Published in In The Family
The world of gay male sexuality has dramatically changed since the 1980s, when I helped design the first generation of safer-sex workshops for gay men. Back then, our goal was to impress upon gay men the importance of always using a condom during anal sex. Boy, were my colleagues and I unrealistic! The "always" part was not something most gay men practiced. Still, the efforts to eroticize safer sex, and the sheer terror many men felt about the possibility of contracting HIV infection, led to falling rates of sexually transmitted diseases and new HIV infections among gay men. With better treatments for those with the HIV infection being developed, AIDS went off many people's radar screens as a mortal threat. But those of us still working in the gay community and with people with HIV and AIDS have been watching with growing alarm as another trend began a few years ago, a trend that eroticizes unsafe sex among gay men.
In the past five years, there have been more reports of men who were too young to witness the horrors and devastation of the first AIDS epidemic now starting to engage in anal sex intentionally without condoms, a practice called "barebacking." Some blamed the change in funding--less state and federal money was designated toward prevention campaigns in the 1990s. Some blamed gay culture, or male hormones, which leads some men to take mortal risks for the sake of sexual pleasure. The fact is that epidemiological reports show that rates of sexually transmitted diseases and new HIV infection among gay men are now rising. The alarming trend of barebacking is not simply that gay men are having anal sex without condoms, but that they are doing so intentionally. Some gay men have had unprotected sex as a result of poor planning, or "relapse" into risk after consistent condom use, or condoms break and they have unsafe sex by accident. In my therapy practice in Manhattan's Chelsea neighborhood, issues related to unprotected sex come up regularly with individual gay men and male couple clients. As a long-term survivor with HIV myself, I have absolutely no romanticization of HIV or AIDS. I watched hundreds of close friends, ex-lovers, neighbors and acquaintances die terrible deaths from this disease. So when my clients calmly describe their decision to have high-risk sex, part of me wants to shake them and yell, "Don't!" As therapists, it is crucial that we do not let our own feelings about the behavior impair our ability to work with these sexual risk-takers in a way that allows them to explore why they are taking these risks and what these particular behaviors mean to them.
I understand the desire to believe AIDS is neutralized and no longer a threat to us. We all would like to be able to have the kind of unbridled erotic expressions we had before AIDS. Frankly, many gay men are somewhat burned out on safer-sex. And my clients have heard about long-term survivors like me who are still here by the grace of luck, good habits and combination HIV antiretroviral therapy. The new drug therapies give gay men a sense of complacency--even if they get HIV, it doesn't (necessarily) mean a death sentence. At least, not right away, right? For the young, who still believe in their immortality, this kind of logic is not so far-fetched. In the early days of the AIDS epidemic, fear propelled men to change how they had sex. Everywhere you looked, there was a gay man dying of AIDS, another memorial service to attend, pages and pages of obituaries to scan for familiar names. Today, thanks to highly active antiretroviral therapy (HAART) and improved prophylaxis along with weight training in combination with testosterone, human growth hormone, and steroids, people with HIV and AIDS are often imposing, muscled hunks despite being infected with HIV. Without visual reminders, even intelligent men who are well-informed about HIV and how it is transmitted are more likely to take sexual risks.
One afternoon, I sat with my client, Roberto, a 29 year-old attorney, who was describing to me his logic about why he sometimes does not use a condom: "I know intellectually this is wrong, but today AIDS just doesn't seem to be a big deal. I hear from my gay uncle who's in his fifties that in the early days of the epidemic it was pretty common to see prematurely aged gay men in wheel chairs, or 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. I guess this contributes to why I'm not as afraid of getting HIV as I should be, and why I am not always careful, sexually."
We can't just blame the barebacking movement on youthful delusions of immortality or lack of historical memory about the AIDS pandemic, because it's not just young gay men who are engaging in high risk sex. Increasingly, I am listening to male couples who are clients talk about emotional intimacy and vulnerability, and sexuality intimacy and vulnerability. Joe was a 30-year-old, HIV-negative Italian American gay man who originally entered therapy to deal with issues around growing up with an alcoholic and violent father. He had a history of depression that was largely controlled by antidepressants. In the third year of treatment he courted and then began a relationship with Arthur, a prominent and affluent health care professional within the gay community who was fourteen years older than Joe. On their first date, Arthur shared that he was an HIV-positive, long-term non-progressor. Joe was not concerned about contracting the HIV virus, since they agreed about what precautions they would take sexually.
