文章信息
- 姜婷婷, 蔡高峰, 潘晓红, 马瞧勤. 2014.
- Jiang Tingting, Cai Gaofeng, Pan Xiaohong, Ma Qiaoqin. 2014.
- 男男性行为者高危性行为社会心理影响因素研究进展
- Psychosocial factors related to the practice of high risk sexual behavior among men who have sex with men:a review
- 中华流行病学杂志, 2014, 35(10): 1177-1180
- Chinese Journal of Epidemiology, 2014, 35(10): 1177-1180
- http://dx.doi.org/10.3760/cma.j.issn.0254-6450.2014.10.023
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文章历史
- 投稿日期:2014-4-2
在美国等西方国家和某些亚洲国家如泰国,MSM是出现艾滋病流行与扩散最早和最主要的人群之一,已经成为HIV感染的重点人群之一[1],也是中国HIV/AIDS感染的高危人群和桥梁人群[2, 3]。MSM中普遍存在的多性伴和高危性行为是该人群感染HIV的主要原因[4, 5]。减少MSM高危性行为的频次可以减少HIV传播的发生[6]。MSM中高HIV感染率已成为亟需解决的社会现实问题。社会心理学是建立在具体社会心理现象之上的理论[7],主要涉及社会认知、社会关系以及群体与群体过程三大领域[8]。MSM作为弱势群体,由这一群体所衍生出的个体认知、社会认知、群际关系和社会关系等都属于社会心理学研究的范畴,从社会心理学角度对MSM高危性行为进行探索对了解MSM内群体以及与外群体的关系有着十分重要的意义。因此,本文对近年来相关研究文献进行综述,从个体、人际和情境等社会心理学角度探讨MSM发生高危性行为的原因,为开展行为干预,制定针对性的预防干预措施提供依据。 1. 个体因素
(1)生理快感和心理亲密感:Newcomb等[9]研究指出,寻求更高水平的生理刺激与无保护性行为的次数存在显著正相关。一项对拉丁裔MSM的研究指出,追求更多的生理快感以及和同伴之间的亲密感是进行无保护性交的主要动机[10]。Calabrese等[11]考察了与使用安全套有关的快感缺失对生活在美国的拉丁裔MSM既往无保护性肛交(UAI)的影响,结果表明,与使用安全套有关的快感缺失是肛交时使用安全套的一个主要障碍。安全套的舒适度和感觉问题会影响MSM使用安全套,Reece等[12]对HIV阳性MSM安全套使用生理舒适度的调查指出,相当一部分MSM存在安全套长度(13%觉得太长,16%觉得太短)和舒适度(21%觉得太紧、9%觉得太松)的问题,只有63%的人报告大小舒适度满意。还有研究指出,MSM无保护性交行为会受到两种决策的影响:为了应对心理脆弱性和压力以及建立与其他MSM的亲密感,从而在性行为过程中不使用安全套[13]。
(2)抑郁:研究指出,相对于一般人群,MSM表现出较高的抑郁水平,而抑郁能显著影响其身心健康[14, 15]。Mimiaga 等[16]的研究指出,有抑郁症状的MSM比没有抑郁症状的MSM有更多的高危性行为。对于抑郁程度与高危性行为之间的关系,Koblin[17]和Reisner[18]等研究指出,中等程度的抑郁更可能使MSM发生高危性行为,这些行为会增加感染HIV和其他性病的危险。Fendrich等[19]研究指出,芝加哥地区高抑郁水平的MSM会报告较多的UAI及与危险性伴发生性关系。Alvy等[20]认为,这也许与研究人群的个体差异有关。抑郁症状与MSM的HIV感染高度相关,其与高危性行为的关系也受到HIV感染状况的调节。在HIV阴性MSM中,高抑郁水平的MSM会报告较多的UAI次数及与阳性性伴发生UAI[21]。在HIV阳性MSM中,抑郁程度与高危性行为的关系存在不同解释:Houston 等[21]指出HIV阳性者的抑郁症状与UAI无关;而O’Cleirigh等[22]对HIV阳性MSM超过12个月的随访调查中发现,中等程度的抑郁水平可以减少其高危性行为。从上述研究得知,HIV阴性的MSM本身较高的抑郁水平会增加高危性行为,导致HIV感染的发生;而MSM感染HIV之后,其抑郁症状与高危性行为的关系,目前尚无定论,需要进一步探索。抑郁症状与其他能够增加高危性行为的活动也显著相关,如药物(酒精、毒品等)滥用[23, 24]、卖淫[25]、多性伴[26]等。
