AIDS optimism, condom fatigue, or self-esteem? Explaining unsafe sex among gay and bisexual men.

HIV prevention among gay and bisexual men has been, for the most part, remarkably successful over the last 20 years. Men who have sex with men (MSM) have been one of the populations most heavily affected by HIV, and as gay and lesbian communities mobilized against the AIDS epidemic, rates of HIV transmission fell precipitously throughout the 1990s. By the end of the decade, however, transmission rates had reached a plateau, and reports of worrisome upward trends began to appear in several major metropolitan areas of North America (Calzavara et al., 2000; Ekstrand, Stall, Paul, Osmond, & Coates, 1999; Kellogg, McFarland, & Katz, 1999) and Europe (Dukers et al., 2001). These upward trends have frequently been associated with increasing rates of sexually transmitted diseases such as gonorrhea and syphilis in Toronto and in major cities of the United States and United Kingdom (Bellis, Cook, Clark, Syed, & Hoskins, 2002; Kahn, Heffelfinger, & Berman, 2002), following a decade when transmission rates had fallen so low that some epidemiologists had become cautiously optimistic that syphilis could be virtually eradicated.

These new trends provoked a good deal of speculation in both the gay and mainstream media concerning "barebackers" and "bug-chasers" as the putative sources of resurgent HIV transmission. Researchers and AIDS service organizations (ASOs) hypothesized that "AIDS optimism" and "condom fatigue" were motives for the new "laxness" in safe sex practice, based on the fact that epidemiological rates began to rise about the same time that the protease inhibitors became widespread in the mid- to late 1990s. The AIDS optimism hypothesis, which became the most widely prevailing explanation for rising HIV rates, claims that MSM have become complacent following the introduction of more effective treatments (primarily protease inhibitors), have lost the sense of urgency surrounding AIDS, and have been reverting to unsafe sex. AIDS optimism explanations appear to circulate most frequently, at least in Canada, in public health circles, and have been prominent hypotheses for research. Self-esteem explanations, which appear to enjoy greater support in ASOs, postulate that unsafe sex is related to a low self esteem engendered by homophobia, sexism, poverty, or other social conditions.

This study investigates the narratives of high-risk gay and bisexual men to see how they account for the interactional processes that lead to incidents of unsafe sex, and to see what role the prevailing hypotheses, and alternative discourses, play in actual sexual interactions. This work, then, seeks to investigate how well widely-circulating explanations accounting for unsafe sex engage with the social circumstances and reasoning processes of men in their sexual relationships. It examines, in particular, narratives of men who have abandoned condom use altogether and employ a language of barebacking to describe their practices. It also sketches implications for HIV-prevention programming based on an analysis grounded in the experiences and discourses of men at risk for HIV.

Since HIV prevention must rely on communicating effectively with those most at risk, it is critical to engage the reasoning, culture, and immediate environment of vulnerable populations. At stake in the scientific investigation of HIV transmission is, then, the ability to connect effectively with the discourses deployed by people in making sense of their own actions. Cicourel (1964), in an early critique of Method and Measurement in Sociology, distinguished between "observers' rules," which are discourses generated by researchers to make sense of other people's behavior, and the rules that people use themselves to give meaning to their own behaviors. Although observers' rules can have value in public policy that shapes action through structural change, they can prove ineffective if change must come about through appealing to the self-understanding of intended audiences. Explanations that fail to be recognized by target populations and do not speak to the discursive coding of their own experience risk falling on deaf ears. The implication of relying on observers' rules for HIV-prevention work is far-reaching, as prevention campaigns devoted to debunking observer's rules may very well be greeted with considerable satisfaction in communities who believe that "other" people responsible for HIV transmission are being addressed. But as HIV prevention tools, such programs may be ineffective, since there may be little or no audience receiving a message that speaks to them, as the prevention message turns out to be addressed to the motivations of a non-existent other. To use anthropological language, there is reason to be cautious about etic understandings of a phenomenon (i.e., explanations that make sense to observers) if emic understandings (i.e., explanations that make sense to the observed) are neglected. Since prevention necessarily appeals to those engaging in a practice, it cannot get emic understandings wrong, or prevention messages will be ineffective.

METHOD

Study participants were recruited through advertisements in the gay press, appeals at meetings of gay organizations, and distribution of recruitment leaflets at gay bars and special events in Toronto. We also invited Toronto-area men with a profile on the website barebackcity.com to participate. The study sought out high-risk men defined by one of two criteria: (a) having had unprotected sex within the last 6 months (N = 51) or (b) having sero-converted within the last 5 years (N = 51). Research assistants sought men of diverse educational, ethno-cultural, and social class backgrounds and made a special outreach to venues and organizations popular with minorities. See Table 1 for a demographic profile of the sample.

After being briefed on the overall objectives of the study and providing their written consent to participate, including consent to audiotape the interview, study participants were typically interviewed for 1 to 1.5 hours and offered $30 in compensation for their time and travel expenses. Interviews were semi-structured, with pre-established probes used to obtain detailed information about recent sexual encounters, such as sex inside or outside a relationship, sex in different venues, and safe and unsafe encounters. They were then asked a series of questions about how and why the encounter "worked" for them, and how un/safe sex entered into the unfolding of the encounter. Men in couples were also asked a set of questions regarding the development of understandings around sexual openness or exclusivity and the management of sexual encounters inside and outside the primary relationship.

