HIV-Negative: How the Uninfected Are Affected by AIDS
Copyright © 1995 by William I. Johnston
New York: Insight Books-Plenum Press
"I've decided that I'm not going to fuck or get fucked without two condoms," said Richard, a 31-year-old community activist. "But there have been times when I've deviated from my standard a little. There have been times when I've let one of the condoms go." Richard told me the times he had used only one condom were when he was embarrassed about letting a sexual partner know his safer-sex standards. "I felt it might be perceived as too weird, too reactionary, just like people used to worry about proposing one condom."
In chapter 15 I suggested that under some circumstances gay men decide that sex without a condom is not always "unsafe." Richard's statement suggests that for him sex with a condom is not always "safe." What this points out is that the terms "unsafe" and "safe" are subjective when they are used by gay men and largely useless when applied to sexual behaviors stripped of their context. Social science researchers, epidemiologists, and AIDS educational materials often discuss sexual behaviors -- such as unprotected receptive anal intercourse -- as if their "riskiness" were inherent. But gay men reveal through their actions and beliefs that whether behaviors are considered unsafe or safe depends on many factors, including HIV status and personal decisions about levels of acceptable risk.
Sex among gay men would be simpler if we all agreed on what was "safe" and what was "unsafe," and in the early years of the epidemic we tried to pretend this was possible. Faced with a frightening new sexually transmitted disease, gay men were the first in the United States to develop educational materials that informed people about the sexual transmission of HIV. These materials frequently placed sexual behaviors along a "spectrum of risk," in which anal sex was considered "very risky," oral sex was considered "possibly risky" or "possibly safe," and mutual masturbation was considered "very safe."
The crudeness of this spectrum was largely due to the lack of reliable scientific evidence about transmission of HIV under various circumstances. The advantages of this spectrum were that it was simple, it proposed a convenient way for gay men to conceptualize risk, and it allowed us to hold out some hope that our sex lives would not be shut down entirely. It also offered a working definition of "safety" that let men say they practiced "safer sex" even though in reality that meant very different things to different people.
Gay men relied on the risk spectrum because there was nothing else available and our anxiety about sexual risk encouraged us to look for guidance to help us make sexual decisions. "Tell us what to do," we seemed to be saying. "How can we have sex in an epidemic?" In the face of uncertainties about risk, we looked for experts who could make decisions for us. This search for experts continues today, principally around the issue of how risky oral sex is. When I worked on an AIDS hot line in Massachusetts, this was the issue gay men asked about most frequently: "Is oral sex safe? Should I swallow cum or spit it out? What about precum?" We had very little data, so I ended up parroting simplistic answers like, "There may be some risk. You might want to avoid getting cum in your mouth or use a condom for oral sex." It was easy for me to parrot those answers because at the time I worked on the hot line I abided by the simplicity of the HIV-risk spectrum myself, avoiding oral and anal sex entirely for many years.
Interestingly, after I got tested for HIV and learned I was HIV-negative, I began to change my attitude about oral sex, and as I did so -- especially after I started having unprotected oral sex with an HIV-negative partner -- my answers to callers became more nuanced. Suddenly, I was better able to hear their concerns and speak with them about the complexities of making decisions about safer sex. At the same time, my hot-line coworker, who had learned he was HIV-positive, became more conservative and directive in his approach to questions from callers about oral sex. "You should avoid oral sex without condoms," he said. "You don't want to get this disease."
I raise my experience on the hot line to illustrate that even when gay men think they are getting "information" from "experts" -- such as by calling an AIDS hot line -- they are often getting no more than one person's view of the issues, a view that is likely to be colored by personal experiences. I also raise it to suggest that since the advent of HIV testing, sexual behaviors can no longer be viewed categorically as "safe" or "unsafe," because some people know their HIV status, and thus know whether they are capable of becoming infected or of infecting others.
