Published in In The Family, Fall, 2003
For many gay men--clients as well as therapists--the all-too-often unexamined assumption that male couples are never completely monogamous is rationale enough for therapists to counsel gay men never to stop using condoms. While research demonstrates that a higher degree of non-monogamy exists among male couples than among either heterosexual or lesbian couples, there are some male couples who choose to remain sexually exclusive. There has not been enough written about how inherently homophobic it is for safer sex campaigns to urge all male couples to always use a condom, even if both are HIV-negative. I suggest that this is homophobic because it implies that gay men are inherently not to be trusted, either to be monogamous or, if they do have sex outside the relationship, to protect themselves and sex partners from transmitting HIV.
The question of whether to stop using condoms arises out of conversations around trust. Many of my couple clients come to therapy at the juncture in their relationships where one or both is ready to move to the next level of trust and sexual intimacy, but they aren't sure how to negotiate it. Mitch and Burt were two HIV-negative men in their mid-thirties, who had been a couple for three years and had recently bought an apartment together. They sought couples therapy to talk about whether or not they were ready to stop using condoms. They had been monogamous for the past two years of their relationship and each had retested negative for HIV in the past two weeks. Mitch said he had been the one to pressure Burt to agree to be sexually exclusive after they dated for six months. It happened after each said, "I love you," to the other.
"While I knew I'd fallen in love with Mitch and wanted to spend my life with him," Burt told me, "when he first raised the monogamy issue it just felt wrong. It was too soon. Even though I wasn't having sex with other men, I didn't want to make a promise that I didn't feel ready to keep. It felt like too much pressure. I wasn't ready to trust him that much at that time. Now it's different."
Mitch said that one of the biggest reasons he wanted a monogamous relationship with another HIV-negative man was so that they could forget about safe sex. Neither had ever had unsafe sex before. The both believed that having a lover in a sexually exclusive relationship was the perfect opportunity to expand their sexual boundaries. "Having that latex barrier between us seems like such a metaphor for our love and relationship--not being able to grow any stronger or closer," Burt said.
I asked them how far each was willing to trust the other, since the potential risks were so high. They gave almost identical responses: "We've already been taking risks to trust each other." They had purchased a condominium together and merged their finances, which involved an extremely high level of trust in each other and in the relationship. They also had a realistic understanding of the potential limits of monogamy. They were confident that if either did have sex outside the relationship, it would be a serious issue but would not necessarily bring the partnership to an end. I inquired if their definition of "monogamy" encompassed having sex together with another person or with other people. At this point, they became noticeably uncomfortable. I commented on their squirming, and asked what it was a response to. In an uncharacteristically sheepish manner, Mitch asked: "Are we monogamous if we occasionally have played together with another guy?"
I told them, "The rules and definitions of your sexual relationship are up to you to decide. But this raises an important issue about safer sex that we need to talk about." I proceeded to explain the concept of "negotiated safety," 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 both are 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. Then, they have to 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.
I explained to my clients that if they decided to incorporate a "negotiated safety" protocol into their relationship, they wouldn't just be agreeing to have anal sex with each other without condoms, they would also be agreeing to make a serious effort to make anal sex without condoms as safe as possible for both of them. I stressed that such an understanding would be premised on their knowing each other well enough to deal with difficult situations together for example, if one of them should have unprotected sex outside the relationship--and that it would work only if they had complete trust in each other. If they agreed not to use condoms, then only their agreement would be protecting them from contracting a life-threatening virus. In other words, the agreement would have to be strong.
We spent four more sessions talking through all of their feelings about safety, intimacy, sexuality, fear of infection and excitement about expanding their sexual explorations. Ultimately, they decided to stop using condoms. A year and a half later, they came back for a follow-up session and reported having completely unprotected sex with each other, as well as occasional, safe, "play sessions" with other men. They had retested negative and were thrilled with the arrangement.
