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.
Read more of Outlier: My Unusual Journey With HIV, fogcityjohn's blog, at TheBody.com.