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Why Do Men Bareback? No Easy Answers

By Michael Shernoff

2006

An excerpt from Without Condoms: Unprotected Sex, Gay Men & Barebacking
Routledge, 2006, List $31.95


"The terrible thing in this world is that everyone has his reasons."

Octave, The Rules of the Game, Jean Renoir, 1939


Toby, a Passive Barebacker

Without Condoms: Unprotected Sex, Gay Men & Barebacking, by Michael Shernoff
Toby is a white, 35-year-old, HIV-negative gay man who came to see me because of depression and loneliness. A successful and ambitious architect, he worked exceptionally long hours to make partner in his firm. His last relationship ended during his final year of graduate school, after 2 years, and he had not had another partner in almost 10 years. Because of his intense focus on work, Toby had not taken the time to cultivate deep friendships. He did have a group of people with whom he would go to clubs to dance a few times a month. Typically, during those outings, he would take MDMA (Ecstasy) and smoke marijuana. He said it helped him lose his inhibitions and cut loose on the dance floor. At the end of the night he would usually end up going home with someone he had just met.

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.


Rationales for Barebacking: Chapter Overview

This chapter asks a lot of tough questions: Is barebacking pathological? Is it correlated to personality disorder? Is it all about sex, sensation-seeking, and pleasure? Or is it, as paradoxical as this may seem, actually an attempt to take care of oneself and to forge a deeper intimacy, closeness, and even spiritual communion? We will look at how current antiretroviral therapies may affect decisions to have unprotected sex, and how fear and lack of fear about the danger of HIV infection play into the decision to bareback. The question of whether sex without condoms in the age of AIDS can ever be a rational decision will be explored. As the title of Chapter 3 promises, there are no easy answers to why men have sex without condoms.
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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.


Why Men Are Taking Sexual Risks

There are abundant theories but no definitive answers about why gay men take sexual risks. After more than three decades of safer sex messages against the backdrop of gay men sickening horribly and then dying, new medical treatments have stemmed the tide of the pandemic and offered real hope for longer-term survival to people with HIV. Gay men want the AIDS epidemic to be over and want to be able to have sex without fear. They want to celebrate their desire without having to worry, negotiate, be fearful, or keep a shield of latex between themselves and their partners. Younger men want to experience pre-AIDS sex. Queer theorist Tim Dean (2000) writes: "In view of statistics on new seroconversions, some AIDS educators have begun to acknowledge that, unlikely though it may seem, remaining HIV-negative in fact poses significant psychological challenges to gay men" (p. 137). To those who have not been working in the gay men's community for the past 25 years, this statement might seem absurd, but it is true that HIV-negative gay men face unique challenges that make it seem almost easier to seroconvert.

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.


Factors That Lead to Sexual Risk-Taking

There are numerous theories for why gay men engage in unprotected sex, and research has explored a wide variety of possible rationales for the behavior. These include:

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.


Rational and Irrational Barebacking

Two researchers at UCLA developed a model of sexual decision making to assess rationales of adults who have unprotected sex. Pinkerton and Abramson (1992) found that "for certain individuals, under certain circumstances, risky sexual behavior may indeed be rational, in the sense that the perceived physical, emotional, and psychological benefits of sex outweigh the threat of acquiring HIV" (p. 561). This seems to be precisely Toby's relationship to barebacking: the benefits gained -- shaking off the constraints of a very buttoned-up work life and having satisfying sexual experiences that also fulfilled social and emotional needs -- outweighed the potential risk of becoming HIV-positive. These researchers state that they do not mean to imply "that risky behavior is rational in any objective sense -- only that, given certain sets of values and perceptions, engaging in unsafe behaviors may appear to the individual to be a reasonable gamble" (p. 561). They also stress that what is rational is a highly subjective matter.

