Characteristics of the sample
Three per cent of men responding to the Omnibus survey (1028/32
373) reported having had any sexual contact with a man and were routed to the blood donation module of the questionnaire (figure). Their mean age was 41.8 years (SD 16.86). Compared with men reporting no such experience, they were younger, of higher socioeconomic status and educational level, and more commonly single (table 1). Five per cent of male Omnibus survey respondents (1634) did not answer the question on male sexual contact and, compared with those who did, were older (41% v
24% aged ≥65), had lower socioeconomic status (40% v
30% in the two lowest socioeconomic groups), had lower educational level (32% v
20% had not completed secondary education), and were more commonly divorced, widowed, or separated (19% v
Recruitment of participants into the survey and qualitative interview
Table 1 Sociodemographic characteristics of 32 373 men responding to the Omnibus survey, by experience of sex with men. Values are numbers (percentages) or respondents unless stated otherwise
Just under half of men reporting male sexual experience (457/1028) agreed to be re-contacted. Eighty eight were selected for in depth interview, of whom 30 participated, 13 declined, and 45 could not be contacted (see figure). The average age of participants in the qualitative interviews was 42 years (range 21–71 years). They represented a range of sociodemographic characteristics and included eight “non-compliers” with the MSM donor deferral, three possible “non-compliers” (the chronology of first penetrative sex with a man and last blood donation was unclear, but there was some indication that they had donated since becoming ineligible), and 19 “compliers.” All (possible) “non-compliers,” however, were aged ≥35, had not donated blood in the past two years, and did not intend to do so again.
Almost half of male survey respondents reporting any same sex sexual contact had ever had penetrative sex with a man, just over half of whom (227/489) had done so in the previous 12 months and 23% of whom described their sexual identity as “straight” or heterosexual (table 2).
Table 2 Sexual practice and identity among the 1028 men reporting any male sexual contact in the Omnibus survey in Britain. Values are numbers (percentages) of respondents
Compliance with the lifetime MSM donor deferral
Of the 474 male survey respondents who reported experience of male penetrative sex, 50 (10.6%) had donated blood in Britain since becoming ineligible under the MSM donor deferral (“non-compliers”) and 11 (2.5%) had donated in the previous year (table 3). Ineligible donation was significantly less common among men who had had male penetrative sex recently (in the past 12 months) compared with those who had last done so longer ago (table 3), and among those who self identified as gay or homosexual compared with those who had not (5.2% v 15.5%, P<0.001). There were no differences in age, socioeconomic status, education, country of residence, or ethnicity by compliance status (data not shown).
“Non-compliers” described their reasons for having donated blood ineligibly in the qualitative component. Some had discounted the blood services’ exclusion based on risk on various grounds—that they practised safer sex or knew their own risk status, because of a belief in the infallibility of blood screening procedures, or because of feelings of resentment over the unfairness of the exclusion in the absence of an equivalent for heterosexual practices.
- “I just said ‘No’ for that question … for whether I’d had sex with men.… I knew I shouldn’t but I did because I knew for a fact that my blood was healthy; I didn’t have HIV … and I also know the fact that any sex that I did have I always took protection.”—“Non-complier,” interview 13
Others had discounted the experience that barred them from donating blood. This was particularly the case for men whose experience of sex with men had happened far enough in the past or just once to be considered insignificant to current risk status. A non-consensual sexual experience was too distressing to recall at the time of blood donation.
- “I answered ‘No’ [to the screening question asking about sex with a man].... I disowned it, um, because I was abused and raped.… It didn’t happen as far as I was concerned at that time.”—“Non-complier,” interview 5
For some, there was a reluctance to assume an identity associated with sex between men. For those who were, at the time, not open about their sexual practices or identity, the need for discretion had deterred self deferral in a public setting:
- “They didn’t know about me [my sexuality] till I was 25 ... and we [father and son] worked together.… It would have been very difficult to say to dad, ‘No, I can’t go and donate blood.’”—“Non-complier,” interview 20
A lack of clarity regarding the terms of the MSM donor deferral was also a barrier to compliance for some ineligible donors.
