Decreasing Sexually Transmitted Diseases:
A service solution for the LGBT community

August 2010

Sexually transmitted diseases (STDs) are continuing to increase at alarming rates around the globe. Various reasons have been proposed as to why infection numbers are not stabilising; particularly in Europe, Australia and Asian regions (Hill-Jones and Noble, 2009). The heterosexual communities in the age-group 18-29, and even more in the LGBT (lesbian, gay, bi and transexual) community have the largest increase in recent years (WHO, 2008). The exact figures of infections are quite difficult to obtain; as governmental bodies around the world have inconsistencies in surveillance techniques of new infections and, of course, infections that have not been treated or picked up go untraced (WHO, 2008). However, if we take, as a sample, Sweden’s national infectious disease bureau new weekly infections, Syphilis cases per week have increased by 125% and Hep A & B by 50% since 2006 (Smittskyddsinstitutet, 2010). In the state of Victoria, Australia the number of Syphilis cases, in particular, has jumped from 1 in 2001 to 1000 in 2008 across communities (Cooper, 2009).

Sexually Transmitted diseases have been around for many years and can only be transferred from one individual to another during sexual activities. The first known major STD, Syphilis, caused death left untreated. The discovery of antibiotics, however, in the 1960s, created a public perception during that period that there was no serious medical threat from STDs; as they were now mostly curable. In the 1980s, however, the outbreak of AIDS took the public off- guard due to general complacency. Large scale campaigns were developed to reduce the possible global pandemic. These campaigns and methods in the western world consisted of posters and television advertisements; using scare tactics on the public, providing awareness and minimising the spread of the disease (Sexually Transmitted Disease, 2010). STD related illnesses strain society on many levels; including economies and the overall health of individuals within the communities they reside. It is indicated that, in the United States alone, $6.5billion was spent on the treatment of STD cases in 2004 (Harrell et. al, 2004) – only recent data that could be obtained.
In this report, the focus will look further into the increase of STDs particularly in the LGBT community; primarily due to the rising rate of new infections, culture of the community, and the attached social stigma. In this community, a large increase in STD cases became apparent in the early 2000s in industrial countries, specifically among men who have sex with another men (MSM); this rate continues to grow (Cooper, 2009). In particular, the rise in recent years of HIV infections, has given concern to the awareness and prevention techniques currently employed around the world. In the European Region, World Health Organisation (WHO), has declared that the rise of HIV is 2-3 times higher than in females owing to the predominant mode of transmission through injecting drugs and MSM. In western European countries, MSM account for about 50% of all HIV-infections, here eastern European countries are slightly discounted due to accurate results from gender norms and stigmatisation of MSM (WHO, 2008). Such increases have pointed to a number of reasons, including: (i) practitioners and suffers are failing to recognise symptoms; (ii) and the “significant decrease” in condom use by MSM in the past sever to eight years (WHO, 2008). Furthermore, in developed western nations, the cocktail of anti-viral drugs has reduced the risk of dieing from the disease once infected. However, unfortunately this has created an attitude from doing all that you can to prevent catching the disease due to fear, to a “I do what I can to limit the risks in my life, but if I do get HIV, there’s these pills I can take” (WHO, 2008).

In addition, the social stigma and perception of an HIV positive individual has not kept up with advancements in modern medicine, in the past physical fitness of an individual indicated potential status. Other potential reasons include: (i) bisexual/curious men are unfamiliar with the community and rising rates; (ii) communication meltdown between positive and negative individuals during sexual arrangements; (iii) and non-constant checking leads to unawareness, therefore, further spreading. In addition to these complacency based traits, the lack of harmonised definitions of behavioural indicators, stigmatisation particularly against MSM, discrimination and lack of political involvement conceal the extent of the epidemic which makes targeted prevention very difficult. This in turn contributes to individuals that are unwilling to be open about their sexuality and therefore creates the hidden culture that is still prominent in most western/eastern countries which leads to discrete, disconnected, and unsafe behaviour and lack of regular STD testings (STI Research and Prevention, 2009).

