by Ryan Gierach
Monday, Apr. 08, 2002 at 4:47 PM ryan.g@journalist.com 213) 386-5119 400 S Lafayette Park Place #215
Barebacking by Gay Men is increasing - or is it?
errorMilton stood with a booted foot on the fire pit and a cigarette hanging from his mouth in the cool Southern California night, his T-shirt hanging from a back pocket. “ I never, let me repeat that for you so you get it right, I never use a condom.” Knowing glances caressed him; a group of six gathered on the L.A. sex club’s patio evidently shared his defiance of STD/HIV prevention messages, which insist they wear protection every time they have sex. The group gradually melted away and into the dark interior to “do it raw.”
Jamie lives close to San Francisco, and has been HIV positive for 12 years, since he was 22. He spoke on condition that only his first name be used, but wanted desperately to tell his story. “I barebacked because I had the biggie — what could hurt me more than HIV? Was I wrong…. When I started getting the eruptions in my [rectum], I hoped I would die — the pain was that bad,” he said. “It got so bad I stopped eating, because that meant [defecating]; I lost 40 pounds and landed in the hospital with now full-blown AIDS and dehydration. All because of chlamydia. Who the f—k ever heard of chlamydia?”
Though reports of barebacking (the willful practice of engaging in condomless sex) have permeated the media for the past several years, it appears that, despite prevention messages, the practice is not going away. Increasingly it is clear that men who have sex with men (MSM) are eschewing safer sex practices credited with reducing HIV transmission rates. Though previously evidence was largely anecdotal, as of 2002, the GLBT and HIV/AIDS communities now have solid empirical evidence on barebacking to consider.
The Center for Disease Control and Prevention (CDC) and San Francisco’s Department of Public Health conducted a study of barebacking in 2001 that found 14 percent of respondents who knew the term had engaged in barebacking over the course of the past two years. CDC researchers and officials point to the rise in STD rates in the MSM community as further proof that barebacking is on the rise, fearing that an increase in HIV transmission may soon follow. “We see STD rates rising in the MSM community; can HIV rates be far behind?” asked Ron Valdiserri, assistant director of STD and HIV Prevention for the CDC.
“We know that [14 percent of men barebacking] is way under-reported,”said Eric Rofes, professor of education at Humboldt State University and the main organizer of the Gay, Lesbian, Bi-sexual, Transgender, and Intersex Health Summit (formerly the Gay Men’s Health Summit). “The study was self-reported, and social scientists are aware that a person’s response to surveys is linked to current cultural norms. In the 1980s, all gay men in the media represented themselves as having 100 percent safe sex, 100 percent of the time. Today, some gay men speak openly about unprotected [anal] sex, but far fewer speak out than the number who actually do it.”
Some point to a seminal piece in Poz Magazine as a conscious starting place for the phenomenon. The national AIDS glossy featured a photo of HIV-positive model and activist Tony Valenzuela in early 1999, buffed, beautiful, and naked on a black steed. The cover read, “Tony Valenzuela and the boys who Bareback take you on a ride inside.”
After 15 years of fear, “sexy” was suddenly back in gay men’s sexual lexicon, says Gabriel Rotello, author of Sexual Ecology: AIDS and the Destiny of Gay Men. He wrote, “The popularization of that term seems to indicate a shift from describing unprotected sex as unsafe sex, to describing it as sexy and alluring, which the term barebacking implies.”
Rofes commented on why some might gravitate toward this line of reasoning. “Sex is walking that line of risk and excitement and danger. By mandating that men always use condoms, we made safer sex boring and a drag, and condom-less sex intriguing.”
Those who walk the line
Gordon Mansergh is a behavioral scientist in the epidemiology division of CDC’s HIV/AIDS prevention department. He was lead researcher for a barebacking study in San Francisco, released this month at the National STD Prevention Conference held March 4-7 at the Town and Country hotel in San Diego. Entitled “The Hidden Epidemic: Confronting Sexually Transmitted Diseases,” the conference was co-sponsored by the CDC, the American Social Health Association (ASHA), and the National STD Prevention Conference. Studies on syphilis, gonorrhea, and Human Papillomavirus (HPV) transmission in men, as well as co-infection of STDs and HIV were also presented during the conference. Mansergh’s partner in the study was the director of HIV prevention studies for the San Francisco Department of Public Health, Grant Colfax.
Mansergh said his work “is the first quantitative study of barebacking ever in the MSM community.” He also noted that the scientists took great pains to tightly define the subject of barebacking, and also to reach out to a diverse set of ethnic groups. “We define barebacking as a socio-cultural phenomenon and were interested in talking only to those who had heard or knew the term barebacking.” Seventy percent of those the surveyors approached in the San Francisco Bay area — in front of bars, clubs and sex venues — had heard about barebacking.
