When the first one of Daniel's close friends was diagnosed with AIDS, the resulting depression had as one characteristic the loss of all desire for sex, even with Alberto. Each time another person either of them knew became ill, Daniel became more terrified about his health as well as Albert's. Increasingly he shut off all sexual thoughts, fantasies, and actions. Even his very infrequent masturbating made him feel bad, since he would remember all the high risk activities he used to engage in. As a result, his relationship with Alberto became increasingly strained.
One evening Alberto came over with a flyer he picked up at the gym with a cartoon depicting two attractive men, one complaining: "I'm pissed off ..sex isn't fun any more!! " and his friend replying "Oh, Yeah? I'll show you great Safer Sex!!" This flyer advertised a workshop on eroticizing safer sex that claimed "You probably haven't thought of half the things you can do with other men practicing safer sex! But we have." Alberto informed Daniel that he had enrolled both of them in the safer sex forum to be held that Saturday, and that both of them would most definitely be in attendance.
Daniel is typical of millions of gay men who, as a result of AIDS, have become phobic about sex. Uncertainty about which sexual practices are low risk, and how one can change long-existing patterns of sexual behavior, have contributed to a heightened sense of anxiety in the gay male community, especially in relation to sexuality. Moreover, a common response to the AIDS crisis is one of anger at having to make certain changes in order to protect oneself and one's sexual partner(s). Another is the feeling of extreme isolation and/or a wearied resignation at having to choose celibacy out of fear of contracting AIDS. Some, like Daniel, simply shut off all thoughts or feelings pertaining to sex.
By early summer 1985, most men who read the gay press had some idea about which sexual practices were low risk and which were not. Until this time, there were no forums outside of therapy or counseling groups for men to discuss and share feelings about these changing patterns of their sex lives. In my practice as a psychotherapist and in conversations with friends, I was hearing that gay and bisexual men were becoming severely sexually impaired as a direct result of their fears about AIDS. Discussing this with my colleague, Luis Palacios-Jimenez, we decided to develop a workshop that would address the difficulties men were reporting in adopting the risk reduction guidelines. We felt strongly that this work needed to be extremely sex positive and upbeat. It would convey that safer sex could still be great sex, that you could have all the sex you wanted, as often as you wanted with as many different partners as you wanted, wherever you wanted, as long as each sexual contact did not include activity that would transmit the virus. We advertised the workshop as a sexual enrichment seminar for gay and, bisexual men, and stressed that it would be fun to attend no matter if you were single, dating, or in a long term committed relationship(1).
As the foundation for our work, we combined some group therapy and sex therapy techniques to create an experiential workshop called "Hot, Horny & Healthy: Eroticizing Safer Sex." As psychotherapists, sex educators, and ga men, we were particularly sensitive to, and empathetic with the difficulties inherent in being able to change one's pattern of sexual behavior. We too were at risk for contracting or transmitting HIV, and, like our clients and friends, were struggling with how to personally make the behavioral changes that would result in satisfying but risk-free sex live.
Looking back on the last 20 years of the gay sexual lifestyle, the drastic change brought about by the AIDS crisis was obvious. The late 1970s was a time of "sexual Camelot' for many gay men, in which there was a seemingly unlimited variety of relationship possibilities. Gay men easily met new people and built strong friendship networks, one relationship category being "fuck buddy" or "boyfriend." These were loosely defined relationships with some ongoing emotional/social continuity with minimal romance and expectations, unless they blossomed into full blown lover relationships as the months or years went on. This was also the era of "fast food sex"--a period when living in urban centers with large gay populations meant that a possibility of sexual adventure was always imminent. People could and did meet anywhere during the course of a normal day, either go home for a quickie and never see each other again, or make a date to get together at some later time. This was also the era when gay male commercial sex emporiums thrived. There were bathhouses in most cities were people could safely meet for anonymous sexual encounters. Similarly there were backroom bars and private sex clubs where sex could safely be had between consenting adults. The key word here is "safely," for back then, safely meant being free from police entrapment and free from physically abusive or dangerous encounters with nongay thugs who preyed on and assaulted gay men. Safely also meant a naive belief that almost any sexually transmitted disease could be cured by contemporary medicine.(2) Gonorrhea, crabs, non-specific urethritis, pin worms, and even syphilis were casually thought of as annoying "occupational hazards" of recreational sex.
It was during this period of life on the sexual fast lane that the seeds of tragedy were unknowingly being spread. In 1977, the New York Blood Center began its pioneering hepatitis B vaccine study in which blood samples from participating gay men were collected, frozen and stored. Years later, when these blood samples were tested for the antibodies to HIV, 8% of them drawn from a sample of New York City gay men during 1977-1978 already demonstrated exposure to HIV.
