Why Do Men Bareback? No Easy Answers
Risks From BarebackingThere are a lot of reasons not to bareback. It is probably safe to say that most gay men who bareback are familiar with a majority of the reasons not to do so. Halkitis et al. (2003) point out for HIV-negative men, initial infection with HIV is the most immediate consequence of barebacking. To make matters worse, they risk the potential for this initial infection to be with a medication resistant/untreatable variety of HIV (Hecht et al., 1998; Wainberg & Friedland, 1998; Boden et al., 1999; Little et al., 1999; Routey et al., 2000; Hicks et al., 2002). The potential of this risk turned real in February 2005, when the New York City Health Department issued a report about a new, rare, and aggressive form of HIV that had been diagnosed in one man, setting off concerns about a new and more menacing kind of HIV infection (Santora & Altman, 2005). The man contracted HIV while using crystal methamphetamine and had sex with multiple partners. This form of the virus was resistant to three of the four classes of antiretroviral drugs used to treat HIV, and the man who had contracted this strain progressed to full-blown AIDS in approximately 3 months.
In a follow-up report in the New York Times, some experts noted "that they had seen the rapid progression of HIV to AIDS and high drug resistance before, though not both in combination. They said that the New York case could indicate more about the vulnerability of the infected man's immune system than about the dangers of the virus in his body" (Perez-Pena & Santora, 2005, p. 39) When questioned about the report of this strain of HIV, many leading AIDS researchers and physicians did not express surprise at the emergence of such a strain of HIV. Dr. Thomas Frieden, the New York City health commissioner, said that "more testing was needed before health officials and scientists could be certain about the extent of the threat. But for now, the responsible reaction was to treat it as a real menace and to alert the public" (quoted in Perez-Pena & Santora, p. 39) Experts counseled caution and the need for further research to be done before determining how potentially serious a threat this new form of the virus posed.
For HIV-positive men, barebacking may lead to "superinfection"3 (Blackard, Cohen, & Mayer, 2002; Jost et al., 2002) and rapid loss of CD4 cells, especially through continual exposure to ejaculate (Wiley et al., 2000). It also puts them at risk for contracting other STDs that may lead to opportunistic infections such as Kaposi's sarcoma (O'Brien et al., 1999; Rezza et al., 1999), co-infection with hepatitis C (Flichman, Cello, Castano, Campos, & Sookoian, 1999; Mendes-Correa, Baronne, & Guastini, 2001), and immune system deterioration (Gibson, Pendo, & Wohlfeiler, 1999; Bonnel, Weatherburn, & Hickson, 2000), (Halkitis et al., 2003, p. 352).
Love, Desire, and RiskIt seems to me that when a person knowingly places himself at risk for contracting HIV, "sexual self-immolation" cannot be the only motivation or appeal. There have to be strong positive forces at work as well. As will be discussed in Chapter 6 and Chapter 7, love and a desire for a greater degree of intimacy and interpersonal connection are often felt to be strong, positive motivations for barebacking. Scott O'Hara, the writer and former porn star already quoted in Chapter 1, gives the following example of how he evaluated the risks and benefits of barebacking even when he had not found out his own HIV status.
"I would say that the risks are commensurate with the rewards. Bareback sex indicates a level of trust, of cohesion, that I don't think is achievable when both partners are primarily concerned with preventing the exchange of bodily fluids" (1997, p. 9).
How the positive rationales for barebacking measure up against the potential risks once again suggests that using an ecological approach that encompasses unconscious, intrapsychic as well as interpersonal factors has the ability to provide a broad and comprehensive way of trying to understand barebacking for each individual who engages in it and is troubled by this behavior. This also demonstrates the difficulties that AIDS prevention workers are up against in attempting to try to design interventions aimed to encouraging gay men to take fewer sexual risks.
