"You Can't Handle the Truth!": Gay Men and HIV Education
June 23, 2010
In 1994, psychologist Walt Odets published a scathing critique of what was then called "AIDS education." Writing in the now-defunct AIDS & Public Policy Journal, Odets examined the approaches used to educate gay men about HIV, and to put it mildly, he found them wanting. While working on my last post (Raw Emotion), I reread his article, entitled AIDS Education and Harm Reduction for Gay Men: Psychological Approaches for the 21st Century, and I was stunned to discover that almost all of what Odets criticized 16 years ago could still be said of much HIV prevention and safer sex education today. Sadly, 10 years into the 21st century, Odets's jeremiad remains both accurate and relevant.
Odets pointed out how much homophobia had influenced the development of HIV education, and he offered a number of suggestions on how that education could be improved. In reviewing his suggestions, I was especially struck by his argument that we should stop withholding information from, and lying to, gay men about sex and HIV. Odets dared to question "the almost universal assumption among educators that if we give men 'too much information' -- which is to say something like the whole truth to the best of our knowledge -- they will abuse it, exercise faulty judgment, or otherwise come up with unintended results."
HIV educators, it seemed, thought we gay men couldn't handle the truth. I wonder, though, whether it isn't the other way around. Maybe it's HIV educators who can't handle the whole truth, or who perhaps don't fully understand it. And maybe we'd all be better off if we brought more truth to the discussion of gay men, sex, and HIV.
So I hope Walt Odets won't mind if I use his call for telling the truth as my point of departure for this post. I think there are certain fundamental truths upon which HIV education must be based. I also think there are certain truths about gay men and sex that we need to admit if we're going to have realistic (and, I hope, successful) HIV education. I don't claim that what follows is original. Most of the ideas expressed are either taken from or shaped by Odets's article, so all credit goes to him. Of course, any misunderstandings or misstatements of his views are my fault and my fault alone. So here are a few truths as I see them:
First, HIV education should begin by acknowledging what I consider the most fundamental truth of all -- that gay men's sex lives have both emotional meaning and social value. In other words, HIV education must proceed from the basic assumption that sex has the same value for gay men as it has for all human beings. HIV education should recognize that gay men are the moral and social equals of straight people. The simple truth is that our sex lives are not some kind of lesser version of "real" (i.e., straight) sexuality.
The reason HIV education sometimes fails to recognize this basic truth is that, as Odets pointed out, homophobia devalues gay male sexuality. To reduce the risk of HIV transmission, gay men are often advised to severely restrict their sexual practices or even to abandon certain practices altogether. We've been told to just give up anal sex because it's too risky, and we've been advised that if we have oral sex, we should do so only with condoms. Does anybody seriously think straight people would be asked to give up vaginal intercourse as a preventive measure?
Why is so much more demanded of gay men? Why do so many fail to recognize that our sex lives aren't just matters of physical pleasure? Sex has deep emotional and psychological value to us. It's how we express love and achieve intimacy. So it pains me that HIV education sometimes treats gay men's sex lives almost as if they're superfluous.
This is especially hard for me to accept as an HIV-positive gay man, because I think sex may be even more important for poz guys than for gay men in general. The stigma of HIV infection can create feelings of unworthiness and undesirability in poz men. For those of us afflicted with such emotions, sex can be tremendously affirming and validating. It can serve as an antidote to the isolation caused by the disease.
For a time after my diagnosis, sex certainly served that function for me. That a man still desired me despite my serostatus was proof that HIV did not necessarily mean an end to my romantic life.
So I guess I'd ask that HIV education acknowledge as a basic truth that sex for gay men isn't just a collection of physical practices to be modified. It's how we relate, connect, and yes, love. Understanding that is where HIV education needs to start.
Second, I think we should re-examine the apparently widespread assumption that most gay men are only having protected sex, because I don't think that's true. Although I don't have any statistics at hand, I strongly suspect the truth is that most gay men have unprotected sex at least occasionally, and some have unprotected sex all of the time. I don't work in public health, so I'm not sure what it might mean for HIV education if we acknowledged what seems to me to be reality. But I have got to believe that it's better to build HIV prevention strategies on the way things really are rather than on the way we wish them to be. And the fact that HIV education has clearly explained to gay men why they should use condoms every time should not lead anyone to assume that gay men do use condoms every time.
Third, now that we're on the topic of condoms, can we at least "keep it real" when talking about them? Look, condoms are unquestionably effective in preventing HIV transmission, and for now they must remain our first line of defense. But we should stop making claims about condoms and condom use that are simply inconsistent with men's actual experience. Let's face it, most men, whether straight or gay, do not find condoms "fun" or "sexy," no matter how many colors, flavors, and textures they come in. Condoms reduce sensation, and that's one reason all men have a hard time using them consistently. Putting on a condom also interrupts the spontaneity and flow of the sexual experience. (If you're still hard after wrestling open the wrapper, pulling the condom out, unrolling it, making sure there's a little space at the tip to catch the cum, and lubing it up, well, then you've got a hell of a lot of stamina.) I think most men probably find sex with condoms a necessary, but inadequate, substitute for natural, unprotected sex. And I don't understand why we can't just say these things out loud.