Pinkerton and Abramson describe three factors that influence an individual's subjective assessment of the relative risks of various sexual behaviors:

In order for an individual to behave rationally while barebacking, his fear of AIDS needs to be relatively small in comparison to the satisfaction derived through unprotected sex. This was exactly how Toby reported feeling early on in therapy. Yet as our work progressed, he began to express a profound ambivalence about becoming infected. Part of him wanted to stay uninfected, and yet part of him felt unsure of whether he would be willing and able to experience what to him seemed like deprivation of his spontaneity if he were to increase his efforts to keep himself HIV-negative. Pinkerton and Abramson conjecture that for many Americans, "fear of AIDS" may be synonymous with "fear of death by AIDS," and that fear of death is not nearly so great as might otherwise be supposed. "Fear of AIDS" is mediated by the subjective probability of perceived risk. Perceived risk is explained as containing three related components: the threat of exposure to HIV, the probability of exposure leading to HIV infection, and the likelihood of AIDS developing from HIV exposure (Pinkerton & Abramson, 1992). Even when gay men possess a sophisticated understanding of how HIV is transmitted and accurate perceptions of how dangerous risky sex can be, many gay men underestimate their vulnerability to HIV infection (McKusick, Horstman, & Coates, 1985; Bauman & Siegel, 1987; Richard et al., 1988).

Grov (2003) also discusses a category of barebackers that he labels irrational risk takers. "Individuals in this category typically deny their own risk or use nonscientific/irrational information when engaging in barebacking" (p. 333). Suarez and Miller (2001) feel that many gay youth who bareback fall into the category of irrational risk takers since they may have never known anyone with HIV and hold pessimistic attitudes about the future largely related to their being gay. Suarez and Miller feel that this combination often leads to young gay men (especially young gay men of color) taking sexual risks.

Pinkerton and Abramson offer possible explanations for the tendency to underestimate the personal risk associated with risky sex, even among "high-risk" gay men. First, they cite a study showing that no one sees himself as the "type of person who gets AIDS" (Madake-Tyndall, 1991). They also suggest that the "I'm not the type" fallacy is often extended to sexual partners. As they note, "Thus, the frightening picture that emerges is one in which it is only the other guy who gets AIDS. To the average gay man, it's those gay men who are overly promiscuous; and to the bath house participants, it's those who aren't careful" (Pinkerton & Abramson, pp. 564-565). They also discuss that results from cognitive psychology indicate that in general people tend to view themselves as "luckier" than the norm, and that this extends to the belief that they will not be the one to get AIDS.


Barebacking as an Example of "Sensation-Seeking"

Again and again, we return to the poignant question of why a person would put his life in jeopardy for pleasure. Sex is a source of pleasure that encompasses biological, psychological, and sociological realities (Reiss, 1989). Sex is not only about pleasure. It can be about belonging, feeling desired, desiring semen, organizing one's life, and providing meanings to one's life. "People have sexual relations for a variety of reasons: for love and intimacy, for recreation, for fun, for friendship, for money, to avoid loneliness, to be touched. The essence of sexual encounters is bonding, blending, mutual pleasure, and loss of inhibition. HIV lurking in the background places strict boundaries on all of these aspects of sexuality" (Coates, 2005, p. xiv). The equation for evaluating how the benefits of barebacking weigh against the inherent risks is not simple. Tim Dean (2000) writes: "Most people can't comprehend why anyone would risk death for a good fuck. From a certain viewpoint, unsafe sex appears as inconceivably self-destructive behavior. Indeed, while such health-threatening practices as smoking, drinking, and drug abuse must be indulged in repeatedly over a substantial period before they are likely to cause harm, HIV infection can result from a single unprotected encounter. Casual, anonymous sex without a condom seems suicidal" (p. 139). But the long-term effects of HIV infection on health are easily denied when faced with the immediacy of sexual pleasure, particularly if one is using drugs that fog one's judgment.

One lens through which decisions to bareback need to be viewed is the role of pleasure and how the search for erotic pleasure is intimately related to desire. For one thing, sex without condoms feels much better and is vastly more spontaneous than having to stop the action, unwrap a condom, and properly put one on. Many gay men are articulate about how thrilling and intimate it is to the feel of the warmth of a lover's unsheathed penis and the smooth stimulation of skin against skin. Carballo-Dieguez interviewed a small sample of men who identify as barebackers. One man told Carballo-Dieguez (2001, p. 229):

The pleasure I feel when I'm having sex, especially if I'm stoned, is so amazing. ... Passion does not call for protection in my mind. Passion is a very raw emotion. ... It is not easy to feel real passion, because there are so many barriers put up and so many acts that people have in themselves that they want to express during sex, that protection does not fit in the fantasy.

