Protease Dis-Inhibitors?

  The Gay Bareback Phenomenon
     
  Gay men's responses to the new therapies are vastly more complex than media portrayals based on a small sample of guys seeking "bareback sex" on the internet.

by Nicolas Sheon and Aaron Plant, Associate Producers, HIV InSite

Despite over a decade of HIV prevention campaigns targeted at the gay community, unprotected anal sex has occurred to some extent throughout the epidemic. The extent of risky behaviors is evident in the thousands of new infections that have occurred among gay men each year. Clearly such risks are not the result of ignorance about the risk of exposure to HIV. New infections are most often attributed in the literature to men "slipping up in the heat of the moment" or while under the influence of drugs or alcohol. Another reason rates of unprotected sex have remained fairly constant is that many seroconcordant couples choose to forgo condoms for sex within the relationship.

Recently, however, a small minority of both HIV-positive and negative men have begun to "consciously, willfully, and proudly" engage in unprotected anal sex. The new phenomenon, referred to as "raw", "skin-on-skin", or "bareback" sex may be linked to the perceived effectiveness of protease inhibitors and the promise of "morning after" exposure treatment. It is unclear how many men are engaging in such defiantly premeditated, risk behavior. Michelangelo Signorile suggests that the number is "small, but growing." While the issue of unprotected anal sex has always been a concern, recent media attention capitalizing on the sound bite allure of the term "barebacking," could potentially create a self-fulfilling media prophecy. Speaking of barebacking as if it were a new fad or fashion, Bruce McDonald claims the trend is "sweeping the country." Why has unprotected anal sex, a concern throughout the epidemic, suddenly become so hip that it merits press attention at this historical juncture? What does barebacking tell us about the effect of past HIV prevention efforts on community organizing? What does it tell us about the role of gay men in HIV prevention as we enter the third decade of the epidemic?

The notion that the new drugs may be contributing to a climate of sexual dis-inhibition became a media phenomenon last summer after Michelangelo Signorile's article "Bareback and Reckless" which appeared in the July issue of Out Magazine. Signorile recounts his chat room cruising with a man who claimed that "HIV is a very manageable disease." Thanks to the new drugs, even if he was infected, he would "probably not die from it." The following month, the New England Journal of Medicine published a letter suggesting that protease inhibitors have "altered the perception of risk" of contracting HIV for many gay men. Twenty-six percent of the men surveyed reported being "less concerned" about becoming HIV-positive because of the new treatments. Fifteen percent had already had unprotected anal sex because of their decreased concern.

These and other authors suggest that one possible rationale for barebacking is that the disease is now more "manageable" because of the drugs. This has lead some to speculate that changes in behavior are likely to occur as a result of the new therapies. According to Edward King, the new drugs have given some gay men "a reason ­ or simply an excuse ­ to abandon safer sex." However, the existence of such a rationale does not necessarily translate into changes in behavior. King goes on to add that "at the moment there's absolutely no firm evidence that this [abandonment of safer sex] is happening."

Dramatic reductions in viral load as a result of the new treatments could create new rationales for unprotected sex. Wishful thinking may lead some men to conclude that undetectable levels of virus in their blood is equivalent to being HIV negative. The new treatments have lead some men to conclude that the consequences of HIV infection for themselves or their negative partners have been minimized. Michael, webmaster of Xtreme'Sex , a barebacking web site, says that now HIV is merely a "minor inconvenience" and that it is "not the catastrophe negatives think it is." While there is agreement that the infectiousness is related to the level of viral activity, as measured in the blood plasma by the viral load test, the degree to which the new drugs affect levels of virus in semen requires further analysis.

A recent Newsweek article speculated that barebacking would also get a "big boost" from the media attention surrounding the new post-exposure prevention (PEP) program in San Francisco. PEP is often referred to as "morning after treatment." However, experts feel that likening PEP to emergency contraception is inappropriate because the therapy regimen lasts for several weeks, causes serious side effects, and can fail to prevent infection. Patients undergoing PEP must also cope with the uncertainty over the treatment's efficacy over many months of follow-up antibody testing.

