Why Do Men Bareback? No Easy Answers
In San Francisco, Morin and colleagues (2003) identified a number of issues that contributed to the decisions gay men make to bareback. These include (p. 356):
- Younger men often deny HIV risk altogether.
- Gay men think it is inevitable that they will become infected with HIV.
- Impulsive sexual behavior impedes the ability or desire to use condoms.
"Commodification" of HIV or the perception, particularly among low-income men, that becoming HIV-positive will entail certain financial and social benefits, occurs. Isolation and loneliness among gay men lead to poor self-esteem and taking risks in an attempt to connect to others sexually. Social power imbalances related to race and class impede equitable sexual negotiations. Drug use among gay men interferes with the ability and desire to practice safer sex.
While a wide spectrum of rationales for barebacking exists, subtle distinctions must be made around the context of the behavior. As Suarez and Miller (2001) write, "The motivation for engaging in UAI with casual and anonymous partners may differ significantly from the motivation for engaging in UAI with regular partners. Whereas UAI between primary partners is heavily influenced by desires to express intimacy, trust, and love, the same behavior between casual/anonymous partners is most probably not affected equally by these same influences" (p. 288). In Toby's case, his barebacking was not related to a desire to feel closer to a beloved partner but rather his desire to connect sexually and socially with other gay men and to feel uninhibited and free. Toby did exhibit symptoms of an ongoing low-grade depression but otherwise presented as an emotionally stable adult but one who was wrestling with unexamined drug dependency issues.
Rational and Irrational BarebackingTwo researchers at UCLA developed a model of sexual decision making to assess rationales of adults who have unprotected sex. Pinkerton and Abramson (1992) found that "for certain individuals, under certain circumstances, risky sexual behavior may indeed be rational, in the sense that the perceived physical, emotional, and psychological benefits of sex outweigh the threat of acquiring HIV" (p. 561). This seems to be precisely Toby's relationship to barebacking: the benefits gained -- shaking off the constraints of a very buttoned-up work life and having satisfying sexual experiences that also fulfilled social and emotional needs -- outweighed the potential risk of becoming HIV-positive. These researchers state that they do not mean to imply "that risky behavior is rational in any objective sense -- only that, given certain sets of values and perceptions, engaging in unsafe behaviors may appear to the individual to be a reasonable gamble" (p. 561). They also stress that what is rational is a highly subjective matter.
Pinkerton and Abramson describe three factors that influence an individual's subjective assessment of the relative risks of various sexual behaviors:
- Fear of AIDS
- Perceived risk
- Sexual fulfillment
In order for an individual to behave rationally while barebacking, his fear of AIDS needs to be relatively small in comparison to the satisfaction derived through unprotected sex. This was exactly how Toby reported feeling early on in therapy. Yet as our work progressed, he began to express a profound ambivalence about becoming infected. Part of him wanted to stay uninfected, and yet part of him felt unsure of whether he would be willing and able to experience what to him seemed like deprivation of his spontaneity if he were to increase his efforts to keep himself HIV-negative. Pinkerton and Abramson conjecture that for many Americans, "fear of AIDS" may be synonymous with "fear of death by AIDS," and that fear of death is not nearly so great as might otherwise be supposed. "Fear of AIDS" is mediated by the subjective probability of perceived risk. Perceived risk is explained as containing three related components: the threat of exposure to HIV, the probability of exposure leading to HIV infection, and the likelihood of AIDS developing from HIV exposure (Pinkerton & Abramson, 1992). Even when gay men possess a sophisticated understanding of how HIV is transmitted and accurate perceptions of how dangerous risky sex can be, many gay men underestimate their vulnerability to HIV infection (McKusick, Horstman, & Coates, 1985; Bauman & Siegel, 1987; Richard et al., 1988).
Grov (2003) also discusses a category of barebackers that he labels irrational risk takers. "Individuals in this category typically deny their own risk or use nonscientific/irrational information when engaging in barebacking" (p. 333). Suarez and Miller (2001) feel that many gay youth who bareback fall into the category of irrational risk takers since they may have never known anyone with HIV and hold pessimistic attitudes about the future largely related to their being gay. Suarez and Miller feel that this combination often leads to young gay men (especially young gay men of color) taking sexual risks.
Pinkerton and Abramson offer possible explanations for the tendency to underestimate the personal risk associated with risky sex, even among "high-risk" gay men. First, they cite a study showing that no one sees himself as the "type of person who gets AIDS" (Madake-Tyndall, 1991). They also suggest that the "I'm not the type" fallacy is often extended to sexual partners. As they note, "Thus, the frightening picture that emerges is one in which it is only the other guy who gets AIDS. To the average gay man, it's those gay men who are overly promiscuous; and to the bath house participants, it's those who aren't careful" (Pinkerton & Abramson, pp. 564-565). They also discuss that results from cognitive psychology indicate that in general people tend to view themselves as "luckier" than the norm, and that this extends to the belief that they will not be the one to get AIDS.
