However she said that around 70-80% of MTF sex workers were HIV+ and gave several reasons for this, including being more vulnerable to taking more money to have (anal) sex without a condom.

She also opined that there was a very high rate of HIV infection in MTF people generally (much higher than the about one in sex or seven for gay men in London).

Now, it may just be the people I know, but this sounds extremely high to me. Had I been at the meeting, I'd have been asking 'Where's the evidence for that?'

Not least because as I understand it most of the surgeons who do gender reassignment won't take HIV+ patients.

In no particular order..

Costs: time and money. Let's say we're a responsible bunch and half of us want to be tested. That's around 100-200 people, and that's likely to be a significant chunk of someone's budget. Would it mean a hundred fewer local residents get access to testing? Is there really that much spare capacity?

It would also take quite a while and/or a significant number of someone's staff to do that sort of number. Memory is telling me that when THT in London do one hour HIV testing at their centres, they limit it to about a dozen people per afternoon/evening.

What tests? Not just what STIs to test for, but which tests to use. HIV would presumably be in the list, even if it is a list of one. The easiest tests to administer are not enormously accurate – better tests need more than a pinprick of blood or a saliva wipe. If the easiest ones are used, then there's going to be '.. and you need to visit somewhere closer to home for another test' said a lot.

Chlamydia and some of the other 'pee test' ones would be good.

Where's it going to happen? The space available (and the cost of that) varies between 'lots and free' and 'not much and not cheap' between venues. In any case, a space may be findable but wherever it is onsite, there are going to be..

Confidentiality issues: Unlike most other testing venues, so many people at BiCon know each other, so confidentiality is much harder.

How do you stop people seeing who's going for testing and who isn't? If there's one hour or similar testing available, people are also likely to be under some pressure to reveal the results to at least some people.

If there is support for people with positive (i.e. they have something) results – and if not, WTF not? – then it will be seen as trivial to see who's got something. Say it's one hour HIV testing. If they go back for a result and are out again in a couple of minutes, then they 'must' be HIV-. If they're there much longer, then they 'must' be HIV+.

Who gets the population data? There's someone who – if I interpret them correctly – wants testing done at BiCon because they want to show that bisexuals are less likely to have various STIs than gay men. I'm very dubious about that, both in terms of our representation of the wider bisexual population and what would be done with results that could be presented as saying that, for example, yes, fewer bisexuals do have HIV and so there's less need for health promotion to us compared to gay men. If someone does this testing, the results are going to be reported to someone and we absolutely need some editorial control.

So, if it is to be done, it needs to be done properly, but that's not going to be easy.

You could, for example, hand some of the pee tests out and let people do them privately (they're 'pregnancy test simple' to do – oh, I'd love to see a pile of pregnancy test kits for people to take: in bulk they cost pennies). There are issues with that ('Hello darling, pee on this for me…') too though.

Much more research is being done on vaginal microbicides, partly because of 'moral' issues (i.e. homophobia and general bigotry) but also because the vagina is a much easier place to get a microbicide to work.

Remember that being on the receiving end of anal sex with an HIV+ man is about fifteen times riskier than being on the receiving end of vaginal sex? Here are some reasons why:

Vagina: thick outer layer of the skin, about forty cells deep
Rectum: one cell layer deep, albeit with thicker cells than the vagina

Vagina: fewer CD4 cells near the surface to be infected by HIV
Rectum: complex and extensive immune structures under surface

Vagina: acidic
Rectum: alkaline

Vagina: an enclosed 'pouch'
Rectum: a long tube, ultimately ending at the mouth. You don't need to go that far, but it's known that lube can be found two feet along, well into the colon, four hours after being placed in the rectum

So there are several trials of vaginal microbicides going on, but it looks like only one potential rectal product is even at a very early stage of trials.

It also doesn't help that understanding of HIV infection in the rectum is still not that well understood, and the rectum and colon are more fragile than the vagina, so there are increased safety issues (it's quite possible that using a vaginal microbicide might not work, and might be actively harmful!)

(Originally published on my blog April 2007)

Men who want to lower their chances of contracting HIV should be circumcised, the world's leading health experts said yesterday.