Interviews were taped, transcribed, and catalogued in QSR N6 and then coded by the research assistants according to a summary of the interview topic guides. The principal investigator reviewed and recoded all transcripts to ensure that all instances of interview text relevant to each topic was retrievable and then identified recurring themes the men used in their accounts. Our analytic strategy was to capture emerging themes from the interviews rather than to code the data into a preexisting scheme. In a first reading of the transcripts, key themes were identified emerging from participants' reflections on their self defined unsafe sexual activities. Interview excerpts relevant to each theme were grouped together. The thematic categories were refined, merged, or divided according to similarities or differences among quotes. This study then provides interview segments representative of the thematic categories where unprotected sex occurs as a topic.

In the following report, in each section the most common pattern of response is reported first, followed by quotes that give some sense of the variation and nuance among narratives. Quotes from all study participants are accompanied by designation of age category, ethno-cultural background, and sero-status, and for men in couples, with length of relationship as well. When respondents name more than one ethno-cultural category in their heritage, the first-named ethnicity is reported with their quotes.

RESULTS

Managing Risk

According to the Ontario Men's Survey (Myers et al., 2004), 74.7% of MSM in the Toronto area report using only safe sex practices with casual partners in the past 3 months, and 54.9% report having only safe sex with regular partners. Of the remainder, many men often or mostly have safe sex but "lapse" from time to time, and some have unsafe sex or have abandoned safe sex altogether. This study selectively recruited men who fall toward the most unsafe end of the spectrum and is not representative of gay and bisexual men as a whole. The high-risk men in this study were selected to include only those with recent experience with unsafe sex. Although most of the men participating in this study reported multiple incidents of unprotected sex, others commented on occasional or exceptional events when unsafe sex occurred despite general adherence to safe sex norms. We left it to study participants to define what they meant by "unsafe sex." In a few instances, they mentioned instances of oral sex usually accompanied by an implied question mark, or an explicit qualifier like "if you consider that unsafe sex." Thus in the following accounts, respondents refer to unprotected anal sex when they talk about unsafe sex, unless otherwise indicated.

Condoms and erectile difficulties. A sizeable portion (about one third) of the 102 high-risk men complained that condom use not only decreases stimulation, but often leads to loss of erection (also reported in Imrie et al., 2002, and Richters, Hendry, Crawford, & Kippax, 2003). Many of the other two thirds find condoms do not inhibit erection or they cause only minor loss of sensation, but this proportion also includes men who consistently assume a receptive role and therefore do not wear condoms themselves, men who do not prefer anal sex, and a significant number who have abandoned condom use altogether and so had no comment on its effect on their erections. In addition, some men reported other kinds of difficulties with condoms; some who practice receptive sex report that the water-based lubricants required for condom use tend to dry, leading to abrasion. Others experienced problems with condom size, either too tight or prone to slippage (presumably too large). Those who have penile piercings reported difficulty in wearing condoms since they tear quickly. This man's comment is representative:

   It will not stay hard if I put one on, come hell or high water.
   Believe me, I've tried. So, you know, since I've started having
   sex, I've basically always had unsafe sex. (30s, British, HIV+)

In addition to the men who report their own erectile difficulties are those who report them in their partners. The following participant was in a relationship with an HIV-negative man:

   At the beginning, I said to have sex with a condom because I love
   him and ... I didn't want to lose him....He told me, 'No, I have
   problems because when I put a condom, my erection, I lose my
   erection.' ... So when he told me 'I can't keep my erection with a
   condom,' so I was thinking, 'Wow, if I try to use a condom with
   him, probably things will not work out.' And at the beginning I
   was thinking like this, but then I decide[d] not to continue [the
   relationship] because I talk[ed] to a counselor. (30s, Latin
   American, HIV+)

One participant pointed out that there is no inevitable relationship between erectile difficulty with condoms and unwillingness to practice safe sex:

   A condom's important. If it prevents me from having an erection,
   I'm not sure what would counteract that, you know. Obviously if
   I lose my erection, well, the other guy is just going to have to
   understand and, you know, find satisfaction elsewhere. (30s,
   British, HIV+)

A few men remarked that they have shifted away from taking a top role in sex toward having more receptive sex as an adaptation to this problem. These views, however, were somewhat uncommon. Many others struggled between finding enough stimulation and maintaining some condom use.

Recent research in Sydney and Toronto has identified a phenomenon of delayed condom use among some gay men; the Polaris study in Toronto found an alarming association between this practice and sero-conversion (Calzavara et al., 2003; Richters et al., 2000). These interviews suggest that delayed use, or episodic use during a sexual experience, tends to flow from difficulties in resolving the tension between condoms and erections.

   I find this more as I've gotten in my 30s. I find if I'm not
   into it, once I put the condom on, I can get soft.... We'd start
   with a condom and then if I got soft, I'd take the condom off
   and I'd put my dick inside and get hard again and then we'd
   put the condom back on. But sometimes the condom just never
   came back on. (30s, French, HIV+)

Similar experiences were mentioned by a significant portion of participants in this study. In some instances, this leads to a pattern of inconsistent condom use, to somewhat symbolic but ineffective condom use, or to pushing the boundaries of safe sex practice.

