Why Do Men Bareback? No Easy Answers
In another article, Crossley (2002) sees that for some, bareback sex is not just an act of sensual pleasure or expression of pathology, but an assertion of sexual freedom, rebellion, and empowerment. This seems to mesh perfectly with her previous thesis about bareback sex being related to meeting the need some gay men have to be conspicuous about not being part of the mainstream. Crossley's observation is in keeping with the points made by Crimp (1989), Rofes (1996), and Moore (2004) about how the vibrant and creative sexual culture created by gay men in the 1970s still exerts a powerful pull on the gay psyche and is a highly valued aspect of gay communal memory and history that contributes to why some men bareback. The following quote (Carballo-Dieguez, 2001, p. 229), by another of the men interviewed by Carballo-Dieguez, illustrates the points that Crossley makes about the power of barebacking as a transgressive act.
It is exhilarating, it is the forbidden thing, it is like a drug, it is what you are not supposed to do, it's getting away with murder.
"When we discuss the issue of sexual risk-taking behaviors -- particularly in a marginalized, outlawed group, such as gay men -- it is imperative to see the historical and cultural forces at work in shaping dynamic understanding of such behavior," writes Marshall Forstein, MD, professor of psychiatry at Harvard Medical School. "No gay man grows up immune to the insidious and overt messages that his sexual desire is in itself fundamentally wrong and unacceptable" (2002, p. 39). Most gay men grow up in a culture where their desires and even existences are marginalized. Many grow up in families where they are reviled or overtly rejected because of their sexual orientation. All of these factors help to strengthen and reinforce the power of internalized homophobia in an individual's psyche. One of the ways that internalized homophobia may play out is an unconscious sense that the individual is unimportant, undervalued, and not worth very much, thus increasing his sense that he is expendable, and so too are the men with whom he has sex and from whom he seeks love and validation. All of this can help to explain why otherwise seemingly comfortably out and proud gay men are not doing everything possible to prevent themselves from becoming infected and preventing the spread of HIV to their sexual partners. British scholar and cultural critic Jonathan Dolimore addresses these dynamics when he says: "What we have learned from Roland Barthes as from Michel Foucault and Oscar Wilde (albeit differently in each case) is that oppression inheres in those subjected to it as their or our identity, and must eventually be experienced and contested there, and never more so than when this subjection involves desire. Identity for the homosexual is always conflicted: at once ascribed, proscribed, and internalized, it is in terms of identity that self-hatred, violence, mutilation, and death have been suffered" (Dollimore, 1998, pp. 325-326).
Risk-Taking and the UnconsciousWhile researchers have asked gay men to explain why they bareback, very rarely do any of them speak of the deep, unconscious factors and forces that may play a role in increasing their propensity to take sexual risks. In his description of contemporary gay sexual practices, Sex Between Men, Los Angeles writer and therapist Douglas Sadownick notes that "sex often is a matter for the unconscious" (p. 5) and "desire is an unconscious manifestation" (p. 216). One of the basic tenets of psychoanalytic theory that Freud (1920) formulated concerns sexuality overlapping with a dimension of negativity. Freud originally called it "the death instinct," but is now commonly referred to as "the death drive." Dean (2000) notes, "AIDS gives ghastly new life to this idea, literalizing longstanding connections (many of them purely mythic) between sex and death (p. 20)." He also suggests that to divorce any account of sexual practices from the unconscious leaves one with merely a commonsensical, conflict-free notion of pleasure and desire. What Dean is most likely speaking to is the reality that the vast majority of safer-sex interventions and programs have all been behaviorally based and have not also tried to address the intrapsychic and unconscious forces that frame our desires and how they potentially become actualized.
Mansergh et al. (2002) discuss that some men intentionally put themselves and/or others at risk of HIV and STDs to meet important human needs (e.g., physical stimulation, emotional connection). It is obvious, yet crucial to note, that most people who engage in sex are in pursuit of pleasure, though pleasure alone is often not the only reason why anyone may seek sexual encounters. As Blechner (2002) states: "If we problemize one extreme but not the other, we may lose perspectives on how decisions of risk-taking are made. Risk of HIV infection is serious. But the risk of loss of pleasure and intimacy is also serious (p. 30)."