Having the foreskin removed lowers the risk of catching the virus by 60 per cent, they said.

(The Metro, London 29th March 2007)

So why not circumcise all men?

The later paragraphs in this story gave some reasons that weren't in all the ones I saw:

.. an additional important intervention to reduce the risk of heterosexually acquired HIV infection in men..

So, not enough on its own, not relevant to the bulk of infections acquired in the UK, and of marginal benefit to women (if fewer men have HIV, fewer women will have HIV+ partners, but if you're a woman and your partner is HIV+, circumcision doesn't help you) but even so, worth trying?

In the UK, the large NATSAL surveys show no difference in STI rates between 'cut' and 'uncut' men, but a 60% reduction in risk sounds a lot – it's about what people are hoping for from a vaccine against HIV, should one be developed – and it comes from three randomised control trials in Africa (you circumcise some men, but not others, and see what happens to them over time) but…

• It's a relative reduction. The absolute reduction was about 1.8% – over the course of the trials, the risk was about 4.8% (uncut) and 3.0% (cut)
• The level of complications was about 1.5% – and these were circumcisions performed in the best conditions they could arrange. Complications vary from serious blood loss and infections, to impotence and total loss of the penis.

So in order to get about a 1.8% reduction in HIV cases in that time, 1.5% of men had problems, some serious. If somewhere in Africa decided to circumcise every man and boy, the complications would increase (these countries have higher priorities for their health budgets than paying for first world standards of circumcision!)

And… the trials were all cut short (sorry! 'terminated early') and this will mask any delaying effect. Imagine that all circumcision did was delay catching HIV by a year, on average. Stopping a three year trial after two years would show a substantial reduction in relative risk – you'd miss all the cut men who caught HIV in the third year! I'd expect at least a decade's follow-up before anyone should consider recommending it in this way.

So it's not particularly surprising to find out that the people running the trials had long track records of favouring circumcision.

And it gets worse: in order to maximise what benefit there is, you'd need to do this in infancy, but there are serious consent issues – you're performing an unnecessary operation with possibly some major complications on someone who can't give consent themselves in the hope that, fifteen or so years later, there might be some benefit.

If they turn out to be gay or bisexual, it will be of no benefit. If a medical advance happens in another prevention technology, there may be no benefit. And if they ask you for advice, you're still going to say 'use condoms'!

Circumcision, just say 'not for everyone'.

TMI disclaimer: I have a foreskin, and I'm very happy with it. There would need to be a serious reason for me to want to lose it and as you might guess, I'm not booking any surgery soon.

He confidently expected that researchers wouldn't find many, despite what the HEA's 'bisexual development group' kept saying, thus demonstrating that bisexual men weren't worth doing anything for.

Everyone – except the bisexual development group, and who cared about them? – would be happy.

But it Didn't Quite Turn Out Like That.

The researchers started out by assuming that if they insisted subjects had been sexual with both men and women in the past year, hardly anyone would qualify. They set the limit at five years and started advertising in the contact ads sections of the mainstream press, inviting men to call a freephone number.

They were swamped with calls and had to reduce the number of ads placed. They estimate that between 20,000 and 34,000 men tried to ring them in the eight weeks the number was operating – 2,500 and 4,250 a week, and thousands more than respond to their annual Gay Men's (sic) Sex Surveys – but they only had the resources to speak to just over a thousand, of whom three quarters were interviewed.

To their surprise, virtually all the callers had indeed been sexual with both men and women in the past year. The researchers were struck by the way that the mean number of partners in that time – six – was the same as their cohort of gay men. Half of the partners of the bisexual men were women, and they were having more anal sex – often without condoms – with women than reported figures for heterosexual men.  They were a strikingly homogeneous bunch: with just two exceptions, there was no significant correlation between behaviour and any of their demographic characteristics. (It was only the number of male partners with whom anal intercourse occurred that was linked: men living with women did so with a slightly lower average of men, and – as can be expected – older men had a lower average as well.) Contrary to the mythology of the 'deceived wife', many of the women involved with the men knew about his same-sex activities and were themselves sexually sophisticated and adventurous.

