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Out for Blood

On bids to reform blood donation policy for men who have sex with men

Under the looming threat of blood shortages, after the coronavirus pandemic forced the cancellation of nearly three thousand blood drives across the country and facing pressure from Congress and LGBTQ advocacy groups, the Food and Drug administration announced on April 2 that they would finally be relaxing restrictions on blood donations from men who have sex with men (MSM). The new policy would prohibit blood donations only from those who have had sex (anal or oral, with or without a condom) with another man in the past three months—a loosening of the twelve-month deferral period adopted in 2015—bringing U.S. policy in line with deferral criteria in the UK and Canada. This move has, predictably, come in for criticism by the usual group of adversaries of the so-called “gay blood ban.” These blood donor activists are, predominantly, a cohort of self-identified “healthy” gay and bisexual men who have taken issue with MSM donor policy as perpetuating what they deem to be an outdated HIV/AIDS-linked homophobia that marks all gay and bisexual men—regardless of their sexual practices or, indeed, HIV status—as possible infection risks.

For these men, donation policy reform is a necessary and overdue recognition of the shifting landscape of HIV testing, treatment, and prevention. In 1983, as reports of AIDS-related illness among recipients of blood donations, many of whom were patients with hemophilia, began to fill the desks of blood transfusion service officials across the world, certain “high risk” groups—including MSM, commercial sex workers, intravenous drug users, and, later, people who have been sexually active in “high risk” regions like sub-Saharan Africa—were asked to self-defer from giving blood. Much has changed since then. While deferral criteria were first introduced in the absence of a known etiology of AIDS and reliable screening methods, the infrastructures of blood safety have vastly improved through the introduction of increasingly sensitive (albeit still imperfect) screening technologies for HIV, the virus long since known to cause AIDS.

In the post-marriage equality landscape, many gay men have thus invested in blood donation policy as the “next frontier for gay rights.”

As well as aligning more closely with the technical capacities of screening for infections like HIV and other blood-borne infections (BBIs), changes to blood donation policy within view of the threat of blood shortages may be especially welcomed by those patients living with blood disorders like hemophilia or thalassemia, whose lives depend on the safe receipt of blood products. Accordingly, the loosening of donation criteria in the face of a possible blood crisis induced by coronavirus ought to be a reminder of who and what is at stake in the negotiation of blood donor deferral criteria: namely, the health of the patient.

It is essential that the patient-recipient remains in view of any political discussion of blood donation policy or the “gay blood ban.” After all, it is the patient-recipient who bears the risks of blood shortages, as well as the risks of BBIs—many of which may present mildly in blood donors but can pose a life-threatening risk to blood product recipients, who are often immunosuppressed. Reasonable discussions about patient safety in the context of MSM donor policy are routinely impeded by ever-present HIV/AIDS moralizing that pits the “innocent” figure of the patient against the queer who “deserves” HIV/AIDS because of their deviant behaviors. Yet popular opposition to the “gay blood ban” does nothing to challenge these punitive logics—it merely shifts their target. As white, middle-class gay men work to assert their potential as disease-free candidates for admixture into the national blood supply, their rhetorics cast doubt on the somatic viability of a range of other individuals—to name but a few: the non-white immigrant, the sex worker, the intravenous drug user, those who take risks, those who are HIV-positive, those who are not buoyed by class and racial privilege—all deemed beyond the pale of full-blooded citizenship.

While the move to a three-month deferral policy for MSM was acknowledged by blood donor activists and other advocates for “gay blood ban” reform as representing a modicum of progress, they were swift to criticize the new deferral period as not going far enough. On April 22, in an open letter to the Department of Health & Human Services, attorneys general from nineteen states and the District of Columbia demanded that the FDA take up a “gender-neutral risk-based” approach to MSM blood donation. The letter did not stipulate what “risky” sexual practices entail, but in an April 16 open letter to the FDA, shared by GLAAD and signed by over five hundred scientists and medical professionals, MSM “in monogamous relationships, those on Pre-exposure Prophylaxis [the HIV prevention drug, PrEP], and those who consistently use condoms” were singled out as potentially low-risk donors. Both letters made nary a mention of the more taboo topics of blood donation from intravenous drug users, sex workers, or people who have been sexually active in “high risk” countries—regardless of whether they do or don’t share needles, use condoms, or are in monogamous relationships.

