Awareness of blood policy history
Participants’ awareness of the history of MSM-specific blood donation policies in Canada varied. The majority of men explained that they knew that there used to be a lifetime ban on blood donation for MSM. However, only a few participants in each province mentioned being aware that there were cases where HIV was transmitted through blood transfusions early in the epidemic. Perhaps not surprisingly, many of these participants tended to be older, indicating a generational component to the perspectives and knowledge on policy history among some men who were adults that lived through the early years of the AIDS epidemic.
Most participants believed that the original lifetime ban was a result of insufficient testing technology, homophobia, and AIDS stigma. For example, one participant stated that the reason for the indefinite ban had “something to do with maybe religion or just the stigma on homosexuality” (age 26, HIV-negative, Toronto), while another claimed, “I think that at that point it was mostly fear and paranoia that caused [the life ban] but since then there’s been a lot more testing and research done to disprove it [as necessary]” (age 34, HIV-negative, Toronto). One interviewee made it clear how discriminatory the original life ban was toward GBM communities: “It just seemed really stigmatizing and growing up and hearing in the community, ‘It’s in you to give and donate. It’s a good thing to do. It helps people and we need blood.’ And then to be completely shut out based on your sexual identity is really stigmatizing and really disappointing” (age 39, HIV-negative, Vancouver).
Despite differences in awareness of the history of MSM blood donation policy, all of the participants knew of the 12-month deferral policy, which was in place at the time of the interviews. They were, in general, quite eager to express their views on whether they considered this policy equitable and what policy alternatives they thought to be improvements to the current practice of deferment. Below, we outline participants’ views on these questions, beginning with their perceptions of the 12-month deferral policy.
Policy equity, scientific evidence, and policy improvements
Most participants expressed that they did not consider the 12-month abstention-based policy for MSM to be equitable. They believed that a fair and safe policy would be one that was the same for all people. For example, one man communicated that the ideal policy would be one where “men who have sex with men [are] allowed to donate blood freely” (age 24, HIV-negative, Toronto).
Viewpoints about policy equity were guided by a general belief that differences in policy rooted in sexuality or identity, or behaviours closely aligned with identity, are inherently unjust and discriminatory. As one participant stated, he wanted “a policy that is equitable and the same for everyone regardless of their sexual orientation, their gender identity, their colour, or their origins and cultural background. I think that the policies now in place across the board are very prejudiced” (age 33, HIV-negative, Vancouver). Another man declared that “If there is a period of exclusion for a gay man, there must be the same thing for other categories of people. And also, if there is not for other categories of people, there must not be [one] for gays” (age 43, HIV-negative, Montreal). Echoing a desire for equitable policy, one participant put it this way: “Yeah, I just think it should be equal. It should be equitable. It should be the same language as what it is for straight people. [ …] just like HIV would affect a straight person’s body the same way it would a gay person’s body” (age 33, HIV-negative, Toronto).
A few participants also commented that having low risk sex like oral sex as an exclusion criterion did not make sense to them: “Well my understanding is that they can now donate blood if they’ve been celibate for a year. What I’m confused about is what they mean by “celibate” because there’s a whole range of sexual practices. Some of them are extremely low risk” (age 33, HIV-negative, Vancouver). Another stated: “if somebody gave somebody head [i.e. oral sex] three months ago, I still think they should be able to donate” (age 27, HIV-negative, Toronto).
A minority of participants thought that a MSM-specific blood donation policy was not problematic. For example, one man described MSM-specific blood donation policies as necessary for public safety given higher rates of HIV among gay men:
Well I think it’s statistically proven that gay men do have higher rates of HIV infection compared to straight people, and also they are statistically having more sex and more dangerous sex than other populations. And I think that as a public safety concern we should place some kind of screening to protect the public. And if the period of HIV infection being undetectable didn’t exist, I wouldn’t have these concerns. But considering that gay people are at a higher risk and there is a period where it’s undetectable, I feel uncomfortable without that kind of [timed abstention] rule [for MSM] (age 26, HIV-negative, Toronto).
Nonetheless, a large majority of participants believed that any MSM-specific policies were discriminatory and that a more equitable policy choice would be one that better matched with current scientific evidence. For example, one interviewee declared that while MSM-based deferral policies made sense previously, they are now outdated: “It’s completely unfair, there is no reason today. There is no reason anymore” (age 43, HIV-negative, Montreal). Another articulated that the policy does not reflect advancements in technology: “The technology is changing. The science is changing. The screening methods are getting better and better and better, so I think our policy needs to reflect that” (age 39, HIV-negative, Vancouver).
