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Laying It Bare: Gay Men and Unprotected Sex in the Age of HIV/AIDS

June 23, 2010

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Motivations: Why Would Gay Men Put Themselves at Risk?

If we could, I'd like to move to what I think is the principal question. And that is: Why? Why, in this era of widespread awareness of the risks of HIV, are men still having unprotected anal sex? And I'd just like to hear from each of you on what your own knowledge and experience shows on that. Maybe we could start with you, Walt. As an individual psychotherapist, what have you found?

"We have liked to feel that [unprotected anal sex] was somehow dispensable -- and it's really not, emotionally. ... [W]e haven't helped men to think about what they are doing."
-- Walt Odets, Ph.D.

Walt Odets: Well, it's a natural behavior, and it's of emotional significance. And I think gay men naturally engage in it. We have liked to feel that it was somehow dispensable -- and it's really not, emotionally. So, again, we haven't helped men to think about what they are doing.

It's a very narrow range in which HIV is transmitted. Anal sex has the emotional import for gay men that vaginal intercourse has for heterosexuals. And it can't be dismissed. And we can't expect that that's going to done all the time, under any circumstances, with a condom.

It's compelling. It's emotionally compelling. And that would be the sort of crux of my answer to that.

fogcityjohn: OK. Rashad Burgess?

Rashad Burgess: I would actually agree with Walt, with respect to it being emotionally compelling for gay men. I mean, sex is not only a physical act; it's very much an emotional act. It's an act that brings intimacy, love, pleasure. And so to not start with that understanding can lead you down a road of significant misunderstandings of sex between gay men.

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But I would also add to that, that I think is really important, is that, you know, given nearly 30 years into the epidemic, and many of the benefits of treatment, the context of HIV -- it's very different. And many communities of gay men do not ... do not have in their face the actual risk, in that moment of making a sexual decision, of HIV.

Additionally, as we have people -- gay men -- this background prevalence of HIV is significantly high in a number, particularly with gay men of color. You really do have individuals at times making choices that ... but yet, not being fully, fully informed. And so they perceive themselves as being at low risk for HIV, while they're doing the things that we all would say are high risk. But yet, them not having appreciation for the actual prevalence of disease -- which results in them actually taking certain risks that they may not have taken if they had a full appreciation of the actual context.

fogcityjohn: Let me make sure I understand you. So you're saying that ... For example, I know, Rashad, you've done a lot of work in the African-American community. Are you saying that people may have, men may make the assumption that their risk behavior is ... their behavior is not risky, and it is, in fact, because of simply the prevalence of HIV within the community in which they live?

Rashad Burgess: That's exactly, that's exactly it. That's exactly it.

fogcityjohn: OK.

Rashad Burgess: That's exactly it.

fogcityjohn: Jeff Parsons: What do you think? What has your work shown are the reasons that men, say ... Why do men engage in this practice, with knowledge of the risks?

Jeffrey Parsons: I certainly agree with what's already been said. Sex without a condom feels better. And it does have more emotional importance for men that, I think, can't be ... Well, it shouldn't be dismissed. But I think Walt's correct; it is too often dismissed, particularly in the majority of the prevention work that we do.

And I certainly think that the majority of gay men out there are not trying to engage in behaviors that put them at high risk for HIV. So I think that what's also been said about the majority of gay men are engaging in behaviors that they think are harm reducing. They think that they are serosorting by having unprotected sex with people that they either think, or at least have been told, are the same HIV status as them. And so men are doing behaviors to try to minimize the risk, for the most part.

But I think that there are also a couple of other factors that do come into play. One of them has to do with substance abuse. And people who are active substance users, who have binge episodes, are simply not able to use all of their, sort of, cognitive and planning skills and abilities to either make or maintain the commitment to use a condom for anal sex.

And the other has to do with, sort of, depression and other mental health issues that you see men, gay men, who are experiencing significant levels of depression turning to unprotected sex as a way to just try to feel a connection to another person. And it ties very much with what Walt was saying about the intimacy and the emotion aspect of unsafe sex.

And so I think that the rates of depression among gay men, and the rates of substance use -- I think that both of these do play an important factor.

Rashad Burgess: This is Rashad. I think I want to add one piece. And I think it's important, in terms of setting context. Because, on the one hand, yes; we're talking about gay men having unprotected anal intercourse, with knowledge of risk.

"Gay men use condoms far more than heterosexuals, pretty much across the board."
-- Rashad Burgess

But I think it's also really important to note that across the board whether or not, if you're looking at our national behavioral surveillance, or you're looking specifically at a number of cities and studies, gay men use condoms far more than heterosexuals, pretty much across the board. And so I do think that is an important context to ... an important piece of information to put out there when talking about the risk of gay men.

fogcityjohn: Actually, I did not know that. I'm glad to hear that my community is at least doing, making an effort in this regard. And I guess one thing that that brings up is, you know, can any of you comment on what it is specifically about the unprotected aspect of anal sex that is so crucial? Because, of course, we're not talking about people not having anal sex at all; we're talking about guys using condoms when they do it.

