During the 1980s I coauthored one of the first efforts to help gay men eroticize safer sex. This sex-positive approach to stopping the sexual transmission of HIV combined with other efforts was so successful that, for many years, rates of sexually transmitted diseases, new HIV infections, and terror regarding the possibility of contracting HIV drastically fell among gay men.
For the past several years, epidemiological reports have shown that rates of new infections of syphilis as well as HIV are again on the rise among gay men, especially among gay men of color. 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. Thus men are not always as careful sexually as they know they should be.
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. “No gay man grows up immune to the insidious and overt messages that his sexual desire is in itself fundamentally wrong and unacceptable”(2002).
Today, many gay men experience safer sex overload or burnout. New drug therapies provide gay men a false sense of complacency, with many believing that if they contract HIV, it doesn’t necessarily mean a death sentence. For the young–who still believe in their immortality–this logic is not far-fetched. In the early days of the AIDS epidemic, fear propelled men to change how they had sex. Everywhere one looked was a gay man dying of AIDS, another memorial service to attend, and pages of obituaries to scan for familiar names.
Today, thanks to highly active antiretroviral therapy (HAART) and improved prophylaxis–along with weight training combined with testosterone, human growth hormone, and steroids–people with HIV and AIDS are often imposing, muscled hunks. Without visual reminders, intelligent men who are well-informed about HIV and how it is transmitted are more likely to take sexual risks.
For example, my client 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.”
Noted gay 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.” As therapists, it is our task to help the client articulate the particular meanings of his high-risk behaviors. It would be simplistic to adduce a single issue or dynamic as the “reason” for an individual’s engagement in unsafe sex. Usually a complex combination of factors underlies such behavior–some which are understandable and adaptive for that particular individual.
Many committed male couples regularly have condomless sex. Men in mutually monogamous, HIV-negative concordant relationships are not at high risk for transmission of HIV if they have sex only with each other–even if they have unprotected anal intercourse. These men obviously trust each other to sustain sexual fidelity. “They do not refer to this activity as barebacking or unsafe sex,” says Blechner. “If there is no virus or other pathogen to transmit, the sex is not unsafe” (2002). Yet, therapists working with HIV-negative male couples must keep in mind the potential fragility of negotiations among nonmonogamous partners and the fact that monogamy may not be permanent.
Some therapists struggle with the reason that gay men find it so important to stop using condoms. Take, for example, Michael and Burt, an HIV-negative couple in their mid-30s that recently bought an apartment together. They come to couples therapy because they want to stop using condoms. Monogamous for the past two years, both retested negative for HIV in the past two weeks.
Michael and Burt say they are excited by thoughts of condomless sex, but neither has ever experienced it. Both believe that being in a sexually exclusive relationship with a man he loves should provide the perfect opportunity to expand sexual boundaries.
In fact, Michael says one of the biggest reasons he sought a monogamous relationship with another HIV-negative man was so that they could forget about safe sex. Adds Burt: “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.”
When working with HIV-negative male couples, many AIDS educators and therapists introduce a concept known as negotiated safety, developed in Australia in the 1980s. The basis is an explicit understanding that both partners know each other’s uninfected HIV status. The only time they forego condoms is when they have sex with each other, making this an acceptable safer sex option. Unprotected sex outside the relationship is forbidden; if either partner engages in unprotected sex, 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 remains HIV-negative.
A British Web site (http://www.freedoms.org.uk/advice/air/air07.htm)
features a sample negotiated safety agreement that can be downloaded and offered to clients. I often suggest that couples visit this site and complete the written exercises to help facilitate discussions about whether they are ready to incorporate negotiated safety into their relationship.
Men in HIV-negative seroconcordant relationships are not the only ones who have high-risk sex. Men in mixed antibody-status relationships perceive the risk to be an expression of intimacy, closeness, love, and commitment. Often it is the uninfected partner who pushes for increased levels of sexual risk-taking. Some HIV-positive men in committed relationships with other infected men also choose unprotected sex. “Since we are each undetectable [for HIV antibodies], there is no way we can test to see whether we have the same strain of the virus,” explains one of my clients.
Some of these behaviors may make the therapist uncomfortable, especially if he has made different sexual decisions for himself. Many therapists, gay or not, pass judgment on sexual practices that are frowned upon by the culture-at-large–anal sex, open relationships, “kinky” sex , condomless anal sex, and group sex. This judgment or uneasiness creates a problem because a certain comfort level in discussing these topics is essential to effective therapeutic intervention. It is incumbent upon the therapist to create a treatment environment in which the client feels safe to broach any form of sexual behavior; otherwise, discussion of the crucial issues of autonomy, forbidden desire, sexual self-confidence, and interpersonal intimacy will almost certainly be hamstrung from the onset, if not foreclosed.
Clinician squeamishness is not only inappropriate and unprofessional, but also is likely to be radically detrimental to the client as well as sabotage treatment. If a therapist is unable to withhold judgment in this highly charged realm, the odds are good that the client will stop treatment with that therapist. Gay men are often appropriately hypersensitive to indications of negative feelings about their sexual practices and desires, even from an openly gay therapist. A judgmental therapist 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 not only to become open-minded but comfortable about sexual-preference choices that may be alien to his own experience, social world, and ethical system.
Gay male therapists face a particular challenge: 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 to handle these issues in his own life. Listening to people describe behaviors that can spread a potentially deadly illness such as 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 judgments 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 control their own strong emotional reactions. In this situation, seasoned clinicians can benefit from paid or peer supervision.
When gay men have unsafe sex in response to depression, loneliness, isolation, a nihilist malaise, or in conjunction with the use of substances, treating these conditions is an essential prerequisite. However, when underlying conditions improve in response to psychotherapy and psychopharmacologic interventions, unsafe sexual behaviors may not necessarily diminish or cease. If therapists gauge clinical success solely on the basis of clients stopping unsafe sex, they are setting unrealistic goals for themselves and clients. Initially, it may seem counterintuitive that no single, obvious therapeutic goal exists for working with men who are not having safer sex.
It is important to differentiate between not having safer sex and having sex that places the individual at risk for transmitting HIV. The therapist must help each client evaluate whether or not having safer sex is adaptive for the client, even if the therapist strongly differs with the position. Despite knowing the risks of certain sexual behaviors, some individuals consciously prioritize pleasure over possible longevity.
Blechner, M. (2002). Intimacy, pleasure, risk and safety: Discussion of Cheuvront’s high risk sexual behavior in the treatment of HIV-negative patients. Journal of Gay and Lesbian Psychotherapy, 6(3), 27-34.
Cheuvront, JP, (2002). High-risk sexual behavior in the treatment of HIV-negative patients. Journal of Gay and Lesbian Psychotherapy, 6(3), 7-26.
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.
Savage, D. (1999). The thrill of living dangerously. Out Magazine, March, 62-64.
Category: AIDS/HIV Articles