I was having drinks with a friend of mine -- we'll call him Patrick here -- this weekend when the subject of having sex with HIV-positive men came up. "Oh, I would never have sex with an HIV-positive guy," he casually remarked -- as if such a thing were already obvious. I was shocked not just by Patrick's statement, but also by the categorical bravado in his delivery. To have sex with HIV-positive men, as he went on to explain, was to expose himself to unnecessary risk of infection. I've been replaying this conversation again and again in my head. How could he be so outrageously calculating in his cooIly expressed exclusionary strategy? Today I want to spend a few moments reflecting on these kinds of statements, because I think many people would uncritically read them as legitimate prevention strategies. I will argue here, however, that in reality that these kinds of strategies that are totally bankrupt in terms of actual risk reduction. Moreover, what I think this kind of statement actually tends to do is not actually promote any real reduction in risk, but rather to reinforce and reproduce harmful stigma against HIV-positive people.
Before we get into a discussion of the ethics of "serosorting" -- the practice of choosing to engage in sex with only sero-concordant men -- I think we should bracket my friend's comments as existing only at the very periphery of this term's broad meaning. While taken at face value, it does indeed seem that my friend is practicing serosorting. But correct me if I'm wrong here, but it seems to me that serosorting was more intended to describe men who were seeking to minimize risk of transmission while engaging in sex without condoms. For my friend, this wasn't the goal of his strategy -- condom use was still part of his risk reduction strategy with other HIV-negative men. This is a very important distinction. What I'm going to be talking about here is men who report consistent condom use, but who continue to latch onto serosorting discourses that discourage serodiscordant sexual practices.
Because of these important differences, I want to suggest that Patrick's comments cannot possibly be said to be purely a method of risk reduction. To explain why I think this is so, we need to evaluate whether or not there is actually any risk worth avoiding by excluding HIV-positive men from your pool of eligible partners. Thus, to help illustrate this, let's attempt to assess the risk of transmission between a known HIV-positive partner and an HIV-negative partner when condoms are used. There is no data to suggest that many HIV infections occur in these contexts, absent condom failure -- rates of which are outrageously low (between 0.4% and 2.3%, depending on who you ask). If we take a generous account, let's presume that rate is 2%. In a single incidence, then, the risk of potential exposure is 1:50.
But exposure does not equal transmission. You can be exposed to the virus and not actually seroconvert. Thus, we need to add into this equation the risk of transmission per sexual encounter in the absence of condoms,which vary depending on a number of factors: whether the poz guy is insertive or receptive, his viral load, genital ulcerations, etc. Let's say the poz guy is doing the fucking, for example's sake. The generic risk in this scenario for a receptive HIV-negative man is 1:122 -- that is, statistically speaking, there is a 1 in 122 risk of seroconversion after getting fucked once without a condom by an HIV-positive man (see here for a summary of this data). If we multiply these two risks together, we get something like a 1 in 6000 probability -- give or take. According to risks of death statistics, this puts a person's risk of seroconversion in this abstract, theoretical scenario somewhere between their risk of death by electrocution (1:5000) and their risk of death by drowning (1:8942). Obviously, this is a gross use of statistics -- but I think it helps illustrate the point: the risk of transmission between serodiscordant couples in one sexual encounter when using condoms is EXTREMELY low. Just about negligible. And this example likely grossly overestimates the risk, due to the fact that condom failure is not the same as sex without condoms. Many people will quickly realize the condom has broken, leading to a much smaller window of possibility for exposure. Thus, the 2% exposure rate included in this example is likely much, much smaller in practice.
Obviously, if we extend this risk over time, then we run into increased risk of transmission for a variety of reasons -- namely condom fatigue reported within serodiscordant couples. But if you use condoms, your risk of becoming infected from hooking up with a HIV-positive guy is probabilistically very low. Thus, excluding them from your dating pool cannot and should not be considered a risk reduction strategy -- unless you are having unprotected sex.
Now that we've established that there is no real prevention rationale for categorically excluding HIV-positive men from your pool of eligible partners, we need to seriously consider the ways in which doing so actually works to reinforce stigma against HIV-positive men. If you ask any HIV-positive man what kinds of difficulties come with seroconversion, many will immediately respond that stigma and the resulting fear of disclosure are today some of their most pressing concerns. New medications have alleviated what used to be a very immediate sense of death, and their adverse side-effects have been dramatically reduced with even more recent advances in treatment protocols. Rather than "purely" medical, the problems that men describe today with living with HIV are very much in the realm of the social.
Take for example a scenario another friend (we'll call him Matt here) described to me recently at a gay bar in Detroit. Matt was dancing with a cute young man, who curiously told him that "You should stay away from me. I'm dangerous." Matt asked him why, and he ambiguously answered that he was contaminated. Matt then asked him directly if he was HIV-positive, at which point the guy stiffened and gave a sheepish affirmative reply before running away. In this scenario, the young man had so internalized this harmful discourse of transmission that paints HIV-positive people as dirty and dangerous, that he himself did the running away. Matt has slept with HIV-positive men before -- this is not a problem for him. But he didn't even have to not reject him -- the HIV-positive man did the rejecting for him!
While this seems like a very contextual and bracketed example, I think it serves to illustrate the kind of emotional damage that stigmatizing discourses may be having on HIV-positive people's lives. I contend that Public Health -- in its ambiguous and contradictory uses of the term "serosorting" (a topic for another essay) -- is part of the problem here. By refusing to explain what this term means, and by remaining quiet in the way it gets practiced, Public Health is serving to reinforce stigma against HIV-positive people by allowing many men to use it as a rationale for their exclusionary practices. This essay is just a gloss on these issues -- it admittedly raises more questions than it answers -- but I desperately think we need to think critically about the way we (I mean both we as gay men, and we as people invested in promoting Public Health) allow stigma to continue operating in our communities through the lens of "health" and "risk reduction." Backed by medical logic, stigma seems rational, logical, and unproblematic. But we need to expose the ways in which these allegedly science-based logics are actually totally bunk in terms of their validity -- and are actually just forms of stigma veiled by scientific authority.