   It's mutual consent where they want to feel my penis
   without the condom and I've obliged 'cause I wanted it
   too ... but no ejaculation and then the penis would come
   back out. Sometimes another condom and sometimes the same
   condom might go back on and, and then ejaculate.
   (40s, British, sero-status not reported)

About a quarter of the men in the high-risk and couples sample remark on some version of ongoing boundary-pushing practice either in themselves or in their partners, including risk "reduction" practices such as assuming the top role in unprotected sex, withdrawing, or not ejaculating in a partner. Below is an example of the risk calculus associated with taking the top position in sex:

   I met a guy off the internet again and he was over at my
   place and we were starting to have sex, and he asked me to
   fuck him without a condom, and it was fine with me because
   I wasn't being fucked. I was doing it. And so we did it and
   then I think it was about two or three days afterwards, we
   got together again and that's when he disclosed to me that he
   was HIV-positive, which at that time I didn't know that I was.
   And maybe I wasn't at that time, so that threw me a bit. But
   he kept on assuring me that, you know, I was safe because I was
   the top. (30s, Scandinavian, HIV+)

The tensions and dilemmas posed by condom use are not easily resolved and result in a variety of outcomes. This study participant described a situation where a partner convinced him to assume a top role without a condom:

   He literally said, 'I want to feel you in me without the
   condom and then I want you to pull out and put the condom on.'
   And we got into it and ... in my head, there's that thought of
   Don't. Don't.' ... Having unsafe sex with somebody, I can lose
   my erection once my mind ... starts to, you know, 'don't.' Just
   shut down. Just, it's gone ... we're done here. Pull out,
   make your apologies, you know, say, 'I can't follow through.
   My ... subconscious won't let me follow through. Something about
   this situation has caused the erection to leave the building.'
   (40s, British, HIV+)

In a number of instances, men reported wrestling with a series of dilemmas about condom use: wanting to maintain an erection that refused to cooperate when sheathed, wanting to accommodate a partner experiencing similar difficulties, wanting to avoid exposure to the risk of infection, wanting to prevent a partner from becoming infected, attempting to keep up some degree of condom use even if consistent use was compromised, and relying on a risk calculation that falls back on withdrawal, taking the top role, or avoiding condom tears. For men who experience erectile difficulties with condom use, these are real dilemmas resolved through actions that may heighten risk.

Momentary lapses and trade-offs. "Heat of the moment" scenarios are frequently found in the study of unprotected sex, and these interviews were no exception. The urgency of passion and the opportunity to connect with a particularly desirable partner, sometimes facilitated with drugs or alcohol, accounted for some unsafe encounters.

   You're so caught up in the act that you forget--not you
   forget, but you push the consequences ... to the back of
   your mind until after the fact it happens. Then you realize
   that you've just risked your life. You can get HIV-positive.
   You can get other sexually transmitted diseases, so after the
   accident ... reality sort of hits. (30s, African Caribbean, HIV-)

Heat-of-the-moment situations can be complicated by trade-off scenarios where men who feel disadvantaged in some way--be it age, ethnicity, or attractiveness--fear to offend a desirable partner and trade away safe sex lest it prove an obstacle to sexual interaction (Ames, Atchinson, & Rose, 1995; Choi et al., 1999; Gold, 1995; Seal et al., 2000; Stokes & Peterson, 1998). This Aboriginal respondent felt unable to assert himself, especially with White partners, preferring that they take the lead in sex:

   I'm always questioning why anybody would want to, you know,
   be with me at all, so. And maybe in terms of, you know, searching
   for that relationship, maybe that's why I put myself in situations
   [of unprotected sex] where I don't have to worry about those
   kind of hurt feelings or whatever....The more masculine and a
   little bit older than I am, the taller, the muscular, that's
   totally, you know, a better thing, for me anyway, in terms of
   looking for a partner. (20s, Aboriginal, HIV-)

Trade-off scenarios, then, can index larger social hierarchies that create an economy of risk where a sense of personal neediness, perception of one's own attractiveness, and the wish not to spoil an opportunity heighten vulnerability.

This quote, also, points toward another complication in sexual interaction. Safe sex is premised by the ability to assert oneself in sexual interaction, yet self-assertion may run contrary to one of the primary significations of erotic connection with men: that of giving oneself over to a partner viewed as stronger and in control (Adam, 2000). Preference for partners who are older, taller, and more masculine may signal an interest in partners who will take charge.

Personal turmoil and depression. Another set of issues associated with vulnerability to unsafe sex, found here and in other studies (Adam, Sears, & Schellenberg, 2000; Calzavara et al., 2001; Gilbart et al., 2000; Semple, Patterson, & Grant, 2000), concerns mood state, particularly stress and depression. A combination of stressful factors precipitated a moment of personal vulnerability for several men in this study.

   I had a monogamous relationship for 21 years with a man. This
   was before I was positive. And we had a wonderful relationship
   and he died of cancer in '89.... After he died I was so angry and I
   was in such an incredible grief and loss response and that's when
   I overdosed on alcohol and sex and that's how I got infected in
   1991. (60s, British, HIV+)

Another participant associated an episode of unsafe sex with a series of stressful events:

   Very up and down in my world: change of jobs, still grieving, you
   know, the loss of my partner, change in cites that I was living
   in, change in homes, selling my home and moving here to Toronto,
   so a lot of shit going on. Yeah. A lot of emotional upheaval at
   the time. (60s, British, HIV-)

Low self-esteem is a popular explanation for HIV transmission in ASOs, and some of the narratives offered by study participants confirm that link.

   When my self esteem is down ... or if I'm depressed and just sort
   of, you know, feeling downtrodden by the world. It's just I ...get
   into that 'I don't care' mode. (30s, Eastern European, HIV+)

HIV prevention messages implicitly exhort people to act safely now in order to preserve themselves for the future. HIV disease is a relatively slow-moving disorder; even if it is left untreated, a decade may pass before life-threatening symptoms of AIDS appear. To be effective, then, the prevention message calls on an autobiographical narrative that life is worth living and that something done now makes sense because the future is a desirable place to be. However, depression and personal turmoil can pull away the underpinnings of this belief. If life does not seem worth living now and the future appears bleak as well, then self-preserving actions no longer make sense.

A relationship can figure prominently into personal narratives about the value of life and of the future. When a current relationship is in trouble or prospects for a new relationship seem grim, the autobiographical narrative to which prevention messages appeal may crumble.