“We further defined the term for them at that point,” said Mansergh, “to mean intentionally setting out to have anal sex without a condom with someone who was not a partner.” The idea was to separate the wheat of the willful barebacker from the chaff of unintentional or situational unsafe sex, or that which occurs within the context of a monogamous relationship.
What Mansergh and Colfax found surprised them. “Only 14 percent acknowledged barebacking in the past two years,” Colfax said. “Some had supposed as many as 60 percent of the MSM community were involved.” He noted that ethnicity played a huge role in the study. Of those who heard about the term barebacking, 83 percent were white and only 60-65 percent were men of color.
Additionally, the researchers found little difference between ethnicities who reported barebacking. “Clearly the higher you go in income and education, the better acquainted with the barebacking sub-culture you are,” Mansergh said. “But also if you are going to do it, it doesn’t seem to matter what ethnicity you are.”
The researcher did uncover an important difference in barebacking when sero-status (HIV status) was factored in. “Twenty-two percent of barebackers reported they were HIV positive,” said Mansergh, “Ten percent who bareback were negative.”
He found somewhat hopeful news in the study in that MSMs have internalized the fact that unprotected receptive anal sex is the highest risk factor and are avoiding it; and also that nearly two-thirds of positive men bareback with other positives exclusively.
“This all tells us,” he said, “that there is a relatively small number of acknowledged hard-core barebackers — that is, small from a cultural standpoint. Epidemiologically speaking, when we see ever-widening pools of infection stemming from just a few sources of transmission, 14 percent is very significant.”
Colfax wondered aloud whether the numbers would translate into a larger socio-cultural phenomenon. “This is self-reported data, and of course, is therefore probably low,” he said, “but it leads us to ask if it is sufficient to push the envelope socially. Will the practice become widespread?”
Come on, the practice is already widespread!
So said Louise Hogarth, an Academy Award-winning documentarian who has been making films on HIV and barebacking for the past few years. She spoke from San Francisco, where she was filming her new documentary entitled “The Gift.” Hogarth says she is “70 percent done” with this film, and what she is finding scares her.
“What are gay men doing to themselves and to one another? Why are they purposefully getting HIV?” she asks. “When I started this film, we were looking at barebacking only and even had another working title — but I must go where the story takes me and that is into the area of sero-conversion through barebacking.”
Hogarth has had several individuals come forward to tell their stories on camera. One man is 40 years old and finally “had it” with being safe and using condoms all the time. He said he saw that HIV was treatable and went out and got infected so he could finally relax.
Another is 20 now; he consciously became HIV positive at 18 because it didn’t seem too big a deal anymore and made life a lot easier — or so he thought. He is now very sick with AIDS and says he regrets believing the pharmaceutical company’s advertising that told him he could climb mountains. “He told me,” Hogarth said, “that he saw the tobacco ads where the lady breathed smoke through her tracheotomy and wouldn’t dream of smoking. He just didn’t know the consequences of HIV.
“What scares me,” Hogarth said, “is that not only aren’t men afraid of HIV anymore — they are embracing it!” But worse, in her mind, are those people out there who know barebacking is not politically correct to speak about, but engage in it anyway. She recalled a story told her by a doctor who sat at a dinner table with two other doctors. “He said that the others were bemoaning that men who knew better would do such a thing. He was thinking the whole time to himself, ‘I have barebacked with you both.’
“I call it sexual Don’t Ask Don’t Tell” she said. “Guys tell me that if they even mention sero-status or condoms, other guys get angry with them. Some actually get asked to leave sex parties if they bring out a condom.”
Others see the same thing — a fear of disclosing that they don’t want to use condoms, even to doctors in a confidential setting. Dr. Daniel Lee is with UCSD’s Owen Clinic in San Diego, one of the country’s leading HIV/AIDS care programs. “[Barebacking is] one of those issues that, if we ask [our patients] directly about sexual practices, etc., it does come up,” said Lee. “The problem is that a lot of people don’t disclose. That’s been kind of an issue. I’ve talked to a couple patients of mine who have admitted, in regards to barebacking. Sometimes patients just don’t want to admit it.”
Most of the data the clinic gets on barebacking comes from anonymous surveys which, again, are self-reported and most likely represent lower numbers than exist on the street. “In our clinic, we have a questionnaire in regards to kinds of sexual practices.
We were recently involved in a little bit of research in looking at safe sex practices, more with like gonorrhea, chlamydia and [other] STDS.”
Lee said that from his experience,
he’s has seen MSMs in their mid-30s and older, if not admitting to willful, unsafe sex practices, then longing for the days when safe sex was not an issue. “I think they do tend to probably be older, or they’re people who have lived longer with HIV who have gotten tired of having to be abstinent all these years and hearing the same messages about wearing condoms and this and that…. Some patients certainly feel that they wish they could go back to the old days when people didn’t have to be safe,” he said. “They wanted to be able to have that sexual freedom to have sex the way they used to have sex — without condoms.”