The consequences of unsafe sex are radically different for people who are HIV-negative and HIV-positive. For the HIV-negative individual, unsafe sex with an infected partner involves the possibility of becoming infected. For the HIV-positive individual, unsafe sex with an uninfected partner involves the possibility of infecting another. In starkest terms, the difference has been compared to suicide and homicide. The analogy is not exact, of course, because HIV infection is not usually premeditated. However, I have heard unsafe sex after HIV testing described by different people, depending on their perspectives, as assisted suicide or murder with the consent of the victim.
The different consequences of unsafe sex for HIV-negative and HIV-positive men can be seen in our attitudes about why people have unsafe sex. When I asked people why they thought uninfected men might have unsafe sex, the answers often cast the HIV-negative as low in self-esteem, depressed, grieving -- in short, possibly suicidal. When I asked people why they thought infected men might have unsafe sex, the answers often cast the HIV-positive as revengeful, demented, irresponsible -- in short, possibly homicidal. Keith, 40, who in chapter 13 discussed his relationship with his HIV-positive partner, Mark, summed up the difference this way: "If you're negative and you're playing unsafe, you're taking a chance. You might as well take a gun and put a bullet in and play Russian roulette. If you're positive and having unsafe sex, you might as well just go out and take a six-shooter and shoot a few people dead."
And yet why should we imagine that the reasons uninfected and infected men engage in unsafe sex are so radically different? Perhaps we engage in unprotected sex because it feels better, seems more natural, connects us to our partners intimately, expresses our desire to share our semen with each other. It may not indicate either suicidal or murderous intention. Further, why should we assume that by becoming infected, people suddenly switch from being suicidal to being homicidal? And yet our culture, by painting the uninfected as "innocent bystanders" and the infected as "guilty perpetrators," reinforces this idea.
Considering the distinct meanings of unsafe sex for HIV-negative and HIV-positive men also allows us to better understand what it is like not to know one's HIV status. If you don't know your HIV status, then you cannot place an unequivocal meaning on unsafe sex. Is it unsafe for you or unsafe for your partner? As I discussed in chapter 3, the position of not knowing whether your sexual behavior is endangering yourself or others is quite familiar to gay men, especially those who had sex in the early 1980s, when testing for HIV was either unavailable or not encouraged.
The ability to simultaneously imagine danger to yourself and to others, so immanent in sexual encounters before HIV testing was available, is drastically reduced when you learn your HIV status. When you learn you are HIV-negative, you gain a heightened awareness of your vulnerability to infection. When you learn you are HIV-positive, you gain a heightened awareness of your infectiousness. What were previously equal concerns are no longer equal; one concern is heightened while the other is attenuated. I discussed this dichotomy in chapter 11, where I postulated that the "meanings of HIV status" are different for HIV-positive and HIV-negative people. I wonder what influence the different consequences of unsafe sex have on whether people who know their HIV status have unsafe sex.
During my interviews, I found that getting gay men to talk about unsafe sex was difficult. Perhaps our community has made it intolerable to discuss unsafe sex because we wish to convey the impression that gay men practice safer sex consistently and enjoy doing so. I usually broached the subject by asking men, "Why do you think some uninfected men have unsafe sex?" I posed this question first because it was less threatening. Then I asked, "When have you had difficulty practicing safer sex?" This second question offered men a chance to discuss unsafe sex they had had or were tempted to have without suggesting they were bad. Interestingly, the answers I got to these two questions were quite different.
The reasons cited for why other people had unsafe sex were almost uniformly harsh. "Why do people smoke? Why do people drive without wearing a seat belt?" asked Scott, 24, a graduate student from Newark, Delaware. "I don't know why people flirt with disaster. I guess the reasons are that unsafe sex is more fun than safe sex -- and irresponsibility." Jesse, a 29-year-old scientist from Philadelphia, suggested that uninfected men have unsafe sex because of "a false sense of security, a sense of abandonment, lack of knowledge, or just plain stupidity."