   Any time I'm down, like especially when ... I felt like something
   was going wrong [with partner] and I needed somewhere to think.
   Don't ask me why I ended up at the bathhouse, but that's where I
   always end up going.... I keep saying, if it's something that's not
   wrong with me, why he's leaving me? Or I'm that repulsive that
   nobody really wants me, you know. At least, when you go to the
   bathhouse and then, you know, people be going in after you, it
   sort of builds up your self-esteem. (30s, African Caribbean, HIV+)

Depression also appears as a factor in studies of adherence to therapy for HIV (Adam, Maticka Tyndale, & Cohen, 2003; Ferrando, Wall, Batki, & Sorensen, 1996; Gordillo, del Amo, Soriano, & Gonzalez Lahoz, 1999; Holzemer et al., 1999; Kalichman, Ramachandran, & Catz, 1999; Singh et al., 1996; Singh et al., 1999), and for similar reasons. Adherence to an onerous and long-term regimen of drug therapy depends on a desire to preserve oneself for a better future, and thus on autobiographical narratives that give coherence and meaning to the self through time. In times or situations where that desire is missing, adherence may not "make sense." About 10 percent of the men in this study explained high-risk activity in terms of personal turmoil or depression.

Disclosure and intuiting safety. Unprotected sex also occurs intentionally. Some men (four in this sample) comment on using intuition or interpreting cues and signs in an attempt to discern the sero-status of a partner (Ames et al., 1995; Lowy & Ross, 1994). Some sero-positive men disclose their status regularly as a prelude to unprotected sex, giving partners the option to continue, withdraw, or employ a condom. Both of these strategies make some attempt to bring sero-status to the forefront and to establish sero-concordance as a reason for dropping protected sex. Only in a few instances do sero-negative men ask their partners' sero-status and drop condom use with a partner who assures them he is also HIV-negative.

   It's gut feeling and also asking them about their sexual
   history and I guess, a level of comfort with that person.
   (30s, French Canadian, HIV-, 5 years)

Two men prefaced their remarks by labeling reliance on intuitive strategies as "stupid," but nevertheless confessed to using them from time to time.

   It's a stupid thing but if I kind of know that is a person that
   is HIV-negative or young, there [is] ... more chance of being
   HIV-negative.... And if you're feeling comfortable.... When I
   go to their place, I use the washroom, I check the cupboards
   to see if they have like lots of medications, lf they have
   lots of medication, the chance [is] that they are on HIV
   medication. And I look at the face and you can kind of see
   that they are HIV-positive. (20s, South Asian, HIV-, 2 years)

The attempt to discern another man's sero-status uses stereotypes and semiotic binaries that have circulated through the press and the public throughout the history of HIV: youth, ostensible heterosexuality, or inexperience may be read as signs of low risk status.

   He said, 'I'm married and I just lost my wife and I'm also
   like just new to this game. I was married and everything.'
   And I just trusted him and I had sex with him without condom.
   (20s, East Asian, HIV-)

Indeed, the "know your partner" advice propagated by some public health authorities may be a significant contributor to unsafe practices by encouraging people to exempt themselves from the need for safe sex through reading signs of their partner's putative safety.

A few HIV-negative men employ intuitive approaches to try to discern the sero-status of prospective partners. A minority (10 in this sample) of HIV-positive men assert their sero-status right away as a way of warning prospective partners.

   I mentioned it at the bar. That's the way I am. When I meet
   someone and ... there's a good chance that we're going to
   end up doing anything, I'm right up front with it. (40s,
   French Canadian, HIV+)

Many of the HIV-positive men interviewed considered sex with condoms unnecessary with other positive men but a priority with negative men. Some positive men felt strongly about making sure that HIV-negative partners practiced safe sex with them.

   I always disclose my status before I have sex. So I can't
   physically have sex with someone without disclosing it.
   It just doesn't work. (20s, African Caribbean, HIV+)

In most cases, positive men believe that disclosure is enough and that a prospective partner will then take appropriate precautions if negative. Though rare, there are a few instances of positive men reporting that negative partners refused to use a condom after having been told.

   I told him 'You know, well, I'm HIV-positive, you know. This
   is your risk if you don't use a condom.' And he said to me he
   didn't care. He didn't like using condoms. He had sex with
   some people that are HW-positive and what not, so I was like,
   'All right. Well, it's your decision.' (20s, British, HIV+)

These rare instances appear to involve HIV-negative men with erectile difficulties and men who have gotten away with having sex with positive men, especially in long-term relationships, without sero-converting, and who have acquired a sense of invulnerability as a consequence.

Only two HIV-negative study participants mentioned using disclosure to try to find other negative men with whom to have unprotected sex. In the first instance, inclusion of sero-status on an internet profile met with rejection by other men. The other HIV-negative study participant interviewed his partners extensively in an attempt to ascertain their sero-status. He spoke lyrically of his desire to be inseminated and described his attempt to reconcile insemination with safety this way:

   It just is a tremendous physical sensation of feeling that symbol
   of manhood inside myself, inside my ass, inside my body. In some
   cases it's a huge high. (40s, Middle Eastern, HIV-)

Yet, he remained well aware of the risks associated with this pleasure and refrained from pressuring partners who preferred safe sex.

Disclosure, then, may be used as a warrant for having unprotected sex. As we will discuss further below, disclosure grounds itself on a particular vision of the sexual actor that has considerable resonance with moral reasoning in the larger society but which is nevertheless problematic in real sexual interactions.