The relationship was problematic from the beginning. Joe felt that Arthur was never as invested in the relationship as he was, and Joe felt that he was much more in love with Arthur than Arthur was with him. This made him feel insecure and sad, especially since he considered Arthur to be a "catch." Arthur was still mourning the death of his lover from AIDS three years earlier, and wasn't emotionally available to Joe in ways Joe wanted him to be. About six months into the relationship, Joe came to therapy and reported that the previous night, while he was the "top" during anal intercourse, he had taken off the condom and continued to have sex with Arthur until they both reached orgasm. Afterward, both men felt excited as well as concerned. They both knew the "top" was not completely free of risk in unprotected anal intercourse with an HIV-positive man, even when the receptive partner's viral loads were beneath the level of detectability.
My first and immediate thought was "You idiot! How could you be so stupid?!" Joe was one of those patients who worked hard in therapy, and whose life was continuously changing as a direct result of the work he was doing on himself. I really liked him and admired the work he was doing. I recognized my own strong, positive transference toward him--affectionate and somewhat paternal--and knew that I had to work extra hard to monitor my reactions. Having lived with HIV for more than 25 years, I had strong opinion about the risk he had taken. The last thing I wanted was for anyone--especially a favorite patient--to become infected. But as Joe's therapist, I had a responsibility not to share my strong negative feelings, which might shut Joe down from discussing this further. So I maintained a neutral facade and encouraged him to say more about what the experience meant to him. Joe said that in addition to the improved sensation that not using a condom provided, it made him feel more spontaneous. But then he described how he had thoroughly prepared for the "spontaneous" experience by first researching available medical literature about the risk he was planning on taking. Despite finding a few medical journal articles that reported the presence of HIV in the semen of HIV-positive men with undetectable levels in their blood, he determined that barebacking with Arthur would be low-risk to him.
I guess that Joe knew I might have a negative reaction to the idea of him engaging in high-risk sex with an HIV-positive partner. I reflected to him that he had obviously been thinking about this enough to do the research, and told him I was curious about why he had never discussed it in therapy. He said he felt ashamed and embarrassed about wanting to have unprotected sex, and worried about how I would react. I reflected back to him it seemed as if he might be projecting his own ambivalence about having unsafe sex onto me. He agreed, and said that he had not actually planned on having condomless sex right away. He didn't discuss it with Arthur before removing the condom. It was, Joe explained, an impulsive behavior.
I suspected that Joe's desire to stop using condoms with Arthur had a lot to do with the way their relationship was going. With their uneven emotional investment, the relationship was rocky, and they had once split up during a weekend trip, later getting back together. Joe used a lot of his therapy time to talk about his sadness and frustration that Arthur was not returning his love in the same measure as Joe's love for him.
A few weeks later, Joe sat down in his usual chair in my office and was visibly agitated. When I asked him what was going on, he said that over the weekend, he had been having sex with Arthur. This time, Arthur was the top, and at one point Joe asked him to remove the condom. Arthur did, although he withdrew before orgasm. Again, I felt my heartbeat quicken, and I had to quell my impulse to shake Joe and tell him to stop taking risks with his life. Instead, I asked him why he had asked Arthur to remove his condom. "I thought that if Arthur took off the condom, it would feel better, and I would feel closer to him." I asked Joe if he thought this act had brought them closer together. Joe said he did. "We both felt so nervous, but we both thought it was incredibly hot!"
Using Joe's statement that barebacking would help him feel closer to Arthur, I started to work with Joe on the connection between sexual intimacy and emotional intimacy. Joe began to cry as he admitted feeling desperate about wanting to make the relationship work. He felt he had to take extreme measures to get Arthur to stay with him. And yet, even risking his life was not enough. Arthur was still reluctant to let the relationship deepen. He had no interest in having Joe move into his spacious apartment, despite the fact that Joe had spent almost every night there for more than eighteen months.