Starting from the earliest indication of STDs, campaigns have been run by private and public institutions in developed nations. These campaigns have ranged from a merit of perspectives; using various forms of medium (e.g. tv, print, billboards, events) to promote awareness and/or prevention of transmission. On review of current initiatives in the area of STD prevention, some key campaigns provided some new light on this critical issue. Listed below is an overview of each and a brief critique on their approaches:

Where has the condom been? In stockholm, the county council in sexual health created gold condom packets that were marked from 1 to 100,000 printed with a code used to post comments on a website on how the condom was put to use. This created a community of funny and filthy stories while highlighting the importance of use. It can be seen that this method is quite fresh in its approach, however it is a concern that the intended use of condoms could potentially be seen as a novelty due to limited edition and story posting aspect promoted in the campaign (Where has that condom been?, 2009).

Structural interventions have been used throughout the LGBT community in particular to curve the rise of STDs. As (Gougherty, 2009) points out, recent initiatives in the San Francisco bay area are proving to have promising results, where the emphasis on prevention is embedded in high risk venues; not focused on altering behaviour of individuals. The article states that these measures are quite new in the STD preventative arena and focus on free water at bars, websites for “protected sex only”, and wrist bracelets at sex clubs reflecting preferences and status. It is fair enough to state the benefits of structural interventions, however the initiatives outline do not focus on the continuous preventative nature of STD protection. (i.e. periodic tests).

Awareness websites have been created for years to help inform individuals of all age groups and communities the consequences of unsafe sex and STD related information. Most of these sites combine a mixture of shock value, audience altered style and overload of statistics and information with various links to testing centres, government institutions, communities and health groups. For example: This approach has recently been extended to social networking sites, such as Facebook, with various groups that explicitly promote safe sex and STD related issues, where individuals can have discussions on the matter; in some cases providing live webcam functionality to a Dr to answer your questions. This type of website is great for information purposes; however, they seem to have a common message, the same formula, and “scare” tactics to promote awareness. We need something fresh in the way we deliver information.

Testing services have also seen a slight refresh. For example, Sweden has introduced a national Clamydia ( online testing facility, this focuses on aspects of convenience and discreetness of an at-home test. An individual may request a test online, sent direct to their premises, once completed, they send the test back free of charge. The results are then provided online using a unique code upon registration. This initiative is great in providing an effective service that will hopeful reduce discouragement to get tested and increase periodic testing, however it does not integrate direct preventative techniques required before infection.

Service design initiative, the Design and sexual health (DaSH) service by the Dott07 initiative in the UK (DaSH, 2007) focused on a integrated service that has an emphasis on local testing stations. It reduces the distance of individuals from testing facilities by being mobile and available in their primary area of living, combined with an integrated online scheduling system, tailoring to suit the individuals needs therefore making it easier to access and efficient in result timelines. It was discovered prior to the development of the service that: (i) individuals felt the testing facility were too far; (ii) some felt stigmatised using existing services; (iii) and there was a disjointed nature of prevention, diagnosing, and treating cases. However, this design solution does not provide a mechanism to inform individuals effectively and efficiency of a partner that has been tested positive. It also does not bridge the possible lack of misinformation in identifying sexual partners that require contacting. The process of back tracing, by informing sexual partner(s) of a diagnosed STD, is the most effective method against prevention to this day (Sexually Transmitted Disease, 2010).

It seems, from the sample of solutions outlined that more is required in resolving the issue of rising STDs. Focusing predominantly on bridging the gap between physical and virtual worlds, reducing stigmatisation due to public perception, with key elements of local, timely, visibility and informative services.

Therefore, in forming an alternative solution to prevention and awareness, let us take a look at the current cultural elements of the LGBT (including MSM) community. One large cultural change underway is the exponential growth rate of the online community. It has even been suggested that physical LGBT communities are crumbling due to the virtual world. In most major cities, the LGBT community is larger online than it is offline. “Most cities identified that while the gay population in their cities appeared to stable or growing, the physical gay community infrastructure appeared to decline” (Atkinson, 2008). The internet appears to be changing the culture of the LGBT community and therefore preventative solutions and awareness need to be integrated into this apparent change. Furthermore, (Gilbert, Petersen and Scanlon, 2006) states that the Internet has facilitated encounters with individuals in this community, resulting in increased risk of STD transmission. In addition, research conducted concluded that the community looks favourably upon online health promotional activities and sexual health information. Various sources state that the LGBT community is actively well connected in comparison to their heterosexual counterparts for shopping, sourcing community information and dating [(Anand), (Arnold, 2007)]. Therefore, the internet is increasingly recommended as a medium to develop and evaluate STD prevention interventions for this population.

