THE QUESTION of whether sex “is worth dying for” was posed by Michel Foucault in his History of Sexuality and speaks directly to why, in the third decade of the AIDS epidemic, gay men are still taking sexual risks. Beginning in the mid-1980’s, a combination of factors influenced sexually active gay men around the world to make changes in the way they had sex, including a desire both to remain uninfected oneself and to avoid the risk of infecting others. Gay men started having fewer sex partners and, still more importantly, began using condoms during anal intercourse. These two factors caused the rate of new infections among gay and bisexual men to drop dramatically beginning in the late 1980’s. But after more than two decades of safer sex messages and tens of thousands of deaths, many gay men are returning to sexual behaviors more commonly seen before the onset of the epidemic by having unprotected anal intercourse (UAI).
The increase in UAI in the United States has given rise to a significant increase in the number of new HIV infections among men who have sex with men (MSM). At the 2003 National HIV Prevention Conference, the Centers for Disease Control reported that the number of gay and bisexual men diagnosed with HIV climbed for the third consecutive year. Studies in Amsterdam, Sydney, Melbourne, London, Budapest, and Russia have documented increases in UAI. Whatever the reasons, gay men in the West are less likely to use condoms now than they were a decade ago.
Unprotected anal intercourse is variously referred to as “barebacking,” “raw sex,” “natural sex,” or “uninhibited sex.” The first time that the term “barebacking” appeared in print was in a 1997 POZ magazine article entitled “My Turn: Riding Bareback,” in which the late AIDS activist and writer Stephen Gendin described the thrill of not using a condom during anal sex with other HIV-positive men.
The statistics underscore that some men are not using condoms during anal intercourse. In a survey of over 14,000 gay men conducted throughout the UK in 2003, 59 percent of the men reported being the active partner in UAI at least once over the last year, and 56 percent reported having been the receptive partner in UAI (Project Sigma, 2004). The best evidence suggests that barebacking is the relatively infrequent act of a relatively large number of gay men. On the other hand, a relatively small proportion of men account for the lion’s share of barebacking incidents. For example, a study of 2,182 men in England showed that one tenth of the men accounted for half of all UAI acts (Coxon & McManus, 2000). Several recent studies have pointed to high and increasing levels of sexually transmitted infections (STI’s) among MSM in all racial and ethnic groups in the U.S. This is seen as evidence for an increase in UAI: an increase in syphilis, which can be detected earlier, is often followed by a wave of new HIV infections.
UAI occurs in all age groups. Many middle-aged gay men who were sexually active prior to the onset of the AIDS crisis are now foregoing the use of condoms. Many men who’ve been practicing safer sex for years are apparently experiencing safer sex fatigue and returning to sex without condoms. As for younger gay men, it was once believed that in-school sex education, increased availability of condoms, and increased awareness would steer them away from unprotected sex, but young gay men currently have among the highest rates of new HIV infection. Bay area psychologist Steve Morin has observed that definitions and perceptions of barebacking have evolved as the practice has grown: “Whereas the term originally was used to describe engaging in premeditated, consciously chosen unprotected anal sex, it has now been incorporated into colloquial discussions to describe the unintentional, unprotected ‘slip-ups’ that occur.”
Studies have shown that unprotected anal intercourse occurs more often between men in an ongoing relationship than between casual sex partners. One 1992 study in England found that UAI was nearly five times more common for men in a regular relationship than for casual partners. Another study (McLean, 1994) found that 71 percent of men in the UK reported that their most recent incidence of UAI had been with a regular partner. In relationships in which both men are HIV-negative and are monogamous, not using condoms for anal sex is not risky because there is no virus to transmit. Most men in these couples do not label UAI as “barebacking,” though they are generally familiar with the term. However, several studies have shown that steady partners who engage in UAI often do not know either their own or each other’s HIV status, making sex without condoms a possibly risky behavior. One study of male couples in Amsterdam has shown that steady partners have become a major source of new HIV infections among gay men in committed partnerships.
Everyone has an opinion about barebacking. Clearly, how it’s viewed depends on the context in which it’s practiced and the population that engages in it. If the partners are married heterosexuals, there’s little or no social disapproval for not using condoms during vaginal or anal intercourse. When the partners are unmarried but romantically involved heterosexuals, there’s more social censure, but it’s still relatively mild. When unmarried heterosexuals who are not romantically involved don’t use a condom, there’s more social censure and disapproval, even when the woman is employing other methods of birth control. The highest level of disapproval for barebacking is when it occurs between gay men, but the degree of censure varies greatly according to the situation. At one end of the spectrum are HIV-negative men who don’t use condoms within the context of a committed, monogamous relationship. At the other extreme are HIV-positive men who bareback with men who either do not know their HIV status or who self-identify as negative. And there are many gradients in between.
It’s probably safe to say that most gay men who bareback are perfectly familiar with the reasons for not barebacking. Even those who are HIV-positive are generally aware of the dangers of “reinfection” and other possible assaults to the immune system. With all the risks inherent in barebacking, why would a person put his life in jeopardy for sex? How one individual weighs the benefits of barebacking against the risks is by no means a simple equation. Usually a combination of factors contributes to the behavior, some of which are understandable and adaptive for any one person. As Pinkerton & Abramson have observed, “For certain individuals, under certain circumstances, risky sexual behavior may indeed be rational, in the sense that the perceived physical, emotional and psychological benefits of sex outweigh the threat of acquiring HIV.”
