I have commented several times on Facebook about my anxiety over the sudden popularity and push for widespread use of Truvada. To be clear, I'm not opposed to the use of Truvada, and I agree that it is an exciting development in fighting the spread of HIV/AIDS. However, while some reject the idea that the promotion of Truvada among gay men has anything to do with barebacking culture -- and subsequently vilify anyone who makes the suggestion -- it doesn't negate the reality that barebacking has become a widespread practice in gay male culture. The insistence that this drug can help curb the skyrocketing infection rates among gay men then problematizes their earlier point about barebacking, especially when coupled with statements about the inefficacy of condom use. At one point I was even called "bareback-phobic," as if I didn't really understand the psychosocial motivations for having unprotected sex. Moreover, I find shifts in language from "unsafe sex" to "condomless sex" to be a dangerous attempt at destigmatizing behavior that continues to be considered high-risk for the transmission of HIV/AIDS. The purpose of this post, however, isn't about my anxiety around Truvada, which I will write about separately. This is about bareback culture.
I recently began reading Unlimited Intimacy: Reflections on the Subculture of Barebacking by Tim Dean. This book is an attempt to present a nonjudgmental quasi-ethnography of bareback culture in order to understand the motivating factors and explain its continuation and growth among gay men. I found myself struggling with the concepts he presented. I spent my teen years living through the '90s and initiated into a gay culture saturated with safe-sex education. Dean makes a number of interesting points, and, because this is an academic book put out by the prestigious University of Chicago Press, it presents plenty of evidence to support his statements. He also explains the complexity of bareback culture and bareback identity in terms I can't refute, as he purposely divorces his theoretical framework from the epidemiological information about HIV transmission in order to distance it from the moralizing I am trying to avoid as well.
One of the many points Dean makes is that there is a liberation in barebacking. It offers sex without barriers that allows for greater emotional intimacy. It allows men who are HIV-positive to share a psychosocial bond based on the shared characteristic of having HIV. It is a mode of anti-homonormativity that acts against the assimilationist trend in gay-male culture over the last few decades. He points out that there are barebackers who have no intention of passing along the virus, that many men who bareback aren't "bug chasers" or "gift givers," that HIV isn't necessarily even part of the decision-making process. He states that the assumption that barebacking stems from self-destructive behavior is reductive, as many monogamous couples bareback, and that current evidence questions the role of barebacking in HIV/AIDS transmission.
These last two arguments are what I have the greatest anxiety about. First, there are methodological problems in so much of the research on STI transmission and barebacking. Second, you cannot discount infection rates and their effect on overall health from decision making. The point he makes about the associations of procreation amidst a culture that acknowledges its risk of contracting a deadly disease feels like an illegitimate argument to oppose the assertion that unsafe sex has some roots in self-destruction.
I understand the desire to have sex without a condom. I can't think of a guy I know who wouldn't. While I won't say I have not or will never engage in bareback sex, there are factors that must be involved in decision making. The CDC states, "Laboratory studies have demonstrated that latex condoms provide an essentially impermeable barrier to particles the size of HIV," adding, "Epidemiological studies that are conducted in real-life settings ... demonstrate that the consistent use of latex condoms provides a high degree of protection." The AIDS Foundation of Chicago states that, when used consistently and correctly -- a qualifier used by the CDC as well -- latex condoms "are 98-99% effective in preventing HIV transmission." While nothing is 100-percent effective, the recent reports supporting Truvada use over condom use because of studies showing their ineffectiveness are invalidated by the larger body of research.
The issue of "condom fatigue," a term I have a very strong negative reaction to, seems less a product of the scant research rejecting condom efficacy and instead evidence of the increased apathy among gay men regarding long-term health. Again, while not all gay men bareback with the intention of contracting or transmitting HIV, there is a nexus of high risk factors for HIV transmission centering around a subset of bareback parties involving drugs, or PNP parties. A number of recent reports from the UK detail concerns of health organizations over the rise of these parties among gay men. There is an element of this that is common to what David A. Moskowitz and Michael E. Roloff point out in their article in the 2007 July-August issue of Culture, Health and Sexuality. There they identify two subgroups of "bug chasers": those who are apathetic to the HIV status of their partners, and those who are ardent chasers looking for serodiscordant partners.
If we are to consider "condom fatigue" legitimate, then we have to recognize the apathy implied. That apathy is toward infection rates and, ultimately, to the person's overall health. Furthermore, another disturbing statistic out of the UK recently was that 94 percent of gay men surveyed were more likely to have bareback sex with someone they found attractive. The link between drugs and bareback sex isn't necessarily correlative, yet drug use is considered a high risk factor for HIV transmission, and drug use is endemic of at least part of bareback culture. Also, a 2003 study showed that HIV-positive men were 50 percent more likely to use methamphetamines during sex, which has implications of higher rates drug use in general. This is consistent with a review of the literature in an article published in Substance Use and Misuse in 2011 by Naomi Braine et al. Isolation, stigma, and self-esteem -- all experienced at far higher rates by HIV-positive gay men than by those who are HIV-negative -- affect both drug use and the likelihood of barebacking.
It is possible that barebacking was not just a tiny subculture but arose out of a larger practice far more widespread than we want to admit. The current culture adds to this the fact that for eight years we had a government redirecting AIDS research and education money toward ineffective abstinence programs. Also, the dramatic changes in drug therapies and a generation who grew up without first-hand experience with the horrific consequences of AIDS have affected discourse on the disease in gay media. The apathy toward infection is dangerous. While people who have been infected shouldn't be shamed, willful ignorance of the debilitating physical and psychological effects of HIV and other STIs, especially in advanced stages of the disease, is dangerous and has become all too common among gay men. The fact that the medications are better and that people are living longer does not take away from the continued side effects, or the inevitable and painful decline of health toward the end of the battle with the virus. In addition, access to those medications varies widely. Access to medications and quality health care is often dependent on economic status and geographic location. Someone living in New York City will have very different resources than someone living in Waco, Texas. The pretense that everyone who is infected will have the same experience as they grow older and deal with the advancement of the disease is lunacy.
None of this is meant to shame people who are HIV-positive. This is merely a plea to be informed. If you make an informed decision, like Dean, to practice barebacking or participate in bareback culture, then so be it. I can't say I will never do the same. However, short-term pleasure, a sense of belonging, and the excitement of abandoning homonormative sociosexual practices cannot be divorced from either a willful rejection of long-term health or a romanticized concept of what the infection leads to. If we label those who "live fast, die young, and leave a beautiful corpse" as self-destructive, then we have to also recognize that this as a factor, however minute, in the psychosocial motivations for barebacking. I'm not an alarmist who thinks all barebackers are poz guys willingly infecting others who are unaware of their status, nor do I support the criminalization we've seen put into effect in numerous states. Yet a recent case in San Diego of a guy who only found out about his partner's serostatus after an ex of his messaged him on Facebook saying the partner was intentionally infecting people is a textbook example of why not discussing HIV status with a casual partner is dangerous, why assuming they're negative either because they looked healthy or said they were is ignorant, and why regularly practicing unsafe sex out of apathy is self-harm. We should know better. We must do better. Until there's a cure, every one of us has the right to make our own health choices. For those of us who want to remain healthy and live past 40, we must be educated and protect ourselves.