John McCoy is not sure whether the increase in bareback discourse on the web reflects changes in actual behavior or just an improved climate for discussing a topic that has been so controversial. Walt Odets, a clinical psychologist, sees the alternating silence and media panic over anal sex as the result of the sex-negative culture prevailing in the United States. In such a homophobic culture, gay men develop what he refers to as a "mangled" identity after having internalized the homophobia of straight society. The drive toward self-destructive behaviors that Odets sees in his young gay male patients is not so much a lack of ethical stamina, but a symptom of gay men's problematic socialization process in a homophobic society. Eric Rofes, agreeing with Odets, argues that gay men's sex lives must be seen as a reaction to years of cumulative trauma. Rofes likens the effects of the AIDS epidemic to the numbing trauma of the Nazi holocaust or the bombing of Hiroshima/Nagasaki. While those disasters are over, AIDS continues to destroy yet another generation.

In this climate of loss, trauma, and societal homophobia, AIDS prevention efforts inevitably tend to silence discussions of anal sex as an act of sexual intimacy and pleasure. When risky behavior is discussed, it is often framed in terms of pathology ("relapse"), sin ("slipping up"), or even murder. The barebacking phenomenon can be seen as a reaction to prevention efforts which have failed to adequately address the complex meanings of sexual behavior in relation to the divergent identities that have developed around HIV serostatus. Moreover, prevention campaigns have not adequately addressed the different needs of negative and positive men. Odets argues that HIV prevention campaigns have been simplistic at best, and patronizingly absolutist at their worst. Gay men have been told to wear condoms "every time," as if such behaviors are sustainable over a lifetime. But what if one is already positive or doesn't care either way? Naturally, people find ways to rationalize behaviors that put their health at risk, whether the risk is fatty foods, smoking, or unprotected sex. Breaking the rules gives meaning to our actions and this quest for meaning has only intensified as a result of the AIDS epidemic.

History provides many examples of misguided attempts to regulate sexual behavior. The relationship between sexual behavior and identity is the topic of French philosopher, Michel Foucault's later works on The History of Sexuality. For example in his analysis of efforts to control childhood masturbation in the seventeenth century, Foucault shows how the experts' discourses on masturbation essentially created the problem they were ostensibly trying to eliminate. By teaching the children about forbidden acts, through stern lectures in the classroom or through hushed admonitions in the confession box, efforts to stop masturbation implanted the very desires they aimed to eradicate. For Foucault, gay identity would have been impossible were it not for the nineteenth century sexologists who first described "homosexuality" as something more than a behavior. The influence of Foucault's ideas on sexuality and community identity can be seen in the responses by queer academics to the politics of sex in the age of AIDS.

Ironically, the attention focused on anal sex as a risk activity has given it even more symbolic meaning as an act of profound intimacy or even rebellion. This problem is only compounded when the target population is one that already sees its identity as a community tied to a recently acquired sexual liberation. Gay men have traditionally been at the vanguard of sexual liberation and experimentation with new forms of human relationships. This experimentation has always existed under the threat of sanction from powerful institutions such as the police, the church, schools, and the family. Barebacking can thus be seen as merely the latest in a long line of challenges by gay men to the sexual status quo and the institutions which support it. Attempts to "manage desire," whether they originate from within or without the gay community, tend to produce "transgressive desire," a fetishizing of certain acts because they are dangerous, stigmatized, and emotionally charged. Thus the barebacking backlash appears to be particularly aimed at subverting AIDS prevention messages by fetishizing not just sex without condoms but the very "exchanges" of fluids that have been prohibited between gay men.