Anton, a 31-year-old graduate student from Pittsburgh, suggested that some men "really like getting fucked and just cannot resist the temptation." Reed, a 36-year-old computer engineer from Charlottesville, Virginia, concurred: "People just want sex sometimes badly enough to ignore the risk, don't we? We sure did when the risks were things like gonorrhea or hepatitis."
Others attributed unsafe sex to denial, low self-esteem, or feelings of despair. "It is tempting to deny the existence of the virus. Perhaps out of frustration or a feeling of immortality, some engage in unsafe sex," said Lenny, a 23-year-old student from East Lansing, Michigan. "Low self-esteem can also contribute to self-destructive behavior, of which unsafe sex is an example." Blake, 33, a library clerk from Portland, Oregon, said people have unsafe sex out of desperation: "When you have so many people dying around you the loss is awesome. I think some people are emotionally suicidal about it so their senses of reason are blurred." Buzz, a 37-year-old real estate investor from San Diego, said, "They no longer care. I don't think anyone feels immune. Clearly they feel it doesn't matter. A friend of mine used to say, 'There is a bullet out there somewhere for me, no use in trying to hide from it.' His bullet found him this summer."
The reasons cited for why my interviewees themselves had unsafe sex were more forgiving, sometimes suggesting that unsafe sex was the result of situational factors. "I was overwhelmed -- literally -- by a couple of guys in a gay sauna," said Harold, 28, of Frederiksberg, Denmark. "One of them kept me busy while the other simply placed himself on top of my cock. I was inside him before I had time to put anything on." Cal, 42, of Rochester, New York, said that "the difficulty is when my partner leads me on and gets me to really want to fuck and then plays the "I won't do that; it's not safe" card. I don't get angry at that point, but I am disappointed."
Drugs and alcohol were also mentioned as playing a role in unsafe sex. "When I get drunk and horny, all bets are off," said Brendan, 43, of Concord, California. "I am unable to say no when real horny, real attracted to a guy, or when drunk." Bart, a 39-year-old psychotherapist, said that when he broke up with a boyfriend who learned he was HIV-positive, the combination of loneliness and anxiety about whether he was infected led him to combine drugs and drinking:
My doctors had me on benzodiazepines because of anxiety. I started drinking a lot. The combination of the benzodiazepines and the alcohol lowered my inhibitional levels to the point that I didn't give a shit about whether I was having safe or unsafe sex. All I cared about was being with someone and not feeling lonely, so I picked up people on a regular basis every night of the week, trying to fill the void that Jack had left.
I'm sure that if I hadn't gotten sober, if I were still drinking and went out to meet people, I would possibly be so drunk that I could get fucked, not know if my partner used a condom, and not care.
Other men mentioned that they "slipped" from safer sex practices because of feelings of safety within a relationship. "In my last relationship, after the three-month mark it became hard to practice safer sex," said Derek, 25, a graduate student from Muncie, Indiana. "After six months, we slipped a few times. When you fall in love, a sense of invulnerability takes over. Stupid, yes, but it happens." Austin, 36, imagined what might make him "slip" and what he does to counter that: "The tempting thing is if you meet somebody and imagine a hot sexual encounter -- the thought passes through your mind. If the temptation was there, and I didn't have the knowledge that I do today, that's when I would have a hard time with safer sex, thinking, 'Oh, I can do this just this one time.' All it takes is for that thought to enter my head, and there's enough knowledge in there to know that it only takes once to become infected. I might think about it, but I don't want to be dead."
It shouldn't have surprised me that the answers I got to my two questions about unsafe sex were different. Psychologists have developed something called "attribution theory" to describe how people evaluate their own and others' actions."One finding of this theory," writes Robyn Dawes, "is the 'fundamental attribution error,' by which we attribute others' behavior largely to personality factors and our own behavior largely to situational factors to which we respond."
