While debate over the issue has focused on POZ's supposed "glamorization" of an act closely linked to HIV transmission, and the alleged danger posed by Scarce's sidebar "Safer Barebacking Consider-ations," the brouhaha has brought to the forefront a widening chasm among gay men working to prevent HIV transmissions. Two visions rooted in vastly different understandings of gay men's relationship to the epidemic have been advanced in the last few years: one argues that even as the medical syndrome of HIV/AIDS continues, the crisis stage of AIDS has passed for gay men; the other berates gay men for moving away from AIDS-crisis mindsets or taking even a single step out of the bomb shelters we've inhabited since the early 1980s. The debate over these two visions is fierce and personal, and daunting questions have emerged: What are these divisive debates really about? Are they another example of internecine warfare driven by personality conflicts, ego battles, and bad manners? Why is gay men's sex once again the target of demonization?
Scarce, who will speak at "The Rubberless Fuck," a Gay City Health Project forum about barebacking (Thursday, April 15 at Oddfellows Hall), is one of the few thinkers trying to honestly answer these questions, and the only one who has engaged in social science research into this frequently mischaracterized subculture.
From the mid-1980s forward, those trying to control the spread of HIV among gay males have counted on a variety of "facts" about AIDS to shift the way we have sex. Because few gay men survived more than a year or two after an AIDS diagnosis, we discussed HIV-infection as lethal and considered each friend who tested positive to be facing a death sentence. As the tidal wave of deaths hit urban centers from 1989-1994, frequent funerals and memorial services drove home the fatal dangers gay men faced when taking risks with sex or needles. When we reached the point where 50 percent of men in the gay ghettos of San Francisco and New York were HIV-positive, AIDS groups constantly reminded gay men that half of their sex partners were likely to be infected, and instructed us to use condoms without fail. These early HIV-prevention efforts were acclaimed internationally because they quickly and skillfully funneled often confusing medical and epidemiological data into easy-to-digest campaigns tailored to the various gay male populations. They were truthful, and they were highly effective.
Today, many of our leading AIDS organizations are asking gay men to believe we are in the same crisis we entered in 1985, despite the fact that the number of diagnoses and deaths are declining. According to the Centers for Disease Control (CDC), the incidence of AIDS among gay men declined 18 percent from '96 to '97, and deaths declined 49 percent. Yet AIDS organizations demand that the "facts" of the 1980s guide our sexual practices today. And they contradict themselves in the treatment arena: They'll throw a pep rally for HIV-positive men, presenting optimistic visions of current and future pharmaceuticals, while, at the same time, they'll scare HIV-negative men with horror stories about side effects and supposedly high rates of treatment failure.
The "facts" of the mid-1980s are not the facts of the late 1990s. The pages of weekly gay papers are not filled with obituaries anymore, and everyone we know who tested HIV-positive in the 1980s is not dead. A syndrome once considered lethal to every carrier of the virus has been undermined not only by the new drug cocktail, but by a range of other aggressive treatments and health promotion activities, and by the undeniable presence of "long-term non-progressors" in our midsts: those infected for more than a decade who retain fully intact immune systems that have somehow stifled viral replication. We now believe many HIV-positive men will never develop AIDS.
The percentage of gay men populating bars, bathhouses, e-mail chat rooms, and gay dating services who are infected is no longer 50 percent, as it once was in New York City and San Francisco. That figure is under 15 percent in most urban centers, and in those high-impact cities of the 1980s, fewer than 25 percent of gay men are HIV-positive.
In 1999, many gay men are engaging in sexual practices informed by current realities, even if they are not as conservative in their behavior as many prevention advocates would like. Most of the men we have sex with are not likely to be HIV-positive, and many HIV-positive men have diminished levels of HIV in their semen, due to new treatments. While still awful and life-threatening, becoming infected with HIV is no longer an assurance of imminent decline or tantamount to a death sentence. HIV-positive gay men are aware that medical researchers continue to disagree about the danger or even the possibility of their re-infection with more dangerous strains of HIV. Even the National Institutes of Health have told us that the statistical risk from a single act of unprotected sex is much less than the 50 percent risk many of us believed it was in the 1980s.