Relationship-Building

Perhaps one of the most consistent findings in HIV research is the tendency of couples, whether homosexual or heterosexual, to shift away from safe sex over time (Appleby, Miller, & Rothspan, 1999; Bochow, 1998; Cusick & Rhodes, 2000; Diaz & Ayala, 1999; Hays, Kegeles, & Coates, 1997; McLean et al., 1994; Middelthon, 2001). Kippax, Connell, Dowsett, and Crawford (1993) coined the term "negotiated safety" to refer to a process whereby couples first ascertain their sero-status, and then, if sero-concordant, proceed through mutual agreement toward unprotected, but nevertheless safe, sex by assuring that HIV transmission could not be at issue. This model of relationship development does occur for many male couples, and some develop complex agreements over time to minimize HIV risk. However, this type of negotiated safety depends on open communication and deliberative rationality that is not characteristic of many relationships. Rather, the shift away from safe sex occurs as part of a set of tacit communications concerning romance, trust, and caring that "just happen" without all of the elements of negotiated safety being in place.

Safer sex decision-making in couples often becomes caught up in presumptions and expectations about monogamy, and since monogamy is frequently presumed to be the proper way to conduct relationships, it generates a logic that paradoxically creates new opportunities for HIV transmission. As Sobo (1995) noted in her study of African American women, monogamy discourse may set a trap that blocks the adoption of safer sex practices and can lead to the denial of factors that expose women to transmission. Although the monogamy script was less dominant among the men interviewed here than among Sobo's sample of women, where it did arise, it carried a similar romantic discourse that undermines the need to practice safer sex. Unprotected sexual practices may come to be read as a sign of the special trust that partners in a couple have for each other (Ames et al., 1995; Bartos, 1994; Bartos, McLeod, & Nott, 1993; Flowers, Smith, Sheeran, & Beanil, 1997; Hospers, Molenaar, & Kok, 1994; Silvestre, Lyter, Valdiserri, Huggins, & Rinaldo, 1989), thereby inhibiting partners from adopting protection lest it be read as an accusation of infidelity.

Relationship anticipation. Anticipating that a relationship will occur, or identifying a new partner as "boyfriend material," is enough to motivate some men to drop condom use as a sign of the seriousness of the relationship.

   Situations I have unsafe sex is when I am looking for relationship
   with that person or I'm looking for a continued boyfriendship
   with this person. It is during that time it is more likely for me
   not to use a condom.... I will not use a condom if there is hope
   of--if he shows an inclination of making me his boyfriend or having
   a relationship. Only then. Otherwise, even if Tom Cruise stand[s]
   before me, I'll use a condom. (30s, Asian, HIV-)

The intensity of a new relationship and an implicit belief in it being monogamous can create the conditions for leaving condoms behind.

   We always did it bareback because, I mean, at the time when we
   were having sex, we anticipated that each one of us wasn't having
   sex with anybody else. And to the best of my knowledge we
   weren't until 2001. (40s, African Caribbean, HIV-)

In this instance, the progression toward dropping condoms was so strong that it overcame concerns that the pair was sero-discordant.

Several study participants sero-converted during the early stages of relationship development.

   I had a relationship with a guy who was a flight attendant and I
   fell in love with him so much. Well he told me that he was okay,
   he was healthy. So I don't know how it happened, but it happened
   and we had sex without condom and all the relationship
   was without condom, without condom, without condom, and
   then I found out I was HIV-positive. So when I find out that, I
   didn't say, 'Oh, he's a guilty,' because no [one's] guilty.... So it
   was my fault, you know.... It happened. So I have to face it. (30s,
   Latin American, HIV+)

Protection against risk is intuitively easier when a partner is an acquaintance or a stranger; romantic engagement and the promise of intimacy are harder to reconcile with the perception of a partner as posing some kind of risk (Joffe, 1997).

Monogamy decision-making. Sexual exclusivity may become a fundamental part of a relationship. Though its implications for HIV prevention usually play only a small part in the decision to adopt monogamy, it is perhaps the best-known way, apart from abstinence, to limit HIV transmission. About one quarter of the men interviewed who were in a couple reported having a sexually exclusive relationship. In other words, sexual exclusivity is not an organizing principle for a large majority of men in relationships. Monogamy often shows itself in the speech of study participants as an accomplishment, rather than a presumption, and as a provisional rule-of-thumb subject to revisiting. Monogamy is often counterposed to an active consideration of alternatives in the narratives of men in relationships. Referring to a past relationship at a time when he was HIV-negative, this study participant remarked,

   Initially we always had protected sex and then at some point we
   discussed monogamy and we both felt confident in the other person,
   that we could trust the other person, that if ... we both tested,
   we both were negative and we both trusted each other that we
   could have unsafe sex until such time as something happened, an
   extramarital affair or something like that, or extra-relational
   affair, and in which case we would have to renegotiate things.
   (British, 20s, HIV+)

Among the men in this study, monogamy scripts appeared most commonly among younger men, men new to gay relationships, and men whose formative years were spent in cultures with limited or absent autonomous gay worlds. A policy of sexual exclusivity prevailed, especially among men in the "honeymoon" phase of their relationship (in the first two years). Sexual exclusivity provided a context for foundation-building in relationships and time for the development of mutual trust. Some couples found monogamy worked for them over the long term, but it was contested in many others who treated it as a passing phase, developed "exemptions," or struggled to arrive at new accommodations.

