by Dr. Jaime García-Iglesias and Joe Strong
In response to the COVID-19 lockdown in the UK, Soho-based sexual health clinic 56 Dean Street launched the campaign ‘Break the Chain’ (also known as ‘Test Now, Stop HIV’): based on the belief that people would not meet for sex during the lockdown, the campaign pushed for postal testing for HIV as a way of ‘breaking the chain’ of onward transmission. The ambitious and well intentioned campaigned relied on the assumption that sexual behaviour is largely driven by health-based best practices. However, early research already suggests that some men-who-have-sex-with-men broke lockdown restrictions in search of ‘intimacy’.
There exists a divide between personal narratives and desires of sexuality (perhaps better termed ‘fantasies’) and the actual realities of everyday experience and decision-making. This divide, and the relationship between fantasies and realities, merits exploration. In fact, health policy and practice must acknowledge the complex realities and fantasies that shape sex and reproductive health behaviours. Our discussion draws on two examples of research that are limited to different groups of men, acknowledging that such complexities can exist among other genders.
Seeking PrEP, desiring HIV
The first project we reflect on was conducted between 2017 and 2018 in the UK, US and France and explored how bugchasers (gay men who fetishize HIV) negotiate their fantasies (narratives of HIV as arousal) and realities (HIV as a medical condition and its consequences). PrEP (a treatment that, with adherence, prevents HIV infection) became a point of tension in these negotiations. This is evidenced by Milo (a pseudonym), who spends hours every day talking to other bugchasers and engaging in condomless sex, aroused by the possibility of being infected, but also sometimes takes PrEP. Milo explained:
“I’m actually on PrEP but not all the time. It’s a great way to stay negative […]. It’s been a few months since I really stopped taking my PrEP regularly. During August, I stopped it for one month […]. It was a real turn-on not knowing what would happen […].”
Martin, thirty-four-years-old, is a similar situation:
“I have these desires to stop taking PrEP but I also am worried about the long-term effects of the virus since I live in a rural place without access to care and the doctors wouldn’t understand why I stopped taking it.”
Milo and Martin evidence the fluid relationships between ‘fantasy’ (arousal at the thought of contracting HIV) and ‘reality’ (concerns about infection). In just a few minutes each (interviews lasted an hour), both men talked about taking PrEP, not taking PrEP, being aroused at the thought of infection and being frightened at its consequences. To dismiss their interview would mean dismissing the insight they provide on their sexual health decision-making, which is profoundly related to their constructed fantasies and perceived realities of HIV.
It may be impossible to understand how fantasy and reality interact for them but exploring and understanding those interactions is still important: after all, as Martin says, a significant concern about accessing healthcare is the fear of being chastised for fantasies desire for HIV.
It may be difficult, or even impossible at times, to understand how fantasy and reality interact in messy, complex and individual ways for these men. However, rather than reducing them to the irrational, which would dismiss these experiences, we should explore and seek to understand them as the important influences in healthcare decision-making that they are: after all, as Martin says, a significant concern about accessing healthcare is the fear of being chastised for fantasies desire for HIV.
Masculinities, paternity and abortion
The second project explored the relationships between men, masculinities and emergency contraception and abortion pathways. Based in Accra, Ghana, the results [still preliminary] highlight the interplay between fantasies and realities (arguably, masculinities are inherently relational to an idealised fantasy of manhood)  For many respondents, these constructions of masculinities centred around idealised notions of fatherhood and, for some, control over reproduction. Attitudes towards the prospect of pregnancies were mixed and related to men’s circumstances and belief they could fulfil masculine ideals.
However, men’s sexualities were complex. Their non-/use of pregnancy prevention methods in sexual encounters did not align consistently with located ideals; men reporting never using contraception during sex despite not being acceptably ‘ready’ for fatherhood. During interviews, some men would report being both ‘happy’ that abortions allowed them to have sex more freely without repercussions of fatherhood, while maintaining that they would never support a person seeking an abortion. Men who had previously supported a partner get an abortion in a specific circumstance did not necessarily have corresponding supportive attitudes to abortions more broadly, their lived realities of pregnancy termination seemingly at odds with their constructed anti-abortion beliefs. Such narratives are complex but were not always constructed as contradictory.
Acknowledging the complementary of men’s sexualities and positionalities allows a better understanding of the messy social constructions of masculinities, which is essential for contextualising the structures and systems of power that pregnant people seeking abortions have to navigate.
Towards a fantasy-reality approach
Following Barbara et al., in second modernity “there are double processes going in with respect to social phenomena where things are rarely one way or another, but one way and another”.[6, p.173] The two examples discussed here evidence how seemingly contradictory sexual and reproductive health decisions reveal complex and difficult negotiations between fantasies and realities. These men’s experiences do not ascribe to fantasies or realities, but fluidly move in between those. Despite the differences between these projects, such complexities emerged in both sets of data.
The key message from Break the Chain campaign, “If everybody gets tested and knows their status, they can make the right health choices,” ignores just how many shades of ‘right’ there are, how many beliefs, desires, and fantasies influence people’s health choices. Health campaigns must acknowledge that seemingly oppositional behaviours are connected on a spectrum: men might find condomless sex arousing whilst routinely accessing PrEP or wish to avoid fatherhood whilst never supporting contraception or abortion access for sexual partners.
Our evidence has major insights for health provision and continues debates about fantasy and reality, such as the influence of fiction on sexual health  or stigma. Thus, perhaps health messages during COVID that assume a prioritised desire to follow the prescribed ‘right’ behaviour (such as not engaging with multiple sexual partners during lockdown ) may not resonate with people’s actual complex, fluid and sometimes contradictory experiences of healthcare decision-making. Rather, we suggest that we embrace such complexity and engage in open conversations about people’s fantasies and realities.
Interventions should look deeper, as Rodriguez says, “into the warm, dark abyss of the lived and the sensed.”, p.341]. Understanding pathways to care, both during COVID and more broadly, means understanding non-linear and sometimes contradictory processes and motivations without dismissing them as irrational.
Dr. Jaime García-Iglesias is a Research Fellow at the University of Hertfordshire and a Mildred Baxter Postdoctoral Fellow (Sociology of Health and Illness Foundation) at the University of Edinburgh. He holds a PhD in Sociology from the University of Manchester. Twitter: @JGarciaIglesias
Joe Strong is a PhD candidate at the London School of Economics, his main research focusing on the relationships between constructions of masculinities and emergency contraception and abortion-related care pathways. Twitter: @JoeStrongDemog
Joe Strong’s work was supported by the Economic and Social Research Council (ES/P000622/1). Jaime García-Iglesias’s work was supported by the School of Social Sciences Doctoral Studentship at the University of Manchester.
For the research based in the UK, US and France: Social Sciences School Board: 2018-4849-6765
For the research based in Accra: London School of Economics and Political Science: REC ref. 000802c; Ghana Health Service: GHS-ERC 008/11/19
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