Much as we try to eroticize safer sex, there is no way around the fact that condoms both decrease the sensation of anal intercourse and interrupt the spontaneity of the sexual act. Sexual fulfillment "encompasses a range of physical, emotional, and psychological factors including, but not limited to, physical pleasure and release, emotional intimacy and security, enhanced self-esteem, and actualized sexual identity. These are all highly valued, immediate benefits of sexual expression (in contrast to the distant, rather ethereal threat of contracting AIDS)" (Pinkerton & Abramson, 1992, p. 565). As previously discussed, recreational sex has been identified by at least certain segments of the gay male community as a means of personal fulfillment and an expression of enhanced freedom and self-esteem. An active sex life is seen as a indication of attractiveness and vitality. A gay man who wants to feel liberated, hot, or sexy might view sex without condoms as the best route to fulfilling his desire to feel any of those ways.

"Sensation-seeking" is defined as "the seeking of varied, novel, complex, and intense sensations and experiences, and the willingness to take physical, social, legal, and financial risks for the sake of such experiences" (Zuckerman, 1994, p. 27). Zuckerman (1993) finds that sensation-seeking and impulsivity are not the same thing, though they are related. They looked at how sensation-seeking, and an individual's affect and the ways risk affects the ability to become sexually aroused, contribute to why men have unprotected sex. These factors illustrate how intrapsychic and interpersonal issues converge to influence an individual's likelihood of taking sexual risks. For instance, men who are high sensation-seekers may be more likely not to use condoms since they value the intensity of skin-on-skin contact during anal intercourse. In short, one man's need for a higher degree of sensation can result in his initiating sexual risk-taking, taking his intrapsychic need into the interpersonal sphere.

Numerous researchers have studied the connection between sensation-seeking and men who bareback. Pinkerton and Abramson (1995) and Bancroft et al. (2003) provide evidence suggesting that sensation-seeking impacts on sexual risk-taking in two principal ways: by increasing the preparedness to take risks in order to achieve the desired immediate benefits and by influencing how the individual appraises the risk. An individual who is highly sensation-seeking is more likely to downplay the risks associated with a particular behavior if he has previously engaged in the behavior (in this case UAI) without negative consequences, such as becoming infected with HIV. Thus as Pinkerton and Abramson (1995) point out, men who are high sexual sensation-seekers seem not to be unaware of the risks associated with their behavior but choose instead to accept these risks. Some of these men may be in denial about the potential risks to their health. Others may simply compartmentalize the risk and not have it affect their behavior. Yet other men engage in a form of magical thinking -- believing that they are invulnerable to infection. There are also men who know and accept the risks and are willing to factor them into the equation as one potential cost to an otherwise important, pleasurable, and valued behavior pattern.

Scragg and Alcorn (2002) and Miller, Lynam, Zimmerman, Logan, and Clayton (2004) find that both extraversion (being highly outgoing with the ability to easily engage other people socially or flirtatiously) and sensation-seeking are related to the desire for a greater number of sexual partners. This seems to make sense since sex with more than one person is inherently a social activity and requires one or more partners (Miller et al., 2004). Schroth (1996) also demonstrated that in a sample of gay men he studied there was a strong correlation between sensation-seeking and high number of sexual activities and high number of partners. Interestingly, this same study did not find any relationship between sensation-seeking and unsafe sexual behavior in the well-educated men among the sample surveyed. This finding is contradicted by empirical observations of the well-educated men I see as psychotherapy patients who bareback and often exhibit characteristics of sensation-seeking.