As evidence began to mount that certain sexual practices were indeed highly risky for transmitting the HIV virus, many gay men began to view any form of gay male sexual activity, and semen in particular, as toxic. For them, sex often was equated with death both consciously and unconsciously. It was an internalized sense of toxicity which resulted in some men feeling dirty, depressed, and isolated. For those men who had previously used "cruising," the search for sexual partners, as a prime form of socializing, giving up sex often brought with it social isolation as they struggled to stay out of the bars, clubs and bookstores. Many inside the gay male community developed sex-negative or "erotophobic" attitudes. These attitudes reinforced underlying internalized homophobic feelings that we had hoped were permanently laid to rest by the evolving sense of pride we felt in being gay. Many gay men's own unresolved homophobia became activated once again, particularly when the sexually transmitted nature of AIDS was used by Christian fundamentalists to suggest that AIDS was God's punishment upon homosexuals.
The workshop represented a timely means of intervention at a crucial moment of the crisis, helping individuals to turn despair and sadness into hope and positivity. What follows is a presentation of the workshop, including important considerations in its development, the workshop process/components, and its outcome. I conclude with a discussion of important factors involved in the implementation of safer sex practices.
A first consideration in developing the workshop was to analyze individual sexual reactions to AIDS and understand how they have evolved over the course of the epidemic. A particularly debilitating reaction was one we called "diet/binge" sexual behavior. In this instance, the individual initially ceases all sexual activity, the rationale being that "there is no sense in having sex if I can't do everything I want. "Yet, this kind of abstinence is usually short-lived, particularly for men who have a history of being sexually active and have stopped directly out of fear of AIDS; during the period of such "enforced" celibacy, they report feeling very anxious, angry, and/or depressed, and soon after, periodically resume sexual activity, often in ways that are highly risky for transmitting HIV. Obviously, this kind of "diet/binge" sexual behavior is mentally and physically dangerous to the individual engaging in it, as well as to his sexual partners. It became clear to us that for people who had been sexually active prior to the current health crisis, there needed to be a way of helping them adjust emotionally to sexuality in the era of AIDS. This adjustment needed to include skills for them to choose whatever level of sexual activity they felt comfortable with, but only in nonrisky ways.
A second consideration was to address the fact that previous attempts at AIDS prevention were limited primarily to the cognitive level, to the detriment of the emotional. Previously, safer sex education had consisted of a physician or health educator simply describing what behaviors were thought to be safe, which ones were of low risk, and which were of high risk and needed to be avoided. In this rendition of AIDS prevention, large groups of gay and bisexual men were lectured to by "experts" explaining how sex should and should not be conducted in the age of AIDS. At the same time, posters and brochures appeared that also listed what was safe sex. Combined with what felt like "forced feeding" methods of AIDS-prevention education, these printed materials were very effective in disseminating the cognitive information about how to protect oneself and one's sexual partners. What were seriously lacking in this approach were ways to help men deal with the emotional upheaval they experienced in the midst of a sexually transmitted disease that was killing thousands of their peers. Moreover, in addition to the emotional and interpersonal difficulties that understandably arose in response to fears about contracting or spreading the disease, there were evidently emotional resistances to changing such intrinsically intimate behaviors as how one has sex.
Thirdly, we needed to provide a new method of AIDS prevention that would rectify other inadequacies of earlier methods, particularly those that reflected a moralistic and judgmental tone. In 1982, gay men in the big cities first began to hear about a new disease--then called "gay cancer" or "GRID" (Gay Related Immune Deficiency). At that time certain physicians, public health experts, and representatives of AIDS service providers began to suggest that this condition might be transmitted sexually. Some of these professionals took the position of suggesting that members of the gay community should begin to change the ways that they were having sex and urged them to have "healthy sex," a term meant to indicate behaviors that would not spread the as yet-unidentified infectious agent then associated with this new plague. Though at that time there was little consensus about exactly what was "healthy sex," the term itself seemed quite reminiscent of the view that homosexual activity was inherently pathological. Moreover, at that time there was a lot of discussion that "promiscuity" itself might be causing AIDS and thus, one aspect of "healthy sex" meant being told to "reduce your number of sexual partners." This was coupled with an emphasis on forming relationships as a way of protecting yourself from contracting AIDS. As well, it implied a strong criticism of the single male lifestyle, without the corresponding psychological and political analysis of why it was difficult for some gay men to have successful relationships. In response, many men in the community dismissed these warnings as "reactionary" and homophobic, as AIDS prevention seemed to be yet another negative injunction from a hostile and disapproving society once again advising the gay community not to have sex. At times, in defiance of such injunctions many people refused to adopt or even contemplate the need to modify their sexual practices.