Monogamy may work, then, as a safeguard for some couples against HIV transmission, but it can also act as a semiotic snare (Adam et al., 2000), setting up the conditions whereby vulnerability to HIV may be increased. One man explained,

   I think my partner assumes like, monogamy, which I also do. I
   know that the reason why, say, we're having unprotected sex is
   because he guarantees to me that ... we're in a monogamous
   relationship.... I hate to see all that trust that he put on me.
   It's like, but if I fool around with someone else, you know, I'm
   obviously not going to say anything. (20s, Southeast Asian,
   HIV-, 2 years)

A semiotic snare refers to a message where a well-understood but unspoken subtext undermines the overt thrust of the message, and includes self-negating propositions in AIDS education messages, unintended meanings that contradict overt messages, and safety messages that promote self-exemption, thereby creating more unsafe practices. Monogamy discourses can have a self-negating outcome, as an ostensibly safe strategy nevertheless leads to the abandonment of condom use.

   If it was my choice, I would prefer to use condoms ... but when I
   bring up the subject about wearing condoms, he comes up with,
   'Okay, why? Are you doing something with someone?' So the fact
   that I want to use condoms, for him, means that I'm doing something
   with someone.... It's really stupid, though. (30s, other
   European, HIV-)

The monogamy presumption, then, makes it more difficult to introduce condom use inside a relationship, thereby heightening the risk to both members of the couple should an unsafe encounter occur outside the relationship.

Barebacking: Development of a Microculture of Unprotected Sex

Unplanned unsafe sex arises in a variety of circumstances: as a resolution to condoms and erectile difficulties, through momentary lapses and trade-offs, out of personal turmoil and depression, and as a byproduct of strategies of disclosure and intuiting safety. But much more evident today than in the mid-1990s are those who have stopped safe sex altogether. O'Hara (1997), who may have been the first to write about barebacking in his book, Autopornography, talked of a recaptured sense of freedom on becoming HIV-positive in being able to return to a sexuality no longer constrained by the fear of infection. O'Hara was clear in his use of the term barebacking as referring to sex among HIV-positive men only; he tattooed "HIV+" on his shoulder to warn all potential HIV-negative sexual partners of his status. Since that time, barebacking has become a more amorphous word, at times standing in for virtually any kind of unprotected sex, but often still retaining a sense of intentional condomless sex (Junge, 2002). It is noteworthy that about one quarter of the 102 study participants invoked the language of barebacking in explaining their own generally consistent lack of condom use. Nearly all of the other men rejected or even resented the possibility that barebacking could be thought to typify their practices, questioned the meaningfulness of the term, or stated they had not encountered or did not understand what barebacking means.

All of these men were HIV-positive and in many cases had been for many years. They had an average age 4 years older than the age of the high-risk group as a whole. They were, then, at the confluence of several factors associated with problematic condom use and with the tendency to push the boundaries on safe sex. Age has an association with a lessened ability to maintain an erection in some men, and research suggests an association between HIV and diminished sexual function, and between HIV medication and sexual dysfunction (Colson et al., 2002). Long-term unsatisfactory experience with condoms appears, among these study participants, to have created a predisposition for abandonment of protected sex in general. In addition, HIV-positivity is not just an individual status. Many of the participants in this study speak of years of participation in support groups, developing friendship networks with other positive men, seeing other positive men regularly on the street, living in subsidized housing where most of the tenants are positive, participating in internet websites and chat rooms with other positive men, and frequenting bars and baths where they have become accustomed to recognizing other positive men. Over time, they begin to speak of shared perspectives and tacit understandings that inhere in interactions with other men. From these conditions, a culture of positive sexuality and the foundations for a barebacking microculture has emerged.

These men often experience several conditions that lead toward diminished sexual satisfaction and more often expressed a variety of condom difficulties. HIV-positive participants talked of defining events in the struggle to resolve the tension between condoms and erections which precipitated unprotected sex:

   He tried to use a condom but he couldn't keep a hard-on so he
   skipped the condom.... I remember feeling alarmed and then I
   thought, well where am I? I'm in a bathhouse in Oakland,
   California, and do I have an obligation to tell this guy my [HIV+]
   status? ... I don't know if I did the right thing or not, but I do
   know that I grappled with it. (30s, Canadian, HIV+, 8 years)

A very similar event was reported by this man:

   Does using a condom affect keeping an erection? For me
   absolutely.... I've heard many people express the same problem....
   I remember one night at the baths, a fellow came in and he was
   going to use a condom. As soon as he put the condom on he said,
   'fuck this,' and threw the condom away, so obviously he was having
   a similar type problem, and I don't know how universal it is
   or isn't. (60s, British, HIV+, 13 years)

HIV has impacted the sexual repertoires of gay and bisexual men over the past two decades. While men who practice safe sex now rarely express an interest in, or say they miss, sexual experiences centered around insemination, some men who have stopped practicing safe sex use almost rhapsodic language to describe the discovery, or rediscovery, of eroticism denied by condoms.

   [With condoms] you just don't have that energy flowing. It blocks
   that flow, that energy and it's just not the same no matter how
   intimate it is and how loving it is.... It's on my conscience, you
   know, if something should happen, if he should become positive
   then ... I ... deal with the guilt feelings of it.... The way that
   I felt as well, when I was younger, before I was positive, that ...
   when you're dealing with love and that kind of intimacy it's worth
   the risk.... What's life live, worth living if you're not
   experiencing that part of life? It's such a special part of who we
   are and what we are as human beings. (30s, Canadian, HIV+)

Sexuality, of course, is as much cultural as it is physiological. The valuation and development of sexual practices occurs in particular social venues and networks over time. Although there is clearly no single set of practices or meanings about sex shared by all gay and bisexual men, these networks constitute microcultures which nurture and enhance particular visions and discourses about eroticism. The revaluation of insemination is one of the elements that characterize those who now feel free of the fear of becoming infected with HIV.