Hoyle, Fejfar, and Miller (2000) conducted a quantitative review of the empirical literature on "normal" personality and sexual risk-taking in which sexual risk-taking behaviors were defined as numbers of partners, unprotected sex, and high-risk sexual encounters, including sex with a stranger. Their work found that a high level of sensation-seeking predicts all forms of sexual risk-taking covered in their review. There was a consistent, but not strong, positive association between impulsivity and sexual risk-taking, with these authors noting that there was a problem in the inconsistent ways that impulsivity was defined. Seal and Agostinelli (1994) showed that impulsivity was one important factor among men who had UAI.


Serosorting

In discussing what they call "rational risk-takers," Suarez and Miller (2001) note that there is a group of men whose sexual behavior is based on "rational" consideration of the risks of specific sexual acts. Among this group are couples who are not sexually exclusive who have negotiated safety1 agreements, and HIV-negative men who only are the insertive partners during condomless anal sex. Suarez and Miller describe a phenomenon that some men use as part of their "rational" approach to barebacking as "serosorting." Robert, the client I described in Chapter 2, is an example of someone who made his decisions to bareback based on the other man's HIV status as an attempt to mitigate the risks of barebacking. Serosorting relies on men discussing HIV status with potential partners and only engaging in risky behaviors with those who are believed to be of a similar serostatus. A study conducted in the San Francisco Bay area among a multiethnic sample of MSM (Mansergh et al., 2002) found that a majority of the men surveyed who had engaged in UAI in the prior 2 years reported engaging in barebacking with a man of the same HIV status when he was the receptive partner. This is obviously not a foolproof method for reducing one's risk of contracting HIV insofar as disclosure of HIV status is not always truthful or accurate (Cochran & Mays, 1990; Rowatt, Cunningham, & Druen, 1999), and some individuals honestly do not know that they are infected.

Despite the limitations of serosorting, Suarez and Miller (2001) report that many barebackers employ this strategy. As evidence, they point to the plethora of personal ads on Web sites devoted exclusively to barebacking as well as on Web sites where gay men cruise for sex where men state their own HIV status and the desired status of potential partners. Hort (2000) posits that barebacking itself is a serosorting strategy insofar as barebacking is often a way for HIV-positive men to disclose their status and assume that anyone who is willing to have unsafe sex with them is also already infected. But as will be discussed in Chapter 5, this assumption is incorrect. Suarez and Miller note that many barebacking ads are posted by men who claim to be HIV-negative and state explicitly that they will only bareback with other uninfected men.


Barebacking to Feel in Control

Whether or not a man is making a rational choice when he decides to bareback is often difficult for others to assess, even psychotherapists who must contend with their own judgments and feelings about this particular highly charged, high-risk behavior. But for barebackers who are neither actively nor passively suicidal, there is an internal logic that makes sense to them, especially when the behavior occurs within specific contexts. For example, one rationalization for engaging in unsafe sex is the belief that having an HIV infection will alleviate their worry about becoming infected. This dynamic was first reported by psychologist Walt Odets (1994), when he described men who felt that they were not destined to survive the epidemic and therefore had no motivation or reason to practice safer sex. Odets writes that many survivors of the epidemic have a sense of the inevitability of their "catching AIDS." One example of this was my client Jeff, a 44-year-old, Jewish, HIV-negative man who enjoyed dancing at New York clubs and going to an occasional circuit party. Since he almost never used condoms but made every effort to limit his sexual partners to other uninfected men he met, he decided to have "HIV-" tattooed on his left arm since he disliked the necessity of asking about HIV status. Immediately after getting himself tattooed he discussed his feeling that it was only a matter of time until he eventually got infected. "When it happens I can just have the vertical bar added to my tattoo so it will accurately read "HIV+," he told me, pleased with his strategy.

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 Connection

Vincke 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 Pressure

Since 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).

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.


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.


Risks From Barebacking

There 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).

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.


Love, Desire, and Risk

It 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 Barebacking

Carballo-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):

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 Research From Great Britain

Unfortunately, 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?

No.

(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 Transgression

Crossley (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).

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 Unconscious

While 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.

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)."


Barebacking and Self-Care

It 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 Prophylaxis

As 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).


Conclusion

The 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.


Notes

  1. 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.
  2. An Axis II psychiatric diagnosis is where the presence of personality disorders or mental retardation is indicated.
  3. 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).

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