These men did not believe that MSM-specific policies were based on the best available science and argued that current deferral policies could be improved to increase the donor supply in a more equitable fashion if they were more closely aligned with scientific evidence and technological advancements. Many articulated how an MSM-specific policy appeared to be based on outdated knowledge and logic that they did not agree with or understand. Thus, opinions about equitable policy and scientifically informed policy were mutually intertwined. For example, one man stated:
I think strong intake and then blood testing that has absolutely no distinguishing between gay men, men who have sex with men and heterosexual, bisexual, pansexual people because it’s based on historical fallacies. Again, nothing has ever been presented to me that has convinced me that the ban against men who have sex with men’s blood makes any sense at all (age 30, HIV-negative, Toronto).
Participants discussed two general ways in which the policy could catch up to existing scientific knowledge on HIV and, as such, could also become more equitable. The first was through universal or “gender-blind”
2 screening practices focusing on risk factors for all blood donors regardless of their sexual orientation. The second was through deferral practices closely guided by HIV/STI testing technologies.
Universal screening and deferral practices: gender-blind screening
Although most participants agreed that MSM are more likely to acquire HIV, with some also referencing increased hepatitis and syphilis transmission, many expressed opinions about deferral-based policies that suggested that these policies were outdated and misinformed about sexual health realities. These opinions were closely connected to reflections on how screening and deferral practices should instead take into consideration a more sophisticated measure of transmission factors that could be equally applied to any sexually active person (regardless of sexual orientation or the gender of their partner). These participants argued that the screening and donation processes should include asking more detailed questions and offering counselling about transmission factors, sexual behaviour, preferred prevention strategies, and recent testing history.
For example, one interviewee declared that the ideal policy would pay more attention to “risk behaviour as opposed to sexuality” (age 34, HIV-negative, Toronto). Echoing this theme, another stated that “we can rely on a valid assessment of the person’s risk level and the fact that they’re gay or not is irrelevant” (age 69, HIV-negative, Vancouver). Some participants prefaced their reflections on what things would look like from a policy perspective in an “ideal” world. For example, one man put it like this:
In an ideal world, then, the rules should be the same for everybody, because straight people get HIV, they get STIs, they’re not always monogamous, they have oral sex, they have anal sex. […] So, it should be the same. I would say make the rules the same for everybody (age 61, HIV-negative, Vancouver).
Some participants articulated that they simply did not understand why blood donation policy was different in instances of opposite-sex versus same-sex sexual activity. For example, one man said: “I feel like it should be exactly the same as straight couples. Whatever rules are in place over there should be fine for us because it’s ‘why’ at this point?” (age 24, HIV-negative, Toronto). A recurrent theme among some participants was the feeling that it is unfair and/or unclear why heterosexuals can have frequent casual “unsafe” sex and still donate blood while they themselves are not able to donate blood when practicing safer sex strategies and/or being in monogamous relationships. One participant added:
We should look more at risky sexual behaviour independently of a person’s sexual orientation or gender. […] Get rid, in fact, we have to extract that thing about sexual orientation in this policy. We are talking about blood, not about sexual orientation. You know, my blood is not supposed to be better or worse. (age 34, HIV-negative, Montreal)
While these participants thought that everyone should be screened based on the same set of “risk factors,” they were generally vague or uncertain on what exactly these risk factors should be. Moreover, some participants made it clear that members of GBM communities have higher probabilities of contracting HIV, contradicting the idea that condomless sex between two heterosexuals versus two men is identical in terms of risk and opposing the notion that risk behaviours can be evaluated independently of the gender of the donor and their sexual partners. Moreover, participants did not speak to how applying a universal risk factor policy which excluded, for example, all individuals based on recently having had condomless sex within a specific time window, could drastically reduce the current heterosexual donor pool.
Relying on HIV/STI testing
Participants discussed how they saw MSM-specific donation policies as inequitable since they did not seem to consider scientific advancements in HIV testing. As one man expressed, a 12-month deferral did not make sense to him because current testing technologies are accurate by 3-months:
Well, we have to evolve with science. If we can, you know, with the efficiency of tests at this moment, I don’t know, we say 3 months, but I read things, it was like 2-3 weeks, they can detect, I don’t know. So policy should evolve with science, if we can detect and minimize risks for others, I would agree with that. Anyway, for me, it’s like this: follow science. (age 35, HIV-negative, Montreal)
The men we interviewed demonstrated varying levels of knowledge regarding how blood donation works in practice. Some participants were unsure whether or not CBS or Héma-Québec relied solely on a potential donor’s answers to the screening to determine the safety of collected blood. Similarly, others expressed confusion about the current 12-month deferral policy because they did not understand why CBS or Héma-Québec had to defer donations based on screening questions if they were going to test all of the blood regardless. Several participants argued that CBS and Héma-Québec should accept all blood donations and then test the blood prior to using it for transfusions, since relying on people’s answers to screening questions is not adequate.