Can you address exactly what makes the difference? Obviously, unprotected anal sex feels better. But what is the emotional aspect of that? Any ideas on that?

"The minute the condom becomes part of the act: this is a reminder to both people that there's something dangerous associated with the act, that instead of making love, they could be killing each other."
-- Walt Odets, Ph.D.

Walt Odets: I'd like to comment on two aspects of that. One is that the presence of the condom ... the minute the condom becomes part of the act: this is a reminder to both people that there's something dangerous associated with the act, that instead of making love, they could be killing each other. And that certainly is something that people want to avoid. So the association of the condom is certainly an issue.

The other is that the exchange of body fluids, the thing that we talk about as the prohibited behavior; the exchange of body fluids is an act of intimacy. It allows one man to have a part of another man inside of him. And that itself is compelling. And that obviously, that exchange of body fluid obviously requires unprotected sex.

So I think those are two big issues. There are many others, of course.

fogcityjohn: What, for example, Walt, what other ones would you see beyond those two?

Walt Odets: Well, there are several other things. The receptive partner often feels that he has to comply with the desires of the insertive partner. Part of allowing someone inside of you puts you in a passive, or receptive, position. And I think very often the receptive partner is compelled, for those emotional reasons. I'm not simply talking about intimidation; but this is emotionally part of the act.

I think that the substance use that Jeff mentioned is often an issue, that people's judgment changes. I think with alcohol, for example, we see a real narrowing of focus and attention. And this, then, excludes all kinds of considerations, like HIV.

I think there are just a number of emotional issues. You're asking a very complex question about something that happens in private and that is driven by conscious and unconscious thoughts and feelings. It's clearly very complicated.

fogcityjohn: Yeah. I realize that the question doesn't have a simple answer. And I'm just sort of hoping maybe we can, maybe you all can touch upon some of the things that, in your experience, you found as motivators. Rashad Burgess, do you have ...?

"When you look at the traumas that gay men often experience ... it does lead to a yearning for intimacy that takes great precedence over the need for someone to prevent themselves from getting HIV."
-- Rashad Burgess

Rashad Burgess: I would add two things. I mean, I'm coming from a little bit of a different angle than Walt. I think, when you look at the traumas that gay men often experience -- as children, as adolescents, as teenagers, and then as young adults -- oftentimes, it does lead to a yearning for intimacy that takes great precedence over the need for someone to prevent themselves from getting HIV.

And so, the rejection of family members, getting thrown out of your home, needing a place to stay ... I mean, the levels of stigma that just exist in many parts of our society will result in individuals having certain emotional needs that that level of intimacy, and intimacy with that level of risk, will oftentimes fill, for those individuals.

fogcityjohn: Jeff Parsons?

Jeffrey Parsons: The one other thing I would add -- I certainly agree with everything that's been said -- is that there are individuals who like to take risks. There are individuals who, that's a part of who they are; that's a part of their personality. And although I don't believe that the majority of them actively are out to become infected, I do believe that a lot of them think that they can play the game of roulette and always keep winning. These are often men who have had repeated episodes of unsafe sex, and yet have repeatedly tested negative.

And so they can develop this almost perception of invulnerability. They just don't think that they are going to get it, or that the chance of them getting it is so small that it's simply acceptable to take risks on occasion.

Walt Odets: Right.

fogcityjohn: And do you think that there is a, I guess, a sense in which men have sort of let their guard down, in the age of effective treatment? Is that a factor that affects their decision making?

Rashad Burgess: Complacency is definitely playing a role here -- in part, because of the benefits of treatment. I mean, when you exist within many communities, and you know of people who are HIV positive that are living healthy, active lives, it does impact the perception people have of the disease and its impact.

Walt Odets: Let me add something there, just to tag something on there. There are people who, consciously or unconsciously, would like to acquire HIV. And I'm not talking about something pathological here. In a relationship where you have a so-called serodiscordant couple, this is a big rift between people. This is a big separation.

And there's only, in terms of HIV, one way to repair that rift. It's for them to get a partner to contract HIV, and to reconnect the relationship in that way. And I think that that's relatively common in relationships. Serodiscordant relationships are emotionally difficult, very often.

fogcityjohn: And so, Walt, you're saying, basically, that in a serodiscordant relationship, acquiring HIV may be seen as an expression of intimacy?

Walt Odets: Yes. And connection. And repair within the relationship. I've seen that in many couples.

fogcityjohn: Very interesting. I'd like to go back to something you said, Rashad. Because you mentioned childhood trauma as a factor in this. And I was wondering, sort of a bit more generally: Is homophobia and the stigma that surrounds same-sex sexuality; is that something that plays a role in this? And if so, how?

