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Recently, an article appeared in the Times about how HIV negative gay men are taking Truvada, a drug to treat HIV infection, as a way to prevent themselves from getting AIDS. It is somewhat difficult to get a read on how widespread or successful this practice is, but the movement of HIV prevention in this direction as well as the hostile reaction by some, is revealing in what is says about gay men and our general attitudes toward sexuality.
Decades into the HIV epidemic, and despite considerable efforts to educate gays and other men who have sex with men (MSM), the HIV transmission rates continue to climb, and a growing number of gay men are engaging in condomless sex. “Condom fatigue” might be a reason, whereby after years of condom use, gay men are tired of using them. If HIV negative men take Truvada prophylactically, studies show that transmission is very much reduced and, as this NY Times article documents, some gay men have chosen to use this as their primary method of HIV prevention. These men have been called derisively, Truvada whores; however, a number of gay men have taken the sting out of this term by defiantly self-identifying in this way, embracing and even emblazoning the moniker on t-shirts.
Perhaps the alarming reaction to prophylactic use of Truvada is not surprising. Our culture has always had harsh words for gay men, women, or anyone who wasn’t a heterosexual man who exhibited and acted upon strong sexual appetites outside of traditional marriage. Gay men’s sexual attractions have been stigmatized in the past, and while there is a growing acceptance of gay and lesbian people in our society, we are still largely uncomfortable with sexual behavior between men. It is worth noting that marriage has long been thought a way to tame men’s aggressive and sexual behaviors, thus domesticating them—and by legalizing same-sex marriage, perhaps the same is wished for gay men.
The discomfort around gay men’s sexuality and sex in general is clearly reflected in the direction and focus of safer sex education efforts in this country. Abstinence, limiting sexual partners, and above all, consistent condom use have been the primary prevention for methods for MSM (and others) promulgated by public health officials. Federally funded studies have prioritized consistent condom use as a primary HIV prevention strategy and thus, the most prominent dependent variable in HIV prevention research. Sometimes men who have sex with long-term partners who are HIV negative are lumped into the same high-risk category as those who engage in casual sex with partners of unknown HIV status. This categorization ignores the basic facts of HIV transmission. HIV is a virus transmitted by blood contact with infected blood or semen. You can get it after one sexual encounter with someone who is positive—or in a sexually monogamous relationship. You can avoid getting it if you have condomless sex with hundreds of HIV negative partners, and/or by using condoms when engaging in intercourse with with someone who is HIV positive. There is some evidence that you can remain HIV negative while having unprotected sex with someone who is positive but who has no detectable viral load as a result of treatment. In addition, it seems if you are negative and taking a specified dose of Truvada, you may also be able to engage in unprotected sex with someone who is positive without being infected. Transmission has little to do with numbers and, more often than we recognize, condom use is irrelevant—and this often gets lost in the discussion about HIV prevention.
Further, and even more disturbing, little attention is paid to the decrease in pleasure inherent in condom use. Serosorting, meaning having unprotected sex excusively with people of the same HIV status, has never been seriously promoted as a method of risk reduction in the US, nor has “dipping” or pulling out of intercourse before ejaculation. I recall seeing a poster in a gayborhood in London advising gay men to: “Cum on his back like a porn star.” What was striking about the campaign was that, unlike our prevention and research efforts in the US, it was sexy and sexual, speaking directly and unabashadly to gay men’s pleasure in a way that would be unacceptable here. In my own HIV prevention research, I distributed flyers to recruit young gay men. On these flyers was a picture of a handsome, well-built man with his shirt open to the navel. HIV prevention agencies balked at helping me circulate them, saying it sent “the wrong image” and was exploitive. These providers’ reactions were wrongheaded and reflected an approach to HIV prevention that was not only shortsighted but sex-negative and culturally ignorant. To recruit gay men for HIV prevention, one must have a clear and thorough understanding of sexual attraction and desire. Handsome, shirtless men get gay men’s attention, and also gets them thinking directly about the topic at hand.
I have sat in on meetings of HIV researchers and prevention specialists who were flummoxed by why the use of condoms of gay men is decreasing. They offered dark interpretations of why gay men and other MSM are not consistently using condoms, such as low self-esteem, poverty, stigma, substance use, and mental illness. What was missing from these (and many other) discussions of HIV risk are the issues of desire and sexual pleasure. For sure, stigma, poverty and mental health issues may likely put men at risk for having unsafe sex. However, it is important to recognize that during the act of anal intercourse, many penetrators or “tops” cannot achieve orgasm while sheathed in a condom due to the reduction in friction. Relatedly, a significant part of the enjoyment of being a bottom is knowing the pleasure he is giving the top through his own submission, which is lost if the top’s pleasure is clearly diminished. Thus, the decision to use condoms is also a decision to prioritize safety at the cost of sexual satisfaction. Promoting “safe” sex will always be limited whereby, currently and throughout history, hot sex has always been dangerous in some way. Thus, “safety” isn’t sexy and can, in fact, be a libido killer.
Further, it must be recognized that gay men have consistently been told their sexuality is wrong—so they are accustomed to finding ways to ignore messages that simply do not take into account their desires, attractions, and pleasures. Thus, a movement or message that promotes abstinence or limiting sexual pleasure will always be seen as suspect; a way to control a type of sexuality that makes society uncomfortable or afraid.
So, back to the issue of Truvada whores…The promotion of the use of prophylactic HIV medications offers an important option for gay men—a way to protect themselves that does not diminish sexual pleasure and takes into account their desires. If we fail to understand issues of pleasure and desire, our HIV prevention efforts will continued to be stymied by our own Puritanism.