Knowledge and awareness
Survey findings revealed extensive lack of awareness of the rules relating to donation by men who had sex with men. Only one in four men with any experience of male sexual contact was aware that having had penetrative sex with another man barred donation. Almost a third believed that only unprotected penetrative male sex was a criterion for deferral. One in four did not know which groups were excluded (table 4). The proportion of “compliers” who cited having had any male sexual contact as their reason for not donating blood was almost as high as the proportion citing having had male penetrative sex (table 3).
Table 4 Perceptions of men reporting any male sexual contact on current and potential revisions to MSM donor deferral* criteria. Values are numbers (percentages) of respondents in agreement with statements†
A high degree of confidence was expressed in the certainty of medical science. Nearly half of all men with experience of male penetrative sex held that they would donate blood regardless of the rules because they believed the screening of blood to eliminate risk (table 4). This confidence in blood testing procedures was a common argument made by participants in the qualitative component against the lifetime MSM donor deferral. The possibility of administrative error resulting in the release of screened but infected blood was rarely mentioned and awareness of the “window period” between infection and detection, and its implications for screening effectiveness, was limited.
Views on the existing lifetime MSM donor deferral
Of the sample of 3914 men and women responding in the first two weeks of the Omnibus survey, most (1425 (78.6%) men, 1672 (79.6%) women) were of the view that the role of the blood services was to protect the blood supply rather than individual rights, agreeing with the statement: “The aim of the blood donation service is to make sure the country’s blood supply is safe and free from infection, not to enable anyone who wants to to give blood.” At the same time, a sizeable minority (38.5% men and 43.5% women) saw the MSM donor deferral as inflexible and excessive, agreeing that: “The current ban on gay men seems too rigid; it doesn’t make sense for a man who has had a single homosexual experience even before the HIV epidemic to be banned from being a blood donor.”
Among men with experience of male sexual contact, less than half agreed that the lifetime ban should be retained to ensure blood safety, and this proportion was significantly lower among men with experience of male penetrative sex (P<0.001) (table 4). Their views were further elaborated in the qualitative research. Although blood safety was recognised as the primary priority of the blood services, the ban was seen as outdated and founded more on the need for public reassurance than current scientific evidence. In view of the perceived absence of an equivalent deferral relating to high risk heterosexual practices, the MSM donor deferral was described as “unfair” and, by some, “discriminatory.”
- “There’s a lot of … STIs and HIV and everything in relationships that don’t involve male-male sex so it’s really discriminatory … maybe it’s the stereotype of guys that sleep around.… It’s kind of offensive for me ... I’ve probably had less sexual encounters than most straight women or men.”—“Complier,” interview 6
The lack of transparency in the rationale for the exclusion was seen to undermine confidence in its scientific basis. The inclusion of oral and protected sex was considered by some as contrary to safer sex messages. Of widespread concern was the “blanket” nature of the ban and its failure to distinguish between lifestyles conferring different risk status.
- “You have gay men, bisexual men, men who identify as heterosexual but have a bit of, you know, a dalliance every now and again, you have that whole range … you have promiscuous people, monogamous people, celibate people. You can never have ... sexual behaviour as a homogenous group.”—“Complier,” interview 4
Qualitative interviews also revealed tensions between concern for the right of the individual to donate blood and the protection of public health. Although giving blood was rarely considered a right, there was a strong sense that all potential donors were entitled to a considered assessment of risk based on current scientific evidence. Some saw the blood services as failing to benefit from potential supplies of usable blood by excluding healthy donors.
Views on revision of the MSM donor deferral
An individual risk assessment approach, taking account of risk status and risk reduction practice, regardless of one’s own or one’s partner’s gender, was widely considered to be the ideal replacement for the current MSM donor deferral.
