Laying It Bare: Gay Men and Unprotected Sex in the Age of HIV/AIDS
June 23, 2010
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fogcityjohn: OK. Now, before we get to the main portion of our topic, I'd like to just ask you all briefly about the issue of language. I'm a lawyer by profession, so language is important to me. And I just wanted to ask all of you if there were what you would call appropriate ways to discuss this topic, appropriate terms that we should use.
I ask this because I did a recent post on this topic at TheBody.com, and someone objected to the use of the term "barebacking." So I'd like to ask you what you thought. How should we talk about this?
Walt Odets, Ph.D., a longtime psychotherapist who has written extensively on HIV prevention and the psychological and social issues facing gay men
Walt Odets: I'd like to respond to that. This is Walt. I think that what we're after here is helping people to think about behaviors that transmit HIV, not about specific sexual behaviors. And the term "barebacking" implies that any unprotected anal sex poses a risk for transmitting HIV. So that would be my objection to it. We're pathologizing behaviors, rather than helping people think about when HIV might be transmitted. And that's one of those broad terms that I think encourages that confusion.
fogcityjohn: Indeed. Rashad Burgess, any thoughts from you?
Rashad Burgess: Well, I think, having clarity around what is it we're talking about is actually important. What I would say is that when you look at the science to mean, on one hand, you have "barebacking" used very broadly to describe any unprotected anal intercourse. And usually it's used in the context of gay men.
And then on the other side, you have "barebacking" used to really identify those that identify themselves as folks that bareback, or identify as a particular group of people who identify as a subculture of barebackers.
So I would argue that we should probably be as broad as possible in the use of the language "barebackers," and those being, individuals who partake in unprotected anal intercourse, irrespective of whether or not they themselves identify as a barebacker.
fogcityjohn: Jeff Parsons? Any thoughts from you on this topic?
Jeffrey Parsons, Ph.D., a professor of psychology and co-director of the City University of New York's Center for HIV/AIDS Educational Studies and Training
Jeffrey Parsons: Yeah. I completely agree about the need to keep a barebacking identity separate from what we might construe as barebacking behavior or simply unprotected anal sex that poses a risk. I also think that intentionality gets pulled into this a lot, and that "barebacking" is often used as a term to refer to intentional unprotected anal sex. Whereas, unprotected sex that happened because the condom broke, or the person had every intention of using a condom, but somehow, one was not used, that doesn't get classified as "barebacking."
So I agree with Walt that, in some respects, there is a bit of pathologizing of it as a behavior. But I do think it's important to recognize that some gay men do identify themselves as barebackers, and have integrated that into a part of who they are, and part of their community.
fogcityjohn: Well, then, I think what I'll try to do, and maybe we should try to do in this discussion, is simply discuss this as unprotected anal sex, and we can talk about issues of intentionality, as well. But I'm going to try, just for purposes of today, to stay away from the term "barebacking."
With that understanding, I would like to get to what I think is probably the heart of the matter. First of all, what do we know about how widespread the practice of unprotected anal sex is among men who have sex with men? Because I think that a lot of HIV education seems to assume that the default setting is that guys are having protected sex. And I'd like to ask you all: Is that a reasonable assumption? Is that true? Or, what do we know?
Walt Odets: I think it's an erroneous assumption. I'd like to back up just for an instant, if I could? "Barebacking" is a term that's widely used and recognized to identify high-risk sex. And if two men, neither of whom has HIV, there is no risk of HIV transmission there. I think I'm saying more succinctly what I said before.
But certainly there's a tremendous amount of unprotected anal sex, and I do think that in this context that we have to make distinctions between negative men, positive men, knowledge of HIV status, and so on.
fogcityjohn: That's an excellent distinction that I probably should have made myself. Because I think we're probably not concerned with, say, two HIV-negative men in a relationship, who have negotiated safety, if you will. What we should probably be focusing on are men who either are negative, or don't know their status, and who are, despite the risk of HIV transmission, continuing to engage in unprotected anal sex with men whose status they may not know. Would that be fair?
Walt Odets: Yes, I think so.
Jeffrey Parsons: To be honest, I would be a little concerned about the first part of that -- this notion that two HIV-negative men in a relationship with negotiated safety and not having concerns. The epidemiological data is increasingly showing that a significant number of new infections are happening in the context of main partner relationships. And I think we sometimes make the mistake of assuming that when somebody is confident in their knowledge that they are HIV negative that may not be the fact.
And so I do think that we have to recognize that we can't just assume that for two people who believe themselves to be negative in a relationship that unprotected anal sex does not pose a risk.
Walt Odets: Yes. But that goes to, I think, more the issue of whether or not their knowledge is accurate; their assumptions are accurate.
Rashad Burgess, chief of the Capacity Building Branch of the Division of HIV/AIDS at the U.S. Centers for Disease Control and Prevention
Rashad Burgess: This is actually a very important issue, particularly in the context of gay men, where, because the background prevalence of HIV is respectively so high, so many gay men are unaware of their HIV status, even though there's a considerable frequency of testing. Individuals will believe that they are HIV negative, and have an operating assumption that they are negative, and enter into relationships assuming that they are negative when they actually are not.
And so one of the challenges we face in having this discussion is having a different perspective for those that we believe to be negative; oftentimes, that belief is not held true. And we have study after study where individuals who thought they were HIV negative, after being tested during the entry point into study, found out that they actually weren't negative.
fogcityjohn: OK. So obviously, having accurate information on that point is clearly quite difficult. But that leads to my original question. Do we have some sense of how many? What percentage of men do in fact adhere only to protected sex? And how many, some or all of the time, are having unprotected sex?
Rashad Burgess: I don't think we have a definitive answer to the proportion of gay men who have sex with men who definitely only have unprotected anal course, or primarily have unprotected anal intercourse. I mean, you look at studies; it ranges significantly.
I pulled some data up, and it ranges from 12 to about 46 percent. So it's a considerable range. It's specific to region of the country; the city, particularly; some differences in terms of race/ethnicity; differences in terms of age; differences in terms of HIV status. So I think that it's difficult to make a broad statement about the proportion of gay men that are partaking in unprotected anal intercourse, because it does vary significantly.
Walt Odets: John?
fogcityjohn: Yes, Walt?
Walt Odets: Just to go back to part of the original question: You used the term "negotiated safety." This is something that originated in Australia about 15 years ago. And it refers to two men that enter in a relationship who have presumably determined HIV status and determined the kinds of sexual behaviors that would occur outside the relationship, if any, and have found a way to have unprotected sex.
I agree with Rashad and Jeff. This is something that often has failed. But we have almost entirely in the United States failed in prevention efforts to educate men in that process. We simply pathologized the behavior and prohibited intervention, and don't discuss it, and don't help them to think about it, help them to understand how they can make that determination.
I see this in psychotherapy patients all the time, very sophisticated people, who really don't know how to go about that.
fogcityjohn: Well, what I'd like to ask you to do, Walt, is, if you could hold that thought for a little later on when we talk about some interventions. Because I think that's a really interesting and important issue. But I would like to get there a little later.
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