Barebacking and Self-CareIt would be simplistic to adduce a single issue or dynamic as the "rationale" for an individual's engagement in unsafe sex. Usually, a complex combination of factors underlies such behavior, some of which are understandable and adaptive for that particular individual. Theories abound as to the resurgence of unsafe sex among gay men. Cheuvront (2002) wisely cautions: "In marginalizing the risk-taker as a damaged other, anxieties and fears about risk of infection are quelled for patients and clinicians alike. However, when risk-taking behavior is seen as situational, treatment provides a context for inquiry, articulation, and understanding of the patient's unique experiences, feelings, and circumstances" (p. 12). It is all too easy and reductionistic to pathologize sexual risk-takers as self-destructive, suicidal, damaged individuals. Cheuvront seems to agree, writing, "The popular media promote the HIV risk-taker as damaged and resigned to the inevitability of infection" (Cheuvront, 2002, p. 10).
Cheuvront (2002) reminds all mental health professionals working with gay men who bareback that "the meanings of sexual risk-taking are as varied as our patients" (p. 15). He cautions that simplistic explanations and understandings can "assuage the clinician's anxiety by making that which is complex and subject to individual differences appear less mysterious and knowable. Yet, this is not a luxury that clinicians have" (p. 15). It is the task of therapists to help an individual articulate the particular meanings of his high-risk behaviors. Regarding sexual risk-taking, Forstein (2002) asks: "Can care for the soul and care for the psyche always occur in the context of caring for the body?" (p. 38)
Part of the difficulty in finding ways to effectively address sexual risk taking is that many gay men use barebacking as an attempt to find closeness and fulfillment of profound emotional needs. Julian (1997) found that barebacking was a way that some men dealt with personal difficulties and sought emotional relief, breaking out of chronic isolation and connecting socially and intimately with another person. As Prieur (1990) notes for some gay men, "An active sex life may be the only tie to community. All social needs are released there; it is the only means of experiencing closeness to others. For a number of gay men, sex is almost a social amenity" (p. 111). In short, taking the risks associated with barebacking is actually the way some gay men are trying to take care of themselves and meet deep and urgent needs and desires. Cheuvront (2002) suggests that for many gay men self-care may indeed include taking risks, which in the context of barebacking means that the benefits derived from condomless sex in the present vastly outweigh any long-term potential risk to their health. In response to this issue, Forstein (2002) posits that "the question becomes one of understanding the nature of the risk and whether that particular risky behavior alone can attend to the needs inherent in the behavior" (p. 42).
I was reminded of this during a conversation with a colleague of mine who was saying that in order to do effective psychotherapy the clinician must remain close to the client's material and experiences without judging what the client is doing in order to afford the individual the best opportunity for emotional change. My colleague was describing a case where one man's clinical and developmental progress coincided with his getting HIV. During the course of therapy the client and therapist came to see how this individual's sexual risk-taking was a form of finding vitality in a very deadened life. Once he seroconverted, he felt enormous relief and became much better able to attend to self-care. As a result, this therapist understood that for this particular individual as well as for others, that on becoming HIV-positive there may be significant meanings and emotional understandings to be derived from this transition which may affirm one's feelings of cohesiveness, capacity to feel understood, and a general sense of participation in the world. "The challenge for the therapist is remaining available to the patient in the wake of these changes" (J. P. Cheuvront, personal communication, March 14, 2005). Analyst Eric Sherman (2005) also poignanatly describes working with a man who was taking sexual risks and became HIV-positive during the course of therapy.
Post-Exposure ProphylaxisAs noted earlier, the advent of combination drug therapies has had a direct impact on some men's perceptions of AIDS, its seriousness and potential lethality. Yet there is another way that combination therapies have a direct relationship with AIDS prevention. Since the late 1990s, one use of combination therapies has been "post-exposure prophylaxis" (PEP), also sometimes called "post-exposure prevention." As explained by a PEP researcher at the University of California San Francisco, "For HIV-infected persons who are exposed to HIV, there may be a window of opportunity in the first few hours or days after exposure in which these highly active drugs may prevent HIV infection" (DeCarlo & Coates, 1997). PEP with antiretroviral medications is recommended by the U.S. Public Health Service (2001) following occupational exposure to HIV. The effectiveness of PEP in the occupational setting has prompted advocacy for the use of PEP following nonoccupational exposures in humans via sexual contact or injection drug use. Although as Martin et al. (2004) note: "There are sufficient similarities between occupational and nonoccupational exposures to consider extrapolating the biological efficacy of PEP in the occupational setting to nonoccupational exposures, there are critical contextual differences that must be addressed before PEP for nonoccupational exposures can be routinely recommended" (p. 788). There are a number of reasons why health care workers, who have an occupational exposure, are not a comparable group of people to those exposed through sex or shared injection drug using paraphernalia. Health care workers almost always know whether the patient they are treating has HIV; sexual and drug use partners do not always know the HIV status of their partners. Health care workers can usually gain access to antiviral drugs within minutes or hours of their injury; individuals exposed through sex or needle sharing probably have to wait at least several hours, if not longer, before they can obtain antiviral drugs (Ostrow, 1999). If postexposure therapy works at all, it works best when administered within 2 to 36 hours of exposure (New York State Department of Health, 2004).