   Swallowing during oral sex [is] like a fulfilment, almost like a
   perfection, you know, where something is done, it's complete;
   we're two people who shared an incredible passionate moment.
   (30s, Middle Eastern, HIV+)

These conflicting discourses about health, pleasure, and sexual communion may collide and require sorting out in different ways according to time and place.

   I liked it, not using the condoms, 'cause it was a risk, you know,
   but now I look back on it and it was stupid. It was really dumb
   ... but, I don't know, it's kind of like a rush, you know, knowing
   that you have somebody else's cum inside of you. (20s,
   Aboriginal, HIV+)

Compare these views to the sense of closure, resignation, and loss expressed by this man:

   Why would you even want to come up some guy's ass anymore
   knowing you have no idea what disease, STD, or otherwise is
   there and again, why would you swallow loads from complete
   strangers not knowing anything about them? And it's just that I
   guess once the message is pounded into your head a hundred
   thousand times over 20 years that sex is death and come is death,
   ... who's ever going to be intimate? I can't see it happening. (30s,
   African Caribbean, HIV+)

HIV education has asked gay men to transition from one erotic mode to the other, and there is a new generation, many of whom have never tried unsafe sex and for whom related sexual practices have never become part of their sexual repertoire. For many, the project of reconstructing an eroticism inclusive of safer sex has been realized successfully, but changes of this kind are not made easily. This respondent throws into relief the transition he has made from one mode to the other:

   Before I was positive I found that [insemination] to be very erotic,
   and a certain closeness from that, but since I found out I was
   positive, ... I prefer ... not to have sex without the condom, so
   it's irrelevant, like it doesn't even factor into my sexual life
   now. (30s, Metis, HIV+)

It must be stressed, against the panic icons of barebackers and bug-chasers circulating in the press and in popular discourse, that none of these practices nor the moral reasoning associated with them overtly intend HIV transmission to happen. No one in this study expressed willingness or acceptance of the idea of knowingly infecting a partner. When the premises of individual responsibility are knowingly absent, many express a strong reluctance to allow unprotected sex.

Supporting Safer Sex

At this historical juncture when HIV rates among gay and bisexual men have stopped declining and in many locations appear to be on the increase, a number of hypotheses have surfaced to explain the apparent exhaustion of traditional methods of HIV prevention. The AIDS optimism theory has become so pervasive that it has acquired many of the trappings of a public health orthodoxy solidified through repetition in the media. Self-esteem theories and harm reduction approaches appear to have more currency in AIDS service organizations. Finally, the construction of barebackers and bug-chasers as a class of men pathologically intent on transmitting HIV finds a place in the press, and in the courts, insofar as the tools of criminal justice are brought to bear as an HIV-prevention strategy. The thesis advanced here, based on interviews with high-risk men and men in couples, is that these hypotheses provide, at best, partial and limited insight into the everyday dilemmas associated with coping with HIV risk. The development of effective HIV programming requires communicative methods congruent with the self-understandings of target groups themselves. Attending closely to the narratives of gay and bisexual men about their own sexuality shows how consistent unsafe sex is with predominant discourses of romantic and erotic communication, and how safer sex decision-making is caught up in semiotic snares built into government and corporate neoliberal rhetoric, scientific and public health language, autobiographical narratives, status hierarchies, body image, aging, and the search for intimacy.

A good deal of health research and public policy explicitly relies on the prevailing health-belief (Home & Weinman, 1998) and knowledge-attitude-behavior (KAB) (Kippax et al., 1993) models of human behavior. Both of these models rest squarely on rationalist and individualist foundations, posing that with proper information, individuals will change their behavior in order to avoid sickness and live longer. These models do explain a lot about why HIV rates have dropped throughout the 1990s, but they leave few, if any, theoretical tools with which to account for the significant amount of transmission that continued to occur even in the late 1990s. When HIV rates show signs of rise, their adherents are once again cast upon default "common sense" conjecture to explain the change. Into the breach has come the AIDS optimism hypothesis, despite such findings as "a large majority of participants (97%) agreed that 'safer sex is as important now as ever'" (Kelly, Hoffmann, Rompa, & Gray, 1998), and several other high-powered studies that have succeeded in identifying only small numbers of men who are willing to support the protease complacency thesis (Miller et al., 2000; Misovich, Fisher, & Fisher, 1999; Remien, Wagner, Carballo-Dieguez, & Dolezal, 1998; Vanable, Ostrow, McKirnan, Taywaditep, & Hope, 2000). As Elford, Bolding, and Sher (2001) pointed out, the mathematics of even the largest estimates of AIDS optimism among gay men are such that the AIDS optimists cannot be generating the epidemiological effect reported in major cities. Interviews of gay and bisexual men reported here and in Vancouver reveal how little combination therapies or AIDS optimism in general enters into the thinking of those engaging in safe and unsafe sex (Miller et al., 2002).

The self-esteem concept is too comprehensive an explanation, in that men who may have no lack of self-esteem in general, at work, at home, and most of the time, may nevertheless be susceptible to stress, episodic depression, or a situational sense of worthlessness that increases HIV vulnerability. Although there may indeed be a grain of truth in the self-esteem hypothesis, it is salient in only some unsafe encounters. Summing up the mechanism of exposure as the problem of self-esteem poses the prevention challenge so abstractly that inaction is the likely outcome.

The voices of men making practical decisions in everyday life show how often situations of vulnerability to HIV infection are the consequence of following, not deviating from, social prescriptions, of attempting to acquit oneself as a good and caring person, and of trying to communicate love and commitment instead of sexual carelessness. Unsafe practices are often less a question of lack of knowledge, attitude, or the disabling of reason than a complex deployment of signs and interactions that must be addressed if HIV transmission is to be affected. They are embedded in what Foucault (1988) referred to as "practices of the self."

