For all of us, sex requires some amount of negotiating with our partner or partners. For HIV-positive gay men, the negotiation process is even more complex and entails decision making at every turn. The choices they make may affect their own health or the health of their partners. Couple this with the emotional aspects of sex, with the need to be desired and wanted, and you have a reality that can be overwhelming.
The complexities of sex for HIV-positive gay men revolve around two main issues -- decisions about disclosing their status to their sex partners, and negotiating the type of sexual behavior that will yield the biggest bang for the buck while keeping all parties involved healthy. Some HIV-positive men find this responsibility overwhelming and simply eradicate sex from their lives. Others, especially when they first learn their serostatus, turn to sex as a means of coping, disregarding their infection. But most positive gay men fall somewhere between the two extremes. They consider the context of each sexual situation, weighing the odds of this sexual behavior or that, and making the decisions that work best for them at that moment. Thus each act of sex involves much thinking and preparation.
The immediate decision most HIV-positive gay men must face meeting potential sex partners is when and how to disclose their status -- assuming, of course, that disclosure is the option chosen. Disclosure is never easy, because the rejection that sometimes follows is emotionally difficult and sometimes even physically harmful; there have been cases where potential sex partners have reacted violently. Some men sidestep this hurdle, assuring themselves that if they are having safer sex they have no obligation to disclose.
Studies of positive gay men's sexual behavior, however, consistently show that with disclosure of status comes safer sex, that communicating serostatus with a potential sex partner before sexual activity begins serves as a type of protection against wandering into unsafe territory. If the partner is negative, then decisions must be made on the part of both men about the sexual behaviors that are acceptable to both of them. If he is positive, the same type of decisions must be made, even though this seroconcordance may at first seem like a blessing. Some HIV-positive men insist that their sex partners also be positive. Functionally, it is easier to deal with a partner who is in the same boat as you are -- there's a mutual understanding about what it is like to live with HIV and what it is like, in this third decade of AIDS, to deal with the complexities of HIV medications and their often debilitating side effects.
Disclosure of status can take many forms, and HIV-positive gay men have developed elaborate and interesting techniques for handling the situation. The hows and whens -- and ifs -- of disclosure are discussed in more detail in "A Code of Silence" by Robert Vázquez-Pacheco, but deserve some mention here.
When using online services (see also "The Meet Rack" by Doug Rose), a simple "I am pos" in his profile is an easy and effective way for a man to disclose his status. Assuming that potential sex partners read the profile, this filters out those who cannot handle the reality of sex with a positive man. It may even attract other positive men, or for that matter, negative men who have developed their own techniques for sex with a positive partner. (I will forego commentary on bug chasers -- HIV-negative men seeking to become infected; that is an essay unto itself.)
If a partner is met in a bar or club or through a friend, the disclosure process is not as easy. Many HIV-positive men have developed an almost reflexlike approach, stating "I am positive" early in the conversation, before the courting dance begins. It is as if no time is to be wasted, and if rejection comes it is before there has been any emotional investment in the relationship. Other men seek a more "natural" time to introduce the information into the conversation.
While direct verbal disclosure is probably the most effective way to communicate serostatus, it requires skill and self-confidence. Some positive men choose to give hints instead, inserting HIV into the conversation in an abstract or intellectual way, discussing friends who are positive, talking about their work with AIDS service organizations, etc.
Finally, there is the abstract approach -- leaving HIV pills out on a table, sporting a "+" tattooed on the arm, or taking HAART meds during a conversation. The possibilities are as infinite as positive men's personalities.
Positive men have been grappling with the issue of disclosure throughout the twenty-plus years of the epidemic. At the heart of this matter is the need both to protect partners who are uninfected and to protect themselves, emotionally and physically.
The negotiation around sex with an HIV-negative man takes a lot of thought. The pos and the neg man both need to consider their options and what will result in the best sex without compromising the health of either. For the negative man an unprotected act could lead to HIV infection. The positive man could be exposed to other STDs or to bacteria that could compromise his immune system. Both have a lot at stake.
For many positive men, the decision is simple: Eliminate from their sexual repertoire the most dangerous act -- topping a negative man without a condom and cumming inside him. There are reams of data that clearly show this to be the act most likely to transmit HIV. But the relative infectiousness of other acts is less clear. And regardless of the specific act, most HIV-positive men recognize that sex without a barrier is probably the most effective means of transmitting HIV and exposing themselves to other viruses or bacteria. But it is equally well documented that many men do not like to use barriers, especially for acts they consider less risky, such as oral sex.
On the continuum of risk in terms of transmitting HIV, getting a blow job from a negative man is less risky than fucking him. But this too represents some risk, and recent data suggest that oral sex is perhaps a more likely avenue of HIV infection than originally thought. But it is apparent from studies of gay men's attitudes, and from their reaction to the latest findings about the possible risks of oral sex, that there is no clear understanding of this phenomenon and the circumstances under which transmission through oral sex takes place. Thus both pos and neg gay men often consider oral sex a risk they are willing to take. Of course, this must be part of the negotiation process. Circumstances that increase risk, such as dental work and cuts in the mouth, may make some negative men less willing to give blow jobs to positive partners.