A fourth and last consideration in the development of our workshop was the ambiguity of the phrase "safe sex" vs. "safer sex," which had by 1984 replaced the term "healthy sex" as the catch phrase of AIDS education. We believed that the notion of "safer" sex had contributed to an increased sexual impairment, largely due to the confusion surrounding exactly which activities posed what level of risk for transmitting the virus. This ambiguity has oftentimes resulted in individuals acting on different definitions of what is "safe," with the need to discuss mutually acceptable limits becoming a chief obstacle to sexual spontaneity. For instance, one person may be unwilling to take the remote risk that HIV can be transmitted by deep kissing. Another may be comfortable kissing a partner, and may even be willing to fellate his partner, provided that there is the assurance that no ejaculation will take place inside of his mouth. Someone else may not be comfortable doing anything more than licking the shaft of a penis if a condom is not worn. In this instance, our emphasis needed to assign relative risk to various sexual behaviors.
We needed to clarify that it is not absolutely safe to perform fellatio on someone who is not wearing a condom, even if he does not ejaculate inside your mouth. It is of course safer if the person being fellatiated wears a condom, yet this is not absolutely safe since condoms can break. The same goes for anal intercourse. In negotiating mutually acceptable limits, the problem can be satisfactorally resolved by both partners agreeing to abide by the more conservative level of risk-free sexual play. Obviously, communication and mutual sensitivity to each other's feelings about this delicate area is the bottom line, as well as the entry point into greatly enhanced sexuality. This is where we come in.
In addressing all of these concerns, our workshop begins by providing men with the opportunity to express their feelings about the changes that must be made--changes they need to make in order to remain sexually active in a responsible way during the AIDS crisis. This helps the workshop participants identify for themselves negative affective responses induced by the AIDS crisis in relation to their sexuality and sex lives. They then are able to begin a process of working through these negative feelings within a safe and non-threatening environment so as to minimize any impairment in their psychosocial/psychosexual functioning. Thus participants begin to see many of their reactions as appropriate responses requiring new crisis management skills. Concurrently, they discover and share how to have fun while remaining sexually active in low-risk ways. Finally they practice negotiating for safer sex with a new or preexisting sexual partner. To these ends, the workshop also helps to foster a community ethic that "we're all in this together, and sexually adapting to the health crisis is a positive challenge."
The workshop begins with people candidly discussing fears about implementing safer sex methods. Most participants at this point express a concern that they are now condemned to boring or extremely limited sex lives. Our response is to reassure the participants that by the end of the workshop they will no longer feel that safer sex needs to be dull or extremely limited. Next, individuals previously having no contact or association with each other, pair up and discuses how AIDS has impacted upon their sex lives. This invariably has the effect of creating a bond of intimacy and identification with a total stranger. A similar strong emotional bonding occurs within the large group as people are then asked to report on what they discussed in the dyads and everyone hears many of their own feelings, concerns, and complaints voiced by others.
How is it possible for a group of strangers to enter a workshop angry, depressed, and uncertain that safer sex could ever truly be fun, and to leave feeling very different on this issue? The success of this workshop is based on two interwoven components: a therapeutic group process that combines a communal cathartic experience with having fun. For many, participation in this group process and discussing one's sexuality with 50-500 other men is a new and very powerful, positive experience. For example, an important juncture of the group process is when participants are asked "What do you miss about sex in the old days?" Answers always included intercourse without a condom, the taste of semen, spontaneity, etc. In sharing their loss, it was pointed out that it was natural and normal to miss these behaviors, and that in fact it was necessary to mourn the loss of old ways of behaving sexually in order to make emotional room for new patterns.
Next, in small groups, people would be asked to make up lists of safer ways to erotically touch or be touched by another man. When watching grown men working on these lists, one would always be reminded of a group of kids at "show and tell." The lists are long and filled with a variety of fun, sensuous, and interesting ways to have foreplay. The groups take turns reading these lists out loud, playfully sharing and elaborating on one another's lists. When questioned, group members admit that these lists contain things that they always liked to do or would enjoy trying. The same process occurs when the small groups are asked to devise lists of ways to safely engage in oral and anal intercourse, mutual masturbation, fun with condoms, and safer orgasms. Laughter fills the room throughout this portion of the workshop. Participants invariably admit that they never dreamed that simply talking about safer sex could be this much fun. The leader responds by stating, if talking about it is this much fun, imagine what it will be like to go home and try putting into practice some of the ideas discussed during the workshop. At this point, many participants realize that it is possible to have a positive, satisfying, creative, and risk-free sex life as a gay or bisexual man in the age of AIDS. Like with all things, it takes work and much practice to become proficient and relaxed ... but what fun can be had while mastering the process!