For political opponents of the “gay blood ban,” a three-month deferral period for MSM still represents an effective prohibition on gay blood; it precludes openly gay and bisexual men from visible participation in the civic practice of blood donation. Symbolically speaking, blood donation deferral criteria are regarded as delegitimizing the position of gay and bisexual men as healthy, health-bringing, and blood-bearing citizens proper, instead marking them out as perpetual and lurking figures of infection. When several countries, including the United States and UK, began recruiting recovered Covid-19 patients for trials exploring the possibility of using donated antibodies as a treatment for coronavirus infection, a number of gay men complained that the three-month deferral criteria still prohibited them from taking part in a possible solution to a national crisis.

The imagined “gay blood donor,” then, is the good gay citizen: hygienic, heroic, and worthy of fusion with the heterosexual national body.

On the April 23 edition of his show, Watch What Happens Live with Andy Cohen, the talk show host and producer Andy Cohen, who had recently recovered from coronavirus, launched into a diatribe about blood donation rules. “After recovering from coronavirus, I wanted to see if there was something that I could do to help people who were infected,” he said. “I was told that due to antiquated and discriminatory guidelines by the FDA to prevent HIV, I am ineligible to donate blood because I’m a gay man.” He thundered on: “When so many people are sick and dying . . . my blood could save a life, but instead it’s over here boiling.”

In the post-marriage equality landscape, many gay men have thus invested in blood donation policy as the “next frontier for gay rights.” With its emphasis on the altruism of blood donors as selfless saviors of the “sick and dying,” blood donor activism conveys certain gay and bisexual men’s desire for national incorporation, to be considered part of the triumphant cure to the global pandemic, rather than as part of the problem. Cohen and others express a militaristic plea to let gay and bisexual men line up, roll up their sleeves, and bleed for the nation, like so many soldiers before them. The imagined “gay blood donor,” then, is the good gay citizen: hygienic, heroic, and worthy of fusion with the heterosexual national body.

The problem with centering this political symbolism within blood donor activism is that it belies the material realities of testing for BBIs. Even though “all donated blood is screened,” as innumerable “gay blood ban” reformists insist as a way of highlighting the apparent redundancy of deferral policies, even the most advanced of BBI testing technologies, including nucleic acid tests for HIV, are not infinitely sensitive. All BBI tests have a window period—the average point between infection and detection by a test, ranging from ten days in the case of nucleic acid tests for HIV, to thirty days in the case of testing for hepatitis B—during which donated blood bearing BBIs still presents a possible infection risk but would otherwise test negative. These inherent uncertainties are, in part, why committed advocates for MSM policy reform typically have to dampen their demand for the complete abolition of deferral criteria at the point of their engagement with the FDA, demanding instead that certain “low-risk” (i.e. monogamous and condom-using) donors be allowed to donate despite the broader epidemiological pattern of BBI transmission. PrEP use, for instance, still operates in a zone of epistemic uncertainty for blood services: the only published study on the matter suggests that PrEP’s viral suppression properties can produce “false negative” results in tests of donated blood samples. “Low-risk” practices like monogamy and condom use are, therefore, put forth as insurance against the blind spots of BBI testing.

These politics appear as an attempt to dislocate certain men who have sex with men from the material and social realities of HIV and BBI epidemiology—that MSM continue to shoulder a disproportionate burden of HIV transmission. In the United States, for instance, the CDC estimates that MSM accounted for 63 percent of all new HIV infections in 2010. Crucially, this epidemiology is classed and racialized. Black MSM made up an estimated 37 percent of all new diagnoses amongst MSM and, amongst young MSM (aged thirteen to twenty-four), young Black MSM comprised 55 percent of all new infections in that year. Another CDC report published in the same year suggested that Black and poor people are at significantly higher risk of HIV infection and subsequently developing AIDS-related illnesses, a result of reduced access and barriers to health care, HIV testing, and life-saving antiretroviral medication. Inasmuch as unequal patterns of HIV transmission persist, with proximity to risk and health outcomes structured by the intersections of race, class, and sexuality, the HIV/AIDS crisis is not, and should not be considered by any stretch of the imagination, over.

The current bids for further reform to MSM donation policy, therefore, rely on a hygienist, “post-AIDS” vision of white, middle-class gay men—a will to politically distance themselves from the ongoing HIV/AIDS crisis via entrance into the national blood supply. In her seminal critical text, Terrorist Assemblages, the queer theorist Jasbir Puar writes, “There is a transition under way in how queer subjects are relating to nation-states, particularly the United States, from being figures of death (i.e., the AIDS epidemic) to becoming tied to ideas of life and productivity (i.e., gay marriage and families).” Implied here by Puar is that such a move is only made possible if life-bringing queer subjects, on their journey into the national fold, are willing to leave behind and overtly repudiate their figurative associations with death. And while there is nothing glamorous or necessarily redeemable about the specter of death with which queerness has been homophobically articulated under HIV/AIDS, certain gay men (blood donor activists among them) have, cushioned by racial and class privilege, been all too eager to sidle themselves away from the implication that they or the sex that they have might still be marked by the virus—even in the face of ongoing crisis. “I was told that due to antiquated and discriminatory guidelines by the FDA to prevent HIV, I am ineligible to donate blood,” Andy Cohen fumed, gesturing to himself and emphasizing the “I” of “I am.” “I, me, Andy Cohen,” he appears to say. The shock registers on his guests’ slack-jawed faces as intended. Even as all of our lives are reconfigured by a new viral reality, the very notion that Cohen might be likely to come into contact with another virus, HIV, is simply too appalling to consider.

