"The terrible thing in this world is that everyone has his reasons."
Octave, The Rules of the Game, Jean Renoir, 1939
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.
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.
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.
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.
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):
"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.
Pinkerton and Abramson describe three factors that influence an individual's subjective assessment of the relative risks of various sexual behaviors:
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.
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.
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.
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.
Recent research finds that men who forego using condoms feel there has been a decrease in social supports for staying safe as well as a shift in community norms toward increased acceptance of unsafe sex. In effect, they feel some peer pressure to bareback (Morin et al., 2003). The shifting winds of the gay sexual culture have a huge impact on members of a minority group that is partially defined by sex and desire. As I pointed out in the previous chapters, accepting, internalizing, and adopting sexual norms are part of most gay men's core identification as gay men. Thus in the immediate aftermath of the onset of AIDS, the community norms for sexual behavior shifted from the anything-goes realities of a pre-AIDS world to adopting safer sex, which allowed many men to remain sexually active. Safer sex and condom use were viewed as core elements of gay pride and as part of the glue that bound the community together. Currently, with the waning of the most obviously horrific aspects of AIDS, the sexual status quo is once again in transition, but this time away from the standard of safer sex, as the pendulum swings back in the direction it had been moving prior to 1982.
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.
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.
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.
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).
With all of these medical reasons not to bareback, Tim Dean (1996) writes: "How can we successfully combat AIDS without understanding the appeal of sexual self-immolation and the full range of defensive reactions to that appeal" (p. 75). Is Dean essentially accusing barebackers of seeking to kill themselves? On some level it would appear so. I certainly understand why this would be the reaction of many people, health care and mental health professionals included, to barebacking. Yet, it has not been my experience from working with and knowing many men who bareback that this is the salient operative dynamic.
"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.
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):
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):
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.
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).
Carballo-Dieguez and Bauermeister (2004) remark that the pulls toward and against barebacking can be seen from a psychoanalytic perspective as a battle between the id and superego or, from a philosophical perspective, as a confrontation between hedonists and rationalists. "Supporters of barebacking reported being motivated mainly by what felt good, appealed to their senses, and made them feel free; they used their reasoning to justify their behavior. Opponents of barebacking stressed moral and ethical imperatives and argued that barebacking pleasure-seeking impulses should be suppressed or tamed" (Carballo-Dieguez & Bauermeister, 2004, p. 11). It is only by offering clients opportunities during therapy to delve into their psyches that they can begin to gain deeper understanding of the multiple meanings that sex and, in particular, barebacking has for them on both the manifest and the unconscious levels. Without gaining access to the various meanings that each man who barebacks brings to specific sexual situations and acts, there is no way that each individual can be certain that he is making the kinds of decisions that will leave him feeling good about himself, his sexual partners, and the acts they engage in together.
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)."
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.
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).
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