Sex is more than actions and positions. Actions contain meanings stemming from relational and cultural values. Use of a condom, for example, may be associated with a negative message because refusing semen may be perceived to be a rejection with far-reaching emotional implications. Vincke and colleagues (2001) note that "considering that people are in search of meaning, sexual acts constitute an emotional and symbolic language. The meanings gay men assign to specific sexual acts can make behavioral change difficult" (p. 57). They also discuss how the major finding of research into the symbolic meanings of sexual behavior relates to AIDS prevention. All people construct and assign meanings to their sexual behavior according to the particulars of the setting, partner, and relationship. The meaning that is constructed is integral to an individual's calculations as to whether or not a particular action is rational. This brings us back to the theory espoused by Pinkerton and Abramson (1992). In specific circumstances, risky sexual behavior is thought of as rational insofar as the perceived benefits derived from sex outweigh the possible risk of contracting HIV. Vincke and colleagues found that men who take sexual risks perceive sexual techniques in terms of the inherent gratification and the associated dangers with "pleasure and danger being two independent dimensions used to structure the cognitive domain of sex" (p. 68). It is useful for therapists working with barebackers to remember this and to explore with clients how danger and pleasure are kept apart as well as how these two dynamics overlap.
The Various Meanings of BarebackingCarballo-Dieguez (2001) found that among men he interviewed who bareback, sex has multiple meanings. For some, sex meant being liked, desired, and needed; finding company in times of boredom; reaffirming one's personal freedom; shedding a stigma; defying the established order; and/or exploring masculinity. In discussing the multiple meanings and implications of sex, Frost (1994) expands upon Carballo-Dieguez's findings, stating, "For many gay men, sexual behavior is a statement of their sense of being gay, an affirmation of their right to be gay, an expression of love, a vehicle through which to achieve intimacy, and a repudiation of the felt prohibition by the greater society. For other gay men sex is a sport, a means of repairing from narcissistic injury" (p. 166). The points raised by both these authors speak directly to feelings that some barebackers have regarding the intrapsychic as well as interpersonal benefits they derive from barebacking.
Many people of all sexual orientations use sex as an attempt to ameliorate psychic pain or social discomfort. Speaking specifically about gay men, Yep, Lovaas, and Pagonis (2002) suggest that for many gay men the interconnection between the sexual and emotional or psychological aspects of their psyches speaks not only to the reality that some gay men use sex as an attempted "panacea" for their problems but also contributes to active resistance to changing risky sexual behavior. One study conducted during the height of the epidemic found that a majority of men surveyed agreed with the statement, "It is hard to change my sexual behavior because being gay means doing what I want sexually" (Aspinwall, Kemeny, Taylor, Schneider, & Dudley , 1991, p. 433) All therapists working with gay men who bareback must spend considerable time exploring the numerous and layered meanings that sex has for each individual and how sex with and without condoms affects the ability of various sexual opportunities and situations to meet these needs. When Toby describes why he barebacks, he is expressing how the various meanings that sex and beliefs about being gay have for him contributes to his unsafe sexual behaviors.
Considering the variety of risks of barebacking to both HIV-negative and HIV-positive men, it is instructive to hear from gay men who bareback about what they perceive are the benefits that outweigh the risks of barebacking. One of the most prominent and prolific researchers on gay men and barebacking is New York psychologist Perry Halkitis. Halkitis and his colleagues have conducted numerous studies on gay men, barebacking, and drug use and publish their research results in an impressively timely manner. In a survey of 518 gay and bisexual men conducted in Manhattan in 2001, the following were the most-often cited benefits of barebacking given (Halkitis et al., 2003, p. 353):
- Barebacking increases intimacy between men.
- Barebacking makes sex more romantic and affirms love between men.
- Barebacking is sexier than sex with condoms.
- Barebacking is more "butch" and manly and affirms masculinity.
- Barebacking is "hotter" than sex with condoms.
There are psychological and emotional benefits to barebacking.
Barebackers' postings on a Web site analyzed by Carballo-Dieguez and Bauermeister (2004) expressed some different attitudes about their behavior than those expressed by the men interviewed by Halkitis. For men who were in favor of barebacking and who acknowledged doing it, the following were their rationales for not using condoms during anal sex (Carballo-Dieguez & Bauermeister, 2004, pp. 7-10):
- Barebacking is enjoyable.
- Barebacking equals freedom.
- Barebackers are well informed about HIV and aware of the risks.
- Barebacking is not too dangerous. (Many respondents believed that most barebackers are already infected with HIV and are having unprotected sex among themselves.)