When asked, 'How do you think of yourself, in terms of your sexuality?' at the end of the interview, over half could not answer and needed to be prompted with a second question: 'What term would you use to describe yourself, sexually?' I was not surprised that even then less than half of the total sample had a bisexual (or similar) identity – many bisexually behaving men simply do not have a 'sexual identity' in the way that activists do. Indeed, more than one in eight identified as straight, despite having just talked about their bisexual behaviour. Fewer than 1% had a gay identity, one reason why materials explicitly aimed at gay men will simply not be seen as relevant by this population.

Looking at the report's conclusions fifteen years on, what is striking is how little has been done since.

• It pointed out that many aspects of the findings could not have been predicted from previous studies, and said that more research had to be undertaken so that many of the new or unanswered questions could be addressed. Nope: research has overwhelmingly concentrated on men reachable via the gay community
• While the authors thought gay men were a higher priority, having a higher known HIV prevalence, this population 'merit higher priority than a number of groups which have been, and continue to be, targeted for health promotion'. Nope: it is also possible that the bisexual men have a higher prevalence than reported, as testing levels were half that for gay men. Equally, government reporting of HIV prevalence makes no distinction between the two populations.
• They said the men 'will not react well to advertisements that overtly refer to homosexuality and/or identify their target group as gay or bisexual men'. Nope: the vast majority of information for men who have sex with men continues to be labelled 'for gay men'.
• Health promotion had to use the media seen by the men: mainstream publications, not the gay press. Nope: if I wanted to reach bisexual men in London, I'd use the Metro and Evening Standard newspapers, plus put ads on public transport. All of these are far more expensive (because they have a much greater readership) than the gay press, and this is one reason why it has not been done.
• Community development work was vital 'to facilitate the exchange of information and experience and the formation of interest groups' outside the existing gay community. Nope: the bisexual community, while not perfect, remains almost totally unfunded in comparison to 'gay' or 'gay and..' groups.

If any recommendations have been ignored the most, it is probably (emphasis mine):

The received wisdom within health promotion has been that the gay community would act as a 'natural' vector of health promotion for bisexual men since they would, presumably, be having sex with gay men at some time. The demographic make-up of this group, their sexual identities (or lack thereof), and their lack of identification with, and use of, the gay community make this an increasingly untenable proposal. .. The main problem when addressing this group of men is that they will not identify with material produced for 'out' gay men. They also may feel themselves not well served by the material prepared for conventionally straight men, because of their greater perceived sexual sophistication and/or specialised tastes.

The report finished by saying that the attitude towards bisexual men and their needs was based 'largely on prejudice and pejorative assumptions backed up by scientific and behavioural research that has, on the whole, failed to ask questions which challenge those assumptions.' That remains true today.

In 1995, the report was given to the HEA.

Oh no! Proof that there is indeed a massive population of bisexual men, having large amounts of potentially risky sex, most of whom are unreachable by going via the gay community! What to do?

Colonel Harry Brighton: Look, sir, we can't just do nothing.
General Allenby: Why not? It's usually best.

Robert Bolt and Michael Wilson's screenplay for Lawrence of Arabia

The report was sat on for about a year. Each time the bisexual development group asked, the publication date was always "in the next couple of months". During that time, some of the findings were leaked to one newspaper, which did a small story on them. Then there was yet another delay. So when it was finally officially published, in April 1996, it was old news and no-one cared. Coverage was minimal and you can judge how much notice was taken of it by reading the rest of this site.

Before long, it went out of print and has remained so ever since. Even Sigma Research dropped any mention of it from their website. It was almost forgotten.

So when someone wanted a copy, I decided to scan mine, OCR it, and convert it to HTML. Some years later, a freely downloadable PDF of the report appeared on library.nhs.uk. So, not least as that version is not searchable (it's a series of scans), and also because I'd added comments to mine, my copy is now here.

Enjoy, and – especially if you're bisexual – get angry.

Page xv sets out the standard against which it wants to to be judged: "What this book is about: The primary aim is to support improvements in service delivery to lesbians, gay men and bisexuals by offering a foundation of sound information… it takes a more critical perspective on sexuality generally .. all sexualities are seen as being in need of explanation." [Emphasis in the book.]