By February 1997, six PEP centers had been established around the United States (Dahir, 1998). As of August 2004, PEP is available through emergency rooms and private physicians throughout the United States, Australia, and Europe. Some professionals worry that if people think PEP works, they will stop practicing safer sex and safer needle use, much as some wanted to block access of women to the "morning after" pill, fearing it would become a substitute for birth control. One important concern is that the availability of PEP following sexual or drug-use exposure could promote increases in high-risk behavior, with repeated requests for PEP (Martin et al., 2004). Margaret Chesney (1997), a co-director of the Center for AIDS Prevention Studies, which is involved with one of the nation's largest PEP clinics at San Francisco General Hospital, stresses, "In addition to the drug therapy, people should be given hours and hours of counseling to help them think about their experience in having gotten exposed, what it means, and how they can keep from repeating it." Martin et al. discuss that for PEP to be a useful intervention for the prevention of HIV infection following sexual or drug-use exposures, it needs to be feasible, safe, and efficacious. They provided risk-reduction education in addition to medication. Martin's research (2004) showed that most individuals do not experience sexual behavior disinhibition after receipt of PEP that includes both antiretroviral medication and risk-reduction counseling.
An informal survey I conducted of five physicians in Manhattan whose practices include large numbers of gay men did not evidence any indications of patients calling these physicians for PEP following a high-risk episode. None of the doctors surveyed reported ever having a patient call immediately after a high-risk sexual exposure to request a prescription for antiretroviral drugs to initiate PEP. One physician described one occurrence when a new patient who had been on PEP three previous times as prescribed by his previous doctors asked if he could have a supply of antiretroviral meds for use "just in case." This physician felt that the man's decision-making process regarding barebacking was partly influenced by PEP availability but did not give this individual the requested prescription. He strongly believed that prescribing the drugs would possibly support increased risk-taking (S. Dillon, personal communication, August 24, 2004).
In a study of how HIV progresses in newly infected individuals, conducted at New York University School of Medicine's Center for AIDS Research, the researchers did not find many study volunteers who have taken PEP. In their opinion, the gay men in this particular study are not very aware that PEP even exists. The men who do know about it seem to have a vague awareness but no specific knowledge. To these researchers it does not seem that the availability of PEP has had a significant impact on risk behavior (M. Marmor, personal communication, August 27, 2004).
ConclusionThe rationales for barebacking are as numerous as the men who do it. I have often heard men who bareback as well as my colleagues in the mental health field question whether the behavior is indicative of some underlying mental disorder or at least of unrecognized internalized homophobia. While indeed for some barebackers either or both could be at play, I have also come to learn that, as some of the researchers cited above conclude, in certain situations for certain men what at first appears to be reckless and self-destructive may be adaptive, affirming, and understandable. If we take a step back from the highly fraught and emotionally charged particulars of this issue and attempt to separate what we think is the "right" way to act now that the sexual transmissibility of HIV is a known fact, from moral judgments about the behavior and people who do it, we can begin to understand why barebacking is not always as "crazy" as it may at first appear to be. There are no easy answers to why men bareback or how this tide can be stemmed or even whether it should be stemmed. But at least we can start to ask better questions and open a crucial dialogue.
- Negotiated safety is an agreement between two gay men in a relationship to go through the process of getting ready to stop using condoms when they have anal sex. The basis is an explicit understanding that both know each other's HIV status and are both uninfected. The only time they do not use condoms is when they have sex with each other. This risk reduction strategy was first reported among gay men in Sidney, Australia (Kippax et al., 1993), and will be discussed in depth in Chapter 6.
- An Axis II psychiatric diagnosis is where the presence of personality disorders or mental retardation is indicated.
- HIV "superinfection" is defined as a second infection with HIV after a primary infection has been established. This is distinct from "coinfection," which is defined as the simultaneous transmission of two or more subtypes of HIV. (Blackard et al., 2002).
This book excerpt has been provided with the permission of Routledge.
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