Between fucking a negative man without a condom and cumming inside him (riskiest) and mutual masturbation, in person or on the phone or Internet (safest) is a vast middle ground of other sexual acts. For both the pos man and his negative partner, an understanding of the relative risks of each is key. Even more fundamental, however, is that there must be a recognition that most of these acts do contain some risk of HIV transmission. Even simply teasing a negative guy's ass with a cock by putting it in and out just a little bit ("dipping") has some risk associated with it. Thus the pos man must grapple with what risks he is willing to take with his partner and the extent to which his partner is comfortable with those risks. Many pos men say that the risk of transmitting HIV is less when they are bottom. To some extent this is true, and giving head or getting fucked by a negative man is less risky than fucking him, but even these behaviors are no substitute for use of a barrier.
Decisions of this sort make sexual negotiation difficult for pos men. If they and their partners are not well equipped with the knowledge of risk, the potential for HIV transmission is heightened. So too, the pos man must grapple with the fact that some sexual acts may expose him to other STDs, which can be a problem for someone with a compromised immune system. Eating ass, for example, while not necessarily a form of HIV transmission, may lead to infection with hepatitis for the pos man.
When disclosure reveals seroconcordance for the pos man and his partner, decision making can be somewhat altered. An issue that has gained a lot of attention lately is the practice of pos men intentionally having unsafe sex with other pos men, a practice known as barebacking. Although barebacking also occurs with negative men, pos-pos barebacking seems to be more common. For some men, barebacking is a preferred choice of sexual relations, and one that until recently was popularly seen as relatively safe. Recent data, however, suggest that this behavior can put the HIV-positive man at risk in terms of reinfection with other strains of HIV. If true, an HIV-positive man risks becoming infected with more virulent and harder to treat forms of the virus than what he already has. In addition, pos men and their pos partners need to negotiate sex in light of possible infection with other STDs, and pathogens that can lead to opportunistic infections such as Kaposi's Sarcoma.
For pos men and their pos partners, these issues have caused some concern about unprotected intercourse. Others view the findings as an attempt to control positive men and to dictate the kind of sex that they can have, even when there is no risk of initially infecting someone.
As is the case with sex with negative men, these issues engender much negotiation, even when both partners are positive. And, as with oral sex, it appears that the potential for reinfecting or exposing themselves to other types of infection is a risk some HIV-positive men are willing to take.
The treatment advances of the last several years have given many pos gay men a renewed hope for the future. For many of them, these medications have led to increased strength and a renewed sense of life, in marked contrast with the deterioration they experienced prior to the advent of the new drugs. These improvements in health have often also been marked by increases in libido and desire for sex. And, of course, the testosterone therapy that is often utilized to help prevent wasting and counter the effects of HIV also leads to an increased sex drive. So, for many pos men, sex, the need for sex, and the reality of sex sound more loudly than ever.
But the act of sex for the pos man is very far removed from the romantic portrayals of films or television. This often "heady" experience can be very emotionally challenging, what with the need to maintain his own health and to assure the health of his partners foremost in his mind. The emotional act of sex thus becomes burdened with notions of responsibility, self-protection, concern about others, and negotiation. And, since a sexual encounter usually involves at least one other person, these thoughts are further complicated by the ideas, thoughts, and considerations of the partner or partners. This is not to say that such thoughts ought to be neglected, but merely to show that a simple roll in the hay is not where it's at for many pos gay men. It's not that way now, and it's unlikely that it ever will be again. The devastating mark that AIDS has left on the gay community reaches even this most intimate level.
This discussion would be shortsighted if it didn't consider the importance many gay men place on sex and sexual adventurism. This cultural phenomenon -- playing itself out in bedrooms, bathhouses, bathrooms, bareback parties, and bushes -- dictates an existence in which sex is central and being desired is intimately tied to the sense of self. Conceptions of masculinity perpetuated by the gay community create even greater demands, as buff appearances are the ideal that gay men are expected to aspire to. Others, such as Andrew Sullivan and Michelangelo Signorile, have written about these matters; my own research in the area of masculinity shows clearly that the "buff agenda" is the order of the day for many pos gay men.
In the past twenty years, pos men have developed a repertoire of strategies to handle the dance around courting and sex, strategies as varied and interesting as the population of pos gay men itself. To some extent, the fact that gay men as a whole have been able to maintain this sexual drive and energy in spite of the madness that surrounds us is itself a testament to our resiliency and our capacity to keep on living. In the end, perhaps it is the act of sex that both kills us and keeps us alive.
Dr. Perry Halkitis is a professor of applied psychology at New York University. With funding from the National Institutes of Health and the Centers for Disease Control and Prevention he has done extensive research on the sexual behavior of gay men, and he is Vice Chair of the Board of Directors of Body Positive, Inc.