Ten Pounds of Prevention
If HIV-prevention efforts are less effective today than they were a decade ago, it may be because much of the current work refuses to fully accept the altered realities in which today's gay men operate. Those who are having sex without condoms are not lacking in self-esteem or filled with internalized homophobia that triggers them to self-destruct. Nor are they necessarily naïve or delusional, believing they are invulnerable to harm or disease. Even those few HIV-prevention programs that have moved into the 1990s, like Gay City in Seattle, which should be commended for organizing the barebacking forum and promoting discussion of the issue, have failed to fully re-envision what an authentic new generation of HIV-prevention efforts might look like. Many groups are finding it difficult to invent models of public health that are not dependent on creating a community mindset of crisis, or that rely on terror, panic, shame, and guilt as primary tools.
Recent articles in local papers and statements by Gay City's leadership suggest this lack of vision may be hampering effective prevention efforts in Seattle. In one recent article in the Seattle Gay News, Gay City's director discusses his placement of "bogus personal ads" seeking partners for bareback sex (he received "a large number of responses"), the supposed source of many new infections, yet also insists, "We are seeing a lot of new infections within committed relationships." Are we so desperate to convince gay men that they're still living under a state of emergency that we point our fingers everywhere, one moment at the sex pigs and the other at men in couples?
A recent media alert from Gay City stated that "alarming HIV-infection rates among gay men" in the early and mid-1990s inspired the founding of the group, yet their barebacking forum materials reference similar "alarming" new infections today. Like many AIDS organizations, Gay City crafts an explanation-of-the-moment for continuing infections among gay men (It's low self-esteem! It's gay men who think AIDS is over! It's those barebackers! It's those crystal users! It's that youthful sense of invulnerability!) in an attempt to extend--year-by-year--the crisis-driven experience of AIDS among gay men into a new millennium.
My concern with the popular use of the term "crisis" as a description of gay men's current experience with HIV/AIDS centers on the fact that in the past 20 years, AIDS among gay men has morphed from the short-term crisis we expected it to be to a long-term endemic challenge. Such challenges demand very different public health responses. It's also important to note that as the mainstream gay community has exited, other communities in the United States are entering the crisis stage of response to HIV/AIDS, particularly urban African American and Latino populations, including many black and Latino gay men. Yet white gay men remain the dominant power base within the AIDS system nationally, and frequently resist relinquishing significant power and resources to these other communities.
Seattle Gay News has done its part to fan the flames of crisis and ensure that thoughtful analysis of gay men's sexual health rarely appears in its pages. Associate Editor Tom Flint insists that barebacking "is a real problem," and argues that his newspaper needs "to bring it out into the open." Yet Flint's paper feels no parallel obligation to discuss the topic with intelligence or critical analysis. While there is no dearth of thoughtful health activists, researchers, epidemiologists, and gay men's health providers in the Northwest, Seattle Gay News devotes its two front-page stories on barebacking to an interview with Michaelangelo Signorile, a nutty New York journalist who has never worked in HIV prevention.
In a bizarre, take-no-prisoners interview, Signorile attributes new infections among gay men to no less than 10 sources: the "glamorization" of barebacking, a "spoiled-brat" mentality among gay men, the failure of prevention campaigns to use fear tactics, ads for protease inhibitors presenting images of buff men with AIDS, the supposed claims of gay writers--Andrew Sullivan and myself--that "AIDS is over," young gay men's lack of personal experience with AIDS deaths, pro-gay policies of the Clinton administration, the transgressive nature of gay men's sexuality, young men's self-indulgence, and the immaturity of gay men's cultures. Grabbing at straws to find an explanation for a phenomenon he can neither define nor comprehend, Signorile is promoted as the leading voice on the barebacking "issue" to the readership of Seattle Gay News.