With this feeling of shared emotional experience as a foundation to build upon, workshop participants are then able to move on and discover for themselves and from each other, that a wide variety of sexual options, including those that maintain spontaneity, are still available. Here, the subject of relative risk is addressed: we indicate to the participants that the only absolutely safe sexual activities for people of any sexual orientation are: abstinence (heaven forbid), sexual exclusivity between two absolutely trustworthy individuals who have not been exposed to HIV (confirmed by two blood tests taken six months apart and no high risk behaviors engaged in during that period), and mutual (on me not in me) masturbation.
Beyond that, safer sex is a matter of relative risk, for everything else involves some degree of risk for transmitting HIV How then to remain sexually relaxed, confident, and spontaneous? For most people this requires at least minimal discussion about what each person is comfortable doing sexually. If, for instance, one man has decided that he is not willing to take even the slight risk of anal intercourse with a properly-used condom, than this needs to become a respected boundary from the onset of sexual play. Once the participants become familiar with the intricacies of safer sex negotiation, they realize that expanding one's sexual options is limited only by the constraints of imagination, and they will find that the use of fantasy, costumes, toys, and food can contribute greatly to a rich and diversified risk-free sex life. Upon completion of this group workshop experience, people report leaving with a renewed sense of sexual possibility and adventure, as well as a confidence about being able to change old patterns.
Finally, in terms of more practical concerns, an important workshop discussion addresses the subject of condom use as an essential component of safer sex. In answering the initial complaint about loss of sensitivity when using condoms, the group is asked to consider that the benefits far outweigh this loss. It is emphasized that in order to grow comfortable with condoms, it is first necessary to experience how "different" the sensations are while wearing one, not how much "worse." Instead of centering on the negative aspects, it is far more important to emphasis the positive changes its use signifies, i.e., "wearing a condom tonight means that both of us can feel good tomorrow about ourselves and what we did" or "wearing a condom means that I can have sex longer before I come." The bottom line for many men is that it is no longer negotiable whether condoms are used, particularly if there is going to be anal sex; they are using them from the start. For straight or bisexual men, the message of concern and caring that this communicates to a woman lover can result in better relations and better sex, particularly for the woman who has most likely had to assume the primary responsibility for pregnancy prevention.
In my discussion with former participants and other men, my discussion with former participants and other it is clear that gay and bisexual men have been able to adopt safer sexual practices primarily because so much of what safer sex is has always been an integral part of their sexuality.(3)
For instance mutual masturbation or solo masturbation in the arms of another are both frequently engaged-in sexual actions; these could even be "the main event" ending in orgasm. (Even prior to the AIDS health crisis, there were sex clubs all over the U.S. for men who preferred mutual masturbation as their primary form of sexual expression). Other safer sexual practices that are common homosexual behaviors include: anal intercourse in which the man who is being penetrated either masturbates himself to orgasm or is masturbated to orgasm by his partner; mutual fellatio or fellatio/manual stimulation in which the man fellating another is simultaneously masturbating himself or being manually stimulated by his partner. Unlike heterosexual sex, where for most men the object is to have an orgasm inside a woman, homosexual sex has not been as singularly focused on penetration and internal orgasm. This has made it easier to modify existing sexual behaviors.
Another positive outcome of the workshop is that participants often come to realize that practicing safer sex can produce some unexpected benefits. A principal benefit is the freedom from worrying about getting sexually transmitted disease, a freedom that goes a long way to increasing sexual enjoyment and abandonment. Another is the greater level of intimacy that is now combined with sex. Once the limits are known, the partners are usually able to completely relax within them. Simply experiencing the shared discomfort and awkwardness that accompanies initial discussions about each person's definition of safer sex, can be a lovely experience bringing two people closer. An additional component of great sex is this increased responsibility for communication--telling the other exactly what one finds pleasing, as well as listening to and acting on this same information from the other. This is certainly a prescription for increased (safer) sexual enjoyment for all people.