The barebacking phenomenon has been most extensively debated on the Web. The anonymity of the internet provides an ideal place to confess and discuss "forbidden desires," as well as find others who share them. Within the last few years, a number of chat rooms, mailing lists, and personal ads devoted to barebacking have allowed men to discuss, and occasionally act on, their desire for "raw" sex. Michael, web master of Xtreme'Sex, contends that his site primarily offers a place where HIV-positive men can meet up to have unprotected sex. In a typical personal ad, a man calling himself "SpecialFX" states he is looking for "real man sex. No condoms. No spermicide. No fucking water-based lubricants. Just hard cocks, assholes, fingers, fists, toys, Crisco, and as much cum as can be delivered. I'm in San Francisco & am looking for simpler things." The webmaster offers the disclaimer that his site does not advocate HIV-positive men infecting HIV-negative men "without consent." "PlowYouRaw," a participant in an Xtreme'Sex discussion group says, "safer sex is not real sex; it's pretend sex. The need for [the] intimacy of actual skin to skin contact is primal." His sentiments seem to reflect those of many other men on the site and elsewhere. But how men act on this feeling is still not well understood. Advocates of barebacking also stress the "manliness" of "real" sex, and the etymology of the term "barebacking" provides a wealth of macho rodeo imagery which is often contrasted with what can seem like a "fussy" and "complex" safer sex regimen.

The nickname, "PlowYouRaw," also points to the symbolic importance for many gay men of "planting their seed." Insemination and exchange of fluids are desires that AIDS prevention messages in general have shunned in their aseptic view of safer sex. For barebackers, the metaphor of planting seed is extended to its logical conclusion; some describe their desire to be inseminated with another's virus. One man from an on-line personal ad asks, "are you already poz, or do you want to convert?" A reply to another personal states, "Will let you fuck me raw only if you promise to give me all your diseases like AIDS/herpes etc. Let's do it..." In barebacking lingo, these men are referred to as "poz hungry" or "bug chasers." Some on-line barebackers refer to HIV as "the gift." Such "gift" exchanges and inseminations only make sense when seen as attempts to build communities based on a shared identity. In the case of barebackers, this identity is built not so much around being positive as around an opposition to what they see as puritanical and sex negative social institutions.

Advocates of barebacking offer many accounts for their risky behavior. Some argue that the "benefits" of unsafe sex outweigh the risks. Some men even see becoming infected as a positive development in their lives. As Jesse Green relates, in his New York Times Magazine profile of Marc Ebenhoch, a young ex-marine, struggling with alcoholism and his frustrated search for intimacy with other men,

"In a way it's a relief," he says, echoing a sentiment I have heard too frequently from newly infected men. "I don't have to wonder anymore. That awful waiting is gone. So now, if I do find someone, the relationship can be 100 percent real with nothing in the way. That's what I want: 100 percent natural, wholesome and real. Maybe now that I'm HIV -positive, I can finally have my life."

Men like Mark feel that being HIV-positive allows them to engage in unprotected sex free from risk and ethical quandaries of infecting a negative partner. Stephen Gendin offers the justification that scientists haven't proven that unprotected anal sex between HIV-positive men is unsafe. "With the risks so hazy, and the benefits so brilliantly clear", he says, "no wonder barebacking is all the rage." Nevertheless, experts argue that lack of scientific data is not a justification for risking reinfection with other strains. Stephen Follansbee of the Castro's Infectious Disease Medical Group suggests, "Until we understand what is protective immunity regarding HIV, it's cavalier to think 'once infected, never reinfected.'" Peter Cohen, editor of the AIDS Knowledge Base, points to the mounting evidence that AZT resistant strains can be transmitted as the compelling reason not to have unprotected sex with other positives.

Despite the optimism over the new treatments, not everyone can either afford or benefit from protease inhibitors. Those who have taken earlier antiretroviral treatments may have developed resistant strains of the virus. Edward King believes the "risk of reinfection with a drug resistant type of HIV is the most compelling reason" that HIV positive men should not engage in unprotected sex with one another. There is also the possibility multi-drug resistant strains of HIV developing. Finally, other STDs may be transmitted via unprotected sex that could be particularly devastating to someone with an immune system already compromised by HIV. However, for many positive men, putting their desire for unprotected sex on hold while waiting for research on viral reinfection to be funded and reach a definitive conclusion is no longer a viable option.