In comparing online usage, sexual activity, and thus potential increase in STD transmission, a study was conducted in 2004 by the University of New South Wales Australia (Murphy et al, 2004) within Melbourne and Sydney gay men and various locations around the world. It pointed to some interesting results, which indicate the very importance of online prevention and awareness services and techniques:

• 50% of gay men reported internet sex-seeking, increasing over recent years – not including group of men that do not class themselves as gay (homosexual) which throughout this report has been referred in totality as MSM;
• internet sex-seekers reported more sexual partners within the previous six months than did non- internet sex-seekers (mean 8.4 parters vs. 3.1) (Murphy et al, 2004);
• other studies referenced indicated that internet sex-seekers were more likely to have had an STD in the previous year than non, and have had high- risk behaviour.

Alternative solution

So far this paper has lead to the following points that must be considered in the awareness and prevention of STDs particularly in the LGBT community: (i) harness the growing culture of the online community particularly the use amongst MSM; (ii) integrating services of the physical world for diagnosis and testing; (iii) importance of visibility; (iv) easy to access; (vi) use of structural interventions; (vii) and be non- invasive. Therefore, a new way of viewing the required elements of an STD awareness and preventative solution is required.

The proposed online service will be integrated within community sites where individuals seek sex predominantly (i.e. dating sites). The service will focus on (i) promoting the potential promiscuous nature of the individual by visualising their network of sexual partners through degrees of separation from each other and therefore inducing reflection on behaviour; (ii) inform the individual of any risk associated to STDs by providing a notification facility of recently diagnosed partner/(s); (iii) integrated testing services for easy to access and efficient diagnosing services and; (iv) provide constant awareness and effective methods of STD related information. It is hoped that the methods outlined combined will provide more awareness and prevention in the community.

The main functions of the service are outlined as follows (refer to Fig. 1 for overview of main message flows):

Sexual activity network

sexual activity confirmation: enables individuals to confirm that they have engaged in sexual activity with each other
privacy: all sexual activity with individuals is kept private and not disclosed;
no history: no backtracking, or “black book” type function provided on sexual relations with other individuals once sexual relation is confirmed with individual
degree of separation: representation of the degree of individuals who have completed sexual activity with same partners is reflected in a family tree structure or degree of separation visualisation. This provocative feature enables individuals to view: (i) their degree of sexual relations; (ii) relations with common partners; (iii) and therefore indicating how easily the transfer of STDs can take place if not safe.

STD alert notification

direct notification: notification of potential STD risk from a recent sexual partner. The notification is given anonymously
degree of separation notification: notification of individuals that have tested positive to an STD that you have not directly had sexual activity, however a direct sexual parter has. Used for awareness and early notification of potential risk
provide notification: easily provide all sexual partners with information that you have been tested positive for an STD.

Diagnostic integrated services

online health services: direct contact with professionals
test ordering: order at home tests for various STDs
appointments for physical testing: similar to the DaSH project, appointments can be placed online at various testing facilities
integrated results: at home tests are linked to institutional health testing services that provide direct information regarding your results.

Awareness information

awareness advertisements: provide awareness campaigns on staying safe and various other elements of STD related issues
statistics information: current statistics on STDs within the community
outbreak alerts: any potential alerts on STD outbreaks within the community.

Figure 1. Message model of main functions

The proposed alternative solution takes into account all identified elements lacking in the critique overview of current solutions discussed in this report, in addition to providing a slightly provocative stance and visibility on the sex based use of online communities under the umbrella of LGBT; particularly focused on MSM behaviour. It is hoped that this will provide a new form of awareness and prevention in STDs. However, it must be pointed out that several potential setbacks are currently visible: (i) individuals are to confirm their sexual activity with each other; (ii) people are honest with their statuson STDs and inform the system; (iii) monitoring degree of separation of common partners for negative purposes; (iv) no constant or substantial uptake. However, it should be noted here that further analysis of the situation, evaluation, and thinking is required to fully understand the complexities in this environment, the features/functions required, privacy, effectiveness and potential of such a solution.

By Aaron Mullane, 2010

Anand. Gay and Lesbian Internet population in US. population-in-us/. Viewed on 5 Jan, 2010.

Arnold, Bruce (2007). GLBT Online. Caslon analytics.

Atkinson, George (2008). Gay Communities In Decline (Published 12 June 2008). University of Minnesota. Viewed on 5 Jan, 2010. yculture.html.

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