Rashad Burgess: I would say it absolutely does -- particularly when you're looking at the risk-taking behaviors of individuals, looking at the risk-taking behaviors of young gay men. I mean, you have young gay men: many experience sexual molestation. Many experience mistreatment by their peers, or by their family members. And so the way in which many find intimacy, or find even security is through relationships through their partner relationships and/or relationships even with older men who, at times -- not exclusively, but at times -- there are certain risks that are taken because this person needs a place to stay, or this young person doesn't have any other resources of their own. And so I think stigma, homophobia, has an enormous role, as well as the impact it has on their own self-esteem, to even be willing to say, to negotiate, safety.

fogcityjohn: Jeff Parsons? I'm sorry. Go ahead.

Walt Odets: Yeah, no. I think what Rashad said is a big one. Jeff mentioned depression earlier on. But self-esteem, which is often connected with problems of depression; the self-esteem issue is a huge one.

Adolescents, gay adolescents, even now -- and this has lessened somewhat -- even now go through a feeling of being isolated, being alone, sometimes of being unique, and a distinct experience of being undesirable. And what they find out as they get older is that their body is very desirable to other people. And that is a very powerful thing. When someone is desiring you, it's a very difficult thing to kind of interrupt and start giving him instructions about how to desire you. And a condom would be one of those instructions. So I think, particularly in younger people, as Rashad said, that their self-esteem is a very, very important issue.

fogcityjohn: To follow up on that point, it does seem that we have a fairly high incidence of new infections, though, in men who are more in my age group -- you know, in their 40s. What's behind that, do you think? Because obviously what you're talking about, in terms of adolescents, coming into adulthood, you know, those things are, I would imagine, sort of in the past for men of my age. What do you think is behind the new infections we are seeing in men, say, in their 40s, in middle age?

Rashad Burgess: Well, let me say: One, you're absolutely, you're absolutely right. You see across the board, not only young gay men getting infected, but actually, we look at infections amongst men that are in their 40s and 50s; the far majority are amongst men who have sex with men almost across the board. There are a few exceptions in America, but very few.

I mean, I think there are a whole host of factors, some of which we've already talked about, that for young gay men are applicable to older gay men.

One thing we have not talked about, that I think is ... that I've experienced many gay men in their 30s and 40s speaking about is issues around loneliness. I don't know if there are others that want to comment on that, but when many gay men wrestle with -- you know, we said depression -- but issues around just pure loneliness, and what does it mean to be an aging gay man in a culture that, in many ways, really values youth ... and if not in, necessarily, age, at least in appearance. And so I think that sometimes that does result in people taking risks that they maybe didn't, would not have taken, when they were younger and they were very desirable, but yet had high self-esteem and resources. And now that they have aged, and are aging, you know, are willing to take certain risks because they are dealing with issues around loneliness and the need to be desired.

Walt Odets: I agree with that. And this is an inversion of the adolescent thing.

Rashad Burgess: Right.

Walt Odets: Where the adolescent discovers desirability, the older man discovers the loss of desirability.

"Youth are likely to say, 'Look, with everything else that I've been through, I can handle HIV.' And we hear the same thing from older gay men who are seroconverting ... : 'Look, you can live 20, 30 years with HIV. I'm already in my 40s. Why isn't it OK for me to just kind of finally be able to relax about safer sex?'"
-- Jeffrey Parsons, Ph.D.

Jeffrey Parsons: And what can happen with both groups -- the sort of young, gay man who is desperate for that boost in self-esteem, to feel desired, perhaps has been the victim of discrimination or some kind of abuse. The HIV, or possibility for HIV infection, then just becomes really secondary. It doesn't get viewed as a major thing. I mean, these youth are likely to say, "Look, with everything else that I've been through, I can handle HIV."

And we hear the same thing from older gay men who are seroconverting, where they say, "Look, you can live 20, 30 years with HIV. I'm already in my 40s. Why isn't it OK for me to just kind of finally be able to relax about safer sex?" And again, if it's tied to a particular contextual situation that is about them feeling desired, loved, wanted, to alleviate perhaps some of that loneliness that they're experiencing, they're more likely to take risks.

Walt Odets: There's also just some exhaustion over a lifetime with dealing with problems like this. And I think we do see in older men -- you know, it's related to what Jeff and Rashad are saying -- but it's a kind of throwing in the towel on protecting oneself. It becomes exhausting. Twenty-five years, a quarter of a century, of trying to avoid an infection, is tiring.

fogcityjohn: I can certainly confirm that in my own case. I think that was certainly a part of my own ... one of the reasons I became infected. So I think that's a very, very important point.

Rashad Burgess: If I could just say one ... and I said this to a colleague of mine: There's not an expectation that non-gay people, heterosexuals, would use condoms for 70 years of their actual sexual life, or 50 years, or however long people are sexually active. And I think that part of what we, as a community of gay men and of HIV prevention providers, researchers, policy folks, is how do you deal with a population of people who has been working very diligently -- I mean, very, very diligently -- to prevent getting HIV? But they've been doing it for 30 years.

And I think that the issue around exhaustion is very real, particularly for people who were in their teens or young adults in the late '70s, early '80s, and who did not get infected then.

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