(3)高危性行为风险感知:① HIV感染知识的缺乏:尽管MSM对HIV/AIDS知识的了解和信仰程度比双性恋和普通人群要高很多[27],但对HIV感染相关知识的认识不足或缺乏仍然是MSM实施高危性行为、感染HIV的主要原因之一[28, 29]。Thomas 等[30]研究印度MSM发生高危性行为的原因指出,由于MSM认为HIV是通过阴道性交和女性性工作者传播的,导致个体采用交替的肛交和口交作为一种避免感染的方式。Mason等[31]指出,在非洲西部,艾滋病感染风险知识知晓率很低,只有3.5%的人知道插入性肛交是最危险的高危性行为。Fay等[32]评估撒哈拉以南非洲地区MSM中HIV相关知识,发现有93%的MSM知道HIV是经过与同性肛交传播的,但是只有67%的人接收到如何防止这种传播的信息。②盲目乐观:研究表明,个体往往对将来可能发生的事情持有盲目的乐观态度,这种乐观态度更多的发生在年轻人和老年人[33]。同性恋者对于感染HIV/AIDS有着盲目的乐观态度[34]。蔡晓峰等[35]的研究指出,在从未做过检测的MSM 人群当中,有62.9%的人认为自己不会感染艾滋病。Fern??ndez 等[28]对495名HIV阳性MSM的研究指出,尽管有97%的人知道如何预防HIV,但仍然有41%的MSM认为自己不会感染HIV且不采取安全措施,32%的MSM则认为自己感染HIV是运气太差。Nelson 等[36]的研究也证明了此结论,尽管了解潜在的危险,大多数MSM仍然会继续进行高危性行为。这种盲目的乐观可能也会阻止MSM(尤其是年轻和老年MSM)感知外界事物的风险,从而来不及采取有效措施,导致感染HIV的可能性增加。
(4)儿童期性虐待经历:儿童期性虐待(childhood sexual abuse,CSA)最严格的定义为:个体16岁之前遭遇过成年男性实施的强迫性性交[37]。相对于没有CSA经历的MSM,有CSA经历的MSM会经历更多的高危性行为[37],拥有更多的性伴,过去6个月内经历UAI的行为要高出2倍[38]。Mimiaga等[39]首次通过队列验证了CSA经历是MSM感染HIV的一个预测因素,有CSA经历的个体会报告更多的高危性行为;相对于没有CSA经历的MSM,有CSA经历的MSM报告更多的药物滥用、抑郁、较低的自我效能感、较差的沟通技巧、较低的安全性行为标准、更多的UAI、与HIV感染者进行UAI等,这些因素会导致有CSA经历的个体更易感染HIV。与该研究相似的是,Catania等[40]考察了影响CSA经历和高危性行为的因素,发现有严重CSA经历的MSM会报告较少使用积极应对方式,较多使用认知和行为消极应对方式,有更多消极/攻击性的性规范,以及较弱的人际关系管理能力,通过这些因素来影响MSM的高危性行为。 2.人际因素——负性生活事件
负性生活事件是指生活中遇到的一些压力和创伤性事件,包括身体和性方面的虐待、重要他人(好友和家人)的死亡或重病、金融压力、就业压力和在法律方面遇到的困难、离异/分居、重大疾病、伤害和事故等[41, 42],它与高危性行为有关。Pence等[43]研究了重大疾病、家庭成员或好友的生病或死亡、经济压力、亲密关系压力等这些消极应激事件与MSM、异性恋和女性感染者的高危性行为之间的关系,结果表明,每一种消极生活事件都与高危性行为增加有关。来自外界的污名与歧视是MSM面临的主要负性生活事件之一。污名与歧视是预测MSM抑郁的一个因素,感受到的污名与歧视得分越高,抑郁越严重[44]。HIV感染者包括MSM,与HIV相关的污名与歧视会转化为一种慢性压力源,导致安全性行为及安全套使用难度加大[45]。负面人际事件(如由于是同性恋而导致被打或辱骂、被不公平或粗鲁地对待、被取笑等)也会导致MSM的UAI行为增加。Jeffries等[46]指出,经历过恐同事件(如被打或辱骂)比没有经历恐同事件的MSM(包括HIV阳性和阴性者),高危性行为的比率有所增加。缺乏家庭支持的MSM也会有较多的无保护性行为[47]。 3. 情境因素