This refusal to be completely honest about condoms wouldn't bother me if it didn't have at least two possible negative consequences. First, if HIV educators continue to tell gay men that condoms are fun when that doesn't comport with the reality of men's experiences, then gay men may disregard or doubt the rest of the educators' message as well. I think HIV prevention education would actually enhance its credibility by admitting the limitations of condoms instead of trying to convince men of something they know isn't true. Second, claiming sex with condoms is just as pleasurable as sex without them may make gay men who find protected sex unsatisfying feel just plain guilty. They may feel that there's something wrong with them if they're not living up to expectations, and they may simply give up trying to stick to protected sex. Wouldn't it be better to tell men their feelings about condoms are normal, and then work to find ways to persuade men to use them?
Finally, let's give Walt Odets his due, 16 years too late. He was absolutely right back in 1994 when he argued that HIV education should be conceived as "harm reduction." It's virtually impossible to make sex "safe," if by that we mean entirely free of risk. So the goal of HIV education should be to assist gay men in making intelligent, informed decisions about how much risk is acceptable. This can only be done by telling gay men exactly what medical science knows about the risks of sexual practices, from mutual masturbation, to giving head, to unprotected anal sex. Give us the statistics and information we need to make our own decisions.
If you think this is either impossible or unwise, consider this. All of us engage in some form of risky behavior every day, whether it's driving a car or going downhill skiing. We are fully aware that driving a car may lead to serious injury or even death, yet we get back in our cars day after day because we make the judgment that the utility of the activity (moving quickly from place to place) outweighs the risk of injury. In fact, we make these kinds of risk assessments all the time by balancing the social value of a given activity against the possibility that it might harm us. There is no reason that such risk assessments can't be applied to sexual activity.
If you've been good enough to read this far, you now know some things I hold true. Maybe if you add your thoughts to this discussion, we can all come a little closer to the whole truth. Who knows? It just might set us free.
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Comment by: Dan
Thu., Dec. 1, 2011 at 11:15 am EST
Thoughtful and insightful article. Thank you.
Comment by: Mike
Fri., Aug. 13, 2010 at 5:59 pm EDT
Alex does bring up a good point and makes me think about men who may purposefully hide their HIV status. I can almost understand the desire not to know, but don't understand the callous disregard from whatever percentage of men who do know but lie. That's how my partner caught HIV, or so he believes, before we were an item. Amazingly, he didn't serioconvert (we think) until years later, after us having unprotected sex many times and I guess because of this I remain negative to this day. I'm quite lucky or blessed, depending on your perspective.
It's been about five years now since his serioconversion and we are still trying to figure out the physical side of things - it hasn't been easy and we've both come close to calling everything off - but we love each other so much and we do try to make it work.
So, my interests in having real, open conversations about why men have unprotected sex (and I think you hit most of them) is very personal. We must do this - we must not stigmatize those who already have HIV nor gay men making aware, honest decisions about their sex lives.
I imagine you have, but have you read Tim Dean's excellent "Unlimited Intimacy"? It's rooted in academic psychoanalysis, but it's quite readable for those not in the academy and gets at the intimacy issue, although it does focus at times on bug chasers, which is not a community you are dealing with. Still, Dean does touch on other aspects of bareback sex. It's worth a look.
Comment by: Terron C.
(San Francisco, CA)
Wed., Jul. 14, 2010 at 11:24 am EDT
Another beautifully articulated, and matter-of-fact post. I thoroughly enjoy reading your informative posts, so keep up the great work! As stated prior, yes, education is extremely helpful, yet, there will always be a need, as well as desire for "higher-learning." However, the pain, and emotion involved in our community runs so very deep, almost to the point of self-destruction.......We must continue to drive out fear, and ignorance, and welcome love, equality, and peace. Blessings.
Comment by: fogcityjohn
(San Francisco, CA)
Mon., Jul. 12, 2010 at 12:06 am EDT
@ Charlie in St. Paul, Brendon in Melbourne, and eisenhans in STL: Thanks so much for the appreciative comments. I really do believe that those involved in HIV prevention need to keep in mind that sex is just as important for gay men as it is for everyone. Prevention education needs to take into account the fact that sex has an importance that goes way beyond the physical.
@ Alex in NYC: Thanks for reading. You raise a very important point. The stigma surrounding HIV is a huge problem in terms of HIV prevention. People who fear they'll be stigmatized if they are known to be positive may well avoid testing. They may then unknowingly infect others. Walt Odets has it exactly right in our recent podcast ("Laying It Bare") when he points out that members of a group of people that's been discriminated against (like gay men) are going to have great difficulty with prevention because they're being told their lives are of lesser value. Other countries understand the relationship between discrimination and HIV transmission. Germany, for example, uses a "structural prevention" approach that seeks to remove the stigma from HIV and tries to validate gay men by combatting societal homophobia. I wish our governments (federal, state, and local) would take a hint from that.
Comment by: alex
Sun., Jul. 11, 2010 at 9:56 am EDT
First: Excellent reply to Richard (hope city) fogcityjohn! Richard's name calling and judgemental onset of his post suggested that he truly is the arrogant one. Unfortunatley he will hear only what he wants to and not what is actaully being said.
