Monday, September 28, 2009

Pleasure and Risk

Garrett Prestage gave the following talk at the Australasian Society for HIV Medicine conference held in Brisbane, Australia in September 9 - 11, 2009 as part of a community organization (ACON) panel. Please give it a read. (Thanks to Michael Hurley for putting this on the LifeLube radar.)

For 25 years I’ve noted various attempts to ‘sell’ condoms to gay men as though they could be erotic or fun, usually using bright colours or a sexy pose or some cutesy addition – the latest being a banana. But it’s never worked – it just seemed to because most gay men have practised safe sex throughout the epidemic.

What do they really think about condoms?

Like most straight men, they hate them – they’ll use them because the circumstances require it but if they had some other option they’d go for it.

In PASH (Pleasure and Sexual Health - a survey conducted in Australia) two thirds of men (including 81% of men who did UAIC - unprotected anal intercourse with casual partners) said that if there was no longer any need to worry about HIV it’d be unlikely they’d continue using condoms. Less than a third (29%) of men who did UAIC agreed that condoms can ever be fun or erotic – even among those who ALWAYS used condoms with casual partners only half could agree with the statement. Three quarters – 78% (including almost all – 93% – of the men who did UAIC) said that sex just feels better without condoms. Over half the men who did UAIC said that condoms are a hassle, they slow down the sex & are a nuisance.

Lots of the men in PASH noted that using a condom makes it harder to keep their erection, or makes getting fucked less comfortable, but they also spoke about the sheer pleasure of sex without a condom & how a condom just gets in the way.

So what’s the point? Well, I would argue that gay men appreciate honest and realistic information that enables them to make up their own minds – and they don’t automatically buy what we tell them. Although I know that most organizations have tried to respond to changes in HIV and changes in how gay men think about risk, we basically continue to give them a message that can be reduced down to ‘but really, you should just use a condom’.

In PASH, the majority (59%) think HIV messages are all the same, and that they never say anything new (58%), & three quarters (75%) say that all HIV messages tell you is to use condoms. So do they have any impact: Well, half the men who did UAIC say they see HIV messages but don’t pay much attention. But that doesn’t mean they’re ineffective. Of course condom reinforcement works in a more subliminal way to reinforce a safe sex culture – and we should retain that. And even though large numbers probably ignore much of the content of the messages, they mostly appreciate their value. Despite their general hostility to condoms, almost all men in PASH, whether they used condoms consistently or not, agreed that condoms provided a sense of security either from infection or from the possibility of infecting their partners and so they agreed they were necessary for this reason.

They’re not idiots and they’re not irresponsible. They know how useful condoms are – but that doesn’t mean we ever fooled them into liking them.

However, as I’ve said on previous occasions, at the beginning of this epidemic, when we had to start promoting condoms & safe sex, the common feeling was that once there was a cure, we’d throw one huge orgy to celebrate. And the reality is that some men have quietly begun to celebrate. Not all men: Some men remain locked into a morbid fear of HIV and couldn’t possibly contemplate taking any sort of risk; But others, still just a minority, but undoubtedly growing, are reassessing the situation. They’re not quite ready to throw caution to the wind – they know it isn’t quite over yet – but they feel the risk has decreased enough that they can relax a bit.

In PASH, one third (31%) including a little under half (41%) the men who did UAIC feel that HIV has become controllable, similar to diabetes, & one in six (18%) including a third (32%) of the men who did UAIC say they’re now willing to try some things that they used to think were too much of a risk.

The sorts of things that some men said in PASH about the risk of HIV transmission are the same as what I’ve heard many of us say quietly as well: For example, one PASH respondent said, “I guess I genuinely believe there's a very low chance of passing on my HIV as a bottom, and because I take my own meds so regularly, I believe there is next to no chance of passing on HIV to another partner."

So, my question is how much longer we think we can get away with treating gay men like children and trying to frighten the minority into submission with a boogie-man that even we don’t really believe in any more?

Sure, HIV is still quantitatively different to other STIs and we all think we should avoid getting infected or infecting anyone else – but it’s now no longer an absolute. It’s a question of how much do I want to avoid it.

People tell me I should eat more healthily. Probably I should if all I cared about was getting all my health indicators into perfect alignment. But, really, if my health is generally pretty good and I have other things in place that make me think the risk of anything really bad happening is probably fairly low, why should I sacrifice eating things that give me so much pleasure? It’s pretty unlikely.

In life we all judge relative risks and pleasures, and pleasure always wins unless the risk is judged to be relatively great.

Until the mid-90s, the risks posed by HIV appeared very great indeed, especially to gay men, and so, of course, they mostly sacrificed their pleasure, at least to a significant extent. But nowadays an increasing number of gay men – still a minority, but definitely increasing – are coming to a different conclusion. They’re not abandoning all caution – they mostly still practice some sort of risk-minimisation. But condoms are no longer an automatic part of that.

