My last post asked the question: If gay guys use condoms more than straight people, why do they get infected with HIV at much higher rates?

I argued that health systems depend too heavily on individual, bio-medical explanations without also accounting for the role of community-level and structural factors in health outcomes. I’m amazed, for example, how rarely the public health system addresses homophobia as a reason why gay guys account for the highest number of new infections in countries like the US, the UK and Canada.

Before I posted that piece, I sent it to an epidemiologist friend to look over in case I got any of my facts wrong. Her reply:

“Nothing wrong at all. Though I’d like another sentence to tell me how getting spat at in the street can lead to increased rates of HIV (the homophobia argument). I don’t disagree, but with a viral disease, the structural can only have an effect by affecting individuals’ exposure.

One thing surprisingly missing, though: role switching in gay sex. It ramps up transmission because bottoms (who are more likely to be infected) can then become tops (who are more likely to pass on HIV). Heteros can’t do it.”

The role switching point is a good one and needs no further explanation.

As for the extra sentence explaining how getting spat at in the street can lead to increased rates of HIV, I’m surprised it needs any explanation at all considering just last year the U.S. justice system saw fit to sentence an HIV+ man to 35 years in prison for spitting on a cop (an act which carries zero risk of HIV transmission, of course).

But, ok, let’s say you’re not a nation hell bent on putting anyone and everyone scary in jail. What then?

I thought it might be useful to explain how structural factors affect health outcomes in general since my main point in that last post was that this is a poorly understood concept, including by people who are paid to improve population health. It results in yet more bio-medical interventions (“Maybe this is the condom pamphlet that will finally get them to listen!…”) without concurrently addressing the ability of high-risk communities to mitigate the effects of macro-social inequality.

The Public Health Agency of Canada sets the discussion up with this example:

“Why is Jason in the hospital?
Because he has a bad infection in his leg.
But why does he have an infection?
Because he has a cut on his leg and it got infected.
But why does he have a cut on his leg?
Because he was playing in the junk yard next to his apartment building and there was some sharp, jagged steel there that he fell on.
But why was he playing in a junk yard?
Because his neighborhood is kind of run down. A lot of kids play there and there is no one to supervise them.
But why does he live in that neighborhood?
Because his parents can’t afford a nicer place to live.
But why can’t his parents afford a nicer place to live?
Because his Dad is unemployed and his Mom is sick.
But why is his Dad unemployed?
Because he doesn’t have much education and he can’t find a job.
But why …?

The bigger picture that the Public Health Agency of Canada wants us to understand is:

“…there is mounting evidence that the contribution of medicine and health care is quite limited, and that spending more on health care will not result in significant further improvements in population health. On the other hand, there are strong and growing indications that other factors such as living and working conditions are crucially important for a healthy population.”

These “other factors” are generally known as social determinants of health. The Public Health Agency of Canada recognizes 12 of them:

  1. Income and Social Status
  2. Social Support Networks
  3. Education and Literacy
  4. Employment/Working Conditions
  5. Social Environments
  6. Physical Environments
  7. Personal Health Practices and Coping Skills
  8. Healthy Child Development
  9. Biology and Genetic Endowment
  10. Health Services
  11. Gender
  12. Culture

Clicking on one of the 12 determinants above will take you to a chart explaining how that particular factor can influence health outcomes, as well as the evidence on which it’s based. “Biology and genetic endowment” refers to penis size, obviously.

When considering how homophobia contributes to increased rates of HIV among gay men, we’d probably start by looking at social exclusion as a determinant of health. Once again, our friends at the government of Canada are on hand to help:

“Social exclusion describes the structures and dynamic processes of inequality among groups in society. Social exclusion refers to the inability of certain groups or individuals to participate fully in Canadian life due to structural inequalities in access to social, economic, political and cultural resources. These inequalities arise out of oppression related to race, class, gender, disability, sexual orientation, immigrant status and religion.”

The key question is how the experience of life at the margins of society (which would certainly include being spit at in the street) affects the likelihood that gays will live below the poverty line, find jobs that pay a living wage, graduate from high school, have recourse to intervention policies that assure their physical safety while at school, benefit from sexual health curriculum that includes harm reduction strategies for sex they actually enjoy or be incarcerated in prisons at rates equal to straight people. It also calls into question how public health privileges academic credentials while excluding experiential knowledge of high risk communities when designing health interventions. Because what use is a sexual health counselor with a Master’s in Social Work who can’t explain how poppers increase my risk during some good old PnP BDSM at the sauna down the street, yeah?

Or, put another way:

Why is Jason in the hospital?
Because his CD4 count is around 100 and he has a bad case of thrush.
But why is his CD4 count so low?
Because he’d been HIV+ for years before he realized it.
But why did it take him so long to realize he was HIV+?
Because he never went to get tested.
But why didn’t he go get tested?
Because he was scared he was HIV+ and the last time he went the nurse lectured him for not using condoms.
But why didn’t he use condoms?
Because sometimes he got so high he just sort of forgot.
But why was he high?
Because getting high is fun and feels a lot better than being sober and depressed.
But why was he depressed?
Because he couldn’t find work so he couldn’t pay his rent.
But why couldn’t he find work?
Because he didn’t have a high school diploma.
But why didn’t he have a high school diploma?
Because he’d been expelled from school for skipping.
But why was he skipping school?
Because he was getting beat up.
But why was he getting beat up?
Because he only hung out with girls and he sucked at sports.
But why didn’t he just go to a new school?
Because his parents kicked him out and he had to look for somewhere to live.
But why did his parents kick him out?
Because they were mad at him for getting expelled, they found drugs in his room and they caught him making out with his boyfriend in the basement – they said it was the last straw.
But why…?

Nico Little updates his personal blog regularly. You can follow it at

Nico Little

Nico Little is an Anglo-Albertan who decamped to Montreal sometime in the late nineties “to learn French and be gay.” He then moved to Ottawa, Ontario, where he worked as an HIV outreach...