Second: Your comment that the value our (gay) sexual practices have to us be viewed in the same manner other's (straight) sexual practices have value to them is exactly where we need to start.
And third" Just prior to reading your blog I read the statistic that 50 to 70% of HIV infections are spread by the 25% of infected people that have no idea (or even want to have any idea) that they are infected. So I would like to add a fourth truth. Somehow our society has to recognize that stigmatizing people wtih HIV (and gay men in general) plays a much bigger role in the spread of HIV then lack of condom use. The safer sex message is only treating the symptom and not the actual problem.
Comment by: eisenhans
(St. Louis, MO)
Sat., Jul. 10, 2010 at 11:39 am EDT
Thanks for this, and for your other posts on the same topic. I look forward to reading more, and to reading Odets' work. So far the biggest consequence of becoming poz for me has been its devastating impact on my mental health. I will bring copies to my therapist and ask him to consider sharing them with patients - poz or neg - who struggle with these issues. They are of immense comfort to me and have helped me begin to forgive myself and heal.
Your and Odets' observations indict the whole HIV-medical-industrial complex. Bareback happens. And it happens for GOOD reasons. Doctors should be making sure that every HIV-neg man has a filled Rx of post-exposure prophylactic medication in his bedside drawer. There's a good chance I'd still be negative if I had had access to this. By failing to put this option in peoples' hands, physicians are creating new patients for themselves (and violating their oaths).
Moreover, it exposes the truth about the HIV public health and social services profession: they ought to be out of business. As a community, we should "fire" every last one - withdraw our financial and social support, even launch ACT-UP-style action to shut them down &/or force reform. They are a total failure and are parasites on our community and nation. Their continuing existence just serves to convince people that something is actually being done to end this epidemic, when nothing could be further from the truth. This in turn prevents reform from taking place. They are as unresponsive today as the medical-industrial complex was to the epidemic when it first began. It's past time for a change.
Comment by: Brendon
Thu., Jul. 8, 2010 at 7:33 pm EDT
Thank you for this post John. I've not heard anyone put forward such a clear, cogent understanding of the issues. That "gay men's sex lives have both emotional meaning and social value" is a starting point that should be adopted by all involved in safe sex education.
Comment by: Jeff
Thu., Jul. 8, 2010 at 5:56 pm EDT
Maybe the situation was different back in the days when an hiv diagnosis amounted to a death sentence, but today and despite the risks involved, I'm sure most sex between gay people, like most sex between straight people, does not involve condoms. Promoting condom use is a worthy goal, but the threat of hiv transmission obviously isn't enough to insure condom use except among those who are very conscientious. What would work, I don't know.
Comment by: Charlie
Thu., Jul. 8, 2010 at 4:10 pm EDT
What a breath of fresh air. You write about sex and safety in a way that values the actual experiences of actual people -- it's incredibly helpful to read such a sensitive and thoughtful post. Many thanks.
Comment by: fogcityjohn
(San Francisco, CA)
Wed., Jun. 30, 2010 at 7:16 pm EDT
@ Richard in New Hope: Clearly, you didn't read what I wrote, or if you did read it, it went over your head. You are laboring under the mistaken impression that I am promoting unprotected anal sex. The opposite is true. If you read my prior post, "Raw Emotion," you'll see that I talk about "curbing the practice." In this very post I explain that condoms have to remain our first line of defense against HIV. Your claim that intimacy isn't validated by semen exchange is belied by the research. If you'd like to hear what some actual experts have to say about this, I would suggest that you listen to or read the transcript of the podcast TheBody.com posted recently on this topic. You'll find it here: http://www.thebody.com/content/art57151.html
Somehow you appear to have gotten the idea that discussing and understanding the reasons men might engage in unprotected anal sex is tantamount to promoting it. Nothing could be further from the truth. To help men make better choices about their behavior, we have to first understand why they engage in it and discover what barriers impede adherence to safer sex practices. You seem to want to cut off this important discussion and simply tell men to use a condom every time. Well, if that message were sufficient in itself, we wouldn't be seeing any new HIV infections among gay men. Unfortunately, we are, so clearly we need to try something different. The fact that you cannot or will not recognize this suggests that it is you, not I, who are arrogant and in denial.
Comment by: Richard
(New Hope )
Tue., Jun. 29, 2010 at 11:48 pm EDT
ayou kill me! Your blogs summon the same. if you are not too arrogant or otherwise occupying a place of denial that, unfortunately, mamy gay men occupy. Namely, the scientific proof regarding the transmission of HIV and other STDs! One cannot and should not engage in unprotected sex! You seem to perpetuate the delusion that "intimacy" is some how achieved by exchanging bodily fluids. Intimacy can be achieved by participation in an evolving and nurtured relationship and isn't validated by ejaculating inside someone; whether they are straight or otherwiae self-identified. It's about Eros vs. Agape! Stop this banal attempt to become the president of the Barebackers of America. Yes, truth is needed for meaningful dialouge about prevention/transmission/acquistion of STD's. Get over it and start promoting what is scientifically based.
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