The Willing and Able: Combatting Homophobia and Stigma in American Blood Donation
In April 2016, my ex-boyfriend and I went to an on-campus blood drive at our high school a few days after we had each had sex with each other. I had been able to donate blood in spite of my personal sexual activity several times before, so I did not believe that this time would be different. I was wrong. Both of us were deferred for a year on the basis that we were a sexually active, monogamous, protection-using gay couple.
For my ex-boyfriends and myself, along with countless other gay and bisexual men across the United States, this anecdote is not unique. In 1983 and 1992, the Food and Drug Administration issued standard-setting recommendations to blood centers to defer sexually active gay men indefinitely from donating, even if the sex was protected and monogamous. In 2015, the FDA revised these recommendations by shortening the deferral period to one year. While some activists and health organizations heralded the revision as a victory, many individuals still believe that the revision does not go far enough. The Food and Drug Administration’s 2015 revision of its earlier recommendations for blood donation is deeply flawed because the recommendations utilize weak scientific and medical reasoning, they codify homophobia, and they continue to fail to save the lives of potential blood recipients. In order to resolve the issues with the Food and Drug Administration’s blood donation recommendations, the United States should acknowledge its potential role in promoting human rights, follow the example of other countries such as Argentina and Russia as possible models for activism and policy change, and facilitate norm realization in other countries.
Before dissecting the problems within the Food and Drug Administration’s 2015 revised version of the 1992 blood memorandum, it is necessary to first analyze the original 1983 recommendations in order to evaluate the flawed foundation of the current recommendations. In 1983 the FDA published their report, “Recommendations to Decrease the Risk of Transmitting Acquired Immune Deficiency Syndrome (AIDS) from Blood Donors,” that recommended the indefinite deferral of several specific groups of individuals. Among these groups, two groups of “persons at increased risk of AIDS” are defined as “persons with symptoms and signs suggestive of AIDS” and “homosexual or bisexual men with multiple partners.” The first definition is problematic because, as outlined throughout the report “HIV and the Blood Supply: An Analysis of Crisis Decisionmaking,” several leading American health organizations, including the FDA, utilize an illusory correlation when referencing the prominence of AIDS among gay men. Essentially, multiple organizations argue that because there is a high rate of AIDS among gay men, gay men must be at an increased risk or predisposed to transmitting AIDS to others. Following this logic, the FDA outlines the standard operating procedures. In this way, major health organizations such as the FDA cemented the idea that same-sex sexual activity was “suggestive of AIDS,” thus laying the groundwork for the codification of homophobia and stigma through blood donation rhetoric and bureaucracy.
Defining persons “at increased risk of AIDS” as “sexually active homosexual or bisexual men with multiple partners” highlights one of the major disparities between the original 1983 recommendations and the 2015 revised recommendations. Here, the FDA provides an important specification that would not be sustained in future blood donation recommendations; in order for someone to be considered at increased risk, they had to be both homosexual or bisexual and sexually active with multiple partners. Under this definition, a gay man in a monogamous, sexual relationship, regardless of whether or not the sex was protected, would still be eligible to donate blood. Although these provisions in no way represent a perfect understanding of the nature of Human Immunodeficiency Virus (HIV), they do demonstrate a primitive understanding that sexual contact with multiple people may play a key factor in the catalyzing the rapid transmission of AIDS, and that same-sex sexual activity alone may not explain rapid rates of transmission or increased risk among individuals.
What scientists now know is that the transmission of AIDS is much more nuanced than sourcing from scapegoated and disenfranchised groups such as queer men, intravenous drug users, sex workers, immigrants, and hemophiliacs. As the United States Department of Health and Human Services highlights in a fact sheet addressing myths surrounding AIDS, “only certain body fluids – blood, semen, pre-seminal fluid, rectal fluids, vaginal fluids, and breast milk – from a person who has HIV can transmit HIV”. Findings such as these help to explain the prevalence of AIDS among each of the aforementioned groups. Rather than each of these groups being predisposed to contracting or transmitting AIDS due to their lifestyles or behaviors, the likelihood of contraction or transmission is determined as a deviation from an otherwise safe practice. For example, intravenous drug users are not predisposed to contract or transmit AIDS because they use drugs, but rather because they may use unsterile needles with traces of other people's’ bodily fluids still on them. Similarly, as the Centers for Disease Control and Prevention points out in a 2017 fact sheet titled “HIV Among Gay and Bisexual Men,” “most gay and bisexual men get HIV through having anal sex without condoms or medicines to prevent or treat HIV.” The high rate of transmission, then, is not due to same-sex sexual activity itself, but rather unprotected sex. With this nuanced and scientifically validated understanding of the causes of AIDS transmission, it should seem that the FDA would revise its recommendations accordingly to allow for sexually active gay men that have exclusively protected sex to donate blood.