Willful Misreading of Data
Daniel Zingale, Executive Director of AIDS Action, the DC-based political arm of what's left of the AIDS movement, has been much in the media lately, discussing what he believes is a huge shift in gay men's sexual practices, based on a recent report from the CDC in Atlanta. When the CDC's Morbidity and Mortality Weekly Report of January 29, 1999 led off with a synthesis of recent studies under the headline "Increases in Unsafe Sex and Rectal Gonorrhea among Men Who Have Sex with Men--San Francisco, California, 1994-1997," they did so out of their mission to serve as sort of a Paul Revere and herald what they believe are dangerous trends in sexual behavior. I look to our nation's AIDS leadership to interpret the CDC's bulletin critically and frame it in useful ways, rather than simply amplify and extend their conclusions.
Zingale interprets the CDC's report showing a rise in the rectal gonorrhea rate among gay men in San Francisco and an increase in gay men reporting unprotected anal sex as the result of a "national complacency" and young gay men who "are cavalier in their attitude about both recreational drug use and HIV risk." Reading the recent epidemiological reports (on which the CDC report draws) through the crisis-tinted lenses of AIDS Inc., he cannot imagine two men fucking without condoms as anything other than "a romanticizing of unsafe sex."
Seattle Gay News promptly followed suit. Drawing very loosely on those same CDC studies, as well as on documents from the Seattle/King County Health Department, Flint writes, "Newly documented information... shows that STDs and HIV are increasing among gay men in Seattle and across the United States. Many therefore fear a new tide of suffering and death which may strike a new generation of gay men, just when it appeared we might have turned the corner of the epidemic and put the worst of the AIDS epidemic behind us."
The recently released studies from the CDC upon which Zingale and Flint base their hysteria may be cause for concern, but not in the narrow ways they are suggesting. The study of increased rates of rectal gonorrhea in San Francisco has been universally read as indicative of increasing new HIV infections among gay men, yet the study contrasts strangely with HIV-infection rates in San Francisco, which show not a rise but a decline and leveling off of new infections among gay men since the mid-1990s. A good portion of these new cases of rectal gonorrhea could be among men already infected with HIV. If so, what's needed is less AIDS hysteria and more general sexually transmitted disease prevention campaigns.
And while the press reported this rise of gonorrhea as "a return to the 1970s," almost all journalists failed to note that San Francisco's infection rate is still a tiny percentage of what it was before the education work of the 1980s. At a San Francisco forum on barebacking last August, staff from Stop AIDS, a pioneering gay men's prevention project in San Francisco, acknowledged that--even with this supposedly shocking rise in rectal gonorrhea cases--the 200 cases reported in 1997 are nowhere near the 9,000 reported annually during the late 1970s and early 1980s. In fact, these "alarming" new rectal gonorrhea rates are below three percent of what we faced in that pre-AIDS period.
Likewise, the much ballyhooed upswing in gay men reporting unprotected anal sex (from 30 percent in 1994 to 39 percent in 1997) can only be understood as a "problem" if one maintains the AIDS absolutist position of the 1980s: Good gay men use a condom every time. This "upswing" in reported unprotected anal sex could suggest many things other than the future tidal wave of new HIV infections predicted by the press and AIDS Inc. In fact, it could mean no upswing at all, but simply that more gay men are reporting unprotected sex, or that more HIV-positive men are engaging in unprotected sex with each other, which would have little implication for new transmissions.
As social scientists are aware, a person's response to surveys is linked to current cultural norms. A gay man, like other people, will tell researchers what he thinks they want to hear. 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 butt sex and debates flare over barebacking subcultures. This new discourse makes it safer for surveyed gay men to "'fess up" and tell researchers the truth about the sex they may be having. The "upswing" could also suggest that more gay men are aware that there are lower levels of HIV in gay communities--sometimes men choose to get fucked without condoms in circumstances where they do the mental calculations and assess that their risk of being infected is minimal.