Barebacking as an Example of "Sensation-Seeking"Again and again, we return to the poignant question of why a person would put his life in jeopardy for pleasure. Sex is a source of pleasure that encompasses biological, psychological, and sociological realities (Reiss, 1989). Sex is not only about pleasure. It can be about belonging, feeling desired, desiring semen, organizing one's life, and providing meanings to one's life. "People have sexual relations for a variety of reasons: for love and intimacy, for recreation, for fun, for friendship, for money, to avoid loneliness, to be touched. The essence of sexual encounters is bonding, blending, mutual pleasure, and loss of inhibition. HIV lurking in the background places strict boundaries on all of these aspects of sexuality" (Coates, 2005, p. xiv). The equation for evaluating how the benefits of barebacking weigh against the inherent risks is not simple. Tim Dean (2000) writes: "Most people can't comprehend why anyone would risk death for a good fuck. From a certain viewpoint, unsafe sex appears as inconceivably self-destructive behavior. Indeed, while such health-threatening practices as smoking, drinking, and drug abuse must be indulged in repeatedly over a substantial period before they are likely to cause harm, HIV infection can result from a single unprotected encounter. Casual, anonymous sex without a condom seems suicidal" (p. 139). But the long-term effects of HIV infection on health are easily denied when faced with the immediacy of sexual pleasure, particularly if one is using drugs that fog one's judgment.
One lens through which decisions to bareback need to be viewed is the role of pleasure and how the search for erotic pleasure is intimately related to desire. For one thing, sex without condoms feels much better and is vastly more spontaneous than having to stop the action, unwrap a condom, and properly put one on. Many gay men are articulate about how thrilling and intimate it is to the feel of the warmth of a lover's unsheathed penis and the smooth stimulation of skin against skin. Carballo-Dieguez interviewed a small sample of men who identify as barebackers. One man told Carballo-Dieguez (2001, p. 229):
The pleasure I feel when I'm having sex, especially if I'm stoned, is so amazing. ... Passion does not call for protection in my mind. Passion is a very raw emotion. ... It is not easy to feel real passion, because there are so many barriers put up and so many acts that people have in themselves that they want to express during sex, that protection does not fit in the fantasy.
Much as we try to eroticize safer sex, there is no way around the fact that condoms both decrease the sensation of anal intercourse and interrupt the spontaneity of the sexual act. Sexual fulfillment "encompasses a range of physical, emotional, and psychological factors including, but not limited to, physical pleasure and release, emotional intimacy and security, enhanced self-esteem, and actualized sexual identity. These are all highly valued, immediate benefits of sexual expression (in contrast to the distant, rather ethereal threat of contracting AIDS)" (Pinkerton & Abramson, 1992, p. 565). As previously discussed, recreational sex has been identified by at least certain segments of the gay male community as a means of personal fulfillment and an expression of enhanced freedom and self-esteem. An active sex life is seen as a indication of attractiveness and vitality. A gay man who wants to feel liberated, hot, or sexy might view sex without condoms as the best route to fulfilling his desire to feel any of those ways.
"Sensation-seeking" is defined as "the seeking of varied, novel, complex, and intense sensations and experiences, and the willingness to take physical, social, legal, and financial risks for the sake of such experiences" (Zuckerman, 1994, p. 27). Zuckerman (1993) finds that sensation-seeking and impulsivity are not the same thing, though they are related. They looked at how sensation-seeking, and an individual's affect and the ways risk affects the ability to become sexually aroused, contribute to why men have unprotected sex. These factors illustrate how intrapsychic and interpersonal issues converge to influence an individual's likelihood of taking sexual risks. For instance, men who are high sensation-seekers may be more likely not to use condoms since they value the intensity of skin-on-skin contact during anal intercourse. In short, one man's need for a higher degree of sensation can result in his initiating sexual risk-taking, taking his intrapsychic need into the interpersonal sphere.
Numerous researchers have studied the connection between sensation-seeking and men who bareback. Pinkerton and Abramson (1995) and Bancroft et al. (2003) provide evidence suggesting that sensation-seeking impacts on sexual risk-taking in two principal ways: by increasing the preparedness to take risks in order to achieve the desired immediate benefits and by influencing how the individual appraises the risk. An individual who is highly sensation-seeking is more likely to downplay the risks associated with a particular behavior if he has previously engaged in the behavior (in this case UAI) without negative consequences, such as becoming infected with HIV. Thus as Pinkerton and Abramson (1995) point out, men who are high sexual sensation-seekers seem not to be unaware of the risks associated with their behavior but choose instead to accept these risks. Some of these men may be in denial about the potential risks to their health. Others may simply compartmentalize the risk and not have it affect their behavior. Yet other men engage in a form of magical thinking -- believing that they are invulnerable to infection. There are also men who know and accept the risks and are willing to factor them into the equation as one potential cost to an otherwise important, pleasurable, and valued behavior pattern.