In fact, this assumption is only partially true. In its 2015 “Revised Recommendations for Reducing the Risk of Human Immunodeficiency Virus Transmission by Blood and Blood Products,” the FDA recommended to all blood donation facilities, among other things, that the indefinite deferral of sexually active gay people be reduced to one year. Claiming to have revised their previous recommendations on the basis of responding to new scientific evidence and accusations of discrimination and homophobia, the FDA adjusted its position back to its core 1983 recommendation regarding donors engaging in same-sex sexual activity. The 1983 recommendation reads, “until the AIDS problem is resolved or definitive tests become available, [sexually active homosexual or bisexual men with multiple partners] should refrain from blood donation because of the potential risk of recipients of their blood.” Despite discoveries in the ensuing decades that AIDS was transmitted through bodily fluid exchange rather than lifestyle or identity, the FDA failed to alter its tone in its 2015 revised recommendations: “Defer for 12 months from the most recent sexual contact, a man who has had sex with another man during the past 12 months.” In contrast with the original 1983 recommendations, the concept of frequent sexual activity with multiple partners has seemingly become irrelevant. Additionally, even in light of the groundbreaking scientific discoveries detailing AIDS as transmissible only through the exchange of bodily fluids, the FDA claims that the use of protection is not a factor in its report: “Throughout this guidance the term ‘sex’ refers to having anal, oral, or vaginal sex, regardless of whether or not a condom or other protection is used.” This is the only mention in the 29-page report of the use of protection, one of the biggest factors, as stated earlier, in limiting the transmission and contraction of AIDS. If one utilizes the early and frequent use of protection, honestly answers blood donor questionnaires, has their blood subjected to screening, and takes responsibility to be tested regularly for sexually transmitted infections (STI), the risk of a blood recipient receiving an infected unit of blood is limited to less than a one in 500,000 chance (“HIV Transmission Through Transfusion – Missouri and Colorado, 2008”). With the chance of receiving an infected blood unit proven to be so miniscule, and the subsequent continuation of the deferral of gay men adding to climate of homophobia and stigmatization, it is irrational to continue the twelve-month deferral of gay men from donating blood in the United States.
While many activists and grassroots organizations have already successfully argued against the continuation of the arbitrary deferral recommendations, little traction has been gained since 2015 because of the lack of a clear path to alternative legislation. Grassroots organizations such as the Gay Men’s Health Crisis, Blood is Blood, and Banned4Life have each worked tirelessly to progress the agenda of allowing gay men to donate blood, uninhibited and without fear of discrimination, by organizing community blood drives, providing resources for HIV testing, and lobbying for policy change. These organizations help to catalyze public sentiment in the United States in favor of revising the 2015 recommendations, but they still fail to offer concrete alternative solutions.
Taking a cue from other countries that have allowed gay men to donate blood without a sexuality-based deferral, United States health organizations such as the FDA, can borrow scientific models for sustainable policy change. Of over a dozen countries that have eliminated the deferral of gay men based on their sexuality, two primary alternatives exist. The first, as used by countries such as Spain, Italy, and Russia, assesses individuals based on their sexual behavior, namely, whether or not they have been using protection during sex, and whether they are having sex with multiple partners, rather than their sexual orientation. Thus far, not one of these countries has experienced an increase in the number of AIDS infections via blood transfusions, indicating that this policy is a successful alternative. The second alternative, as utilized by countries like Argentina and Peru, uses the same strategy as the first alternative, but additionally connects the policy change to the progression of queer rights in those countries. For countries with more conservative views towards their queer population, such as the United States under the Trump administration, the first alternative may prove more suitable, while countries with more outspoken support for their queer communities may opt for the second alternative.
Through the work of grassroots organizations and pressure from the international community, the United States Food and Drug Administration will hopefully revise its recommendations and allow for queer people to freely donate blood to save lives. Perhaps then, the United States can begin to reclaim some of its former reputation as a champion of human rights by setting a precedent for blood donation rights around the world.