healing, for me, begins with untangling these threads, addressing the parts that belong to me and handing the rest back to whoever dumped them there without my consent. This work is laborious and gradual, but one thing is clear: We all play a part, and we all have work to do. There is a community here willing to catch us when we fall.
Miguel Garcia is a native Detroiter and Chicano queer mental and sexual health advocate. He currently works for a community health agency based in Detroit and is completing his degree in Boston.