As tensions with Arthur escalated, Joe became depressed. They continued to have unprotected anal sex, with Arthur withdrawing prior to orgasm. Joe became more and more agitated. He got tested for HIV, which confirmed that he was still uninfected. Then he called me for an emergency session. Instead of feeling relieved about being HIV negative, Joe said, he felt even more despondent and desperate. He said that no matter what he did to try to please Arthur, he always wound up feeling the way he did as a child when his father was drinking and became emotionally unavailable to him. Joe recognized that part of his attraction to Arthur had been his fantasy of having an older, attractive man take care of him and love him in a way that he had never experienced from his father. He realized now that this would never happen. I asked him what he thought the solution was? Without skipping a beat, he said: "I need to get out of this before I do something even crazier than I have been doing." I couldn't let him see how delighted I felt inside. I had been worrying about him for weeks.
Having made the connection between his need for his father and his yearning for Arthur, Joe was able to talk about his feelings about unsafe sex in a deeper way. He described how every time he and Arthur had unprotected sex, he felt badly about himself and worse about the relationship. He was angry that Arthur had gone along with his suggestions to dispense with condoms, as if it had been a test, and Arthur had failed. By the following session, Joe had ended the relationship with Arthur. Though sad, Arthur was not greatly distressed, and did not try to convince Joe to reconsider. This confirmed Joe's confidence in his decision. Within a week of the break-up, Joe's depression began to lift.
Male couples living in the age of AIDS need to balance different desires, sexual tastes and levels of comfort regarding what sexual risk-taking, if any, is acceptable. How these issues are raised, discussed and negotiated are indications of the emotional climate created in the couple's daily interactions and shared emotional life. Research confirms that both HIV-concordant and HIV-discordant male couples are having unprotected sex . Men in HIV- concordant relationships reported significantly higher rates of unprotected anal intercourse than discordant couples, according to a 1997 study by C. Hoff et al in the Journal of AIDS and Human Retrovirology.
Therapists can't assume their gay couple clients are practicing safer sex. Because this may be an area fraught with shame and even denial at times, we have to ask the question in a neutral way and then help our clients explore how they arrived at their decision and how each feels about the level of sexual safety they practice. I use this conversation also as a way to illuminate the dynamics of their communication styles as well as issues related to power, control and emotional safety.
Frank and Jesus, both HIV-negative, sought therapy because of tensions that had arisen about using condoms for anal sex. Frank was a 35-year-old WASP, well-educated and employed as a teacher at a private school. Jesus was a 23-year-old Puerto Rican immigrant who was employed as a dishwasher in a diner. They met while Frank was on holiday in Puerto Rico and they fell in love. Jesus relocated to New York so they could be together. Before meeting Jesus, Frank had never had unprotected anal intercourse. Now together in a monogamous relationships, they had gone together to be re-tested for HIV infection and both tested negative. The problem they were experiencing was around how much risk they each felt willing to take, sexually, in their relationship. Jesus repeatedly asked Frank not to use a condom, and despite not being completely comfortable about it, Frank complied. But Frank insisted that Jesus wear a condom when topping him. At times, when Frank decided he wanted to use a condom when topping Jesus, Jesus became upset. Jesus told me, "Since neither of us is supposedly having sex with anyone else, when he wears a condom I wonder who else he has been messing around with. I think that he must not want to give me a disease that he got from another guy."
Frank explained his way of thinking about monogamy, Jesus and condoms: "It's because I love him so much that I want to use a condom." He addressed Jesus, "I hate it that every time I decide to use a condom, you freak out thinking that I'm cheating on you. Even though I trust you, it's so early in our relationship that it's hard for me to accept that you trust me enough for me to not put on a rubber." Frank said he needed Jesus to wear a condom, even though he believed that Jesus had been "faithful."
Two themes emerged that were intimately related to condom use: defining the relationship, and power. Jesus and Frank had different understandings of where the relationship was, developmentally. Having given up his life in Puerto Rico to move to New York to be with Frank, Jesus felt ready to have a commitment ceremony, and thought of them as already married. When Frank heard this, he responded: "But honey, we've only been living together for three months! We're still getting to know each other. I feel that it's way too soon to consider us married. We are definitely moving in that direction. Once we're both sure about the relationship as we can be, I'll probably be ready for both of us to stop using condoms. But up until then, please try to relax about this."
