Why Do Men Bareback? No Easy Answers
At first, his reasoning seemed as slippery as a child telling himself that he might cheat on the test because he was destined to fail, and getting caught would spare him the misery of bringing home an F. This kind of illogical logic is not uncommon, even in adults. In the early 1990s I remember working with Matthew, a 36-year-old, biracial Wall Street professional who came to see me. He was so worried about whether or not he had become infected during a recent weekend-long sexual orgy that it was interfering with his very demanding job. As he described himself, usually he was conservative about sexual risk-taking to the point that his unwillingness to tongue-kiss brought several promising relationships to an end. Yet, there were certain situations in which he engaged in UAI, though only as the insertive partner, feeling that while this was not completely risk-free, it was relatively safe. During our first therapy session, Matthew commented that since he was a sexually active gay man, it was inevitable that he would become infected with HIV. This gave him some inner permission to take sexual risks. "That way, once it happens I will no longer obsess about whether or not I am infected," he explained, slumped and miserable on my couch.
Semen Exchange and Emotional ConnectionVincke and colleagues (2001) found that "the incorporation of semen is an important value for many in gay cultures, a means of showing devotion, belonging, and oneness. Unsafe sex can therefore be an expression of positive values and of good feelings" (p. 58). There is something deeply erotic, profoundly connecting and, some feel, even sacred about one person giving his most private and special fluid, semen, to the other as a gift of love and a symbolic joining of two souls. The many levels of meaning and special significance that giving and receiving of semen has for gay men cannot be underestimated as a contributing factor to the rise in barebacking -- especially in romantic couples, as will be examined in Section 2 of this book. Early in the second decade of the AIDS epidemic Odets wrote, "Now that a decade of prohibition has made semen exchange relatively unusual and 'special,' it has become all the more powerful and meaningful" (Odets, 1994, p. 432). Obviously, what it means to give or receive semen varies from one gay man to another. Some have described drinking semen as literally ingesting the vitality, strength, manliness, or very essence of the man whose semen they either drank or received anally. There are men who feel that sharing their own or receiving the semen of a lover is a visceral as well as symbolic gift of love or a spiritual communion. There are those who revel in experiencing the esthetic and sensual pleasures in giving or receiving semen. By no means is this a comprehensive list. The meaning of sharing semen between two men is as varied as the men who engage in this act.
The Psychology of Peer PressureSince attempts to satisfy sexual desire that go beyond masturbation necessarily involve interacting with one or more people, attempting to categorize an individual's motivations for barebacking as either being predominantly intrapsychic or predominantly interpersonal creates an artificial distinction that grossly oversimplifies the dynamics at play. As Bancroft et al. (2003) point out: "After a period of focusing on education about safer sex, there is now increasing attention being paid to situational and individually oriented factors that may help to explain high-risk behavior" (p. 555). Bay-area psychologist Stephan Morin writes, "The normalization of the term 'barebacking,' combined with media attention and community-level discussion about it, have contributed to the perception that the behavior is widespread in the community, creating a [new] social pressure to conform" (Morin et al., 2003, p. 357).
Bancroft et al. (2003) studied the impact of sexual arousal and the relationship between mood and sexuality on sexual risk-taking. They found that the patterns of contact, where people met for sex, and how many partners they had was related to whether or not they took sexual risks. Their findings showed evidence that much "cruising" behavior by men in public places that results in public sex is relatively low-risk because the sexual activity is usually limited to mutual masturbation or oral sex.
Is Barebacking Symptomatic of Mental Illness?In contrast to the researchers above who have shown that for some gay men barebacking is a rational activity, there are social scientists who have tried to determine whether men who bareback have a documented higher level of mental disorders than do men who do not take sexual risks. Gerrard, Gibbons, and McCoy (1993) have shown that affect can influence judgment and decision making. They found that some depressed, anxious, or sad people take greater sexual risks while others who have the identical affect are more sexually conservative. Thus it seems apparent that affect alone is not the determining factor in why some gay men bareback.
Some researchers investigated whether suffering from an anxiety disorder could increase an individual's risk-taking behaviors. Two studies show an association between sexual risk-taking and the use of sex to reduce tension or cope with stress (Folkman, Chesney, Pollack, & Phillips, 1992; McKusick, Hoff, Stall, & Coates, 1991). Yet neither of these studies demonstrated that a correlation existed between the way the participants used sex and a diagnosable mental disorder. Research by Halkitis and Wilton (2005) on the meanings of sex for HIV-positive gay and bisexual men found that of the 250 men interviewed, most discussed the role of sex as a mood stabilizer, stress reducer, and facilitator of intimacy. Though Halkitis and Wilton were only reporting on HIV-positive men, my clinical experience shows that most gay men, no matter their HIV status, would concur. Clearly, some people use sex to anaesthetize themselves to tense or difficult feelings or situations. This seems to speak directly to at least part of the function that sex in general and sex without condoms served for Toby in coping with his everyday sadness, loneliness, and other nonpathological feelings.
