An excerpt from Without Condoms: Unprotected Sex, Gay Men & Barebacking
Routledge, 2006.
"The terrible thing in this world is that everyone has his reasons."
Octave, The Rules of the Game, Jean Renoir, 1939
Toby, a Passive Barebacker
Without Condoms: Unprotected Sex, Gay Men & Barebacking, by Michael Shernoff
Toby is a white, 35-year-old, HIV-negative gay man who came to see me because of depression and loneliness. A successful and ambitious architect, he worked exceptionally long hours to make partner in his firm. His last relationship ended during his final year of graduate school, after 2 years, and he had not had another partner in almost 10 years. Because of his intense focus on work, Toby had not taken the time to cultivate deep friendships. He did have a group of people with whom he would go to clubs to dance a few times a month. Typically, during those outings, he would take MDMA (Ecstasy) and smoke marijuana. He said it helped him lose his inhibitions and cut loose on the dance floor. At the end of the night he would usually end up going home with someone he had just met.
Toby did not seek out barebacking, but he allowed it to happen if the other man wanted to do it. He said he never discussed HIV status with the men he went home with unless the other man initiated the discussion. If a sexual partner initiated the use of condoms for anal sex, Toby said he felt relieved and gladly used them. But if the other man did not bring up the topic, Toby wound up going along with whatever the other man wanted to do sexually, even if it meant having UAI. Toby almost never made a date to see any of these men a second time. Toby was sexually versatile but preferred to be the top.
On the weekends when Toby stayed home, he either met men in online chat rooms for sexual hookups or went to sex parties. Again, his attitude toward condom use was passive. If the other man wanted to use them, that was fine with him. But if the other fellow never brought up the topic of condoms, neither did Toby. It was clear that he was well informed about HIV transmission and about the risk he took of becoming infected by barebacking. When I explored this passivity toward using condoms, he explained that he worked such long hours and so intensely that when he did have time off it was essential that he be able to stop thinking and just go a bit wild and lose control. Ostrow and Shelby (2000) describe psychotherapy with men like Toby who use drugs to enable them to lose inhibitions and engage in fantasy sex that they might otherwise have difficulty engaging in without guilt or remorse.
Toby was an only child raised in the Midwest by a devout Baptist single mother who had been deserted by Toby's father shortly after Toby's birth. Toby came out to his mother after he finished graduate school and moved to New York. She did not react well to the news, retreating into the condemning language of her church. She told her son that being a homosexual was going to land him in hell unless he repented and changed his ways. She also told him that he was going to get AIDS because he was gay. Toby sounded bleak when he described the Christian literature she regularly sent him about the evils of homosexuality and how gays were being plagued by AIDS as punishment from God.
I asked Toby what he thought about his mother's views of his sexuality. He said he was frightened -- what if what she said was true? -- and sad that their relationship has become so combative. He said she was relentless about sharing her views on Toby's "sinful affliction," even after Toby asked her not to raise this subject every time they spoke. I was surprised to hear that he continued to speak with her once a week and to visit with her for a week at Christmas. We explored his conflicted feelings about his relationship with his mother. On the one hand, he recognized that the way his mother treats him was damaging to his self-esteem and was deeply painful. On the other hand, as the only child whom she struggled to raise, he felt a strong sense of loyalty and obligation to her.
I shared with Toby my concern that his barebacking activity was putting him at risk for fulfilling his mother's prophecy that he would get AIDS. He said he worried about it at times, and he had no conscious desire to contract HIV, but he was not willing to kill (his exact expression) the spontaneity of his recreational sexual exploits. In the rest of his life, he was responsible and reliable. In this one area of his life, he wanted to be totally free. I wondered if Toby's behavior was an unconscious desire either to prove his mother right or to get sick and die as a hostile "fuck you" to his mother. I did not begin to share any of these possibilities with Toby until many months after our initial consultation. Every few months Toby would get retested for HIV, and as of this writing he remains HIV-negative.