As one interviewee stated: “I’m presuming that at some point they’re testing the blood so if your blood is fine then I don’t see why it’s relevant who you’re having sex with” (age 23, HIV-negative, Vancouver). When asked about screening questions, one man mentioned, “I think it’s irrelevant [to ask screening questions]. It is not the nurse’s business. Once again, the test is the best thing” (age 22, HIV-negative, Montreal). While another declared that “I think they [sexually active persons] should both donate blood and it should just be tested” (age 26, HIV-negative, Toronto).
Several participants articulated that a point-of-care HIV test or a mandatory HIV/STI test should be a part of the blood donation process. For example, one participant described how he thought this could work in practice:
I think that it should be rapid point of testing at the donation site. If you test [HIV] positive, you’re ineligible. They refer you to see a doctor or tell you to go see your family doctor or schedule an appointment for you to go see your family doctor. Whatever it is that they do, I feel like they should ask you questions in regards to your sexual history, especially for like intravenous drug use and your general kind of health. But at the end of the day the sex that you have shouldn’t really play a part if you’re eligible to give blood (age 34, HIV-negative, Toronto).
Interestingly, while the above participant was critical of sexual behaviour being a factor in determining donor eligibility, he did not consider the potential for safer drug use and agreed with a blanket deferral for intravenous drug users. Most participants we interviewed thought that the blood donation process could become more equitable by asking questions about past HIV testing history, accepting all blood donations and testing the blood prior to use, and/or having a mandatory point-of-care HIV/STI tests as part of the blood donation process.
Considerations of a 3-month deferral policy
We asked participants about their opinions on a donation policy shift from a 12-month to a 3-month abstention for sexual activity between MSM before this 3-month policy was implemented. Viewpoints about this proposed 3-month deferral policy reflected the participants’ general opinions about deferral policies specific to MSM, as discussed above. The majority who believed that any MSM-specific policy was discriminatory and inequitable continued to consider a 3-month deferral to be an inadequate policy change. However, though most did not consider a 3-month deferral to be an ideal policy, there were variances in how participants understood the potential benefits and limitations of this proposed change. That is, while the opinions discussed above represented more general views on the relationship between equity, science, and policy-making—and thus offered somewhat open-ended and general reflections on policy improvements—the 3-month option was a clear and specific policy alternative that caused participants to evaluate issues of equity and scientific evidence in relation to pragmatic aspects of policy-making, including the notions of compromise and incremental improvement.
Participants expressed three general viewpoints about a 3-month deferral policy: Step in the Right Direction, Ambivalent or Uncertain about Implications, and 3-Month Deferral not an Improvement. The last viewpoint also included the sub-category 3-months not being long enough of a deferral. A connecting thread across these policy perspectives was that this policy change would not be able to resolve the fundamental issue of inequity currently affecting MSM blood screening practices in Canada.
Step in the right direction
Several participants vocalized that they considered a 3-month deferral to be a positive (albeit imperfect) policy change. Though they did not consider this to be the ideal policy, they understood this to be an incremental step in the right direction. For instance, one man reacted to the proposed policy change with “Wow. Getting half shorter [than 6 months]. That will be even more positive” (age 67, HIV-negative, Vancouver). He mentioned that this would make more people eligible to donate. A few interviewees described the 3-month deferral as being “okay” or “a good idea” as this period of time would more closely approximate the window period of current HIV testing technologies.
One participant described the 3-month deferral as a pragmatic “stepping stone”:
I think [a 3-month deferral is] a little bit more realistic. There probably could be an even better policy but if we’re talking about [being] realistic and making progressions that would be a big step compared to the one that’s in place right now and I think it’s a lot more realistic for more individuals if they think that donating blood is a high priority for them. (age 22, HIV-negative, Vancouver)
This participant went on to clarify that more research is needed to improve the policy and that “the work shouldn’t just stop there [3 months]. There should be more consideration into not having a time policy, and screening based on sexual practices…”.