Symbolic reforms have no bearing on or relation to the wider material, social and political conditions of disenfranchised queers and those most at-risk of transmittable disease.

In the process, then, of establishing the figure of the “gay blood donor” as an altruistic, upstanding, and biologically viable citizen within whom the very possibility of HIV cannot cohere, blood donor activists tacitly or explicitly reify old classes of deviants. Speciating “low-risk” from “high-risk” MSM, a now familiar pattern emerges: good, married, monogamous, condom-using gay men are set against their perverse, barebacking, promiscuous, non-monogamous opposites. (It must be said that, despite what the moral purity of blood donor activist rhetorics would have you believe, there is no such person as and no permanence to being a “gay man who has safe sex.” Every gay man is but one encounter, one moment of passion, one broken condom, one lost wallet, one drunken night away from becoming the risky barebacker he staked his reputation against. Even monogamy is porous and frequently perverted. After all, gay marriage can end in gay divorce.)

But those who aren’t lucky enough to pass the purity tests of blood donor activism far exceed a critical gaze on gay sex. To the would-be “gay blood donor,” the risky queers against whom he claims inclusion include the commercial sex worker, the intravenous drug user, the “high risk” immigrant, and even the “promiscuous straight man who has had hundreds of opposite sex partners”—all of whom are either established as too deviant by omission from “gay blood ban” politics or are openly cited as examples of bad practice. Politics like this do little to challenge the moral regime carved out at the height of HIV/AIDS crisis that marks some people living with HIV or AIDS as “innocent” and others as “deserving.” They merely shift the bounds of moral and biological purity to encapsulate the “low-risk” MSM, at the expense of collective solidarity both with people living with HIV and AIDS and those who exist in closest proximity to it. 

The bottom line is this: the sexualized, racialized, and classed nature of the HIV crisis cannot be addressed by pursuing symbolic reforms that center condom-using, monogamous and, tacitly white, middle-class gay men. Rather, as I have suggested, such a politics effects a dislinkage with ongoing crisis and, in an era of anti-retroviral therapy, PrEP, Undetectable = Untransmittable, condom-use, and state-sanctioned monogamy, falsely portrays HIV/AIDS as a thing of the past. Symbolic reforms have no bearing on or relation to the wider material, social and political conditions of disenfranchised queers and those most at-risk of transmittable disease. In fact, symbolic reforms often serve as a cover up for political regimes that have deepened grooves of racial, class and sexualized inequality. Observe how quickly and uncritically the abolition of MSM policy in Bolsonaro’s Brazil or Orbán’s Hungary has been applauded in the gay press—both states where conditions of the queers worst off (not cisgender, not white, not affluent) have worsened. Hungary’s blood ban reform, for instance, arrived mere weeks after the right-wing government prepared to push through legislation that would put an end to the legal recognition of trans people.

Addressing the “gay blood ban” alongside other forms of exclusionary blood donor deferral criteria, including bans on sex workers and intravenous drug users and onerous restrictions on migrant populations, requires confronting the true nature and causes of an unequal landscape of HIV transmission: institutional and systemic racism; homophobia; economic barriers to testing; uneven access to and poor representation within HIV education; the prohibitive cost of PrEP and antiretroviral medication; stigma amongst and between affected communities; the hostile environment for immigrants; the criminalization and hyper-policing of sex work and drug use; limited access to needle exchanges, and so on.

Even as a new and devastating global pandemic proffers a political opportunity for certain gay and bisexual men to unlink from the HIV/AIDS crisis that has marked and haunted them and to restore the image of the viable gay male body, queer men must resist the temptation to repudiate the ghost of HIV/AIDS past and place stock in a narrow set of lifestyles, embodiments, and practices that will only ever shore up our conditional acceptance. Rather, we must invest in landscapes of health and a politics of sexuality that facilitates, prioritizes, and, crucially, shores up the well-being of a wider range of experiences beyond the white, monogamous, condom-carrying gay man. Only by flattening the contours of HIV transmission may we find a just and equitable end to the “gay blood ban” and beyond.