Moreover, safer sex often means prolonged lovemaking or sexual play as the focus has been taken off of genitally oriented sex ending in orgasm--an aspect of safer sex that is new to many men. Reducing the focus on a hard penis can help the couple to relax and learn that it doesn't always have to be hard in order for sex to be fun. Men who remain sexually active and sexually satisfied into their seventies and beyond are often cognizant of the fact that a soft penis has feelings also. In moving away from genital sex and towards a more sophisticated and an ever increasingly satisfying sex life, it is more likely that all of the body surface can be experienced as a potential erogenous zone; in learning how to eroticize all parts of the body, many performance anxieties are thus eliminated. In these ways, safer sex can become a training ground in which all men can prepare for future decades of pleasurable sexual activity.
The ultimate goal of our workshops has been to help people accept the limitations of sex in the age of AIDS with good humor and a sense of adventure, and to transform negative attitudes into dynamic and positive ways of adjusting. As children of the sexual revolution, few of us were prepared to cope with a new lethal sexually transmitted disease, one that has so negatively impacted upon the sex lives of millions of people--men, women, gay, bisexual, or straight. Remaining sexually healthy and sex-positive in the face of AIDS will continue to pose numerous challenges for all sexually active people for the foreseeable future. High on the list of challenges is achieving a degree of responsible sexual health via the incorporation of safer sex practices. Yet for safer sex to be viewed as something more than limitations on one's sexual expression, it is necessary to acknowledge its contributing role in enhancing one's sense of self-esteem and dignity by feeling more in control of one's life. After all, the very best sex is about connectedness between people and bridging the gaps between individuals; safer sex is surely a central component to this. Moreover, in successfully meeting these challenges come rewards like a heightened level of interpersonal satisfaction and enhanced sexuality, and the self-dignity derived in refusing to return to the sexual dark ages we left behind.
Ending on a more poetic note, I'd like to close with a few appropriate words from William Wordsworth:
"What though the radiance which was once so bright
Be now for ever taken from my sight,
Though nothing can bring back the hour
Of splendor in the grass, of glory in the flower;
We will grieve not, rather find
Strength in what remains behind..."
We presented the workshop to two hundred of the leading AIDS prevention specialists in the U.S. at the National Lesbian/Gay Health Conference in Washington, D.C. in March, 1986. Afterwards, we were invited to present it in cities all over North America and to train local people in how to run the workshop. As well, AIDS service organizations throughout the United States, Canada, Australia, and Western Europe have adopted the workshop as a cost efficient and effective means of helping men who have sex with men change from high-risk to low-risk sexual behavior. Luis and I have presented the workshop to over 15,000 men all over North America, and subsequently have written a "Facilitator's Guide to Eroticizing Safer Sex, A Psychoeducational Workshop Approach to Safer Sex Education" (Palacios-Jimenez & Shernoff, 1986).
1. The workshop was first developed and presented for a conference sponsored by Gay Men's Health Crisis (GMHC), the world's oldest and largest AIDS service organization. It was expanded and revised to become one component of the GMHC "800 Men" study of different AIDS prevention interventions. This workshop soon became the center piece of the all-day safer sex forums that Gay Men's Health Crisis conducts in New York City each month. The "800 Men" study clearly demonstrated two things regarding developing effective AIDS prevention strategies: The first is that men would give up high-risk sexual behaviors only when sufficiently scared about contracting AIDS them selves; the second is that specifically sex-positive interventions the incorporate visuals, e.g., videos, were necessary in order to get men h adopt low-risk sexual behaviors.
2. I say almost any disease could be cured as this was also the era of herpes and burgeoning hepatitis B rates. Even with some strains of hepatitis B killing large numbers of gay men, most people carried on sexually with an astounding nonchalance about diseases. Also during this time, an epidemic of enteric parasites like Amoebiasis, Giardia, and Shegilla were treatable, but only with expensive and long-term therapies that often did not work the first time.
3. There are strong indications that gay/bisexual men have incorporated changes in their sex lives: reports from clinics that treat sexually transmitted diseases around the country show ever decreasing cases of rectal gonorrhea and hepatitis A and B. These reports, combined with studies done by Dr. John Martin at Columbia University in New York and Dr. Leon McKusick at the University of California, San Francisco, all demonstrate such change. An essential reason why large numbers of gay and bisexual men have been able to make the transition into safer sex is that most of them know at least one person who is currently sick with AIDS or who has already died from the disease. Thus AIDS is not something distant or abstract, but is perceived as a very real direct personal threat to one's health and well being.
Palacios-Jimenez, L. & Shernoff, M. (1986). Facilitator's Guide to Eroticizing Safer Sex: A Psychoeducational Workshop Approach to Safer Sex Education, New York: Gay Men's Health Crisis.
Published in Does Anyone Still Remember When Sex
Was Fun? Positive Sexuality in the Age of AIDS, 1990, Kendall Hunt Publishing Co.
©1990 Michael Shernoff