In response, Jesus told Frank that being told he had to wear a condom even though Frank had made love to him with a condom played up all the power inequalities in their relationship. Frank was white; Jesus was a man of color. Frank was older, better-educated and financially secure from both his job and family money. Jesus had not been to college, came from a poor family and earned considerably less money than Frank. In addition, Frank was a native of New York, and a native English speaker, while Jesus was an immigrant and English was his second language. Jesus had only one other friend in New York, and felt dependent on Frank socially and emotionally, which made him feel extremely vulnerable. They lived in an apartment that Frank owned. Most of the things in their home were Frank's.
I admired Jesus for his courage in raising these issues. I've seen gay couples stew in silence about power differences for years
and years, to the detriment of the relationship. I congratulated Jesus on his ability to see their condom disagreement in this
larger context. Frank was also visibly relieved to have these matters on the table for discussion. Each admitted to having
spent time thinking about all of these things independently. Hearing and exploring each other's feelings about power and
intimacy and trust took weeks of therapy, and they both felt it strengthened the emotional foundation of their relationship.
Instead of putting all in terms of sexual trust, they could start to talk about emotional trust. Although Jesus was hurt that
Frank did not think of them as married, he said he believed Frank did have the goal of being in a long-term, committed,
monogamous relationship with him. Believing they shared the same relationship goal allowed them to begin discussions
about ways that the power and control inequalities could be addressed. They explored how to restructure decision-making
about household chores, spending money, socializing and even what language to speak, since both were bilingual. These
conversations led to Jesus saying he would try not to make an issue of Frank's condom use. At their last session, Jesus told
me: "I guess that when Frank stops using a condom, it will be alright for me to stop using them also, and that will mean that
our relationship has really moved to the next level."
Is it irresponsible for therapists to help gay men negotiate arrangements to have unsafe sex? I don't believe it is. Our role is to
make sure individuals have all the information available so that they can make informed choices for themselves. Sometimes,
as in the case with Joe, we help them look at their own motivation to take such a significant step. Other times, we help them
look at what emotional connection they are yearning for, and that they believe sex without condoms will achieve. I have
observed in my practice that despite knowing the risks of certain sexual behaviors, some gay men consciously prefer to
prioritize pleasure over possible longevity. Despite my personal opinion about this, I believe that the essence of good
psychotherapy is to provide each individual with the opportunity to deeply explore all of his or her feelings and motivations
about this position in a nonjudgemental environment. I remember the days when AIDS service organizations refused to
provide any services to intravenous drug users unless they were either in a methadone program or abstinence-based program.
It was this rigidity that led to many active drug users not receiving AIDS prevention, education and treatment services until
proponents of harm reduction began to advocate for changes in this area. Even if I completely disagreed with the decisions
my clients made about unsafe sex, what can I do to stop them? During therapy, am I to engage in a paternalistic power
struggle with men wrestling with these choices? Or show my disapproval by cutting them off and stopping treatment? I don't
think so!
Love is one of the most complicated factors motivating individuals not to have safer sex. Lust can make people do some seemingly irrational things, but when it comes to irrational behavior, nothing compares to love. For some people, love can be a healthy and empowering force. For others, it is part of the intrapsychic and interpersonal mix resulting in unhealthy loss of autonomous sense of self. Many people, across the spectrum of mental and emotional health, find that love is the organizing principle of their personality and self-concept. For these 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. As in the case of Joe, high-risk sex may be an attempt, conscious or unconscious, to make someone love them.
"Is love, in fact, self-sacrifice," asked actor Charles Ludlam, "or is there another way of expressing love?" Though he was not speaking about sexual risk-taking, this question is one that therapists working with people who have unsafe or unprotected sex, even within a committed relationship, would do well to ponder.
Michael Shernoff, M.S.W., is in private practice in Manhattan, is adjunct faculty at Columbia University School of Social
Work and is contributing editor to this magazine. He can be reached via his web site www.gaypsychotherapy.com
Key Words: Gay men, male couples, unsafe sex, high risk sex, condoms, barebacking, HIV, AIDS, psychotherapy, counseling, gay male sexuality, condomless sex,