(1)酒精和毒品等兴奋剂的使用:酒精、毒品和兴奋剂等物质的使用对HIV感染的影响已得到证实。Chesney等[23]指出酒精和毒品滥用可以帮助缓解个体的抑郁情绪,但是会增加高危行为。UAI等高危性行为的增加与经常饮酒和酗酒有关[48]。Woolf-King等[49]的研究指出,兴奋剂、勃起功能障碍药物、酒精使用和强迫性行为与自身HIV感染状态不一致的UAI高发生率之间存在独立相关,强迫性行为与UAI之间的关系受到兴奋剂和勃起功能药物使用的影响。有研究认为,MSM中高危性行为的一个潜在的预测变量是饮酒[50];但也有人提出了不同意见:尽管某些兴奋药物的使用和高危性行为之间存在着显著正相关,但饮酒作为高危性行为的一个预测因素研究还没有得到证实,年轻MSM饮酒对高危性行为的影响受到寻求刺激水平以及酒精饮用量的影响[9]。因此,有关酒精使用和高危性行为之间的关系需要进一步探讨。
(2)以同性恋为主题的色情媒体的影响:从20世纪90年代开始,MSM安全性行为的减少及HIV感染率增加与以同性恋为主题的色情消费或色情媒体(sexually explicit media,SEM)的增加存在一致性。在MSM社区,SEM是普遍存在的,色情图片在MSM中具有高度的可接受性[51]。Stein等[52]考察了观看UAI的色情描述与进行UAI是否相关,结果表明,观看UAI的色情描述与进行UAI之间存在正相关。观看较多无套肛交SEM的MSM有可能存在更多的高危性行为[53],这一研究结果也提示,对无套肛交SEM的偏爱会导致MSM经历较多的高危性行为。Rosser等[54]推测,观看几个小时安全性交或无套性交的SEM可能会增加或降低安全性行为的流行。因此,需要考虑MSM本身对SEM的偏爱类型以及不同类型的SEM与高危性行为的关系,从而制定相应的干预策略。 4. 其他
Shuper等[55]指出,个性特征(强迫性行为、寻求刺激、精神病性冲动)是预测MSM HIV高危性行为的因素之一;Dyer等[56]指出,MSM的性行为特征(包括单纯同性恋和双性恋)也会影响其高危性行为,在酒精作用下,双性恋会比单纯同性恋报告更多的无保护性行为;年龄[1]、教育水平[57]、种族[58]、低社会责任感[59]、自尊[60]等也与高危性行为相关。 5.展望
MSM发生高危性行为的原因复杂而多样。为了更深入地阐述MSM高危性行为的原因,必须采用多种研究方法并考虑各种影响因素,其方法是深入MSM,并建立信任关系,利用观察法、定性访谈等社会学研究方法从MSM自身切实了解高危性行为的原因,另外还可以尝试建立高危性行为与潜在影响因素关系的行为模型,在模型条件下分析不同因素对MSM高危性行为产生的影响,为完善MSM防治措施提供依据。
目前已有很多研究探讨MSM高危性行为的深层原因,也有很多有意义的发现,只有将这些发现与实践结合起来,才能产生良好的干预效果。如抑郁、CSA经历、消极生活和人际事件等因素影响MSM的高危性行为,就需要结合现有的干预措施根据不同的MSM加入相对应的干预手段,通过心理咨询、团体辅导和个体辅导等方式减少这些因素对MSM的影响,从而降低MSM高危性行为;观看UAI的色情 视频可以增加MSM的高危性行为这一研究结果,为有关部门打击和限制淫秽视频提供了依据,可在一定程度上降低MSM的高危性行为等。因此,针对我国MSM,应充分考虑并结合社会心理学影响因素,将干预工作多面化、综合化、个体化,使其具有实用性、可操作性和实效性,有效减少该人群中HIV新发感染的发生。
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