I am not arguing that the sexual practices of gay men raise no significant and serious concerns around health or that the new treatments are a panacea. I simply think that pushing a state-of-emergency mindset takes its toll, and drives new infections up rather than reducing them. The obsessive marketing campaigns telling us to "use a condom 100 percent of the time" have made anal sex more central to gay men's desires, and have exacerbated the challenge rather than mitigating it.
I believe the willful misreading of epidemiological data, the continued churning out of crisis-based press releases, and the escalating depiction of gay men--particularly young gay men--as dumb, self-destructive, and responsible for undercutting the assimilation-based, best-little-boy progress of the "responsible" gay community, have enormous consequences in terms of gay men's health. These factors will also hamper effective community organizing and further contribute to the declining credibility of gay community institutions among gay men--especially young gay men.
Who's being lazy, irresponsible, and self-destructive here? Gay men in their 20s and 30s, or AIDS Inc.? It's easier to blame new infections on young gay men, mischaracterizing all whose sex falls outside the narrow dictates of use-a-condom-every-time mantras, than it is to take a fearless look at the current state of prevention. Prevention efforts targeting gay men are sorely in need of re-visioning and re-direction. We don't need more brochures, more programs to improve our supposedly sagging self-esteem, or more sound bites and marketing messages. Gay men need a multi-issue, multicultural gay men's health movement.
Rather than portraying us as panic-stricken victims living in crisis, AIDS organizations could conceptualize gay men as resilient survivors (of AIDS as well as homophobia). Rather than invent an emergency-of-the-year, such groups should adopt a long-term, sustained approach to health promotion, embedding HIV-prevention efforts in broader, meaningful programs focused on sexually transmitted diseases, heart disease, cancer, and addiction. They should explore issues of aging, diet, exercise, and spirituality, and grapple with the ways in which issues of masculinity play out in our social and sexual practices. As much energy and as many resources should flow into gay men's strengths and victories as is directed toward their failings and defeats.
By misrepresenting gay men who organize their sex and relationships outside of the crisis-driven dictates of 1980s prevention, AIDS leaders and journalists cross an important line. In a political climate of homophobia and sexphobia, they're using an all-too-willing mainstream media to divide gay men into good and bad. And if they wonder why popular support for AIDS groups is plummeting among gay men, they need look no further than their own press releases. AIDS organizations that patronize and defame gay men should not be shocked when gay men no longer support their efforts. Instead of bringing together a savvy and creative brain-trust to create a multi-issue health movement, AIDS organizations point fingers at the bad boys (barebackers, circuit boys, and those lazy, self-centered young queers) and continue to see AIDS work as somehow separate from the broader public health context in which we live. Instead of creating a new generation of HIV-prevention messages rooted in the altered (and ever-changing) facts of HIV infection, AIDS organizations recycle the education models and supposedly common-sense assumptions of the 1980s, while making--at best--mild adjustments.
An ever-widening gap has opened between rank-and-file gay men and the institutions which many of us created, funded, and staffed as volunteers. Until AIDS leaders cease to patronize the common gay man by presenting us with "facts" that have little likeness to the realities of our lives or the findings of balanced biomedical research, and until they cease to treat us with contempt, they ensure the further erosion of their funding and volunteer base in gay communities.
This is why Michael Scarce's visit to Seattle may be critical to the redirection of local prevention efforts. Scarce will be publishing a landmark book this June, entitled Smearing the Queer, which critically examines a range of health issues facing gay men and argues for an activist approach to health promotion. In his upcoming book and hopefully in his appearance in Seattle next week, Scarce provides a vision motivated by an appreciation for gay male cultures and a commitment to gay men's health and survival. Scarce is likely to be one of the most important leaders in the emerging gay health movement.
Eric Rofes is the author of DRY BONES BREATHE: GAY MEN CREATING POST-AIDS IDENTITIES AND CULTURES (Haworth, 1998), a professor of education at Bowdoin College in Maine, and a long-time gay community organizer.