One participant expressed that he saw the 3-month deferral as a real improvement on either the 12-month or a potential 6-month deferral, because there would be more people eligible to donate. He described the 3-month policy change in positive terms: “So I feel like it definitely would be better if that happened. It would just be one step closer to becoming like good for everyone” (age 26, HIV-negative, Toronto). While another man stated: “It’s more reasonable, you know. At least, it fits with something we hear often, that is, after 3 months, you are sure and certain that you did not get anything if you did expose yourself to a risk” (age 35, HIV-negative, Montreal).
Ambivalent or uncertain about the implications
While the previous category positioned a 3-month deferral as a productive, incremental compromise, this group was far more uncertain about whether or not this policy shift signified any real improvement. For example, one participant mentioned that “It does seem like it’s a lot of the same. I guess comparatively three months is better than a year. But putting a time limit on it versus actual life practices is kind of backwards thinking” (age 26, HIV-negative, Toronto). One man argued that this policy shift would probably increase the blood donor pool with a fairly good-sized group, but he ultimately argued that such a policy “in all actuality does not affect whether or not I’m eligible or not eligible if I’m meeting all the criteria that’s set. So why is there a time limit?” (age 30, HIV-negative, Toronto).
Some participants who expressed degrees of uncertainty with this policy change tried to determine the extent to which this reform may increase the eligible donor pool of MSM. For example, one participant believed that the policy shift would broaden the pool of eligible donors but would still fail to reach most people who are regularly sexually active. Hence, he reflected on how such a change would be “a step in the right direction but not one hundred percent” (age 34, HIV-negative, Toronto). Some participants tried to balance both sides of the argument for this policy shift, ultimately appearing ambivalent about a policy change.
One participant struggled to weigh the practicality of a 3-month abstention-based policy that aligns better with what we know about testing, with his strong desire for universal non-MSM specific based deferral practices:
Well, 3 months. That’s difficult. For me, it coincides a little with screening [i.e. HIV testing]. That is, you know, I mean, I imagine in 3 months, well, as I say, maybe 3 months makes more sense, but still, having sex with a man should not be a criterion for exclusion (age 34, HIV-negative, Montreal).
Multiple participants appeared to understand the idea of a 3-month deferral period—or window period—given how this length of time is part of HIV and sexual health testing culture.
One man first expressed mild interest for the 3-month deferral and said that he would be able and willing to donate under this policy. However, when he asked if this 3-month deferral would affect all potential donors and was told that it would remain specific to men who have sex with men, he opined: “Oh okay. No, that’s so unfair. Then three months is still not fair” (age 24, HIV-negative, Vancouver).
Another similarly stated that he did see the 3-month policy to be an “improvement” but his ambivalence was pronounced: “Yeah. I guess if there was a lack of other options, I would rally behind it” (age 30, HIV-negative, Toronto). This participant mentioned that the deferral policies did not “make any sense to me” and that he was cautious about how his own prejudices toward HIV and higher risk sex may be affecting his evaluations of this potential policy change. Similarly, one interviewee thought the 3-month policy would “be productive I think. I mean if the only possible way to approach it is to approach it from the perspective of an abstention period” (age 23, HIV-negative, Vancouver). Yet he was still unclear as to why this particular temporal change:
I’d be interested to know what the buffers are. Why is it 3 months for example? What’s the rationale there? Is it just to be on the safe side? Because I feel like I need to know more. I feel like that cannot just possibly be it. But yeah, I think three months is more likely to be successful but still it is again a long time and it’s a lot to expect of people in terms of to dictate that people would want to [donate]. (age 23, HIV-negative, Vancouver).
One participant considered the 3-month deferral to be “a little bit more realistic” than the current policy (age 34, HIV-negative, Vancouver). However, he did not understand the logic whereby some people could donate blood and be sexually active and other people had to abstain. In his opinion, “given the testing that we have today it should just be like no sexual contact for X period of time for anyone donating blood. You know, probably like a month, I tend to think.” Meanwhile another participant described the 3-month deferral as being “more like possible” (age 27, HIV-negative, Vancouver) to increase his eligibility. However, he argued that he had worked hard to overcome shame around sex and body image issues. Being sexually active was really important to him because “it’s healing, it builds community and it’s fun. So I don’t think, you know, 3 months, I’ve certainly gone that long [without sex] but I still don’t think it, like I think there’s, I guess I’m a very sex positive person and any sex negative policy irks me the wrong way, or rubs me the wrong way. It irks me.” This participant echoed a theme common across many interviews: MSM blood deferral policy is anti-gay sex.
