A Trans Man Discusses PrEP and Condomless Casual Sex
In bed with a casual hook up, I said: "I realize that when we're already naked is probably not the best time to have a discussion about condoms, but it's not exactly the worst time, either."
"I'm happy to use condoms. No problem," he replied.
"Well, um, how do you feel about not using condoms?," I asked sheepishly.
And then he said it: "Are you clean?"
John (not his real name) would tell me later that I looked like I was about to punch him when he asked me this question. Instead, I continued grinding steadily and rhythmically against his cock as I told him about pre-exposure prophylaxis (PrEP), treatment as prevention (TasP) and how people living with HIV are just as "clean" as anyone else. I explained that it would be much safer for him to have sex with someone who is HIV positive and on treatment than for an HIV-negative person to have sex with someone like him. I explained that those who most often transmit HIV to others are unaware of their status. They may get tested and sincerely believe themselves to be HIV negative. But many, like him, are vulnerable because they're not on PrEP and rely solely on their partners' claims to be negative in deciding whether or not to use a condom.
I'd been on PrEP for a little over 13 months. In that time, I'd had a penis inside me without a condom twice -- once with a trusted partner after we'd both just received our sexually transmitted infections (STIs) test results, and once during a non-consensual encounter at the bathhouse when a guy took the condom off when I wasn't looking.
My encounter with John was the first time I'd come close to condomless sex with a casual hookup. I'd been thinking about the possibility for months, but I'd been too afraid to follow through. You see, I learned this past February that transgender men like me have been excluded from every clinical efficacy trial of PrEP to date, which means there's no data about how well Truvada (tenofovir/FTC) works to protect me from HIV compared to cisgender (non-transgender) men or women. There's good reason to believe that it will prevent HIV infection, but there's also good reason to believe that it may not be as efficacious for people who have receptive vaginal sex. Is PrEP efficacious enough to reliably prevent HIV in trans men? Probably yes. But it's a question researchers haven't yet fully answered.
The rational decision I arrived at was to have condomless sex only with guys who are on antiretrovirals -- either PrEP or treatment. John was neither; he was about as risky a hookup as I could have picked for my first time barebacking. But he was a nice guy (which is not an effective STI/HIV prevention strategy) and this was the first time I had felt even the slightest bit comfortable letting down my defenses enough to push through the fear. If we're being honest, I was just too exhausted to keep those defenses up any longer.
I'd been waiting years for this moment.
You see, I was raised with abstinence-only education and grew up believing that condoms didn't work -- but that I had to use them anyway, because otherwise I would surely die. This lifetime of programming became especially problematic after I divorced my husband, with whom I hadn't used condoms during our marriage, and began taking testosterone.
Like nearly all trans guys on testosterone, I developed vaginal atrophy -- a condition that also commonly affects post-menopausal cisgender women and causes deterioration of the vaginal walls. Sex with condoms grew increasingly painful, and I consistently experienced bleeding and tearing every time I had sex. My doctor gave me localized estrogen to treat the condition, which helped, but my vagina is most definitely not the same as the vaginas of the healthy, pre-menopausal cisgender women who were included in PrEP research studies. I'm also not having sex with the same kinds of guys as those women are, because their partners were heterosexual cisgender men, and my partners are almost exclusively gay cisgender men.
Two months ago, while lying around in a sling at the bathhouse entertaining myself between suitors, I discovered a new bump inside of me. It was painful, and frightening. I scheduled an appointment with a gynecologist to have it looked at, and I refrained from sex for the next five weeks while I awaited her insight.
It turned out that condoms were the culprit. Not a latex allergy -- just a normal consequence of the friction from condoms rubbing against my fragile tissue, which was already prone to tearing and inflammation. The pain I'd gotten used to tolerating, which I'd learned to associate with "safer sex," was actually something my body didn't want me to ignore. Sex with condoms consistently hurt, but I had chosen to disregard the discomfort because my fear of condomless sex was more intense -- until it wasn't anymore.
Over the few weeks following my doctor's visit, I had extensive private conversations with some of the world's top HIV researchers and educators about my struggle to decide whether I would continue using condoms. There's no scientific evidence available to give me any greater assurance than what I already know: PrEP will probably work, but possibly not as well as it works for cisgender men. It's obviously a safer alternative for me right now than condoms, which I need to stop using because they're putting me at higher risk of infections than barebacking does.
At last, there I lay, naked and hungry for the touch of the man situated between my body and a 400-thread-count blanket. He thanked me for telling him about PrEP and said he'd look into it. My hips bucked gently against him, impatiently awaiting the decision to which I had not yet committed myself.
He said, "We can use condoms if you want, you know. It's okay to use them."
So much of this story he doesn't know. And how could I tell him? He's a hookup, not my boyfriend. My struggle to find freedom from the confines of my transgender body is not an erotic tale. My pain, both physical and emotional, is not welcome in his bed. We do not have that kind of relationship. I cannot tell him what it would mean to me to use condoms. I can't tell him how this would reinforce a life-long narrative that sex is about his pleasure to the exclusion of my own; that I would have to suppress my own pain while he uses my body for his own enjoyment; that I would feel helpless and sad. This is what it means to me to use condoms. He didn't need to hear all that.
So I decided: "I'm on PrEP. Neither of our HIV statuses will change from this sex. Let's just enjoy it."
Brandyn Gallagher, a Seattle activist and community servant, has devoted his life to the redistribution of happiness by raising awareness about HIV stigma, social justice, and the struggles of queer and gay people in pursuit of equitable health care access.