However, it almost immediately opts out of doing so (page xvii) "Bisexuality is not often specifically mentioned in this book. This is not out of any desire to exclude bisexuals. However, the marginalisation of bisexuals within the dominant culture is determined by the 'homosexual' rather than the 'heterosexual' component of their sexualities. Moreover, the concept of bisexuality is often used by those who wish to reinforce the idea that there is something 'real' about dividing people up into homosexual or heterosexual. In this strategy, 'bisexual' becomes what is called a 'residual category', a kind of theoretical rag-bag into which you simply toss anything that does not neatly fit your schema. There are, therefore, compelling theoretical reasons for not falling back on the 'lesbian, gay and bisexual' formula, so I have referred to bisexuals only where the context demands it."

The rest of the paragraph, as well as the rest of the book, provides strong evidence that it is, in fact, out of an offensive desire to exclude bisexuals.

So, for example, it is not true to say that the marginalisation of homosexuality is determined solely or even mostly out of the 'homosexual' component – she is ignoring (and in fact reinforcing) the dominant monosexual binary divide and the presumed non-monogamy issue (the latter is why bisexuality is considered "inherently wrong" by the Church of England which is accepting of the leity's monogamous homosexual relationships).

The "concept" (and reality) of bisexuality is something that threatens those who wish to "reinforce the idea that there is something 'real' about dividing people up into homosexual or heterosexual"!

Try translating it into a racial context: "In this strategy, 'mixed race' becomes what is called a 'residual category', a kind of theoretical rag-bag into which you simply toss anything that does not neatly fit your black or white schema." Ouch.

To go onto cite "compelling theoretical reasons" for exclusion in a book that purports to be particularly inclusive, without any acknowledgement of the biphobia involved is, perhaps, the most offensive single extract.

The exercises are a perfect example of how the offensiveness permeates the entire book:

Page 10: Readers are asked to name as many well-known gay men and lesbians as they can think of, with the comment that they'll probably find the former easier. Bisexual people? "If you yourself are lesbian or gay, how did it make you feel…" Bisexual readers are left feeling non-existent!

Page 33: "Take note of any articles that deal with lesbian or gay issues…" Bisexual issues? She then asks about images of opposite sex / same sex couples without mentioning one of the central issues around bisexual visibility: how do you show 'bisexuality' without showing three (or more) people?

Page 34: "Now obtain a few copies of gay publications (.. Diva, Gay Times.. ) .. How easy was it for you to get hold of these publications?" Bisexual publications?

The next exercise mentions "gay, lesbian and bisexual" readers, so we can see that the "only where the context demands" omission of 'bisexual' elsewhere is probably deliberate.

As in page 47: "For heterosexual readers .. For lesbian or gay readers". Both ask the reader to consider "lesbian and gay readers". In both cases, what about bisexual readers?

Page 81: "Write down a list of slang terms of 'gay man' [and] 'lesbian'." Slang terms for bisexuals? It's not as though there aren't any.

Page 84: After asking to arrange sexual acts into those which may be done by two women, two men or a man and a woman, "What does this tell you about the sexual practices of lesbians, gay men and heterosexuals?" Bisexuals?

Page 150: "How many of the stories are written by a lesbian or gay man .. What overall image of lesbians and/or gay men is put across?" How many by a bisexual? What image of bisexuals?

The next exercise includes "lesbian, gay or bisexual service users", but only "the lesbian and gay community". The bisexual community?

Not that the reader is given any clue that the latter exists. The "substantial" list of resources on page 190 onwards includes sections on history, but fails to reference any on bisexual history; on autobiographies, but fails to reference any by bisexuals; on professional and practice issues but only two books include the b-word in their title (one is LG&B, one L&B women); on "exploring different avenues" (none bisexual); on "exploring lesbian and gay studies" (ditto); and "journals" (ditto).

Finally "sources of information" mentions the London Lesbian and Gay Switchboard (which at the time of writing the book excluded anyone with a bisexual identity from being a volunteer) and the London Lesbian Line (ditto) but not the Bisexual Helpline which had then been running for fourteen years. Even when the organisations which are listed explicitly include bisexuals in their title or subtitles, such as Parents' Friend, it is excluded from the listings.