That desire is counter-balanced, however, with a sense of responsibility to others, Lee said. “There are always those issues of, I think, guilt for some people in regards to barebacking. [But] I think especially in those who do do it, they feel that as long as they are upfront with the other person — whether you’re talking about HIV status or not — that as long as the other person consents, it’s okay to do that. I think that the people who admit to barebacking, at least, probably feel … that it’s not their responsibility. As long as it’s with another consenting adult, and they know what risks they’re taking, they don’t worry too much about it.
“Partly it may be a little bit of a rebellious act for some people,” Lee continued. “It’s kind of a way for them to assert their power, so to speak…. It’s a little bit disturbing, but I always feel that it’s a person’s choice to do what they choose to…. As a health care provider, it’s certainly not something that we promote, but I’m very much of the idea that life is all about choices.”
Terry Cunningham, chief of the San Diego Office of AIDS Coordination, said there have been no specific messages in the San Diego area that have dealt with barebacking, but that he feels all prevention messages inherently deal with the issue. “We have looked (at the problem of barebacking),” said Cunningham. “It is addressed through the contracts that we have out for MSM in the community.” Asked if Cunningham’s office has any concrete sense of how large the proportion of willful barebackers is to that of those in the community who are simply practicing unsafe sex due to a lack of education, Cunningham said, “You know, the county isn’t the sex police, so while we are aware of the problem and the practice, we really don’t have either the mandate or the ability to intervene or do more than get information out there. It’s basically the individual’s choice and we try to give them the information that will provide them with the knowledge that they need to make a wise decision. That’s about as far as we can go. ”I think any safe sex message is targeted toward not barebacking,“ added Cunningham. “You just have to look at the whole gamut of being healthy. I don’t know whether a campaign that says ‘Don’t bareback’ in the community is going to be something that is effective….There’s only so much that you can do with information.”
Attitudes among the Latino MSM population
Robin H. Slade, chair of the San Diego-based Bi-National AIDS Advocacy Project (PROCABI), which works to reduce the impact of HIV/AIDS in the San Diego and Tijuana border region, took part in a recent study of HIV rates in gay and bisexual men in the border region, funded by the state. Slade said he feels a majority of the barebacking activity in the Latino community is more a lack of education. “It’s not like it is in the Caucasian community where barebacking is because, ‘I want to feel you within me without a condom,’ and all this other stuff,” said Slade. “That doesn’t come into it…. A majority of the Latino population believe if you’re not receiving body fluids, you can’t get infected. We’ve got people who are active, not passive, that continue not to used condoms, because they don’t think that they can get infected. It’s a cultural thing; they think, ‘I’m not receiving anything, how can I get infected?’ ”Things are changing,” Slade noted. “People are starting to use condoms [though] we found that there are certain condoms they won’t use. They want a condom that they can’t feel when they’re using it. So, we’re going to the extra large condoms, which are loose fitting, but still provide the protection.”
Knowledge is power,then?
Too many men walk around without the knowledge they need to make informed choices; too many like the 20 year-old who won’t smoke, but caught HIV; too many like Jamie, who had HIV and didn’t think a mere STD he’d never even heard about could hurt him. CDC researchers recently found that roughly 25 percent, or 180,000 to 280,000, of people with HIV/AIDS still do not know they are infected. “I’m surprised at the size, not at the fact,” said Tim Teeter of the San Francisco AIDS Foundation. “I haven’t seen a ‘get tested for HIV’ poster in San Francisco in years,” he said. Teeter says bringing rapid HIV testing technology to market could lead to greater testing. But he says there also must be greater education.
The CDC agrees. “The two biggest reasons why people are not getting tested is because they either don’t perceive themselves [as being] at risk or don’t want to find out they are HIV positive,” a spokesperson for the CDC said. “So it remains a tremendous barrier to overcome to promote increased testing.”
So even while testing for HIV has increased in the urban centers, still many men catch and transmit HIV and other STDs unknowingly. One of the recent studies presented at the CDC’s STD conference in San Diego noted rises in STDs among MSM in every major urban center — and that over 50 percent of the MSM who reported an STD last year across the country were co-infected with HIV. Alarmingly, over 30 percent of those men didn’t know they had HIV before their STD test.
Public health officials note with alarm that many STDs are a catalyst for HIV transmission and vice versa. The CDC’s Ron Valdiserri said, “HIV is transmitted from two to five times more often when an STD is present. And STDs are far easier to catch when HIV is present. We fear this rise in STD rates among MSM will translate to increased HIV rates.”
