Why Do Men Bareback? No Easy Answers
Routledge, 2006, List $31.95
"The terrible thing in this world is that everyone has his reasons."
Octave, The Rules of the Game, Jean Renoir, 1939
Toby, a Passive Barebacker
Toby did not seek out barebacking, but he allowed it to happen if the other man wanted to do it. He said he never discussed HIV status with the men he went home with unless the other man initiated the discussion. If a sexual partner initiated the use of condoms for anal sex, Toby said he felt relieved and gladly used them. But if the other man did not bring up the topic, Toby wound up going along with whatever the other man wanted to do sexually, even if it meant having UAI. Toby almost never made a date to see any of these men a second time. Toby was sexually versatile but preferred to be the top.
On the weekends when Toby stayed home, he either met men in online chat rooms for sexual hookups or went to sex parties. Again, his attitude toward condom use was passive. If the other man wanted to use them, that was fine with him. But if the other fellow never brought up the topic of condoms, neither did Toby. It was clear that he was well informed about HIV transmission and about the risk he took of becoming infected by barebacking. When I explored this passivity toward using condoms, he explained that he worked such long hours and so intensely that when he did have time off it was essential that he be able to stop thinking and just go a bit wild and lose control. Ostrow and Shelby (2000) describe psychotherapy with men like Toby who use drugs to enable them to lose inhibitions and engage in fantasy sex that they might otherwise have difficulty engaging in without guilt or remorse.
Toby was an only child raised in the Midwest by a devout Baptist single mother who had been deserted by Toby's father shortly after Toby's birth. Toby came out to his mother after he finished graduate school and moved to New York. She did not react well to the news, retreating into the condemning language of her church. She told her son that being a homosexual was going to land him in hell unless he repented and changed his ways. She also told him that he was going to get AIDS because he was gay. Toby sounded bleak when he described the Christian literature she regularly sent him about the evils of homosexuality and how gays were being plagued by AIDS as punishment from God.
I asked Toby what he thought about his mother's views of his sexuality. He said he was frightened -- what if what she said was true? -- and sad that their relationship has become so combative. He said she was relentless about sharing her views on Toby's "sinful affliction," even after Toby asked her not to raise this subject every time they spoke. I was surprised to hear that he continued to speak with her once a week and to visit with her for a week at Christmas. We explored his conflicted feelings about his relationship with his mother. On the one hand, he recognized that the way his mother treats him was damaging to his self-esteem and was deeply painful. On the other hand, as the only child whom she struggled to raise, he felt a strong sense of loyalty and obligation to her.
I shared with Toby my concern that his barebacking activity was putting him at risk for fulfilling his mother's prophecy that he would get AIDS. He said he worried about it at times, and he had no conscious desire to contract HIV, but he was not willing to kill (his exact expression) the spontaneity of his recreational sexual exploits. In the rest of his life, he was responsible and reliable. In this one area of his life, he wanted to be totally free. I wondered if Toby's behavior was an unconscious desire either to prove his mother right or to get sick and die as a hostile "fuck you" to his mother. I did not begin to share any of these possibilities with Toby until many months after our initial consultation. Every few months Toby would get retested for HIV, and as of this writing he remains HIV-negative.
Fifteen or 20 years ago, I would have been appalled and quite judgmental about Toby's behavior and probably gone into overdrive to try to save Toby from his own impulses. With the advantage of 20/20 hindsight, it is now clear that the rescue approach to treating men who bareback is rarely, if ever, effective. Most of the time, these clients just stopped therapy with me. They did not want or need a rescuer, as well-intentioned as I was. Although it still hurt to hear Toby describe the potentially deadly risks he was taking, I had to practice patience, compassion, and empathy. He was the only one who could take himself out of these high-risk situations, and then only if and when he decided that he wanted to.
Along with my protective feelings for this young man, I felt clinical curiosity about what was driving Toby to take sexual risks with such an apparently casual attitude. Researchers have been eager to find out more about the category of barebackers that Toby falls into -- men who are not trying, at least consciously, to become infected with HIV, but who are willing to take risks in order to satisfy deep intrapsychic and interpersonal needs.