In light of this, the epidemiological ramifications of the bareback phenomenon for the gay community could be devastating. Recent CDC reports of an increased incidence of rectal Gonorrhea is pointed to by Gabriel Rotello who argues that a small "core group" engaging in unprotected anal sex could end up infecting "a whole other generation of gay men." For those within the gay and lesbian community who have devoted so much time and energy to fighting AIDS, the phenomenon of "bug chasers" and the bareback fetish are demoralizing. As Signorile concludes, "What looked like a bright and glorious future, an end to the epidemic, could easily turn into a disaster for all of us." Barebacking could affect future funding of HIV prevention. Signorile worries that once the behavior gets enough media attention, there will be a backlash from liberals and conservatives alike. Yet, no one has fanned the flames of media attention more than Signorile himself. Moreover, for the adherents of Sex Panic, a group of queer academics and journalists, the argument that gay men should behave more like married heterosexuals is rejected as assimilationism that works against community organizing.

It is important not to lose sight of the fact that alarmist media accounts from both sides of the HIV prevention debate are using anecdotal evidence to generalize about the feelings of all gay men. The media focus on a small group of positive men could backfire and contribute to the climate of fatalism. Rafael Diaz, of the Center for AIDS Prevention Studies, notes that the responses to the new therapies in his cohort of Latino gay men are vastly more complex than the account provided by gay journalists which are based on middle-class men who look for partners on the internet. He questions the dual assumption that the new drugs make men less worried about HIV and more willing to take risks. For example, Diaz notes that many Latino men are well informed about the limitations of the new therapies, suspicious of the long term toxicity of the drugs, and fearful that the new drugs will disrupt safer sex strategies that rely on seroconcordance.

The barebacking phenomenon is a symptom of a larger debate over the role of identity and desire in HIV prevention. It reflects a struggle for the hearts and minds of gay America that is causing serious rifts in this already divided community. For prevention workers, the lesson offered by the barebacking phenomenon is that gay men are not the dupes portrayed by the media. The barrage of contradictory headlines claiming that "AIDS is over" while barebacking is "sweeping the nation" must be analyzed in terms of their commercial appeal as sound-bites. Alarmist and reductionist perspectives on such a complex phenomena as barebacking must not be allowed to eclipse the role of prevention science and constructive, community-based discussion.

References and Links

 

 

Michelangelo Signorile, "Bareback and Reckless" from Life Outside : The Signorile Report on Gay Men


 

 

"Treatment Advances May Be Changing Perceptions of Risk" James W. Dilley, M.D., William J. Woods, Ph.D. William McFarland, M.D., Ph.D., M.P.H.


 

 

Edward King has published extensively on HIV Prevention and Gay Men and in particular what he terms the "DeGaying of AIDS." King is also a prolific web publisher. His articles appear on his personal AIDS Pages , the AIDS Treatment Update, the Mining Company AIDS Pages, and Positive Nation whence the above quotation was taken.


 

 

The following articles discuss the risks of viral reinfection:

Role of Viral Load in Heterosexual Transmission of Human Immunodeficiency Virus Type 1 by Blood Transfusion Recipients. by Eva A. Operskalski, et al. American Journal of Epidemiology, Oct. 97.

Effects of reverse transcriptase inhibitor therapy on the HIV-1 viral burden in semen. by B.L. Gilliam et al. Journal of Acquired Immune Deficiency Syndromes adn Human Retrovirology 1997 May 1, 15:1, 54-60.

Who's Afraid of Reinfection? Mark Schoofs, POZ May, 1997

Do New Drugs Affect HIV Prevention? Factsheet prepared by CAPS

What HIV Negative People Need to Know About New HIV Treatments FactSheet prepared by ACT UP Golden Gate

HIV Watch: Acting Cautiously is the Best Option by Lee Klosinski, Positive Living, Oct. 97

Do Drugs Reduce Infectiousness? by Edward King

HIV Prevention and the New Virology by Edward King

Safer Sex for HIV Positive Men, by Paul Ward, Positive Nation

Possible cross-infection between HIV+ couple response to a question by Rick Sowadsky, MSPH


 

Dr. Follansbee is quoted in "Positive and Unprotected" by Bill Strubbe. SF Weekly, July 9, 1997.


