男男性行为人群安全套污名化的概念构建

目的: 中国男男性行为(men who have sex with men，MSM)人群中的艾滋病流行现状严峻，现已成为感染和传播艾滋病的重点人群。目前MSM人群中预防与控制艾滋病的瓶颈为安全套持续使用率低，不安全性行为发生率高。MSM人群安全套使用率低的最主要原因是与安全套相关的污名化。尽管很多研究提及MSM人群中与安全套相关的污名化问题，但尚未对MSM安全套污名化进行定义，亦无其测评工具。因此本研究构建MSM人群安全套污名化的概念和操作性定义，为该群体艾滋病高危行为干预提供新的视角。方法: 利用循证的方法，通过系统综述和Meta整合的方式，基于“PICoS”框架纳入文献，提取纳入文献中的质性研究证据，通过主题分析法进行概念合成，构建MSM人群安全套污名化的概念和操作性定义。结果: 根据概念合成的结果，MSM安全套污名化是指：从个体、人际和社会层面，自我表现出的对安全套和安全套使用行为的偏见、排斥和羞耻，以及羞辱或区别对待携带/购买/提出使用安全套的个体。其在操作层面包括4个维度：信任关系符号化、艾滋病/性病符号化、性话题羞耻化、传统性认知符号化。根据社会生态学模型的架构，信任关系符号化是指MSM人群认为不使用安全套代表性伴之间的相互信任，而使用安全套难以表达性伴间的亲密、信任与忠诚。艾滋病/性病符号化指MSM人群认为使用安全套是预防或已感染艾滋病的“代名词”。一方面，如果一方提出使用安全套，则可能被认为已感染HIV或者有不安全性行为经历，导致难以开口；另一方面，他们认为如果性伴“无艾滋病”(往往是错误的认知，如：性伴虽然没有艾滋病，但可能有感染HIV的高危风险)，则完全没有必要使用安全套。性话题羞耻化指对性行为相关的话题难以启齿，不好意思携带/购买/提出使用安全套或羞于进行是否使用安全套的对话。传统性认知符号化指对“性”或者“性行为”的认知有局限，认为“真正的性行为”是肉体与肉体无阻隔的接触和所有体液之间的交换。结论: 本研究首次提出MSM安全套污名化这一概念，并对其进行操作性定义。其概念包括3个层面、4个维度。该概念的构建有助于了解MSM人群对安全套的态度认知，为今后艾滋病行为干预的检测增加了文化敏感性和行为敏感性的指标。.

Objective: The epidemic of acquired immune deficiency syndrome (AIDS) among men who have sex with men (MSM) is severe in China. And MSM has now become a key population for the infection and transmission of AIDS. At present, the bottleneck of AIDS prevention and control among MSM population is low rate of continuous condom use and high incidence of unsafe sexual behavior. Inductive summarization of the literature revealed that the most critical reason for low rate of continuous condom use among the MSM population was condom-related stigma. Although many studies mentioned condom related stigma among MSM populations, there has been no any definition of MSM-related condom stigma and no measurement for it. Therefore, the paper aims to explore barriers to condom use among MSM, then construct the conceptual and operational definition of “MSM-related condom stigma” through Meta synthesis and concept synthesis, and provide a new perspective for AIDS prevention and control among MSM. 

Methods: Based on evidence-based method, “PICoS” framework and Meta-synthesis was used to include the literatures. Then, we used synthesized qualitative evidence from included studies to construct the concept and operational definition of MSM-related condom stigma by the means of thematic analysis and concept synthesis. 

Results: According to the results of the concept synthesis, MSM-related condom stigma refers to any taboos or misbeliefs about condom use or feeling ashamed or embarrassed to talk about using condoms which perceived by individuals at the individual, interpersonal, and social levels. It was demonstrated through 4 sub-themes at operational level: a symbol of distrust, a symbol of HIV/sexual transmitted infections (STIs) prevention, a symbol of an embarrassing topic, and a symbol of violating the traditional cognition of sexual intercourse. According to the Social-ecological Model (SEM), a symbol of distrust refers to that the MSM population believes that not using condoms represents mutual trust between sexual partners, while using condoms is difficult to express intimacy, trust and loyalty between sexual partners. A symbol of HIV/STIs prevention at the interpersonal level refers to that the MSM population believes that condom use is a “symbol” for the prevention or infection of AIDS; on the one hand, if someone proposes to use condoms, he may be considered infected with HIV or have unsafe sex experiences, thus, making it difficult to propose condom use; on the other hand, if they believe that sexual partners are “AIDS free” (often a wrong perception, such as sexual partners may have the risk of AIDS infection although they do not have AIDS), it is considered that condom use is completely unnecessary. The environmental level includes a symbol of an embarrassing topic and a symbol of violating the traditional cognition of sexual intercourse. A symbol of an embarrassing topic refers to the MSM population feels shame about topics related to sexual behavior and is embarrassed to carry/buy/propose condom use or be ashamed to engage in conversations about whether to use condoms during sexual behavior. And a symbol of violating the traditional cognition of sexual intercourse: The MSM population have limitations in their perception of “sex” or “sexual behavior” and believe that real sex (behavior) is unobstructed contact between the bodies and exchange between all body fluids. 

Conclusion: The concept of MSM-related condom stigma is proposed for the first time, and its operational definition is given. The concept includes 3 levels and 4 dimensions. It is helpful to understand MSM people’s attitude and cognition towards condoms, and adds indicators with cultural sensitivity and behavioral sensitivity to the behavioral intervention for AIDS in the future.