The U.S. Food and Drug Administration (FDA) recently revised its decades-old policy on a lifetime prohibition of gay men donating blood. This ban, rooted in the early days of the HIV epidemic when transmission was poorly understood and (full-blown crazy) levels of stigma and discrimination abounded, has long needed to change. For me, the revised guidelines represent minimal progress because they exclude any gay man who has had sex with another man in the last year.
The 12-month waiting period in the revised guidelines puts U.S. HIV policies on a par with those of other developed countries and has been heralded as a major victory for gay rights. Analysts note that there is also a year-long waiting period for heterosexuals who have sex with prostitutes or with people who inject drugs. While these restrictions limit a small number of men who have sex with women, they virtually eliminate the vast majority of men who have sex with men (MSM).
I don't feel good about (and certainly not grateful for) the revision. While the old guidelines denied us a seat at the table, the new ones allow only a few gay men to sneak in the back door after a very long wait. For many HIV-positive gay men I know, this has an uncomfortable resonance with the old days when many, if allowed to visit their families, were forced to unpack on the porch and eat off disposable plates.
These policies feel less reliant on science and more on morality. The FDA states that the new standards reflect a lack of science permitting a lift of the 12-month ban, but there are tests, for example, that can determine the safety of the blood supply with greater accuracy than that reflected in this sweeping prohibition. I fear that the new guidelines, while seemingly a step forward, may actually do more harm both to gay men and public health. For gay men the message is clear: sex with another man -- no matter what your sexual practices, marital status or health -- disqualifies you. Ironically, it has been noted that allowing gay donations could significantly improve the supply.
"I feel like damaged goods."
As a psychotherapist, I have heard these words uttered countless times by gay men, regardless of serostatus. A lifetime of negative messaging by family, community and powerful institutions like the church that gay men are flawed, inferior and even dangerous, takes a terrible toll on the self-worthiness of an individual. Add to that other layers of stigma, such as serostatus, race, ethnicity, work status or co-occurring mental health or substance use disorders, and one's sense of self, even in the healthiest and most resilient person, can be seriously and even permanently deformed.
Stigma is expressed through various forms of discrimination, including violence, that are traumatic. Such "enacted stigma" is familiar to anyone bearing characteristics that are devalued or discounted by society. But the damage doesn't stop with a barrage of critical judgments and/or deeds from the outside. Stigma burrows deep into the psyche of an individual resulting in "felt stigma," which can color one's self-concept with shame and unworthiness and significantly increase the possibility of numbing these negative feelings with substances, compulsive behaviors or mood disorders.
I credit the FDA with making some movement on this issue, but we are far from where we need to be. It continues to taint the sexual behavior of MSM in a way that, I feel, stigmatizes and ultimately stifles frank and honest dialog about sex and serostatus, thus affecting efforts at prevention, testing and even honest dialog between individuals. This decision seems to capture the state of policy versus practice these days. Institutional decisions are laden with moral drag and feel detached from actual behavior. They reinforce feelings of internalized stigma while promoting discrimination in a way that totally disconnects many MSM. People begin to tune it all out, including important public health conversations, because the policy and the messaging feel hurtful and, frankly, irrelevant.
Stigma continues to thrive and harm. It may be artificially sweetened or served up in a "lite" version, but it is always there and is proving to have a remarkably long shelf life.
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