STDs by themselves are very dangerous to those carrying HIV, according to the medical experts. “Human Papillomavirus (HPV) has been shown to cause anal cancers, and more so in HIV positive men, who are more susceptible to cancers like that,” Dr. Ken Mayer said. Mayer practices at Fenway Community Health Clinic in Boston and is one of the world’s foremost experts on HIV. He spoke at the San Diego STD conference between trips to Seattle for the annual Anti-Retroviral Conference and Thailand for an Asian-Pacific HIV conference.
Mayer presented a study done at
Fenway that showed STDs are on the rise in the MSM community. “The STDs like anal or throat gonorrhea and anal syphilis and anal chlamydia often go undiagnosed because the
symptoms are hard to detect,” Mayer said. “When that happens and HIV is present, there will be far greater physical consequences, such as in chlamydia, where tremendous and painful anal eruptions can develop along with other more serious rectal problems.” While chlamydia is curable, it often goes undetected; herpes is incurable.
Jamie’s doctor told him that he had probably caught chlamydia a decade ago. “I guess I’m glad I didn’t get that HPV and anal cancer,” he said, “but I can’t imagine it’s much worse than what I got.”
Hepatitis C, a difficult to treat form of common hepatitis, is most often transmitted through needle exchange or oral/fecal contact — such as rimming. “Hep C is horrible for those with HIV,” said Mayer. “Co-infection of HIV and hep C makes each disease progress faster and more difficult to treat.” Indeed, we see many deaths in the obituaries from hepatitis or liver failure, which are usually brought about due to co-infection with AIDS, but seldom anymore do we see “complications of AIDS” listed as the cause of death.
The catch here is that “use a condom every time” is wearing thin even in scientific circles. A 30-page report, which grew out of a June 2000 meeting of officials from the National Institutes of Health, CDC, FDA and USIAD, concluded that scientists don’t really know whether condoms work against a battery of diseases, and that more research is needed to determine whether condoms can protect against transmission of human papillomavirus (HPV), chlamydia, syphilis, chancroid, trichomoniasis and genital herpes. However, their report states that evidence definitely supports condom use in preventing the spread of HIV and gonorrhea in males.
If using a condom doesn’t protect you, what will?
Tom Coates heads up the STD Prevention Studies Program for UCSF. He has long been a national spokesperson for HIV and STD prevention advocates seeking to place the absolutist philosophy of condom use at all times and in every situation into perspective for most men. “We must develop a message that rests on a tripod of responsibility for others, altruism, or a selfless interest in the well being of others, and self-interest in our own sexual health,” he said. He feels that talking about only one virus has shot prevention efforts in the foot. “We need to talk about the sexual health of people, not just HIV.”
Eric Rofes agrees, “When prevention is based on one virus, those with it see anything else as unimportant. Likewise, a focus on substance abuse and its connection with HIV becomes ineffective. Saying that, ‘If you abuse alcohol or drugs you’ll get HIV’ just makes those who already have HIV laugh. Instead, we need to talk about sexual health as part of the whole person’s health. The message becomes instead, ‘If you use drugs or catch an STD or HIV, all these bad things will happen to you.’ That makes a more compelling argument.”
Rofes believes that condom-only prevention messages, while potent in the crisis of a decade ago, are now meaningless, or worse, create more disease. “By making unprotected sex taboo, we made it more enticing to men who see themselves as sexual renegades,” Rofes said. “Tell a child who yet hasn’t dreamed of putting his hand in the cookie-jar not to put his hand in the cookie jar and watch the cookies disappear. The only way to combat disease and nurture MSM sexual health is through shifting funding streams to a focus on sexual values of the MSM culture and then on the health issues that [arise] because of them.”
John Copeland, head of prevention and education at Shanti, the first AIDS service organization to provide direct services to clients in Los Angeles, said he agrees. “We need real sex education for everyone,” he said. “Funding must be directed to programs that will make youths who might be gay accept gay sex as normal, and not something to go out and experience with no knowledge, and in shame.”
Copeland shared some of the stories he hears in counseling and emotional support groups — stories that chill the most hardened listener. “They can’t meet guys because their parents and society disapprove, so they get all drunk or high and go out to West Hollywood and get f—ked by a dozen guys in one night and end up sick. All because of discrimination and squeamishness and prudery. Let’s help people be healthy, not force them to be sick.
“Look,” he said, “people are going to bareback…. The question we face is how do we teach people to use negotiated safety techniques and about sexual health in general? The CDC ought to sponsor anti-homophobia campaigns across the nation. We should be teaching sexual health that includes negotiated safety to parents and in the schools, and the CDC would do well to promote gay marriage as disease prevention. Yes, of course continue to talk about condom use; but let’s face reality. Where human sexual behavior is in question, one size does not fit all.”