Not an improvement
The last viewpoint was that the 3-month deferral policy was not a significant improvement on the current 12-month deferral policy. These participants were exceedingly critical of any policy change that further differentiated between homosexual and heterosexual sexuality. One man argued that “abstinence isn’t the solution” (age 33, HIV-negative, Vancouver) and another mentioned “I don’t think the [reduced] timeframe makes any difference” (age 69, HIV-negative, Vancouver). Many participants argued that a 3-month abstention policy is still an inequitable policy. One man put it like this:
For me, it’s discrimination. This is an injustice we must correct it. Do we say it’s 3-months for everybody, straight people as well, we want that waiting period as well after intercourse? Fine, but also for straights (age 43, HIV-negative, Montreal).
Many participants made it clear that a 3-month deferral leaves us in the same situation as a 12-month deferral: a policy that discriminates. One participant expressed his concern like this: “Because you are homosexual, you have to wait 3 months, 6 months? And the straight couple, they don’t wait? I mean, the man and the woman, the woman, she can have 4 partners in one evening, and the next day, she will give blood. But us, because it’s ok with the straights, you’re homosexual, you wait 3 months. I don’t follow” (age 65, HIV-negative, Montreal).
Some interviewees were critical of the 3-month policy because they did not see it changing anything since they were not going to go 3 months without any sexual activity. As one man described, the 3-month deferral would be “still problematic” because “who’s going to be celibate for those periods of time? Full stop” (age 36, HIV-positive, Toronto). Meanwhile, another participant questioned whether it was realistic or impactful because “you may [just] find the occasional person that will do that” (age 59, HIV-positive, Vancouver).
For one man, the 3-month deferral does nothing to address the equity issues key to the current debates on blood donation:
I have a problem with the deferral because it’s still aiming at the gay population but the bisexual and the straight man who had unprotected sex [with women] and goes to the clinic and gives blood has an easier time than us. So I have a problem with this. (age 63, HIV-positive, Toronto).
Similarly, one interviewee described the 3-month policy as “unrealistic,” mentioning that no one was going to want to donate under that policy and describing the 3-month deferral as:
A bit of a slap in the face because it’d be straight up ignorant. It’s not actually looking at the [sexual] partnership. Again, pulling up to a [gay] couple that’s been together for 20 years and being completely monogamous— for some reason they have to stop having sex for 3 months just [because] the blood might be tainted. What? Like, it’s not realistic in the slightest. (age 24, HIV-negative, Toronto)
Another participant argued that the 3-month deferral would only be a good choice if “it was applied to heterosexuals as well and if it’s the same rules for everyone then yes but if it’s just targeting gay men I’d say no” (age 49, HIV-negative, Vancouver). This participant described the policy change as somewhat impractical and not a significant change. Many men expressed that they did not think moving to a 3-month deferral would increase the blood supply by much given the improbability of most people remaining sexually abstinent.
The following participant was skeptical of whether or not service providers at blood donation clinics would actually want to take the blood donation of any MSM under a 3-month deferral policy because it would be difficult to prove that men had actually been abstaining:
I’d be interested to know what that ends up looking like in terms of service providers even in that scenario where it’s a 3-month testing abstention period, would service providers actually even want gay men’s blood. Would they believe them enough? Would it be a pool of candidates who could be trusted enough in terms of the accuracy of the information provided? That’s a question I would ask, yeah. (age 23, HIV-negative, Vancouver)
Three months not long enough of a deferral
Four participants expressed criticisms of the 3-month deferral because they did not think it was long enough of an abstention period. These men believed that certain behaviours, like condomless anal sex, should exclude GBM from donating. One participant thought that a “one year [deferral] is good enough” arguing that it would be difficult for people to remember their sexual activity histories and thus longer abstention periods act as a safeguard (age 26, HIV-negative, Toronto). Another man also thought 3 months might be “a little bit too soon” because it takes up to 6 months for HIV symptoms to “crop up” (age 33, HIV-negative, Vancouver). He preferred a 6-month abstention-based policy. One participant described syphilis testing results to say that he thought a 6 or 9-month deferral would be more ideal (age 34, HIV-negative, Toronto). Finally, another man questioned whether or not 3-months might be too soon: “It’s possible that I will not know what happened, given a sexual relation 3 months ago, what are the impacts on my life right now, I do not know. 3 months, I may not have time to be tested, I did not have a reason to be tested. 6 months, I think it begins to be a little more, I would not say reasonable, but you have a chance of having a confirmation if I have a doubt” (age 58, HIV-negative, Montreal).