Alex, 20, has heard safer sex messages all his life.
“I grew up with condoms. Everyone around my age, unless they went to a Catholic school, has had a good sexual health education in school.”
He dismisses as “nostalgia” the feelings that some older gay men seem to have about the superiority of condomless anal sex. “I think sex can be just fine, even better, with condoms,” says Alex.
But just over a year ago, Alex contracted HIV. He was sexually experienced and used to practising safer sex. But for reasons that remain elusive to himself, he had condomless anal sex with someone he barely knew. Neither Alex nor his sexual partner raised the issue.
We’re 20 years into the AIDS epidemic and we’ve been saturated with safer sex messages. How to explain the fact that the number of newly-diagnosed cases of HIV among gay and bisexual men doesn’t appear to have decreased significantly for the past few years?
“I think maybe safer sex messages are targeted to the head, and not to the heart,” muses Ed Argo.
“People know what they should be doing. They seem to have more trouble knowing what they should be feeling.”
Argo, 36, was diagnosed HIV-positive three years ago and his low CD4 count indicated he had been infected years earlier. He had never allowed himself to even consider that he was HIV-positive. “It was sort of, I haven’t been tested so I’m negative.”
Only when a close friend was dying at Casey House did “a light bulb go on.”
A surprising number of people can be judgemental about those who test HIV-positive today. Yet human beings knowingly do a lot of things that involve risk – like smoking and driving too fast – and sexuality is a particularly potent force. It’s the rare person who hasn’t engaged in some not-completely-safe sexual encounter.
So while it’s not realistic to expect to eradicate sexual transmission of HIV, reducing it further – sparing people the trauma of years of drugs and illness – is a worthy and achievable goal. But it means facing up to some significant challenges.
“Promoting safer sex is inseparable from creating positive gay, bisexual or queer identities,” concludes a 1998 Canadian report, Sexual Meanings And Safe Sex Practices.
Yet some insist that the professional AIDS sector has not helped. Public health and some AIDS service organizations have “shamed people into not talking about how they live their lives,” argues Arn Schilder, a researcher with the British Columbia Centre For Excellence In HIV/AIDS.
Very often, men just “say what they think they are supposed to say” about their behaviour, observes Argo, who is now a volunteer at the AIDS Committee Of Toronto. “It’s as if programmed words start coming out of their mouths.”
ACT counsellor John Gaylord says, “There can be a lot of shame about having unprotected sex, about admitting you were dumb enough to do it. I’m not saying people are dumb; I’m saying they feel dumb.”
Perhaps because of this, a surprisingly high number of people identify oral sex, generally considered a low risk activity, as the way that they contracted HIV, notes Robert Trow, counsellor with Toronto’s Hassle Free Clinic.
“It’s not that they’re not telling the truth. I think people have a kind of selective memory, maybe especially for risky activities.”
Blow jobs without a condom are, for the one giving the blow job, deemed low risk by the latest guidelines from the Canadian AIDS Society. Using a condom shifts the activity to negligible risk, the guidelines state.
But Barry Adam, co-author of the Sexual Meanings report, argues that the lack of clear research findings about the safety of oral sex – in particular, the swallowing of cum – leaves men creating their own interpretations of safe and unsafe sex.
Adam stresses that his report found no evidence that new drugs were making men complacent about safer sex, nor that “an ideology” of barebacking (unprotected anal sex) had taken hold.
The factors he identifies are far less headline-grabbing. For example, the “know your partner” advice promoted by public health authorities contributes to unsafe practices. It encourages men to exempt themselves from the need for safe sex by “reading signs” of their sexual partners’ “safety,” says Adam, a professor at the University Of Windsor.
This is the “he looks okay” school of assessing risk.
In Adam’s opinion, a key question is, “How do we make protected sex into a sign of caring, not a sign of distrust?”
Several studies show, for example, that male sex trade workers typically practice safer sex regularly with clients, but report not being as conscientious with lovers and friends.
Unsafe sex is also linked to “the turmoil and difficulty of coming out,” Adam told the annual conference of the Canadian Association For HIV Research (CAHR) in May.
For men who have absorbed the message that homosexual sex is bad, it can be hard for them to subdivide gay sex into “good bad” (safer sex) and “bad bad” (unsafe sex), he pointed out.
“Gays and lesbians are the only ones who are taught to hate themselves before they know who they are,” said Michael Botnick of the University Of British Columbia. “There is a strong relationship between knowing you’re gay, having to resist homophobia and developing risk behaviours – sexual or otherwise. This might help explain why infection rates aren’t coming down.”
Botnick said of the 345 men in his Vancouver study, almost 35 percent reported having had at least one episode of non-consensual sex under age 18.
Alcohol abuse also comes into the picture. The Village Clinic in Winnipeg found that 86 percent of the gay men in its study believed there was a link between “wanting to get drunk and wanting to get laid,” the CAHR conference was told.
“If someone is inhibited and drinks to overcome that, then what happens to safer sex?” asked researcher Karin Linnebach.
An unexpected effect of prevention campaigns is that they may actually heighten the kinds of tension and inhibitions that people turn to alcohol to alleviate, the study suggested.
An ongoing study of recently infected men indicates that “a prior negative HIV test seemed to rationalize continued risk taking,” explained Liviana Calzavara, a researcher and University Of Toronto professor.
The men were all “extremely knowledgeable” about safer sex, she said, but they took risks for a variety of reasons: being too excited to stop, being drunk or stoned, being upset by a trauma like a death in the family and being willing to take risks to feel close to a partner.
Meanwhile, a large Montreal study of gay men found that entering a stable relationship was the strongest indicator predicting a shift from lower to higher risk sex. The next two key reasons were a “lower perceived” control over condom use in anal sex, and having an increasing number of HIV-positive friends.
Alex, 20, has heard safer sex messages all his life.