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Article Excerpt
During the first wave of the AIDS epidemic, sexually active gay men began using condoms during anal intercourse (Martin, 1987). But many are returning to the ways of sex before the onset of AIDS--having unprotected anal intercourse (UAI). Also known as "barebacking," the practice is occurring among most sectors of gay-identified men, and it has been studied specifically among white, black, and Latino men in New York City (Halkitis, Parsons, & Wilton, 2003); San Francisco and New York City (Parsons, Halkitis, Wolitsky, Gomez, & Seropositive Urban Men's Study Team, 2003); Detroit and Milwaukee (Seal et al., 2000); and Baltimore, Dallas, Los Angeles, Miami, and Seattle (Centers for Disease Control and Prevention [CDC], 2002a). Sexual behavior that poses a risk of transmitting HIV is on the rise among all men who have sex with men (MSM) (CDC, 2002b), but this article is limited to men who identify as gay or bisexual. At the 2003 National HIV Prevention Conference, the CDC reported the number of gay and bisexual men diagnosed with HIV during 1999-2002 increased 17 percent (CDC, 2003). The rates increased most among white men, followed by black and Hispanic men. Research has explored a wide variety of reasons gay men engage in bareback sex. These include attitudes toward condom use (Van de Ven, Prestage, French, Knox, & Kippax, 1998); the relevance of risk in committed versus noncommitted couples (Elford, Bodling, & Sherr, 2002); identification with the gay community (Seal et al., 2000); the combined effects of internalized homophobia and racism on young gay men of color (Seal et al.); internalized homophobia (Meyer & Dean, 1998); a sense of fatalism (Kalichman, Kelly, Morgan, & Rompa, 1997); and the effects of substance use (Halkitis & Parsons, 2002), depression, antigay violence, and childhood sexual abuse or substance abuse (Stall et al., 2003). Loneliness, HIV status, unmet intimacy needs, alienation from the gay community, and love might well warrant consideration as well.
Environmental stressors such as racism, homophobia, and economic disadvantage may play a role in the rise of barebacking. Internalized homophobia can contribute to barebacking by creating an unconscious sense that a gay man is unimportant and undervalued, thus increasing his sense that he is expendable, and so too are the men with whom he has sex and from whom he seeks love and validation. Many gay men of color cite social inequities that result in lower education, lack of access to health care, substance use, and poor mental health as contributing to apathy regarding sexual risk taking (CDC, 2002a; Gomez, Mason, & Alvarado, 2005). Men of all ages are engaging in barebacking. Middle-age gay men who were sexually active before the onset of the AIDS crisis, are foregoing the use of condoms (Bonnell, Weatherburn, & Hickson, 2000). Men who practiced safer sex for years and even decades reported experiencing safer sex fatigue or burnout as a reason for returning to sex without condoms (Halkitis et al., 2003). In-school sex education, increased availability of condoms, and knowledge of HIV and safer sex all helped younger people become aware of how to avoid HIV infection and other STDs. These programs have done a great deal to decrease the amount of unsafe sex (Rotheram-Borus et al., 2001), yet HIV infection among young people remains high (Koblin et al., 2000), especially among young gay men of color (CDC, 2002a).
DEFINITION
Originally, barebacking only referred to men who intentionally engaged in UAI, distinct from men who had UAI that occurred from poor planning or accidents (Gauthier & Forsyth, 1999). The term has evolved (for both HIV-negative and HIV-positive MSM) as "intentional anal sex without a condom with men who are not a primary partner (i.e., not someone the individual lives with or sees often and with whom the individual feels a special emotional commitment)" (Mansergh et al., 2002, p. 654). Barebacking is also known as raw sex or natural sex.
COMBINATION THERAPY AND BAREBACKING
Having high-risk sex has been linked to the advent of combination HIV antiretroviral therapy (Vanable, Ostrow, McKirnan, Taywaditep, & Hope, 2000). Antiretroviral therapies provide gay men with a misplaced sense of complacency. Many believe that contracting HIV is not a big deal anymore--certainly not a risk to life. Without visual reminders, even men who are well informed about HIV and how it is transmitted are more likely to take sexual risks. As "Roberto," a 29-year-old attorney who is a client of mine explained:
"I know this is wrong, but today AIDS just does not seem to be a big deal. I hear from my gay uncle who is in his 50s that in the early days of the epidemic it was pretty common to see prematurely aged gay men in wheel chairs, or covered with lesions, or who looked like they had just come out of Dachau. I have never knowingly seen anyone who was seriously ill with AIDS. I guess this contributes to why I am not as afraid of getting HIV as I should be and why I sometimes bareback."
It is incumbent upon social workers to use psychoeducational interventions to ensure that clients understand that a chronic illness is not the same as a mild or unimportant medical condition. Combination antiretroviral therapy continues to be effective over time, yet 10 percent to 30 percent of people who receive combination therapy rail to respond or experience viral breakthrough (Waldholz, 1996). Among the possible side effects associated with combination therapy are nausea, vomiting, diarrhea, skin rashes, headaches, fever, chills, depression, peripheral neuropathy, and lipodystophy or...
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