Fifteen or 20 years ago, I would have been appalled and quite judgmental about Toby's behavior and probably gone into overdrive to try to save Toby from his own impulses. With the advantage of 20/20 hindsight, it is now clear that the rescue approach to treating men who bareback is rarely, if ever, effective. Most of the time, these clients just stopped therapy with me. They did not want or need a rescuer, as well-intentioned as I was. Although it still hurt to hear Toby describe the potentially deadly risks he was taking, I had to practice patience, compassion, and empathy. He was the only one who could take himself out of these high-risk situations, and then only if and when he decided that he wanted to.
Along with my protective feelings for this young man, I felt clinical curiosity about what was driving Toby to take sexual risks with such an apparently casual attitude. Researchers have been eager to find out more about the category of barebackers that Toby falls into -- men who are not trying, at least consciously, to become infected with HIV, but who are willing to take risks in order to satisfy deep intrapsychic and interpersonal needs.
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Factors That Lead to Sexual Risk-Taking
There are numerous theories for why gay men engage in unprotected sex, and research has explored a wide variety of possible rationales for the behavior. These include:
Negative attitudes toward condom use (Odets, 1994; Flowers, Smith, Sheeran, & Beail, 1997; Hays, Kegeles, & Coates, 1997; Kelly & Kalichman, 1998; Van de Ven et al., 1998a; b; Appleby, Miller, & Rothspan, 1999)
How being in a committed compared to a noncommitted couple relationship affects whether a condom is used (Elford Bolding McGuire & Sher, 2001; Vincke, Bolton, & DeVleeschouwer, 2001)
Strongly identifying with or feeling alienated from the gay community (Hospers & Kok, 1995; Hays et al., 1997; Seal et al., 2000)
Internalized homophobia (Meyer & Dean, 1998; Canin, Dolcini, & Adler, 1999)
A sense of the inevitability of becoming infected with HIV as a gay man (Kelly et al., 1990; Kalichman, Kelly, & Rompa, 1997)
The effects of substance use (Stall, McKusick, Wiley, Coates, & Ostrow, 1986; Stall, Paul, Barrett, Crosby, & Bein, 1991; Leigh & Stall, 1993; Stall & Leigh, 1994; Hospers & Kok, 1995; Woody et al., 1999; Royce, Sena, Cates, & Cohen, 1997; Chesney, Barrett, & Stall, 1998; Ostrow & Shelby, 2000; Halkitis, Parsons, & Stirratt, 2001, Halkitis et al., 2003; Halkitis & Parsons, 2002; Kalichman & Weinhardt, 2001).
There are probably a multitude of other issues at play as well. As psychologist and former researcher at the CDC Ron Stall was quoted as saying in an article in the Manhattan gay newspaper Gay City News, "There are studies that demonstrate a variety of psychosocial health issues, including depression, antigay violence, childhood sexual abuse, or substance abuse, can lead gay men to have unsafe sex" (Stall, quoted in Osborne, 2002, p. 1). In my own practice, I have identified several factors that appear to lead to sexual risk-taking: loneliness, being HIV-positive, having unmet intimacy needs, feeling alienated from the gay community, being in love, and a craving for deeper intimacy and trust.
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Barebacking as an Example of "Sensation-Seeking"
Again and again, we return to the poignant question of why a person would put his life in jeopardy for pleasure. Sex is a source of pleasure that encompasses biological, psychological, and sociological realities (Reiss, 1989). Sex is not only about pleasure. It can be about belonging, feeling desired, desiring semen, organizing one's life, and providing meanings to one's life. "People have sexual relations for a variety of reasons: for love and intimacy, for recreation, for fun, for friendship, for money, to avoid loneliness, to be touched. The essence of sexual encounters is bonding, blending, mutual pleasure, and loss of inhibition. HIV lurking in the background places strict boundaries on all of these aspects of sexuality" (Coates, 2005, p. xiv). The equation for evaluating how the benefits of barebacking weigh against the inherent risks is not simple. Tim Dean (2000) writes: "Most people can't comprehend why anyone would risk death for a good fuck. From a certain viewpoint, unsafe sex appears as inconceivably self-destructive behavior. Indeed, while such health-threatening practices as smoking, drinking, and drug abuse must be indulged in repeatedly over a substantial period before they are likely to cause harm, HIV infection can result from a single unprotected encounter. Casual, anonymous sex without a condom seems suicidal" (p. 139). But the long-term effects of HIV infection on health are easily denied when faced with the immediacy of sexual pleasure, particularly if one is using drugs that fog one's judgment.
