Attitudes, behaviours, and acceptability related to current and future blood donation policy: A qualitative study of gay, bisexual, and other men who have sex with men in Vancouver, Toronto, and Montréal

The Canadian blood donation system relies on the participation of volunteer donors and at the same time seeks to screen out ‘high-risk’ donors. The success of any policy change relies on how donors interpret and will comply with screening questions and what level of perceived risk to the safety of blood the public will accept. Until 2013, any man who had sex with a man since 1977 was deferred for life from donating blood. Since then, eligibility criteria for men who have sex with men (MSM) have been evolving, initially to a 5-year, then a 12-month, and most recently (June 2019) a 3-month deferral. This means that a man must abstain from sexual contact (anal or oral sex) with other men for at least 3 months to be eligible to donate blood. We examined the attitudes and acceptability of gay, bisexual, and other men who have sex with men (GBM) toward the deferral policy (at the time of the interviews this was a 12-month deferral), and their opinions on possible reforms to this policy. 

In-depth, one-on-one interviews with 47 GBM were conducted in Vancouver, Toronto, and Montréal. The GBM interviewed were recruited from Engage, a large national surveillance study focusing on GBM health. Participants of varying age, ethno-racial background, HIV status and sexual risk profile were recruited. The primary objectives were to understand attitudes toward and acceptability of the blood deferral policy in place at the time of the interviews (12-month deferral), their opinions on possible reforms to this policy, and their willingness to donate blood under future policies. We also examined perspectives on plasma donation. 

Most participants were opposed to any blood donation deferral for MSM-specific sexual activity and considered such a policy inequitable and illogical. A fair and safe policy was considered one that was the “same for everyone”. Participants believed that gender neutral policy (e.g. focusing on risk behaviour rather than sexuality) and HIV testing-related strategies could be integrated into the blood donation process. GBM’s opinions concerning a possible (later implemented) change to a 3-month MSM deferral could be fit into three broad categories: 1. step in the right direction; 2. ambivalence and uncertainty; and 3. not an improvement. A second analysis focusing on the 39 HIV-negative participants’ interviews through the lens of sexual citizenship and biological citizenship showed complex connections between perceptions of these concepts in relation to blood donation. At an individual level, most participants said they were “safe”/“low risk” and “willing” donors and that they would gain satisfaction and civic pride from donation. A smaller group did not prioritize biological citizenship goals associated with expanding blood donation access nor did they see this as a sexual citizenship priority for GBM.

In a third analysis of the 39 HIV-negative participants, we found that many GBM expressed a general willingness to donate plasma if they became eligible—like with whole blood donation, GBM conveyed a strong desire to help others in need. However, this willingness was complicated by the fact that most participants had limited knowledge of plasma donation and were unsure of its medical importance. Participants’ perspectives on a policy that enabled MSM to donate plasma varied, with some viewing this change as a “stepping stone” to a reformed blood donation policy and others regarding it as an insufficient and constructing GBM as “second-class” donors. When discussing plasma, many men reflected on the legacy of blood donor policy-related discrimination. Our data reveal a significant plasma policy disjuncture—a gulf between the critical importance of plasma donation from the perspective of Canada’s blood operators and patients and the feelings of many GBM who understood this form of donation as less important.

Overall, the analyses suggest that many GBM are highly aware of their sexual risk levels and are looking for intelligible scientific rationales for why the blood donation deferral policy must be different for GBM versus heterosexuals. Most participants anticipated that their sexual practices would continue to make them safe donors in the future. Many participants expressed a willingness and desire to donate blood if they became eligible and most believed that blood donation was important. No interviewee conveyed any indication they would be non-compliant with Health Canada’s current or future donation policy. Most participants did not understand what plasma/plasma donation was. Some were interested in being plasma donors, but they did not think it would be fair if GBM could only donate plasma and not blood. Repair work is required by Canada’s blood operators to build trust with diverse GBM communities.

Canadian Blood Services and Héma-Québec should: 1. Continue to consider evidence-based alternatives beyond MSM deferral-based policies, including “gender blind” or behaviour based screening models; 2. Better communicate the reasons why a 3-month deferral is necessary for MSM given existing testing technologies; 3. Perform outreach and dialogue with communities of gay, bisexual, and queer men to establish trust; and 4. Demonstrate that policy decisions are being based on up-to-date scientific evidence, including emerging findings through quantitative and qualitative studies across Canada. 

An important limitation is our specific focus on the exclusion from donation of men based on same-sex sexual practice over other possible exclusion criteria. While this focus was helpful to complete the initial objectives of our study, we do believe that it is important to consider other intersectional grounds of GBM exclusion for donating blood—recognizing the heterogeneity of this group and that some GBM may continue to find blood donation policies inequitable because they are excluded for other reasons, such as those related to country of birth. Further analysis is necessary to robustly account for how sex-based deferral policies may be negatively perceived by trans and non-binary people and the multiple reasons why some GBM may continue to find blood donation policies highly problematic beyond the GBM-specific deferral.

Grace, D., Gaspar, M., Lessard, D., Klassen, B., Brennan, D. J., Adam, B. D., Jollimore, J., Lachowsky, N. J., & Hart, T. A. (2019). Gay and bisexual men's views on reforming blood donation policy in Canada: a qualitative study. BMC public health, 19(1), 772. https://doi.org/10.1186/s12889-019-7123-4

Summary of this paper: Gay, Bisexual, and Queer Men Call for Equity and Evidence in Blood Donation Policy

Grace, D., Gaspar, M., Klassen, B., Lessard, D., Brennan, D. J., Lachowsky, N. J., Adam, B. D., Cox, J., Lambert, G., Anand, P., Jollimore, J., Moore, D., & Hart, T. A. (2020). It's in Me to Give: Canadian Gay, Bisexual, and Queer Men's Willingness to Donate Blood If Eligible Despite Feelings of Policy Discrimination. Qualitative health research, 30(14), 2234–2247. https://doi.org/10.1177/1049732320952314

Summary of this paper: Many Gay, Bisexual, and Queer Men Willing to Donate Blood if Eligible but Find Current Deferral Policy Discriminatory

Grace, D., Gaspar, M., Klassen, B., Lessard, D., Anand, P., Brennan, D. J., Lachowsky, N., Adam, B. D., Cox, J., Lambert, G., Jollimore, J., & Hart, T. A. (2021). Stepping Stones or Second Class Donors?: a qualitative analysis of gay, bisexual, and queer men's perspectives on plasma donation policy in Canada. BMC public health, 21(1), 444. https://doi.org/10.1186/s12889-021-10480-x

Summary of this paper: Stepping Stones or Second Class Donors?

Findings from this research on acceptability of Sexual Behavior Based Screening (SBBS) were cited in Canadian Blood Services submission to Health Canada for regulatory approval of "Alternative criteria for Men who have Sex with Men, Source plasma donation, London and Calgary" and informed implementation of that program (Sept 2021). This research informed the overall approach to implementation of SBBS and how Canadian Blood Services approaches issues of inclusivity in our donor screening.