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Why We Need to Re-Assess Barebacking, Stop the Stigma and Be Honest About the Risk

June 17, 2013

Bob Leahy

Bob Leahy

As editor of a respected online magazine for people living with HIV, I made a choice, rightly or wrongly (probably the latter), so that in our magazine's first year or two we didn't cover barebacking. We thought it was too inflammatory a subject, thought it might encourage people to do it, thought that people would think we were irresponsible.

That changed in a big way when we featured Josh Landale, Josh Kruger, Michael Bouldin, Jake Sobo, Mark S. King and a handful of others for whom barebacking is either part of their lives or they have come to terms with it. Barebacking is, after all, increasingly a part of the lives of many gay men, and the practice inevitably raises difficult issues for all people living with HIV too, given that many have an undetectable viral load now. So, as a culmination of all of those things, our magazine covered barebacking issues frequently in the last twelve months. In fact, opinion pieces from barebackers, many poz, have been common in our pages.

Meanwhile our community's collective knowledge of the science of what is safe and what is not -- and we have covered that extensively too -- has progressed, so that informed voices outside the prevention community are able to offer the kind of nuanced messages and lead discussions that the prevention community itself is sometimes challenged to do.

As Scottish HIV expert Roy Kilpatrick says: "Individuals are often ahead of planners and providers, and are fairly savvy when it comes to working out ways of reducing risk." I tend to agree. And much of the most relevant and listened-to dialogue today is undeniably via social media, not through government funded campaigns.


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So Where Do I Stand on Barebacking?

It still seems heresy to say it, but clearly barebacking can be pretty damned safe. It can also be not a wise thing to do, depending on the circumstances. We'll talk about the specifics in a minute. But ALL barebacking has been painted with the same brush so that this, the most natural form of sex, has become so stigmatized -- curse the epidemic -- that the dialogue around it has become tainted. So barebacking, whatever the circumstances, still has the air of bad behavior, of irresponsibility, of dirtiness -- behavior that needs to be curbed, however sex-positive the language we couch that in.

But those attempts to pathologize what is essentially normal, pleasurable and healthy haven't been very successful. Meanwhile that same official dialogue has been marked by finger pointing, obfuscation and large doses of hypocrisy. (Dare I suggest that some of those who earnestly warn us of the dangers of barebacking are, or were, themselves barebackers? How did all those HIV-positive young men who inhabit the halls of HIV prevention work become poz, after all?)

We've all become way too judgmental. How many times have you heard poz folks put down -- really put down -- for daring to suggest that their undetectable viral load renders them virtually unable to transmit the virus? How many government dollars have been spent on campaigns that try to convince them otherwise with unhelpful understatements like "We now know that (in general) an undetectable viral load lowers the risk of HIV transmission to sexual partners." So we are not supposed to notice that statement misrepresents all the arguments our people have made before the Supreme Court of Canada that the risk is negligible, not merely reduced? It's thus understandable, if not inevitable, that gay men are turning away in droves from listening to how prevention people view and express risk. That makes me uncomfortable, not because gay men are turning away (many of them are smart and informed), but that our prevention people are losing control, or sometimes not even part of, the dialogue.

People who have made their peace with barebacking are often accused of being anti-condom. I know that because I've been the subject of such accusations. They are not true. I support the use of condoms in a huge variety of situations. I also make it clear to everyone who will listen that there are other situations where condomless sex doesn't really concern me very much.

So what are the "safer" forms of barebacking that I am talking about that I don't have much of a problem with?


Poz-on-Poz Barebacking (Serosorting)

Attempts have been made over the years to scare us with reports of reinfection, superinfection and the like. Those threats have just not been borne out. Nobody is dying from superinfection. True. there is the possibility of infection with STIs during condomless sex and this has potentially more serious consequences than for a negative individual, but some will -- and certainly do -- consider that level of risk falls within acceptable parameters. In any event, my take is that if you are poz and you like to fuck other poz guys without condoms, and know the potential consequences, go for it! Same goes for serodiscordant heterosexual couples.