 

 

Green, J. (1996). Flirting With Suicide. New York Times Sunday Magazine (September 15, 1996) pp. 38ff.


 

 

"Riding Bareback Skin-on-skin sex been there, done that, want more" by Stephen Gendin, POZ Magazine June, 1997


 

 

Walt Odets is a clinical psychologist and HIV prevention consultant for the Gay Men's Health Crisis, NY. He can be heard debating with Gabriel Rotello in

Odets has written several important articles critiquing HIV prevention efforts

and a book entitled In the Shadow of the Epidemic: Being Negative in the Age of AIDS, Duke University Press, 1995.


 

 

See Eric Rofes's book is Reviving the Tribe : Regenerating Gay Men's Sexuality and Culture in the Ongoing Epidemic for an excellent critique of prevention campaigns targeted at gay men, and an analysis of how safer sex messages produce transgressive desire.


 

 

The term "replapse to safer sex" was coined by researchers at the Center For AIDS Prevention Studies. Researchers at the UK's Project Sigma wrote a critique of the use of "relapse," arguing that the term projected a moralizing and pathologizing connotation to what was a natural desire for unprotected sex. See


 

 

In his work as an HIV test counselor, Nicolas Sheon noticed how many of his clients behave as if the HIV testing process were a form of penance or confession. His web site features a "virtual confession box" which allows safer sex "sinners" to unload their guilt through a confidential email to a virtual priest who gives an absolution.


 

 

Some of the more inflamatory rhetoric in the debate on bath house closures in New York was written by Gabriel Rotello in his New York Newsday Editorials. Rotello referred to bathhouses as the "killing fields" and unprotected sex he witnessed in a sex club as a "sex murder/suicide." AIDS Activists, writing in Policing Public Sex, and Lingua Franca have disputed such perspectives, arguing that the Bathhouses serve as crucial venues for safer sex education that is sex positive. The ACLU has noted an alarming trend toward the criminalization of unprotected anal sex, as infected individuals face legal charges.


 

 

Xtreme'Sex web site offers links to many of the works cited in this review. The site's Fac tfantasy section provides an analysis of information about the science of viral mutation, replication, and reinfection, from a barebacker's perspective. Xtreme'Sex even includes a link to Project Inform.


 

 

"A Deadly Dance" by Marc Peyser, Elizabeth Roberts, and Frappa Stout. Newsweek, September 29, 1997. p. 76.


 

 

In his research on how test counselors talk to clients, Nicolas Sheon interviewed a test counselor who recognizes the importance of insemination for many gay men who have unprotected anal sex. The counselor's narratives are posted along with others in the Counselor Reseources Section of the author's Managing Desire web site.


 

 

" ;Xtreme' sex -A return to anything-goes, or merely better communication about HIV?" from Dallas Voice April 18, 1997



 

 

A S ex Panic Summit is scheduled to coincide with the Creating Change Conference in San Diego November 13-15, 1997. See also


 

 

Gabriel Rotello's recent writings on "Sexual Ecology" have generated a great deal of controversy. Here is a sampling compiled by Edward King and expanded by Nicolas Sheon.

Book reviews

 Extracts & debates

 Rotello interviewed

 


 

 

Combination therapy costs on average nearly 15-20, 000 US dollars per year. The demand for publicly funded AIDS Drug Assistance Programs (ADAPs) has grown so precipitously since 1995 that many ADAP programs are using lottery systems or not accepting new patients. See the Report by Kaiser Family Foundation.


 

 

A recent study found that nearly half of a sample of AIDS patients did not see a lasting benefit from Protease Inhibitors.


 

 

Studies of Drug Resistance in Anti-retroviral therapy are abstracted in Update from the International Workshop on HIV Drug Resistance, Treatment Strategies and Eradication, by Steven Deeks, for HIV InSite


 

 

Rafael Diaz's new book, Latino gay men and HIV: Culture, Sexuality, and Risk Behavior is due out this month. See also: