Harm Reduction for Barebacking?
I came to New York City, like many other gay men, looking for a place where I could be myself and escape the repressive, conservative, and homophobic society of my native Chile, where you can't talk about sex, period. What I actually found -- in the city where the Stonewall Riots happened and the gay rights movement began -- was an only slightly less homophobic society. I found a city facing the same problems as other societies that preach abstinence or perfect behavior as the only way to deal with the complicated issue of human sexuality.
After living here awhile and working in the HIV and LGBT fields, I began to hear people talking about "condom fatigue" and the rise of "barebacking" among gay man, including the use of websites as a way to practice it. I learned about concepts like "PNP" (Party and Play -- mixing recreational drugs and sex) and the reality of burnout and the tiredness of old prevention campaigns.
What Is Barebacking?
Barebacking is gay slang for intentional unprotected anal intercourse. Different from just skipping the condom in the heat of passion, barebacking means making a deliberate decision before sex to not use one. (The term "barebacking" may not be acknowledged by all men who practice this behavior -- some men use the terms "raw" or "natural" instead. Health professionals who are tailoring programs toward barebackers must recognize this in order to design effective prevention services.)
Internalized homophobia can be an important stressor that contributes to barebacking. According to Michael Shernoff, it creates an "an unconscious sense that a gay man is unimportant and undervalued, thus increasing his sense that he is expendable, and so too are the men with whom he has sex and from whom he seeks love and validation."
Research conducted in New York has shown that use of crystal meth correlates directly with barebacking among white, black, and Latino (but not Asian) gay men. A study of gay meth users in New York City suggested that men with certain psychological profiles are attracted to methamphetamine, use it in environments and contexts that are sexually charged, and as a result are more likely to engage in barebacking. Whether men use the drug intentionally as a way to facilitate barebacking or whether barebacking is a byproduct of methamphetamine use -- or some combination of the two -- are issues that need further exploration.
Barebacking and the Internet
Men looking for sex partners have found the internet very useful for connecting with other men, and it's used by gay men of all races, ethnicities, educational backgrounds, and ages. The increasing use of websites for hookups correlates with the increasing number of HIV infections, and with the rising use of crystal meth. In fact, there are websites that cater specifically to barebackers, and many of them purposely avoid information about the risks of barebacking or ways to prevent HIV. Any mention of barebacking risks is often met with harsh criticism on these sites.
A recent survey of 1,178 men who have sex with men (MSM) in Los Angeles and New York City found that barebackers spent significantly more time on the internet looking for sex than non-barebackers, and HIV-positive barebackers specifically spent the most time online looking for dates.
The Culture of Barebacking
Some perceive barebacking as a lifestyle, in the belief that it is a matter of personal choice. These men may have problems fitting into the "safer-sex world" and feel that society or the government cannot tell them how to live their lives.
Some men take on the identity of the barebacker in an attempt to remain "sexual outlaws." Others choose to bareback on the basis of a committed monogamous relationship, believing that bonds of trust keep them safe and strengthen the ties between them. In addition, the exchange of semen is perceived by some men as an important and emotionally binding choice.
Trust and the decision to have unprotected sex often go together, as seen in the worldwide epidemic of infected married women who felt safe in what they thought were monogamous relationships. This is not to say that people, gay or straight, in committed relationships cannot ever take off the condoms. The motivations for having unprotected sex within committed relationships may vary but whatever the reason, there needs to be a frank and open discussion about what that means . . . and what happens if one partner does have sex outside the relationship.
Harm Reduction is a public heath philosophy intended as an alternative to the outright prohibition of certain potentially dangerous lifestyle choices. The idea is that some people will always engage in risky behaviors like casual sex or drug use, so the objective of harm reduction is to mitigate the potential dangers and health risks. These strategies meet individuals "where they are."
A harm reduction approach includes sex education that emphasizes tools like condoms and clean needles to protect against disease transmission and pregnancy. This runs contrary to the ideology behind abstinence-only sex education, which holds that telling young people about sex can encourage them to engage in it. Supporters of harm reduction cite statistics showing it to be significantly more effective at preventing teenage pregnancy and STDs than abstinence-only programs. Critics maintain that harm reduction makes dangerous behavior seem safer, leading to an increase in that behavior. But most research has overwhelmingly shown the latter to be untrue.
Some have suggested that a harm reduction approach could be applied to barebacking, as follows:
- Reducing the number of partners
- Serosorting: Choosing partners only of the same HIV status
- Strategic positioning: An HIV-positive man taking the receptive (bottom) role during barebacking with an HIV-negative man
- Withdrawal: Pulling the penis out before ejaculation
- Negotiated safety: An agreement between two partners in a committed relationship to go through a process that will eventually lead to removing condoms during sex
In the end, this debate comes down to the definition of harm reduction. Yes, decreasing the number of your partners from ten a night to one a night will lower your risk -- but the chance of infection is still high. Traditional harm-reduction approaches, like clean needles and condoms, can dramatically reduce the risk of HIV infection, but only abstinence eliminates it. That's why we talk about "safer" rather than "safe" sex. Applying the term "harm reduction" to actions that reduce risk only slightly sends a confusing message at best.
The other approaches suggested are equally questionable. "Serosorting" out all people with HIV is simply a fantasy (see page 10), as is early withdrawal (ask any woman who got pregnant from pre-cum). And while studies have shown that the insertive partner is at less risk than the receptive partner, the risk for both partners is still significant. The only way that barebacking can be called an HIV prevention strategy is when two HIV-positive people have sex, since no new HIV infection is possible. However, this does not apply to STDs or different strains of HIV.
The fact is that recently infected individuals have very high viral loads for up to three months before an HIV antibody test will show a positive result. A research letter published recently in AIDS argues against serosorting: "Our conservative calculations show that serosorting based on disclosure is not likely to be an effective prevention strategy when the prevalence of recently infected 'HIV-negative' disclosers comprises approximately 4% of the potential sex partner population? By ignoring the increased potential for HIV transmission by recently infected individuals, serosorting may paradoxically increase the number of new HIV infections in certain populations."
"Negotiated safety" within a relationship is possible only after HIV testing and open, honest discussion. A study of 500 HIV-negative and -positive MSM in the Multicenter AIDS Cohort Study found that about 15-20% of those who said they had arrangements that precluded outside sexual partners actually had multiple partners despite their negotiated arrangements. So even this type of "negotiated safety" is not foolproof.
Nevertheless, MSM are using these strategies, regardless of how effective they may or may not be. A study of 1,168 MSM in New York and San Francisco found evidence of attempts at serosorting, strategic positioning, and early withdrawal in both cities.
Breaking the Myth
The CDC reports that HIV infections are on the rise among MSM (from 56,680 in 2001 to 60,259 in 2005), and barebacking is most likely playing a part. People may think, "Now that I have HIV, I can bareback -- what could be worse?" or, "My friend with HIV takes only one pill once a day -- no big deal," or, "HIV isn't a death sentence anymore," and of course, "My partner told me he's negative; I saw his HIV test results from yesterday."
But the fact is that getting HIV today is not the same thing as being infected in the '80s. Up to 30% of new infections are of strains of the virus resistant to HIV meds. Also, there have been cases of HIV-2 in New York -- a type of HIV that used to be found only in parts of Western Africa. Some HIV meds don't work against HIV-2.
Making decisions based on HIV test results is risky. A partner's negative HIV test today means only that he was negative three months ago. The immune system needs time to create the antibodies that the HIV test looks for. In fact, many new infections are occurring during the "window period" (the time between infection and when an HIV antibody test will return a positive result), since people in the window period have a very high amount of HIV in their body.
A 2005 CDC survey found that of 450 MSM who tested HIV positive, 48% were unaware they were infected. And HIV-positive men seem to be learning that disclosing their HIV status will lessen their chances of finding a partner. A study published in the American Journal of Public Health in 2003 found that 42% of HIV-positive men who reported any sexual activity (protected or unprotected) had not disclosed their HIV status to their partners. And a California study of 250 Latino men (200 negative and 50 positive) who used the internet to seek sex partners found that about 41% of the HIV-positive men misrepresented their status to prospective partners.
Many theories have been presented to explain the increase in barebacking behavior: a lack of social support within the gay community, "condom fatigue," a desire to regain a sense of belonging by joining the "community" of barebackers, and of course, the added sense of intimacy that unprotected sex may provide. We need to find innovative prevention approaches that address these problems, rather than offering false hopes that could lead to more people with HIV. Going from 100% risky behavior to 0% risky behavior overnight isn't realistic. New approaches to counseling gay men who either choose to bareback or who do it without thinking -- including approaches that address the way the internet can facilitate multiple partners -- must be created.
Risk reduction does have tangible benefits: If you are driving at 70 mph and you slow down to 55, your risk of being in an accident and of sustaining a serious injury drops. But can this be applied to barebacking? Unfortunately, the "harm reduction" methods being proposed don't go nearly far enough. There is no such thing as being only partly HIV positive. In the end, most suggestions for lowering the risk of HIV from barebacking sound less like harm reduction and more like tap dancing in a mine field.
Rafael Madrid is an HIV Health Educator at ACRIA.