Taking Advantage of an Undetectable Viral Load

And why not? Having carefully reviewed the evidence, including all that scaremongering talk about virus in the semen, serodiscordant sex where the positive partner has an undetectable viral load sounds pretty damned safe to me. That it remains controversial to say this, I know, but how many known infections have occurred in this scenario? Zero heterosexuals, one homosexual is the answer, although you'll have to dig for that. It almost seems some would rather have you think people are dropping like flies. Let's not fool ourselves; we are talking here about a level of risk of serious harm that is infinitely less than a positive person smoking ten cigarettes a day.

Let's be clear, there is a reason some informed negative guys seek out poz guys to have sex with. If you are a negative guy, and want to stay that way, condomless sex with a partner who is undetectable is -- gasp -- one hell of a lot less risky than condomless sex with a partner of unknown status or one who tells you he is negative. Honestly!

A word of caution. I've already used the word "risk" a lot and perhaps that's not wise, because its meaning has all the characteristics of Jell-O. There is, for instance, a huge rift between how risk is described by prevention people vs. how it is processed by mere mortals. It's just not the same animal. For example, given the almost complete lack of new transmissions emanating from people with an undetectable viral load, it's hard to agree with those professionals who still maintain any form of barebacking is "high risk". It strikes me, in fact, we need to come up with language which is way less judgmental and way more reflects the reality of the lives of gay men and others for whom "risk taking", in their sexual and non-sexual lives is a way of life. We are, after all, talking about responsible people making responsible decisions based on the best evidence available. It's exactly how we decide to cross the road, or not, or fly in an airplane, or not, despite the hazards. We do what works for us. Let's leave the judgements of others out of it.

Treatment has brought about many opportunities for people living with HIV, including the opportunity for better health, longer life and -- yes, maybe condomless sex. Why can't we celebrate the fact that we can have that responsibly, at least in certain circumstances, while being clear about where condoms actually do make sense?

That will involve less posturing on the part of the prevention community and improved skills in explaining the science accurately -- lamentably that isn't always done well, and sometimes incorrectly -- and in a way that gay men and others can relate to.

Some will of course say we don't have enough evidence to advance that approach, that HPTN 052 applied only to heterosexuals, that we don't know its applicability to gay men. All these things are true. But we are almost there, and many experts agree, including the highly respected BHIVA, that despite the lack of specific data, the impact of ART in gay men who fuck is likely to mimic the reduction in infectiousness already found in heterosexuals on ART. But if you don't believe that and wish to wait for the research to catch up, be prepared for a wait of at least three years. In the meantime, you'll want to play it safe and wear a condom -- or two.


Harm Reduction Techniques

Even where a partner's status is unknown, there are still ways to mitigate the risk, like strategic positioning -- recognizing that a top is less vulnerable than a bottom, for instance. More progressive agencies like Toronto's ACT, while encouraging condom use, also offer help to barebackers who want to explore harm reduction techniques. I like that approach.


So When Do Condoms Make Sense?

In many, many situations.

It certainly makes sense for negative guys to use a condom when they don't know the status of their partner. That includes the status of partners who say or think they are negative. Assume everyone is positive -- and NOT undetectable -- and you can't go too far wrong.

That is why I am not anti-condom. While condoms are not the answer to ending the epidemic -- if they were it would have long ended by now -- they are certainly part of an expanding arsenal of strategies, notably treatment as prevention, that ultimately will. So god-awful as those things are, negative guys, and some positive guys sometimes, still have to use them.

So condoms will need to be part of the lexicon of gay men for some time. And so should barebacking be. There are in fact opportunities to explore barebacking out there which fall at the very low end of the "risk" spectrum by any sensible standard, yet we've tended to outlaw them for no reason other than fear. The art is to differentiate what those safer opportunities are -- and we need better help than we are getting to do that.

This article is an adapted version of one written by Bob Leahy that originally appeared on PositiveLite.com.

Follow Bob on Twitter @ruraltweeter.

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