Rationales for Barebacking: Chapter OverviewThis chapter asks a lot of tough questions: Is barebacking pathological? Is it correlated to personality disorder? Is it all about sex, sensation-seeking, and pleasure? Or is it, as paradoxical as this may seem, actually an attempt to take care of oneself and to forge a deeper intimacy, closeness, and even spiritual communion? We will look at how current antiretroviral therapies may affect decisions to have unprotected sex, and how fear and lack of fear about the danger of HIV infection play into the decision to bareback. The question of whether sex without condoms in the age of AIDS can ever be a rational decision will be explored. As the title of Chapter 3 promises, there are no easy answers to why men have sex without condoms.
This chapter offers multiple meanings that men who have sex without condoms themselves attribute to the behavior. The more we can understand the underlying motivations of unprotected and unsafe sex, the better we can have effective community conversations about how to prevent the spread of HIV and other sexually transmitted diseases (STDs). Lest we forget the potential serious consequences of having sex without condoms, I include the latest information about the health risks of condomless sex, discussing the relative safety of HIV-positive men who bareback with other infected men.
Why Men Are Taking Sexual RisksThere are abundant theories but no definitive answers about why gay men take sexual risks. After more than three decades of safer sex messages against the backdrop of gay men sickening horribly and then dying, new medical treatments have stemmed the tide of the pandemic and offered real hope for longer-term survival to people with HIV. Gay men want the AIDS epidemic to be over and want to be able to have sex without fear. They want to celebrate their desire without having to worry, negotiate, be fearful, or keep a shield of latex between themselves and their partners. Younger men want to experience pre-AIDS sex. Queer theorist Tim Dean (2000) writes: "In view of statistics on new seroconversions, some AIDS educators have begun to acknowledge that, unlikely though it may seem, remaining HIV-negative in fact poses significant psychological challenges to gay men" (p. 137). To those who have not been working in the gay men's community for the past 25 years, this statement might seem absurd, but it is true that HIV-negative gay men face unique challenges that make it seem almost easier to seroconvert.
San Francisco Bay area psychologist Walt Odets (1995) was one of the first mental health professionals to question why gay men who had thus far escaped becoming infected with HIV were placing themselves at risk for becoming so. Odets described HIV-negative men who struggled in a world and gay community that, however unintentionally, considered their difficulties inconsequential as compared to those of men who were fighting for their lives. These uninfected men's growing invisibility triggered old childhood feelings of being an outsider, and for some, contributed to an acute psychological crisis that often created a confluence of behaviors and thought patterns that placed them at risk for contracting HIV.
Some have suggested that during the '80s, gay men unconsciously colluded with the general public's equation of a gay identity with an AIDS identity (Odets, 1995; Rofes, 1996). New York social worker Steve Ball (1998) describes how during the height of the AIDS epidemic HIV-negative gay men often found themselves in the role of caregiver, mourner/widower, or outsider, due to their not being infected with HIV. Some of these men felt that they were not entitled to express their deep fears that they might become infected or discuss their loneliness or burnout when so many peers were dying around them. The dynamics described by Odets and Ball are part of the communal and psychosocial realities that early in the epidemic played a role in contributing to the spread of HIV.
In 1988, I wrote about how fear was one large component of what propelled gay men to change how they were having sex (Shernoff & Jimenez, 1988). Should we conclude that safer-sex campaigns have lost their effectiveness today because gay men are no longer afraid? Gay men who were recently surveyed about their failure to use condoms during anal sex repeatedly told researchers that current AIDS prevention messages do not feel relevant to them and do not convey an urgency about why condom use is important (Halkitis, Parsons, & Wilton, 2003; Carballo-Dieguez & Lin, 2003; Morin et al., 2003). For many younger gay men and for newly sexually active gay men, AIDS is associated with the past (Van de Ven, Prestage, Knox, & Kippax, 2000). In the last 20 years, the roar and urgency of HIV prevention campaigns have faded.