It's also (again largely by omission) in the index – apart from the passages in the introduction, there's only one 'bisexuality' reference, to page 20, where after a (far too short) bit on Kinsey, mentioning Humphreys' The Tearoom Trade, the idea that sexual identity often does not indicate behaviour, and the fact that the boundaries are not fixed, she says "It is clear from these accounts that such experiences" – having sex with both men and women! – "do not fit into the category of bisexuality." It was at this point that I threw the book across the room.

"Indeed," she goes on, " 'bisexuality' is itself a complex question, about which there is much debate and disagreement" and then gives two inadequate references.

Compare that to about sixty references for both 'gay men' and 'lesbians', and again imagine translating this into a race context: what would you say about a book on race issues in health that acknowledges that there were differences, said it was going to cover all ethnic minorities but which had sixty references to Afro-Caribbean people issues and one on South Asian people?

(Example picked because while both are minorities, there are more people of South Asian origin in the UK than Afro-Caribbean origin, just as there are more behaviourly bisexual people than exclusively homosexual ones.)

The body text contains numerous more examples – such as the repeated division of men into "gay and non-gay": it's entirely unclear where bisexual men are in that binary divide – but I would hope this is enough to show why it wins an 'offensive biphobic crap' award even without its stated aim of treating all sexualities equally.

My first reaction on reading that was "Erm, what would do that, apart from spermicide?" (Which I hope you all know is a no-no for this as the damage it does to the skin – the main one was originally designed as an industrial cleaner – outweighs any theoretical benefits to such an extent that it can lead to more infections amongst frequent users!)

But a quick Google reveals that there was indeed a study published in 2001 which named Astroglide (Silken Secret is the same stuff except in an applicator), Vagisil and ViAmor as including 'two' substances which had an effect on HIV in a test tube over 24 hours. It got quite a bit of coverage at the time.

Helpfully, the journal in which this was published is currently free (for all of December only) so you can look it up for free:

What I found particularly odd is how few other articles have cited this one. If it really was significant, I'd expect rather more than five in the past five years. (Journals have a vested interest in pointing out how often their articles are cited elsewhere, so they tend to be good at listing as many as they can.)

The other odd thing was how few other sexual lubricants there were in their tests. Most of the rest of the 22 listed are 'mild vinegar' douches!

So it was off to the Astroglide website, which lists the ingredients for Silken Secret, and I couldn't see anything that's obviously different from lots of other lubes. They also don't make any 'kills HIV' claims for it either.

..and looking up one of the five articles that references this study, it looks like I was right: it's that they were lubricants (as opposed to, say, douches) which is significant, rather than any inherent quality of those three named lubricants.

Someone else looked at a different variety of lubes and vaginal treatments and found they all had the same basic effect. KY Jelly is the most famous one the second survey rather than the first.

They also looked at what ingredients had this effect and considered that most had some effect, but it was the gelling agents that had the most effect.

As two of the three products (three out of four, considering that Astroglide = Silken Secret) in the first study were by the same manufacturer, I wonder if they did some PR to push the results to give their products a boost.

Incidentally, another one of the five articles is about finding a neutral placebo product to test against in such trials. They killed a lot of bunny rabbits (to look at the effects on rabbit vaginas of their candidates) and infected quite a few primates (just to make sure it had no preventative effect) before coming up with something. Ah, the joys of medical research.

And the other one of the five studies to cite the original one was about being cruel to mice, erm, giving them Ketamine (!) and then sticking various lubricants up their bottoms to see what effect that had (!!)*

Interestingly, the three lubes mentioned as having some adverse effect on (mouse) rectal tissue – though not as bad as spermicide – were… Silken Secret, Vagisil and ViAmor. Oops.

Oddly enough the makers have kept bloody quiet about this study but, again, those three were the only three sexual lubes tested (out of seven substances: two spermicides, these three, a designed-to-be-neutral placebo and a proposed new lube) and it's quite possible most have the same effect.

Moral of the story? Look up the original report and don't trust the press release.

Oh, and try to do your research without killing primates in particular, and mammals in general.

(*) But reading the Sigma Research reports on their annual sex surveys, I suppose that taking K and sticking lube up their bottom does indeed reflect the reality of life for some gay men