- “It [would] no longer discriminate against a group of people, it makes it more sensible in a way that if a man’s had sex with 50 women then I think he’s a lot more at risk than if another man’s had sex with two men, kind of thing. So ... it’s fairer and more acceptable.”—“Complier,” interview 22
This option was, however, acknowledged to involve more in depth questioning that would be costly, complex, and a potential deterrent to the wider donor population. A one year MSM deferral (since last sex with a man) was viewed as a generally acceptable, equitable, and sufficiently cautious alternative.
- “It’s a step in the right direction and it would bring sex with men into the same category as other increased risky sexual behaviours.”—“Complier,” interview 4
A five year MSM deferral was typically dismissed as “tokenistic” and designed rather to appease gay and bisexual men than to take account of current epidemiological evidence. Such a revision was thought likely to have little impact on the number of eligible donors while retaining the potential to provoke negative public reaction. A one year deferral, on the other hand, was considered more scientifically sound, accounting conservatively for the window period for infections and any risk of men donating towards the latter part of a deferral period. Alignment with donor deferrals for most other high risk groups, and with other countries, was an important consideration for some, who felt that discrepancies undermined confidence in the current exclusion criteria.
- “It should be consistent. The world ... is a smaller place. We all travel consistently ... you can’t tell me the rules in one country should be different to the rules in another.”—“Non-complier,” interview 20
Possible response to a revised criterion
Roughly half of survey respondents with experience of male sexual contact held that a changed criterion would not affect their motivation to donate blood (table 4). There was no significant difference by compliance status. One in three felt they would be more likely to give blood under a revised criterion because the lifetime MSM donor deferral had served as a deterrent in the past. Roughly the same proportion saw themselves as more likely to donate under a revised rule because of newly conferred eligibility, and the proportion was significantly higher among current “compliers” than “non-compliers” (P=0.030) (table 4).
These views were echoed in the qualitative research by men who were currently acting in accordance with the lifetime donor exclusion but who would become eligible under a revised criterion.
- “I would give blood.... I don’t have unprotected sex outside my relationship, I don’t have unprotected sex inside my relationship, so ... I’d give blood, yeah.… My impression is that it would cause other gay men to give blood.”—“Complier,” interview 25
Those who would remain ineligible foresaw little effect on their donating behaviour. Although most participants felt they would continue to comply with a revised donor deferral criterion, many were reluctant to speculate on other men’s likely future compliance. Although some felt that a revised criterion may encourage donation towards the latter part of a deferral period—on the basis of perceived low risk to the blood supply—this was seen as avoidable by providing a clear rationale for the rule and taking this concern into account when setting deferral periods.
Views on the communication and implementation of a revised criterion
Less than half of survey respondents reporting male sexual contact considered the current donor deferral rules to be clear and easy to understand, and almost three quarters felt that more explanation was required regarding eligibility criteria (table 4). Clear and transparent communication of the rationale for deferral was considered essential by participants in the qualitative research, both to facilitate compliance and to reassure excluded groups that the criterion was founded on evidence rather than prejudice.
Confidentiality was seen as a vital issue. Concerns were raised regarding the reliability of self reported information on sexual behaviour in the semi-public setting of blood donation sessions. This issue was particularly salient for men who were not publicly open about their experience of sex with men.
- “I wouldn’t want my colleagues to know about stuff like that really, and they could quite easily look over your shoulder ... or if you tick the box and you were excluded, then they’d want to know why you couldn’t give blood, so ... it’s probably not the best place to do it ... on the day in the actual centre?”—“Non-complier,” interview 9
An online screening questionnaire, which could be completed privately and submitted remotely in advance of donation sessions, was seen as a preferable means of ensuring anonymity.
In terms of communication, participants favoured a broad advertising strategy combined with tailored information targeted at men identifying themselves as gay or bisexual, and potential donors. Generic messages were considered appropriate for mainstream advertising, while more targeted messages could make specific reference to sexual practices resulting in deferral. Web based resources were seen as an important source of additional information for those who remained unsure of their eligibility.