Obviously, not every gay man behaves in ways that are sexually responsible or even empathic to his partner. I've seen other clients where the inability to successfully negotiate differences about safer sex ultimately led to the relationship's end. Donald and Ted, two HIV-positive men, sought therapy for relationship counseling. Ted was reluctant to define their relationship as "permanent," citing Donald's inability to commit to sexual exclusivity as the reason. Donald described Ted's lack of emotional commitment as his reason for having sex with other men, and the result was a vicious circle for which Donald was unwilling to assume any responsibility. Donald wanted to dispense with using condoms, but Ted's health was more fragile than Donald's, and this made him extremely uncomfortable. He knew Donald was having sex with other men and was afraid of contracting a sexually transmitted disease. Donald insisted that his doctor had told him that it was perfectly safe for him not to use a condom, but Ted's doctor had told him that it was not safe to dispense with using a condom. Donald was not at all empathic to Ted's concerns or feelings about this issue.
When Ted allowed Donald to have unprotected sex with him, Donald broke their agreement about how far he could go and Ted was furious at the health risk to which Donald had exposed him. When they discussed it in a chilly therapy session, it emerged that there had been other such incidents, and this pattern reinforced Ted's growing distrust of Donald. Ted began to feel distant and doubtful about the viability of their relationship. All of these issues were discussed, and they agreed to separate.
As I listen to my clients describe their sexual behaviors that have the potential of spreading a potentially deadly illness like AIDS, I am aware of more difficulty maintaining my 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. 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. Although I am a seasoned clinician, I always benefit from paid or peer supervision in these kinds of situations.
The following case was one of my most controversial, and many therapists might disagree with the approach I took. Therefore, I believe it is useful to discuss. Jake and Mark were healthy, HIV-positive men in their fifties. Each had lost a previous lover to AIDS. Neither had a detectable level of HIV. They had been together for two years when they consulted me prior to moving in together. They had concerns about how this change would impact them individually and as a couple. It was clear that they loved each other deeply and had a rich, interesting and sensual partnership, which was sexually exclusive.
The men wanted to explore relaxing their stringent adherence to safer sex practices. "Since we are each undetectable there is no way we can test to see if we have the same strain of the virus," said Mark. "I love him more than I have ever loved any of my previous partners. Being able to have unsafe sex would be a form of spiritual communion for me. It would make me feel even closer to him than I already do."
Jake, on the other hand was not comfortable with the even low level of possibility that he might be "giving this man, whom I adore, an opportunity that could negatively impact his health, even though he is willing to accept that risk." When I questioned Mark about changing their sexual status quo he said that they were both middle-aged men who were already infected and had lived more than a decade longer than either had expected. He did not see what difference it would make in the long run to his health, even if Jake gave him a different strain of the virus. Concurrent with trying to decide whether or not to have unsafe sex, they were also considering whether or not to open up their sexual relationship to include an occasional menage-a-trois. They both felt strongly that prior to risking a "three way,"they would disclose their HIV statuses to any potential sexual partners, and would practice safer sex.
My assessment was that Mark was not depressed, impulsive or self-destructive. He understood that there was some possibility of becoming reinfected with another strain of HIV. He was conversant with the medical literature that was currently debating the entire issue of reinfection, which in the current medical terminology is labeled "HIV superinfection." Jake was emotionally autonomous enough for it to be unlikely that he would feel obliged to do things he was uncomfortable with.
Eventually, Jake decided that he would try having unsafe sex with Mark and see if he could relax his fears and
enjoy it. It too ka few times, but eventually the relaxing of safer sex practices became pleasurable for him and they
both felt it greatly enhanced their sex life. They also decided they didn't want to go back to safe sex practices, so
they decided not to expand their sexual repertoire to include sex with other people.
Gay male therapists working with gay men face a particular challenge, for it is all too easy for us to project our
own feelings into clients' 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. I found it helpful to differentiate between my
clients having unsafe sex, and having sex that placed them at risk for transmitting HIV to each other. I have come
to see that there are circumstances where dispensing with condom use is completely non-pathological, but I always
help my clients explore concerns about trust, monogamy and degrees of risk when they contemplate abandoning
safer sex.
Key Words: Gay men, male couples, gay male sexuality, condoms, love, HIV