One lens through which decisions to bareback need to be viewed is the role of pleasure and how the search for erotic pleasure is intimately related to desire. For one thing, sex without condoms feels much better and is vastly more spontaneous than having to stop the action, unwrap a condom, and properly put one on. Many gay men are articulate about how thrilling and intimate it is to the feel of the warmth of a lover's unsheathed penis and the smooth stimulation of skin against skin. Carballo-Dieguez interviewed a small sample of men who identify as barebackers. One man told Carballo-Dieguez (2001, p. 229):
The pleasure I feel when I'm having sex, especially if I'm stoned, is so amazing. ... Passion does not call for protection in my mind. Passion is a very raw emotion. ... It is not easy to feel real passion, because there are so many barriers put up and so many acts that people have in themselves that they want to express during sex, that protection does not fit in the fantasy.
Much as we try to eroticize safer sex, there is no way around the fact that condoms both decrease the sensation of anal intercourse and interrupt the spontaneity of the sexual act. Sexual fulfillment "encompasses a range of physical, emotional, and psychological factors including, but not limited to, physical pleasure and release, emotional intimacy and security, enhanced self-esteem, and actualized sexual identity. These are all highly valued, immediate benefits of sexual expression (in contrast to the distant, rather ethereal threat of contracting AIDS)" (Pinkerton & Abramson, 1992, p. 565). As previously discussed, recreational sex has been identified by at least certain segments of the gay male community as a means of personal fulfillment and an expression of enhanced freedom and self-esteem. An active sex life is seen as a indication of attractiveness and vitality. A gay man who wants to feel liberated, hot, or sexy might view sex without condoms as the best route to fulfilling his desire to feel any of those ways.
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Barebacking to Feel in Control
Whether or not a man is making a rational choice when he decides to bareback is often difficult for others to assess, even psychotherapists who must contend with their own judgments and feelings about this particular highly charged, high-risk behavior. But for barebackers who are neither actively nor passively suicidal, there is an internal logic that makes sense to them, especially when the behavior occurs within specific contexts. For example, one rationalization for engaging in unsafe sex is the belief that having an HIV infection will alleviate their worry about becoming infected. This dynamic was first reported by psychologist Walt Odets (1994), when he described men who felt that they were not destined to survive the epidemic and therefore had no motivation or reason to practice safer sex. Odets writes that many survivors of the epidemic have a sense of the inevitability of their "catching AIDS." One example of this was my client Jeff, a 44-year-old, Jewish, HIV-negative man who enjoyed dancing at New York clubs and going to an occasional circuit party. Since he almost never used condoms but made every effort to limit his sexual partners to other uninfected men he met, he decided to have "HIV-" tattooed on his left arm since he disliked the necessity of asking about HIV status. Immediately after getting himself tattooed he discussed his feeling that it was only a matter of time until he eventually got infected. "When it happens I can just have the vertical bar added to my tattoo so it will accurately read "HIV+," he told me, pleased with his strategy.
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Semen Exchange and Emotional Connection
Vincke and colleagues (2001) found that "the incorporation of semen is an important value for many in gay cultures, a means of showing devotion, belonging, and oneness. Unsafe sex can therefore be an expression of positive values and of good feelings" (p. 58). There is something deeply erotic, profoundly connecting and, some feel, even sacred about one person giving his most private and special fluid, semen, to the other as a gift of love and a symbolic joining of two souls. The many levels of meaning and special significance that giving and receiving of semen has for gay men cannot be underestimated as a contributing factor to the rise in barebacking -- especially in romantic couples, as will be examined in Section 2 of this book. Early in the second decade of the AIDS epidemic Odets wrote, "Now that a decade of prohibition has made semen exchange relatively unusual and 'special,' it has become all the more powerful and meaningful" (Odets, 1994, p. 432). Obviously, what it means to give or receive semen varies from one gay man to another. Some have described drinking semen as literally ingesting the vitality, strength, manliness, or very essence of the man whose semen they either drank or received anally. There are men who feel that sharing their own or receiving the semen of a lover is a visceral as well as symbolic gift of love or a spiritual communion. There are those who revel in experiencing the esthetic and sensual pleasures in giving or receiving semen. By no means is this a comprehensive list. The meaning of sharing semen between two men is as varied as the men who engage in this act.