British psychologist and researcher Michelle Crossley (2001, 2002) writes that one factor might be a decrease in the effectiveness of the "health promotion" campaign to change gay men's sexual behavior. Gay men who come out today are raised with AIDS awareness and come out to a chorus of safer-sex messages. But Crossley notes that most "health promotion" campaigns -- for example, convincing people to stop smoking and lose weight -- have only limited long-term success. She wonders if the "safer-sex" messages ever had much effect on gay male sexual behavior. Crossley raises an interesting question that is difficult to quantify. Obviously, there were a confluence of factors in the early days of the epidemic -- most prominently fear, the horrors of sickness, and grief of deaths -- and these things made safer-sex AIDS education programs more compelling to the target audience. Crossley suggests that it is impossible to evaluate the efficacy of safer-sex messages in and of themselves since concurrent to when they first began appearing, gay men were overwhelmed by the terror that they might be infected by the then-new disease that was rapidly killing their friends and lovers. Though highly unscientific, comments shared with me by men who attended the safer sex programs I ran in the 1980s (the workshops will be described in more detail in the next chapter) reported that they felt that these interventions proved helpful to them for changing how they had sex in response to AIDS. The men who spoke or wrote to me after attending the workshop often described an enormous relief. They spoke of how important and useful it was for them to simply be in a room with other gay men sharing feelings about how sex needed to change. They also appreciated the permission that was given during these workshops to remain sexually active, albeit with some big differences from what they were used to. They reported being thrilled to be able to participate in a process that helped them reclaim the joy and fun of gay sex amidst all of the sex-negativity and sex-equaling-death messages that were inundating them. Thus, participating in this AIDS prevention workshop helped scores of men feel confident of their ability to make the necessary sexual changes and sustain them.
Factors That Lead to Sexual Risk-TakingThere are numerous theories for why gay men engage in unprotected sex, and research has explored a wide variety of possible rationales for the behavior. These include:
- Negative attitudes toward condom use (Odets, 1994; Flowers, Smith, Sheeran, & Beail, 1997; Hays, Kegeles, & Coates, 1997; Kelly & Kalichman, 1998; Van de Ven et al., 1998a; b; Appleby, Miller, & Rothspan, 1999)
- How being in a committed compared to a noncommitted couple relationship affects whether a condom is used (Elford Bolding McGuire & Sher, 2001; Vincke, Bolton, & DeVleeschouwer, 2001)
- Strongly identifying with or feeling alienated from the gay community (Hospers & Kok, 1995; Hays et al., 1997; Seal et al., 2000)
- Internalized homophobia (Meyer & Dean, 1998; Canin, Dolcini, & Adler, 1999)
- A sense of the inevitability of becoming infected with HIV as a gay man (Kelly et al., 1990; Kalichman, Kelly, & Rompa, 1997)
- The effects of substance use (Stall, McKusick, Wiley, Coates, & Ostrow, 1986; Stall, Paul, Barrett, Crosby, & Bein, 1991; Leigh & Stall, 1993; Stall & Leigh, 1994; Hospers & Kok, 1995; Woody et al., 1999; Royce, Sena, Cates, & Cohen, 1997; Chesney, Barrett, & Stall, 1998; Ostrow & Shelby, 2000; Halkitis, Parsons, & Stirratt, 2001, Halkitis et al., 2003; Halkitis & Parsons, 2002; Kalichman & Weinhardt, 2001).
There are probably a multitude of other issues at play as well. As psychologist and former researcher at the CDC Ron Stall was quoted as saying in an article in the Manhattan gay newspaper Gay City News, "There are studies that demonstrate a variety of psychosocial health issues, including depression, antigay violence, childhood sexual abuse, or substance abuse, can lead gay men to have unsafe sex" (Stall, quoted in Osborne, 2002, p. 1). In my own practice, I have identified several factors that appear to lead to sexual risk-taking: loneliness, being HIV-positive, having unmet intimacy needs, feeling alienated from the gay community, being in love, and a craving for deeper intimacy and trust.
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