It makes sense according to this theory that in "explaining" unsafe sex my interviewees should judge unsafe sex practiced by others as evidence of character flaws -- irresponsibility, stupidity, sexual incontinence, low self-esteem, self-destructiveness -- but judge unsafe sex practiced by themselves as largely influenced by circumstances -- forced sex, intoxication, the influence of intimate relationships or "hot" partners. I may have unwittingly encouraged my interviewees to respond in this way by the way I phrased my questions. The first question asks "Why?" -- eliciting responses that focus on character -- and the second question asks "When?" -- eliciting responses that focus on specific situations and events.
In chapters 13 and 15 I discussed positive-negative couples and negative-negative couples, each time assuming that the partners in these couples knew each other's HIV status. But lots of sex happens between men who don't know each other's HIV status, and therefore the need to "negotiate" safer sex is still very much with us. This chapter could have been titled "Unknown-Negative Couples" because a principal question facing gay men who are trying to decide what is "unsafe" and what is "safe" for themselves is this: What kind of sex should I have with a partner of unknown HIV status?
The common answer is to treat every sexual partner as if he is HIV-positive, and many of the men I interviewed operate in this way, especially with new partners. Some men told me that they would trust someone if he said he was HIV-positive, but they would not trust someone if he said he was HIV-negative. Believing someone who says he is HIV-negative was equated with believing that "the check is in the mail" by one man I spoke with. As a result, most of the men I interviewed were cautious about sex with people of unknown status and unwilling to acquiesce to a partner's definition of safer sex if it was less cautious than their own.
Many of the men I interviewed balked at the use of the word "negotiation" to describe decision-making about sexual behavior. Peter, 26, a teacher from Toronto, told me that his definition of safer sex was "non-negotiable" unless his partner's was more conservative. "Anything he's not comfortable with we won't do, but I won't compromise my standards." Brent, a 36-year-old software engineer from Los Angeles, agreed: "I don't feel you should have to negotiate. If you don't do anything your partner doesn't want to do, you should be okay. Of course that makes each person responsible for his own actions and for letting his partner know what he considers acceptable, but I believe that's the way it should be."
How then are we to let partners know what we consider acceptable? "Fortunately, I am a physically large person," said Jimmy, 47, a psychology doctoral student from Kentucky. "Ain't nobody doing nuthin' I don't want them to do," he added. We should all be so lucky. Most of the men I interviewed used a combination of nonverbal and verbal communication to convey their safer-sex guidelines. Saying only that you practice "safer sex" and leaving it at that doesn't mean very much unless you suggest what you will and won't do in bed -- or wherever you have sex.
Some of the men I spoke with had found ways of communicating their standards without killing the spirit of sex: "I have two rules that I usually point out to my partners," said Harold. "First, anal sex means using a condom. Second, if we start doing something that I am not familiar with or feel uncertain about, they must stop if I tell them to. I like trying something new, but want to keep it within my safe-sex limits." Dudley, 42, who in chapter 13 discussed his relationship with an HIV-positive partner, Michael, said that when he has sex with other men, he is usually a "top man" but sometimes a "bottom":
A few weeks ago I was in San Francisco. I wasn't with Michael; I was traveling with some friends. I picked up a guy. I knew from the moment I picked him up that he really wanted me to be the top, so I was always in charge. Once we got back to the hotel, I basically said, "There are a few rules we're going to play with tonight." That's part of the S/M thing: "These are the rules." The first thing was that I had a glove. The second was that we'd wear condoms. He just said, "Yes, sir. Yes, sir."
I've never been with a top who I hadn't talked to ahead of time. Sometimes I think tops can get out of hand. But I'm a very pushy bottom. In that situation I would say, "Hey. Wait a minute here." I've never gotten into a situation where I wasn't able to get out or felt it wasn't right.
Austin is direct with partners who suggest things he is unwilling to do: "I just say, 'For me, this is the bottom line. This is where I feel comfortable. If you don't feel comfortable with that, this is not going to work for us. I have the rest of my life to think about, and this is just my decision.'"