I’m going to quote something from Elizabeth Pisani’s writing in the Guardian a couple of days ago to put this in context. She’s talking about the tension between trying to promote HIV-prevention at the same time as let people know that if they get HIV they’ll still be able to live a normal life. I’m selectively quoting from a fairly long article.

She says: “If there’s absolutely nothing wrong with having AIDS then why should be bother with HIV prevention messages? … AIDS industry dinosaurs like myself know that AIDS really is something bad. What we’re not so good at admitting is that it is practically non-existent in rich countries… Treatment readily available means you can have HIV without getting AIDS for decades, maybe forever. And the treatment is free for patients (LifeLube note - not in the USA), if not for the taxpayers… HIV is no longer a mass murderer in rich countries. It’s an inconvenient disease that will have you taking pills for the rest of your life, cost taxpayers lots of money and make big pharma rich… ‘HIV increases your tax bills. Protect yourself!’ Not really a line that’ll get you reaching for the condoms is it?”

And, really, plenty of gay men know this is the reality. They still try to reduce risk, but it isn’t a life-or-death priority any more.

What is a big part of gay men’s decision making though is the question of trust. How well they know someone, how well they can trust the situation they’re in, how much they can trust their sexual networks. And key to this is knowing someone’s HIV status.

Most men when asked will recite what we’ve all been taught is the correct line: In PASH 93% agreed that you can never really be sure of someone’s HIV status – but two thirds (66%) also believed that there are some men whose HIV status they could be sure of, plus three quarters (72%) felt that knowing someone’s HIV status is a way to reduce HIV risk. And when they were asked about the casual partner that they’d last engaged in UAI (unprotected anal intercourse) with, nearly half said they were very confident that they knew his HIV status.

So, all these serosorting campaigns that are based on telling men that they can’t really be sure of knowing someone’s HIV status are probably fairly meaningless. Yes, gay men nod approvingly to this statement, but for many the statement is only meaningful in the abstract. And then it simply doesn’t apply to this particular guy, because I know him, or I trust him, or I trust this situation.

We don’t provide him with any tools to minimise his risk in these situations – other than to imply that he’s a fool for trusting anyone. And we mostly justify this because the Seroconversion Study is full of stories where this trust was misplaced – but of course it is. These are the stories of the men who were unlucky enough for it to go wrong.

But when we look at data from our other research what we see is that many others are doing the same thing and not seroconverting: A substantial proportion of men are engaging in UAIC with partners they believe they know, and mostly with partners they believe they can trust. And the HIM data (Health in Men study in Sydney) tell us that while these sorts of decisions may be riskier than using condoms, they’re significantly more protective than when they have UAI with men whose HIV status they don’t know.

Nonetheless, we know from the Seroconversion Study that often this trust can go awry. This statement from a PASH respondent tells us a lot about why it can go awry: “He asked me if I was neg. If he'd been positive I would have assumed he wouldn’t have cared."

So, he’s placing his trust in the situation. His logic was that a pos man wouldn’t have bothered asking if he was neg & then proceed to have UAI with him. His implication about the irresponsibility of pos men is clearly misplaced but his assumption that this guy was neg based on the interaction was probably a reasonable one but even so a pos man might have used that information to decide whether he should be top or bottom.

When we look at the Seroconversion Study data, the lesson we need to learn from them is not that we need to get gay men to behave like they did a decade ago and return to absolutely consistent universal condom use with casual partners. Not because it’s not a worthy ambition to get gay men to take up condom use in the same way again – but it’s simply not reality. It won’t happen.

The lesson from the Seroconversion Study is that we need to provide gay men with some practical tools so they can make informed decisions about the safest circumstances for them to discard the condoms, and so they start to reflect on what’s really going on for them when they feel they can trust the situation they’re in.

When is that trust rational and when is it misplaced?

Mostly, gay men still want to protect themselves and their partners from HIV, but not at the expense of enjoying themselves. It’s not our job to decide for them that there’s only one way they should behave, or that virtually no degree of risk is acceptable. Our job is to provide them with the tools to enable them to put into practice their perfectly reasonable decisions about relative risk and pleasure.

After 25 years I think we can trust them to get it right.

1 comment:

  1. "to reinforce a safe sex culture – and we should retain that."

    Thank you! I'm sick of this false dichotomy that hiv prevention advocates in our communities are falling into--either you're a "condom nazi" (bad) or "radical harm reduction advocate" (good). These things don't have to be mutually exclusive--we can continue to promote and distribute condoms AND promote harm reduction for individuals who decide not to use condoms but want to protect themselves and each other.


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