Unprotected sex arises in a variety of disparate circumstances: as a resolution to condoms and erectile difficulties, through momentary lapses and trade-offs, out of personal turmoil and depression, and as a byproduct of strategies of disclosure and intuiting safety. It is also strongly associated with relationship development and the communication of trust and intimacy. In addition, the development of a culture of unprotected sex among a subset of urban HIV-positive men poses further challenges in crafting adequate HIV-prevention programming. Neither ignorance, nor obstinacy, nor irresponsibility explains much about unprotected sex among gay and bisexual men today. Most are well-informed, sophisticated calculators of risk, and any prevention message that fails to respect the knowledge levels widespread in the community will surely fall on deaf ears. There is no average gay man nor average factor determining unsafe sex and no single message that can address the multiple situations and overlapping social and sexual microcultures, each with its own vulnerabilities to unsafe sex.

Implications for Prevention Programming

This study came about as part of a community-based research project with the AIDS Committee of Toronto, a leading AIDS service organization in Canada, with a mandate to conduct HIV-prevention work. It is clear from this study, and others in the research literature, that vulnerability to unprotected sex arises from a disparate set of psychological and sociological factors. The implication for prevention programming is that messages that can capture the interest and address the concerns of one set of men are likely to lack resonance with others. The challenge, then, is to delineate the cultural coordinates of various networks of men in order to develop well-targeted programming that will be effective. One of the problems and challenges of current HIV prevention is that many messages are already well-known and that different microcultures have taken up these messages in various ways, some assimilating them profoundly and others carving out exemptions from prevailing messages for themselves.

The approach of the AIDS Committee of Toronto has been to develop three campaigns to make headway in some of these areas of vulnerability, recognizing that these initiatives cannot provide a fully comprehensive prevention program given the exigencies of the limited resources available to it.

Assumptions campaign. A campaign pioneered by the San Francisco AIDS Foundation has been adapted to address a fundamental problem related to the emergence of a barebacker microculture. Although HIV-positive men who have sex with other HIV-positive men do not contribute to new cases of HIV disease, it is clear that a subset of HIV-positive men are assuming that a new sex partner who does not introduce a condom is also HIV-positive, while some HIV-negative men are assuming that no condom means a prospective partner is HIV-negative. The assumptions campaign calls on men to question these assumptions and to reinforce the need to use condoms with men of unknown sero-status rather than assuming their sero-status.

Condom use campaign. This campaign consists of print resources that address erectile dysfunction issues for older men and for other men who may have difficulty maintaining erections when using condoms. This approach does not start from the presumption that gay men are simply suffering from "condom fatigue" and must be reminded of the seriousness of the AIDS epidemic as a way to exhort them to use condoms consistently, nor does it presume that the disuse of condoms follows from the belief that AIDS is now easily treatable. Neither of these beliefs can be confirmed from this study's interviews with high-risk men. Rather, the condom use campaign attempts to offer some practical advice related to a recurrent theme among high-risk men whose narratives implicate erectile difficulties as a strong incentive in compromising or abandoning condom use.

Relationship-building. This campaign seeks to strengthen gay men's ability to develop relationships with other men, both sexual and romantic, that do not entail the heightening of HIV risk. The link between romantic discourses and willingness to drop condom use is an issue traditionally neglected by HIV-prevention campaigns.

Campaigns of this sort are just a start on a large agenda of issues that feed into vulnerability to unprotected sex. Interviews with high-risk men raise a range of additional prevention implications, such as the need for further research on prevention alternatives to condoms such as microbicides and vaccines; to challenge the stigma and rejection of people living with HIV that increase the difficulty of disclosing sero-status to new partners; to supplement prevention messages that rely exclusively on the premise of self-preservation as an incentive for safe sex, with an appeal to gay men to look out for, and take care of, other men; to depict men drawn from a greater diversity of ages and ethnocultural backgrounds as desirable to diminish the power of beauty hierarchies that influence men to "trade off" safe sex; and to support prevention programming for men moving to Canada from different cultures, especially from cultures in which homosexual relations are not organized around gay identity and HIV prevention has not included homosexual men. This study suggests that strategies and messages of this sort will resonate with gay and bisexual men in everyday sexual interaction.

Note. This research was made possible by grants provided by the Canadian Strategy on HIV/AIDS and the Community-Based Research Program of Health Canada. The views expressed herein are solely those of the authors and do not necessarily represent the views or policy of Health Canada.

Manuscript accepted December 30, 2004

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Barry D. Adam

University of Windsor

Winston Husbands

AIDS Committee of Toronto

James Murray

Ontario Ministry of Health and Long-Term Care

John Maxwell

AIDS Committee of Toronto

Address correspondence to Barry D. Adam, University of Windsor, Department of Sociology and Anthropology, 401 Sunset Avenue, Windsor, Ontario, Canada, N9B 3P4; e-mail: [e-mail].

Table 1. Participant Demographics (n = 102)

Education
  Graduate Degree                           11
  University Degree                         36
  Some College                              39
  High School Grad                          11
  Some High School                           4
Income
  [greater than or equal to] $60,000        11
  $40,000-59,000                            13
  $20,000-39,999                            29
  $10,000-19,999                            27
  < $10,000                                 19
Ethnicity
  British                                   20
  French                                     6
  Other European                            13
  Canadian                                  13
  African/Caribbean                         13
  Aboriginal/Metis                          13
  Asian                                     12
  Latin American                            10
  Middle Eastern                             1
  Don't know                                 1
Sero-Status
  HIV-negative                              31
  HIV-positive                              15
  Don't know                                 5