There are numerous theories for why gay men engage in unprotected sex. These include: negative attitudes toward condom use; being in a committed relationship; strongly identifying with or feeling alienated from the gay community; internalized homophobia; a sense of the inevitability of becoming infected eventually; the rise of the Internet as a place to meet sexual partners; and the effects of substance use, especially the recent dramatic increase in the use of crystal methamphetamine by gay men. In my own practice, I’ve identified several additional factors that appear to lead to sexual risk taking: loneliness; being HIV-positive; having unmet intimacy needs; and being in love and wanting to deepen intimacy and trust with a partner.
One rationalization gay men often give is that HIV is no longer the death sentence that it once was. Indeed there’s now research confirming that the increase in high-risk sexual behavior is connected to the advent of combination antiretroviral therapy. New drug therapies have given gay men a misplaced complacency; many believe that contracting HIV is not such a big deal anymore, certainly not a risk to life. Such reasoning is common in young men who still believe in their own immortality.
Thanks to highly active antiretroviral therapy and improved prophylaxis that prevent most of the AIDS-related opportunistic infections that once were invariably fatal—along with testosterone, human growth hormone, steroids, and weight-training—people with HIV can be imposing, muscled hunks. For several years now, advertisements run by pharmaceutical companies for antiretroviral drugs have pictured robust and buff young men (and women) engaged in strenuous physical activity like climbing mountains or sailing. These visual representations reinforce the notion that HIV is no longer a life-threatening or even a serious condition.
British psychologist Michelle Crossley suggests that condomless sex may be for some gay men a current manifestation of their need to hold on to a transgressive aspects of their “outlaw sexuality.” She sees this as a consistent feature of the gay male psyche since the early days of gay liberation. Today, the focus has shifted to gay marriage, service in the military, and parenthood. For men who once relished their self-image as sexual outlaws, barebacking is one way to do something that’s considered transgressive.
Other men put themselves at risk to meet important human needs, such as an emotional connection with another person. Obviously, people who engage in sex are in pursuit of pleasure, but it’s often not the only reason for seeking a sexual encounter. As Manhattan psychologist Mark Blechner states: “Risk of HIV infection is serious. But the risk of loss of pleasure and intimacy is also serious. … 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.” There is something deeply erotic, profoundly connecting and, some feel, even sacred about one person giving his semen to another. It can be seen as a “gift” of love and a symbolic joining of two souls, and this too must be seen as contributing to the rise in barebacking. Bay Area psychologist Walt Odets spoke to this point early in the second decade of the epidemic: “Now that a decade of prohibition has made semen exchange relatively unusual and ‘special,’ it has become all the more powerful and meaningful.”
Social scientists have found that some barebackers are “rational risk-takers,” men whose sexual behavior is based on a rational consideration of the risks of specific sexual acts. Among this group are HIV-negative men who only play “top” during condomless anal sex, and couples who are not sexually exclusive and have negotiated safety agreements governing their sexual behavior with outside partners. Researchers have also identified a phenomenon known as “serosorting” whereby men discuss their HIV status with potential partners and engage in risky behaviors only with those who are believed to be of a similar serostatus.
While the risks of barebacking are well known, the potential benefits that go into the risk analysis are not so well understood. New York psychologist Perry Halkitis and his colleagues have conducted numerous studies on gay men, barebacking, and drug use. In a survey of 518 gay and bisexual men conducted in Manhattan in 2001, the benefits cited most often centered on sexual satisfaction and emotional intimacy. Respondents were asked to rank fourteen items on a 1-to-5 scale, of which the following nine were the most significant (with their mean scores):
Barebacking is sexier than sex with condoms 3.12
Barebacking increases intimacy between men 2.93
Barebacking makes sex more romantic 2.62
Barebacking is “hotter” than sex with condoms 2.58
Barebacking is more “butch” and manly 2.45
There are psychological benefits to barebacking 2.43
There are emotional benefits to barebacking 2.35
Barebacking affirms love between men 2.14
Barebacking affirms masculinity 2.10
The initial wave of AIDS prevention messages and interventions in the 1980’s helped to transform radically how gay men had sex. One factor in this early success was that these messages were unapologetically gay-positive and sex-positive. Subsequent generations of AIDS prevention messages often failed to address effectively the reality that for many gay men sex remains a primary method of connecting with other men on a variety of levels, and contributes to some men’s willingness to take sexual risks. Another failing of the prevention strategy has been the lack of attention paid to the realities and risks of steady relationships. It is vital that the variety of needs of both single and partnered men be factored into all future AIDS prevention efforts.
References
Coxon, A. P. M. & McManus, T. J. “How many account for how much? Concentration of high-risk sexual behaviour among gay men.” Journal of Sex Research, 37 (2000).
Halkitis, P., Wilton, L., Parsons, J. & Hoff, C. “Correlates of sexual risk-taking behavior among HIV seropositive gay men in concordant primary partner relationships.” Psychology, Health & Medicine, 9 (2004).
McLean, J. Boulton, M., Brookes, M. Lakhani, D., Fitzpatrick, R., Dawson, J., McKechnie, R. & Hart, G. “Regular partners and risky behaviour: Why do gay men have unprotected intercourse?” AIDS Care, 6 (1994).
Odets, W. “Seronegative gay men and considerations of safe and unsafe sex.” In Therapists on the Front Line: Psychotherapy With Gay Men in the Age of AIDS, S. Cadwell, et al., eds. American Psychiatric Press, 1994.
Pinkerton, S. & Abramson, P. “Is risky sex rational?” The Journal of Sex Research, 29 (1992).
Michael Shernoff, LCSW, is a psychotherapist in private practice in Manhattan and is on the faculty of Columbia University School of Social Work. He’s currently writing a book on barebacking, to be published by Brunner-Routledge in late 2005.
