Published by Cicatelli Associates Inc
After more than two decades of safer sex messages, people dying, vast changes in the medical treatments of HIV and AIDS, many gay men are returning to the ways of sex before the onset of the AIDS epidemic. Statistics underscore this fact. At the 2003 National HIV Prevention Conference in Atlanta, hosted by The Centers for Disease Control and Prevention, The CDC released data which reported the number of gay and bisexual men diagnosed with HIV climbed for the third consecutive year in the United States in 2002, fueling fears that the disease might be poised for a major comeback in this high risk group. "HIV diagnoses among men who have sex with men surged 7.1 percent in 2001, according to date collected by the CDC from 25 states that have long standing HIV reporting. New diagnoses in men who have sex with men have increased 17.7 percent since 199, while remaining stable in other vulnerable communities." (Reported in Simao, 2003)
Concurrent with these reports is the emergence of a phenomenon among gay men known as barebacking, or having anal sex without condoms intentionally, as opposed to poor planning or relapsing. This phenomenon is not to be confused with accidental unprotected sex that results from poor planning, or "relapse" after consistent condom use. Barebacking is a premeditated activity that threatens to unravel years of safer-sex education and place an entire new generation of gay men at lethal risk. In a study by Mansergh et. al. (2002) in the San Francisco Bay Area, 554 men who have sex with other men were asked if they had heard of "barebacking." Most had (70%) and a small minority (14%) had done it during the past two years. And it was across the board. There were no differences by race, ethnicity, or sexual identity. The authors of this study discuss that some men intentionally put themselves and/or others at risk of HIV and STD "to meet important human needs (e.g., physical stimulation, emotional connection) other than physical health." The 2002 New York City Community Health Survey found that about one third of men who have sex with men who have 3 or more sex partners reported no condom use the last time they had sex ( NYC Department of Health and Mental Hygiene, 2003).
An article in a national gay and lesbian newsmagazine called Internet chat rooms "the new gay bars" (Fries, 1998). Several studies conducted both in the United States and Europe have shown that people who use the Internet to meet sexual partners have increased levels of high risk behaviors (McFarlane et al., 2000; Elford et al, 2001; Kim et al, 2002). Many of the factors that contribute to "cyber cruising," using the Internet to find sexual partners, also foster high-risk sex. "There are studies that demonstrate a variety of psycho-social health issues including depression, anti-gay violence, childhood sexual abuse or substance abuse can lead gay men to have unsafe sex" (Stall, quoted in Osborne, 2002). Loneliness, HIV status, unmet intimacy needs, feeling alienated from the gay community, and love also need to be factored in.
Significant numbers of gay men have online profiles stating they are "chem friendly" or want to "party," both of which mean they seek to have sex while using methamphetemine (aka speed, crystal meth, crystal or Tina), GHB, "ecstacy" or other "party drugs." Research documents that high-risk behaviors that spread HIV and other STDs occur more frequently among individuals who have poor impulse control, particularly if their sexual activity takes place under the influence of alcohol or drugs (Stall et al, 1986; Leigh, 1990; Stall et al 1991; Stall & Leigh,1994; Royce et al, 1997; Chesney et al, 1998; Halkitis, Parsons & Stirratt, 2001; Halkitis & Parsons, 2002 ).
Another contributing factor to the increase in high risk sex is that those who have been practicing safer sex for many years have reported experiencing safer sex fatigue or burnout and as a result, some have returned to sex without condoms. Theories abound as to the resurgence of unsafe sex among gay men. "When we discuss the issue of sexual risk-taking behaviors--particularly in a marginalized, outlawed group, such as gay men--it is imperative to see the historical and cultural forces at work in shaping dynamic understanding of such behavior," says Marshall Forstein, MD, professor of psychiatry, Harvard Medical School (2002). There are many explanations for why some gay men have high-risk sex. Complacency about HIV/AIDS fostered by the development of combination antiretroviral therapy is one of them. In the early days of the AIDS epidemic, fear helped propel sexual behavior change. One could not venture into a gay neighborhood, without coming face to face with what was then the emaciated and dying face of AIDS. Today, thanks to antiretroviral therapy, improved prophylaxis, and the use of testosterone and human growth hormone, men with HIV and AIDS are often muscled hunks. Without visual reminders, even intelligent men who are well informed about HIV and how it is transmitted are likely to take sexual risks.
For example, Roberto, a 29-year-old attorney, describes the reason that he sometimes foregoes a condom: "I know intellectually that condomless sex is wrong, but today AIDS simply doesn't seem to be a big deal. I hear from my gay uncle who's in his 50s that in the early days of the epidemic, it was common to see prematurely aged gay men in wheelchairs, covered with lesions, or who looked like they'd just come out of Dachau. I've never knowingly seen anyone who was seriously ill with AIDS. This fact contributes to the reason I'm not as afraid of contracting HIV as I should be and am not always careful sexually."
Psychoanalyst Mark Blechner (2002) states: "Young gay men today may be lucky not to have lived through the terrible times of the early days of the AIDS epidemic, but consequently, many such people do not share the great sense of relief that the previous generation felt at being able to stay alive by mere condom use. Some instead feel resentment and deprivation at the constraints of safer sex." He further suggests that it is easy for older people who have enjoyed condomless sex, yet survived the epidemic to be smug about how the tradeoff between condom use and safety is obviously worth it. For younger people, who in any case feel invincible, the subjective valuation of condoms, risk, health, and pleasure may be different (Blechner, 2002).
It is all too easy and reductionistic to pathologize sexual risk-takers as self-destructive, suicidal, damaged individuals or to believe that "for some gay men danger is a permanent fetish"(Savage, 1999). Cheuvront (2002) reminds all therapists working with men who are not having safer sex that "the meanings of sexual risk-taking are as varied as our patients." He cautions that simplistic explanations and understandings can "assuage the clinician's anxiety by making that which is complex and subject to individual differences appear less mysterious and knowable. Yet this is not a luxury that clinicians have." As therapists, it is our task to help the patient articulate the particular meanings of his high-risk behaviors.Regarding sexual risk taking, Forstein (2002) asks: "Can care for the soul and care for the psyche always occur in the context of caring for the body?" Cheuvront (2002) suggests that for many gay men self-care may indeed include taking risks. In response to this, Forstein (2002) posits "that the question becomes one of understanding the nature of the risk and whether that particular risky behavior alone can attend to the needs inherent in the behavior."
Many therapists, gay or not, have a hard time with sexual practices that are frowned upon by the culture-at-large -- anal sex, open relationships, "kinky" sex and group sex, etc. -- and are not judgement-neutral about them. This creates a problem, for in the matter of preventing HIV and other STDs, a certain comfort level in discussing these topics is an essential prerequisite to effective therapeutic intervention. It is incumbent upon the therapist to create a treatment environment in which the patient feels safe enough to broach any and all forms of sexual behavior; otherwise, discussion of the crucial issues of autonomy, (forbidden) desire, sexual self-confidence, and inter-personal intimacy will almost certainly be hamstrung from the onset, if not foreclosed.
If a therapist is unable to remain non-judgmental in this highly charged realm, the odds are good that the client will stop treatment with that therapist, for gay men are often - quite appropriately - hypersensitive to indications of negative feelings about their sexual practices and desires, even from an openly gay therapist. If a client should remain with such a therapist, the latter is likely to do harm. Therapists should identify and address their own ambivalent feelings with regard to sex in general, and make a sustained effort to become not only open-minded but comfortable about sexual-preference choices that may be alien to their own experience, social world, and ethical system. Some therapists come from religious or cultural backgrounds that make it difficult to be nonjudgemental about homosexuality and gay sex. But as a result of cultural diversity trainings that include addressing one's homophobia may learned how to contain these feelings and biases during therapeutic sessions with gay men.
Faced with the reality of gay men having unprotected anal intercourse (UAI) and possibly spreading HIV to women sexual partners as well as to other men, any therapists will find him or her self having a host of complicated feelings and reactions that have the potential to interfere with providing the most sensitive and effective counseling or therapy. Listening to people describe behaviors that can spread a potentially deadly illness like AIDS increases the difficulty of maintaining therapeutic neutrality. Many clients judge themselves for having unsafe sex. It is understandable that therapists may also have harsh negative judgements of clients who are having high-risk sex. This is especially likely to occur if an HIV-positive individual does not acknowledge there is anything wrong with behaving in a way that can possibly spread the virus. Listening to clients describe participating in unsafe sex can be so highly charged that therapists must be prepared to have strong emotional reactions which they need to control. In the matter of such control and how to achieve it, even seasoned clinicians can benefit from paid or peer supervision.
Gay male therapists working with gay men face a particular challenge, for it is all too easy for them to project their own feelings into discussions of safer-sex issues. Every gay male therapist, regardless of his HIV status, has had to decide how he was going to handle these issues in his own life.
It is important for therapist to be able to distinguish between unsafe and high risk sexual behaviors. As Blechner(2002) notes, if two HIV-negative men engage in unprotected anal intercourse, the sex is not high risk since there is no virus present to be transmitted. Thus there are circumstances where dispensing with condoms is completely nonpathological and adaptive. Men in mutually monogamous, HIV-negative concordant relationships are not at high risk for transmission of HIV if they only have sex with each other - even if they have unprotected anal intercourse. It is useful for therapists to be familiar with the concept of "negotiated safety"(Kippax et al., 1993; Prestage et al., 1994) which is an agreement between two gay men in a relationship to go through the process of getting ready to stop using condoms when they have anal sex. The basis is an explicit understanding that both know each other's HIV status and are both uninfected. The only time they don't use condoms is when they have sex with each other, making this an acceptable safer sex option. There must be no unprotected sex outside the relationship; if either partner does so, then he must immediately inform his partner prior to their having sex again. They resume using condoms until subsequent HIV tests prove that the partner who had unprotected sex is still negative. A British website, (http://www.freedoms.org.uk/advice/air/air07.htm) has a sample negotiated safety agreement that can be downloaded and given to clients. I often suggest that couples visit this site and do some of the written exercises offered there to help facilitate discussions about whether they are ready to incorporate negotiated safety into their relationship
For committed couples with concordant HIV status who are not having protected anal intercourse, the increase in intimacy, closeness, and spontaneity may outweigh any potential risks of infection or superinfection. One therapeutic goal should be to facilitate patients' talking about what level of risk is acceptable for them. This entails helping individuals to evaluate their capacity for tolerating and managing uncertainty and ambiguity, especially as this pertains to the potential for HIV superinfection. (HIV "superinfection" is defined as a second infection with HIV, after a primary infection has been established. This is distinct from "coinfection" which is defined as the simultaneous transmission of two or more subtypes of HIV) (Blackard et al., 2002).
Therapists need to help each client evaluate whether he feels not having safer sex is adaptive for him, even if the therapist strongly differs with the position taken by the client. An example of this is noted by Rofes (1996) and confirmed by my clinical observations when despite knowing the risks of certain sexual behaviors, some gay men consciously prefer to prioritize pleasure over possible longevity. As Remien et al, (1995) and Remien et al, (2001) report men in known sero-discordant relationships do have high-risk sex. These authors report that men in these relationships perceive the risk to be an expression of intimacy, closeness, love and commitment, and that often it is the uninfected partner who pushes for increased levels of sexual risk taking. For some people, sex and love become inextricably linked, and rather than risk losing love they have unprotected sex. For people unable to differentiate between lust and love, unprotected sex is often an effort to hold on to the illusion of, or the potential for, love. Assuming that the only goal of this work is for every gay man to have safer sex every time is analogous to maintaining that the only goal for any individual who has a problematic relationship with substances should be to abstain from the use of alcohol and drugs. When working with men who do not use condoms for anal intercourse, the combination of sexual risk-taking, personal and public health issues, self actualization, desire, love, recklessness, self-destructiveness, and self-expression on the part of clients can be volatile, challenging each therapist to strive for profound levels of professional curiosity, and empathy in combination with clinical sophistication.
References
Blackard, J.T., Cohen, D.E., & Mayer K.H. (2002). Human immunodeficiency virus superinfection and recombination:
current state of knowledge and potential clinical consequences. Clinical Infectious Diseases, 34(8),1108-1114
Blechner, M.J. (2002). Intimacy, pleasure, risk and safety: Commentary on Cheuvront's "High-risk sexual behavior in the
treatment of HIV-negative patients. Journal of Gay and Lesbian Psychotherapy, 6(3), 27-34.
Chesney, M.., Barrett, D. & Stall, R.D. (1998). Histories of substance use and risk behavior: Precursors to HIV
seroconversion in homosexual men. American Journal of Public Health,88(1),113-6.
Cheuvront, J.P. (2002). High-risk sexual behavior in the treatment of HIV-negative patients. Journal of Gay and Lesbian
Psychotherapy, 6(3), 7-26.
Elford, J., Bolding, G., Sherr, L. (2001). Seeking sex on the Internet and sexual risk behavior among gay men using
London gyms. AIDS, 15(11),1409-1415.
Forstein, M.. (2002). Commentary on Cheuvront's "High-risk sexual behavior in the treatment of HIV-negative patients.
Journal of Gay and Lesbian Psychotherapy, 6(3), 35-44.
Freedoms.org. (2002). http://www.freedoms.org.uk/advice/air/air02.htm.
Friess, S. (1998). A place where no one knows your name. The Advocate: The National Gay & Lesbian Newsmagazine,
752, 24-31.
Halkitis, P.N., Parsons, J.T., & Stirratt, M. (2001). A double epidemic: Crystal methamphetamine use and its relation to
HIV prevention among gay men. Journal of Homosexuality, 41(2),17-35.
Halkitis, P.N. & Parsons , J.T. (2002). Recreational drug use and HIV risk sexual behavior among men frequenting urban
gay venues. Journal of Gay & Lesbian Social Services, 14(4), 19-38.
Kim, A., Kent, C., & McFarland, W. (2001). Cruising on the Internet highway. Journal of Acquired Immune Deficiency
Syndromes, 28(1),89-93.
Kippax, S., Crawford, J., Davis, M., Rodden, P., & Dowsett, G.(1993) Sustaining safe sex: a longitudinal study of a sample
of homosexual men. AIDS, 7(2), 257-63
Leigh, B.C. (1990). The relationship of substance used during sex to high-risk sexual behavior. The Journal of Sex
Research, 27,199-213.
McFarlane, M., Bull, S.S., & Rietmeijer, C.A. (2000). The Internet as a newly emerging risk environment for sexually
transmitted diseases. Journal of the American Medical Association,284(4),443-446.
Mansergh, G., Marks, G., Colfax, G.N. Guzman, R., Rader, M., Buchbinder, S. (2002). Barebacking in a diverse sample of
men who have sex with men. AIDS, 16(4), 653-659.
New York City Department of Health and Mental Hygiene, (July, 2003). A report from the 2002 NYC community Health
Survey, reported in NYC Vital Signs, 2(6).
Osborne, D.(2002, Oct 11-17). An holistic Approach to Health: GMHC to fold multiple life issues with HIV prevention.
Gay City, 1(20),10.
Prestage, G., Kippax, S., Noble, J., Crawford, D., & Baxter, D. (1994 Nov. 3-6). Sydney men and sexual health: negotiated
safety in a cohort of homosexually active men. Annual Conference Australian Society of HIV Medicine, (Unnumbered
abstract). 6, 125.
Remien, R.H., Carballo-Diéguez, A., & Wagner, G. (1995). Intimacy and sexual risk behavior among serodiscordant male
couples. AIDS Care, 7, 429-438.
Remien, R.H., Wagner, G, Dolezal, C., and Carballo-Diéguez, A. (2001). Factors associated with HIV sexual risk behavior
in male couples of mixed HIV status. Journal of Psychology and Human Sexuality, 13:2, 31-48.
Rofes, E. (1996). Reviving the Tribe: Regenerating gay men's sexuality and culture in the ongoing epidemic. Binghamton,
NY; Harrington Park Press.
Royce, R.A., Sena, A., Cates, Jr. W., & Cohen, M.S. (1997). Current Concepts: Sexual transmission of HIV. New England
Journal of Medicine, 336,1072-1079.
Savage, D. (1999). The thrill of living dangerously. Out Magazine, March, pp.62, 64, 118.
Simao, P. (July 29, 2003) Rise of Internet Fuels Fears of AIDS Resurgence. Reuters News Service http://reuters.com/newsArticle.jhtml?type=internetNews&storyID=3179188
Stall, R.D., McKusick, L., Wiley, J., Coates, T.J., & Ostrow, D.G. (1986). Alcohol and drug use during sexual activity and
compliance with safe sex guidelines for AIDS: The AIDS Behavioral Research Project. Health Education Quarterly,
13,359-371.
Stall, R.D., Paul, J.P., Barrett, D.C., Crosby, G.M. & Bein, E. (1991). An outcome evaluation to measure changes in sexual risk taking among gay men undergoing substance use disorder treatment. Journal of Studies of Alcohol, 60(6), 837-845.
Stall, R.D. & Leigh, B. (1994). Understanding the relationship between drug or alcohol use and high risk sexual activity for
HIV transmission: Where do we go from here? Addiction, 89,131-4.
Key Words; HIV, AIDS, AIDS prevention, safer sex, condoms, condomless sex, barebacking, gay male sexuality, unprotected anal intercourse