- Barebacking is a personal responsibility.
Barebacking Research From Great BritainUnfortunately, in the United States we have only small-scale studies from which to draw larger conclusions. The federal government has resisted funding any national study of gay men's sexual behaviors even though the findings would be of great interest and use to social scientists in terms of designing effective and targeted AIDS prevention programs that were culturally specific for the various subpopulations of gay men. Social scientists researching AIDS prevention among gay men in the U.S. have been stymied by conservatives in Congress who, in response to vocal activists of the religious right wing, have blocked all efforts to fund a national survey of gay men's sexual habits by either the National Institutes of Health (NIH) or the National Institute of Mental Health (NIMH).
But in Great Britain, large studies of gay men's sexual behavior have been conducted. Sigma Research evolved from Project SIGMA, which, between 1987 and 1994, carried out a five-phase cohort study of gay and bisexual men funded by the United Kingdom's Medical Research Council and the Department of Health. Sigma Research is a semiautonomous unit affiliated with the Faculty of Humanities and Social Sciences of the University of Portsmouth; it has undertaken more than 50 research and development projects concerned with the impact of HIV and AIDS on the sexual and social lives of a variety of populations. This work includes needs assessments, evaluations, and service and policy reviews funded from a range of public sources.
The 2003 Gay Men's Sexuality Survey (GMSS) had more than 4000 respondents (Reid et al., 2004), with respondents from all racial, cultural, and economic backgrounds. This makes it a reliable cross-section of gay men throughout Great Britain. Among the many findings from this extensive study was information about barebacking. A project conducted by SIGMA (Henderson, Keough, Weatherburn, & Reid, 2001) was an attempt to gain insight into how men who did not know their HIV status managed the physical as well as psychological sexual risks that were part of UAI. The majority of men surveyed in this study reported that UAI was momentary and was terminated immediately after penetration. Often the enjoyment was tempered by concerns about HIV risk, which competed with the pleasure derived. A second group of men acknowledged that UAI continued for longer than momentary penetration. Some of the men in this group had problems with initial penetration and used momentary penetration without a condom to enhance their erections in order to put a condom on and then continue until ejaculation. In contrast to this were accounts where some men decided not to use a condom at all but withdrew prior to ejaculation as a risk-reduction strategy (coitus interruptus). There was a third group of men in this study who did not use a condom, and UAI ended with ejaculation inside of the receptive partner. One man who was the insertive partner described his feelings as follows (p. 21):
(Interviewer) So how was that?
Brilliant. I mean this was even better because I came inside him.
(Interviewer) Were you concerned at that time? Was it going through your head what you were doing?
Absolutely, definitely, but it was just so good and I just didn't want to stop. [laugh] But it was good, it was brilliant. He was enjoying it again, I was enjoying it.
(Interviewer) After you finished what happened? Did you talk at all?
(Interviewer) Did you think about it later?
Yes again. I thought about it after and I've wanked about it since, you know, the joy of it.
Barebacking, Internalized Homophobia, and TransgressionCrossley (2004) suggests that condomless sex may be for some gay men a current manifestation of their need to hold on to transgressional aspects of their outlaw sexuality. She sees this as a consistent feature of gay men's individual and social psyche since the early days of gay liberation. In today's world where the political focus of much of the gay liberation movement has become gay marriage, gays serving openly in the military, and gay parenthood, the goals of organizations fighting for gay rights have shifted from gay men radically transforming American society to now assimilating into it in conservative and heteronormative ways. For men who have relished their identity as "sexual outlaws," barebacking is consciously one way to behave in a transgressive manner that is generally prohibited by mainstream society as well as by many within the gay community. Is there anything "nastier" and more transgressive than going against the expectations of society and literally and metaphorically tasting the forbidden fruit of unbridled, forbidden (queer) passion that is not constrained by the tight covering of latex bondage? As Gauthier and Forsyth (1999) note, "Breaking the rules for some is simply very exciting" (p. 94). "Hard as it may be to understand, some gay men have unsafe sex because they want to ... skate close to the edge. Danger can be erotic, even the threat of contracting a deadly disease" (Peyser, 1997, p. 77).
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