(-) Their findings showed evidence that much "cruising" behavior by men in public places that results in public sex is relatively low-risk because the sexual activity is usually limited to mutual masturbation or oral sex.
(-) "One possibility is that these men seek out sexual partners to alleviate depression. Another is that depression decreases self-esteem, leading these men to engage in sexual behavior that they might otherwise not find acceptable. Rather than driving away a potential sexual partner by trying to negotiate sexual behavior, these individuals may be willing to accept whatever sexual activities the partners want as a way of achieving relief from depression and isolation"
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The underlying question we have to grapple with is what risk-taking do we consider acceptable, healthy, and even laudable, and what risk-taking do we consider unhealthy and unacceptable? For instance, I am an experienced scuba diver with more than 30 years of diving experience. One of my passions is to dive among large ocean-going animals and I am thrilled when I sight sharks. This is obvious sensation-seeking behavior and potentially higher risk than a swim at the shore. Yet this pattern of behavior is far from impulsive, as each dive is carefully planned and done under the close supervision of experienced dive guides. Some might perhaps diagnose this passion of mine as pathological since inherent in it is the possibility of a potentially fatal shark attack. I think of it as a fun and exciting recreational activity that provides enormous pleasure and satisfaction that greatly enhances my life. There is an obvious parallel between my choice to scuba dive in places with a high likelihood of close encounters with potentially dangerous sea critters and men taking what for them are calculated sexual risks. Just because a behavior entails risks does not make it de facto pathological and self-destructive.
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Sex is more than actions and positions. Actions contain meanings stemming from relational and cultural values. Use of a condom, for example, may be associated with a negative message because refusing semen may be perceived to be a rejection with far-reaching emotional implications. Vincke and colleagues (2001) note that "considering that people are in search of meaning, sexual acts constitute an emotional and symbolic language. The meanings gay men assign to specific sexual acts can make behavioral change difficult" (p. 57).
(-) Mansergh et al. (2002) discuss that some men intentionally put themselves and/or others at risk of HIV and STDs to meet important human needs (e.g., physical stimulation, emotional connection). It is obvious, yet crucial to note, that most people who engage in sex are in pursuit of pleasure, though pleasure alone is often not the only reason why anyone may seek sexual encounters. As Blechner (2002) states: "If we problemize one extreme but not the other, we may lose perspectives on how decisions of risk-taking are made. Risk of HIV infection is serious. But the risk of loss of pleasure and intimacy is also serious (p. 30)."
(-) However, when risk-taking behavior is seen as situational, treatment provides a context for inquiry, articulation, and understanding of the patient's unique experiences, feelings, and circumstances" (p. 12). It is all too easy and reductionistic to pathologize sexual risk-takers as self-destructive, suicidal, damaged individuals. Cheuvront seems to agree, writing, "The popular media promote the HIV risk-taker as damaged and resigned to the inevitability of infection" (Cheuvront, 2002, p. 10).
Cheuvront (2002) reminds all mental health professionals working with gay men who bareback that "the meanings of sexual risk-taking are as varied as our patients" (p. 15). 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" (p. 15). It is the task of therapists to help an individual 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?" (p. 38)
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The rationales for barebacking are as numerous as the men who do it. I have often heard men who bareback as well as my colleagues in the mental health field question whether the behavior is indicative of some underlying mental disorder or at least of unrecognized internalized homophobia. While indeed for some barebackers either or both could be at play, I have also come to learn that, as some of the researchers cited above conclude, in certain situations for certain men what at first appears to be reckless and self-destructive may be adaptive, affirming, and understandable. If we take a step back from the highly fraught and emotionally charged particulars of this issue and attempt to separate what we think is the "right" way to act now that the sexual transmissibility of HIV is a known fact, from moral judgments about the behavior and people who do it, we can begin to understand why barebacking is not always as "crazy" as it may at first appear to be. There are no easy answers to why men bareback or how this tide can be stemmed or even whether it should be stemmed. But at least we can start to ask better questions and open a crucial dialogue.