One of the most common symptoms of depression is decreased libido, so it is curious that sex drive, paradoxically, seems to increase in some depressed gay men. Psychologist Thomas Coates, who is on the faculty at the David Geffen School of Medicine at UCLA, suggests two possible explanations: "One possibility is that these men seek out sexual partners to alleviate depression. Another is that depression decreases self-esteem, leading these men to engage in sexual behavior that they might otherwise not find acceptable. Rather than driving away a potential sexual partner by trying to negotiate sexual behavior, these individuals may be willing to accept whatever sexual activities the partners want as a way of achieving relief from depression and isolation" (Coates, 2004, p. 6). Coates also points out that there is now research that seeks to explore what the relationship might be between depression, depressive symptoms, and gay men taking sexual risks. He states, "In particular, studies suggest a complex interplay among a variety of factors that interact with depression and the conditions that increase risk or undermine risk reduction" (Coates, 2004, p. 5). Bancroft et al. (2003) note that negative affect could have different effects on sexual risk-taking in different people, with a tendency for negative affect to increase sexual risk-taking in some individuals and to reduce it in others. This is important for mental health professionals to keep in mind when working with gay men who bareback. It is important that they not assume that an individual's depression or anxiety is by itself the significant contributing factor for why he is having UAI, while it very well may be part of the overall equation contributing to why this individual has high-risk sex.
Regarding the connection between sexual arousal and sexual risk-taking, Canin et al. (1999) noted that sexual arousal and the desire for sexual satisfaction impose a sense of urgency that can distort judgment and result in men taking sexual risks. Bancroft et al. (2003) found a correlation between men with erectile difficulties and engaging in UAI. A man who lacks confidence about his erectile ability is likely to be reluctant to use a condom, which would probably aggravate the erectile difficulty. He may, therefore, be more likely to engage in UAI, either as a "top" or a "bottom" (Bancroft et al., 2003). Bancroft's research was conducted prior to the introduction of Viagra in 1998, which is prescribed to treat erectile dysfunction. Thus medical and mental health providers should inquire about the existence of this particular sexual dysfunction in men reporting barebacking, with the intention to refer them for treatment of this problem. If the erectile difficulty is successfully treated, the person may be more willing to use condoms for anal sex.
When sexual risk-taking is examined within the context of diagnosed personality disorders, there is some correlation between men with an Axis II2 diagnosis and sexual risk-taking. Jacobsberg, Frances, and Perry (1995) reported on the prevalence of personality disorders among gay men seeking an HIV test. The study subjects who tested HIV-negative had a significantly lower rate of personality disorder (20 percent) than did those who tested HIV-positive (37 percent). The presence of the personality disorder was assessed prior to the individual knowing his HIV status, thus suggesting an association between personality disorder and HIV risk. Ellis, Collins, and King (1995) found that gay men who did not use a condom during anal intercourse with casual partners often met criteria that resulted in their receiving a diagnosis of personality disorder. When they examined this finding they discovered that Antisocial Personality Disorder was the main predictor of sexual risk-taking among the homosexually active men they studied.
To Diagnose or Not to Diagnose?What is the usefulness of this information for the therapist working with an individual who reports barebacking? Zucker (1996) raises troubling questions about how the traditional diagnostic interview has a heterosexual bias built into it that results in sexual minority individuals being more likely to receive a diagnoses of personality disorder. The terms "impulsivity" and "sensation-seeking," as used in the social science literature, sound value-neutral, but in fact they may not be. They often contain biases that blur the line between spontaneity and impulsivity. Even though a correlation has been shown to exist between high sensation-seekers and impulsivity, this alone does not necessarily mean that all gay men who are high sexual sensation-seekers exhibit characteristics that would deem them diagnosable as having a personality disorder, though obviously some do.
Impulsivity is one important diagnostic criterion of both antisocial personality disorder and borderline personality disorder. Some barebackers are very impulsive individuals, yet this alone, even when combined with the at-risk sexual behavior, is not sufficient to render a diagnosis of Antisocial Personality Disorder in a man who barebacks. On the other hand, for some barebackers this may indeed be an appropriate diagnosis. An important caution is in order when the presence of a gay man's barebacking behavior, high sensation-seeking, or impulsivity might lead a clinician to diagnose the existence of borderline personality disorder. Labeling an individual or pattern of behavior as sensation-seeking also contains explicit judgments about normal behaviors and what levels of risk are acceptable. Important questions are raised, however, about to whom the risk is acceptable and under what circumstances?
The underlying question we have to grapple with is what risk-taking do we consider acceptable, healthy, and even laudable, and what risk-taking do we consider unhealthy and unacceptable? For instance, I am an experienced scuba diver with more than 30 years of diving experience. One of my passions is to dive among large ocean-going animals and I am thrilled when I sight sharks. This is obvious sensation-seeking behavior and potentially higher risk than a swim at the shore. Yet this pattern of behavior is far from impulsive, as each dive is carefully planned and done under the close supervision of experienced dive guides. Some might perhaps diagnose this passion of mine as pathological since inherent in it is the possibility of a potentially fatal shark attack. I think of it as a fun and exciting recreational activity that provides enormous pleasure and satisfaction that greatly enhances my life. There is an obvious parallel between my choice to scuba dive in places with a high likelihood of close encounters with potentially dangerous sea critters and men taking what for them are calculated sexual risks. Just because a behavior entails risks does not make it de facto pathological and self-destructive.
With the mental health professions' long history of diagnosing gay men as psychologically abnormal and disturbed because of their homosexuality, it is important that the simple fact that a man has high-risk sex does not become the sole criterion for him to be diagnosed as exhibiting psychopathology. Does an individual's desire to behave in ways that may be labeled as either impulsive or sensation-seeking now place him at risk for receiving yet another diagnosis that reflects society's intense negativity toward gay male sexuality? This is where astute diagnostic skills and cultural sensitivity to particular realities in the lives of gay men are required in order to not inappropriately pathologize men who are behaving in a manner that the society or clinician is uncomfortable with or sees as inappropriate, without denying the possibility that for some gay men their sexual risk-taking may be part of a constellation of symptoms that justifies a psychiatric diagnosis.
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