The challenge facing gay men in the age of AIDS is to find guidelines that balance risk and pleasure. Gay men are sometimes willing to discount desire and pleasure entirely in their search to avoid risk. Alan, 31, who in chapter 13 discussed safer sex with a positive partner, said that gay men should not dismiss pleasure from the equation: "One thing that irks me about safer-sex education is desire and pleasure's absence from the checklist of things to consider," said Alan. "If we ignore that, are we discrediting ourselves? The desire for pleasure is a big variable: How much are you salivating for that cock? How much is your asshole itching for that cock? Those are key elements in any decision-making process and can't be discounted. I'm not saying I'm not careful. I'm saying a key part of my decision is how badly do I want the sex. A lot of times that means doing it safely instead of not doing it at all."
Drew, a 30-year-old customer service representative from Pawtucket, Rhode Island, finds that acknowledging his sexual appetite is useful. He suggested that abstinence for long periods of time may be dangerous for him:
If I haven't had sexual release for six months, I'm much more vulnerable than I am if I haven't had it for three. That's why I try to have sex more frequently, so I don't go, "Oh. It's a dick. I can finally suck it." If I have sex every two months, it's like, "Oh, it's just another dick. No big deal." I consider abstinence just like dieting. They say that people's weight fluctuates because people go on extreme diets. It's the same thing: people are starving themselves from sex. When they have it, they're going to binge. So you can imagine in a binge phase they may think, "Fuck the condoms."
Drew believes he actually reduces his risk by allowing himself some pleasure regularly.
Richard, 31, who in the beginning of this chapter mentioned using two condoms for sex, hopes that gay men who have been abstinent for a long time out of fear can find a way to have sex and still address their concerns for safety. "One of my wishes is that people establish guidelines they can live with that maximize both pleasure and peace of mind," he said. "Particularly peace of mind, because that is the piece that people find hardest to achieve. Pleasure is a little easier. Isn't there a way to find a place -- a spot on the continuum -- that you can live with?" Richard offered his own example: "I have sex with lots of people lots of times -- with people who are positive, negative, and of unknown status. I'm an example that this can happen and there are others."
Austin seemed to me to have found a good balance between the desire to achieve pleasure but to avoid risk. For him, being sexually cautious was not something he felt resentment about. "I don't have any resentments about having to practice safer sex," he said, "because I'm imposing my own rules. Nobody is telling me to do this. I'm not mandated to do this. I'm making a choice. Nobody's taking anything away from me. I'm giving myself my life by making the decision to have safe sex, so I don't feel constrained." Austin did not particularly mourn the fact that some forms of sexual intimacy were not available to him:
It's very hot and erotic to be with a naked man. You don't have to be having anal sex or oral sex. To be with a naked man is a very hot thing. It's very nice to be close to somebody. I don't have to be focused on those things that I've chosen not to do.
Tucker, 31, who in chapter 15 compared protected sex in negative-negative couples to a war effort on the home front, was like Austin in his confidence that safer forms of sexual interaction can be satisfying. He went on to suggest that gay men may even have an advantage over others in their capacity to enjoy safer sex:
There are ways to get off without being unsafe, and I'm willing to do that. Even just jacking off with someone can be really hot and a lot of fun.
Do you like Shakespeare? Do you know Henry V? At the end of the play, King Henry is going to marry Katharine, the daughter of the king and queen of France. He wants to kiss her but she says no, it is not the fashion for maids in France to kiss before they are married. Henry says, "We are the makers of manners, Kate."
Gay men redefine sex. How we fuck, straight people consider second best anyway. Anything to us can be sex because we don't have the same rules. We are not limited to putting Tab A in Slot B.
Tucker suggested that gay men -- by virtue of their position in our culture -- have always taken the opportunity to express intimacy in new and striking ways. Our experience growing up as sexual outcasts has equipped us well for the challenge of balancing risk and pleasure. "We've broken every rule that was made for us when we were in the closet in high school anyway. That's why we were so stigmatized," said Tucker. "We were thrown apart from the tribe from the beginning, so we can invent everything over for ourselves."
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Conclusion · Appendix A B C · Notes · Contributors