Scragg and Alcorn (2002) and Miller, Lynam, Zimmerman, Logan, and Clayton (2004) find that both extraversion (being highly outgoing with the ability to easily engage other people socially or flirtatiously) and sensation-seeking are related to the desire for a greater number of sexual partners. This seems to make sense since sex with more than one person is inherently a social activity and requires one or more partners (Miller et al., 2004). Schroth (1996) also demonstrated that in a sample of gay men he studied there was a strong correlation between sensation-seeking and high number of sexual activities and high number of partners. Interestingly, this same study did not find any relationship between sensation-seeking and unsafe sexual behavior in the well-educated men among the sample surveyed. This finding is contradicted by empirical observations of the well-educated men I see as psychotherapy patients who bareback and often exhibit characteristics of sensation-seeking.
Hoyle, Fejfar, and Miller (2000) conducted a quantitative review of the empirical literature on "normal" personality and sexual risk-taking in which sexual risk-taking behaviors were defined as numbers of partners, unprotected sex, and high-risk sexual encounters, including sex with a stranger. Their work found that a high level of sensation-seeking predicts all forms of sexual risk-taking covered in their review. There was a consistent, but not strong, positive association between impulsivity and sexual risk-taking, with these authors noting that there was a problem in the inconsistent ways that impulsivity was defined. Seal and Agostinelli (1994) showed that impulsivity was one important factor among men who had UAI.
SerosortingIn discussing what they call "rational risk-takers," Suarez and Miller (2001) note that there is a group of men whose sexual behavior is based on "rational" consideration of the risks of specific sexual acts. Among this group are couples who are not sexually exclusive who have negotiated safety1 agreements, and HIV-negative men who only are the insertive partners during condomless anal sex. Suarez and Miller describe a phenomenon that some men use as part of their "rational" approach to barebacking as "serosorting." Robert, the client I described in Chapter 2, is an example of someone who made his decisions to bareback based on the other man's HIV status as an attempt to mitigate the risks of barebacking. Serosorting relies on men discussing HIV status with potential partners and only engaging in risky behaviors with those who are believed to be of a similar serostatus. A study conducted in the San Francisco Bay area among a multiethnic sample of MSM (Mansergh et al., 2002) found that a majority of the men surveyed who had engaged in UAI in the prior 2 years reported engaging in barebacking with a man of the same HIV status when he was the receptive partner. This is obviously not a foolproof method for reducing one's risk of contracting HIV insofar as disclosure of HIV status is not always truthful or accurate (Cochran & Mays, 1990; Rowatt, Cunningham, & Druen, 1999), and some individuals honestly do not know that they are infected.
Despite the limitations of serosorting, Suarez and Miller (2001) report that many barebackers employ this strategy. As evidence, they point to the plethora of personal ads on Web sites devoted exclusively to barebacking as well as on Web sites where gay men cruise for sex where men state their own HIV status and the desired status of potential partners. Hort (2000) posits that barebacking itself is a serosorting strategy insofar as barebacking is often a way for HIV-positive men to disclose their status and assume that anyone who is willing to have unsafe sex with them is also already infected. But as will be discussed in Chapter 5, this assumption is incorrect. Suarez and Miller note that many barebacking ads are posted by men who claim to be HIV-negative and state explicitly that they will only bareback with other uninfected men.
Barebacking to Feel in ControlWhether or not a man is making a rational choice when he decides to bareback is often difficult for others to assess, even psychotherapists who must contend with their own judgments and feelings about this particular highly charged, high-risk behavior. But for barebackers who are neither actively nor passively suicidal, there is an internal logic that makes sense to them, especially when the behavior occurs within specific contexts. For example, one rationalization for engaging in unsafe sex is the belief that having an HIV infection will alleviate their worry about becoming infected. This dynamic was first reported by psychologist Walt Odets (1994), when he described men who felt that they were not destined to survive the epidemic and therefore had no motivation or reason to practice safer sex. Odets writes that many survivors of the epidemic have a sense of the inevitability of their "catching AIDS." One example of this was my client Jeff, a 44-year-old, Jewish, HIV-negative man who enjoyed dancing at New York clubs and going to an occasional circuit party. Since he almost never used condoms but made every effort to limit his sexual partners to other uninfected men he met, he decided to have "HIV-" tattooed on his left arm since he disliked the necessity of asking about HIV status. Immediately after getting himself tattooed he discussed his feeling that it was only a matter of time until he eventually got infected. "When it happens I can just have the vertical bar added to my tattoo so it will accurately read "HIV+," he told me, pleased with his strategy.
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