Author's Note: After publishing, I corrected the 1:122 risk of transmission per incidence for HIV-negative people engaging in unprotected receptive anal intercourse with HIV-positive men from the originally cited 1:132. I also added a link to Poz Magazine's summation of this theoretical risk data. Many people have emailed their frustrations with my gross misuse of statistics. I don't dispute this. Indeed, the kind of very sketchy analysis I engage in is problematic if you are interested in the actual, "real" statistical risk. I'm not really so interested in the precise number, and I don't think it matters much in making this argument. To my knowledge, even if we look at the outcomes here -- seroconversions reported when using condoms with HIV-positive partners -- we just don't see large numbers of transmissions. But I certainly welcome and encourage further research that is invested in precisely quantifying these risks -- and the variety of factors that are bound to contextualize them.
The PEP guidelines we use in Australia (available at www.ashm.org.au) posit a 1:33 risk of infection for a known-positive insertive partner who comes inside. I guess I'm a bit skeptical about the Poz.com description of where they got their estimate, and I would call it an estimate rather than "data".
Like you, I'm troubled by the easy confidence of the neg guy who breezily announces he would never have sex with a poz guy due to his right to self-protection. But I explain it using the concept of stigma rather than risk calculation. You could step out the risk calculation -- risk of condom breaking times risk of infection times risk of PEP failure = 1 in 10,000 year risk at an average rate of partner change -- and he'll still insist that's too big a risk to take, and by that point he'll be really defensive too.
I think it's more effective if you can get him to acknowledge how he feels about the possibility of HIV infection, validate his right to protect himself, and express the hope he can act on that right without causing pain to any poz guy he might encounter along the way.
Thanks Trevor, as always, in both your reaction to your friend's statement and following through with this essay.
This plain dismissal of an entire portion of our community based upon serostatus is an all too common one, both for myself and I'm sure for the many others that attempt to bridge the divide - for many different reasons.
If only rationality, reason, or even compassion were at play here, but alas that often doesn't seem to be the case. I see this as no different as being dismissed for being too old, or not being the right color. It's outright discrimination based upon fear, ignorance, and a lack of human compassion. One that is often wholly supported by many of our peers, institutions, and so-called community organizations as being at the least politically correct and at best justifiable. Unfortunately this is not relegated to any particular demographic and I have encountered flat refusals to even converse or have any kind of interaction solely based upon serostatus from many different individuals, no matter their education, experience, background, or geography.
The not-so-great irony and sad realization is that these are the same forms of discrimination based upon sickness, disease, and undesirability that have plagued and made our communities suffer for countless generations. I suffer each time I am flatly rejected with no recourse and we all suffer as a community by these falsely constructed barriers between us. I feel deep regret for the individuals who falsely believe and use these beliefs to discriminate actively, thinking that they are somehow protecting themselves by exorcising the sick and diseased from their "healthy" world. These same individuals when they perchance seroconvert or god forbid have their 30th, 40th, or 50th birthday, will they be that dancer on the dancefloor with Matt? If so, I'd much rather work on the sero-divide now rather than continue to suffer the ongoing consequences of decades of poor public health policies, little to no sexuality education, and social marketing campaigns and interventions that preach but don't educate!
In terms of risk of infection, for our work we use Vittinghof's per-contact estimates, here's what he says:
"Estimated per-contact infectivity of URA with HTVseropositive partners was 0.82 percent (table 3), while per-contact risk of URA with HIV-positive and unknown partners combined was 0.27 percent. In contrast, per-contact risk of PRA with HIV-positive or unknown partners was 0.18 percent, although a substantial proportion of this risk may be due to condom failure."
Which is a less than a one in 100 chance, hence Poz's quote of 1:122. It seems the Australians are quoting the upper-end of the 95% confidence interval for these estimates.
As usual these are generalized estimates and do not take into account such things as Trevor mentioned, such as the actual infectivity of the individual (are the virally suppressed), other STDs present, etc.
You can read the article here for free:
http://aje.oxfordjournals.org/cgi/reprint/150/3/306
Vittinghoff E, Douglas J, Judson F, McKirnan D, MacQueen K and Buchbinder SP. Per-contact risk of human immunodeficiency virus transmission between male sexual partners. American Journal of Epidemiology 1999;150:306-11.
Thanks for posting that citation, Larry -- and helping to interpret the 1:33 number from Daniel. I've never heard that number before, but have many times seen the 1:122 number cited from studies and in journalistic accounts (though much less so in the latter -- perhaps out of a fear that people will misinterpret this "generic" abstract risk as practical risk they can apply directly to their own lives -- the two are not the same).
And thanks for your kind words! As you hint, I'm worried that health is becoming a new way of justifying discriminating sexual practices -- which I think extends often to areas of race and class. I don't know that many would consciously admit it, but I'm sure that some guys refuse to have sex with Black men because of statistics saying they are much more likely to be HIV-positive. There's a kind of perverse use of statistics in these scenarios to map out risk reduction strategies -- strategies that may fly in the face of reason. I'm not trying to make people's DESIRES problematic here -- but rather their use of discourses of health to justify discriminatory practice. Public Health's silences and failures to communicate meaningfully and effectively in the HIV prevention arena are a gigantic piece of the problem -- I'm not just indicting individual CHOICE here (in fact, I would be more apt to defend choice - and more invested in critiquing the kinds of discourses that enable those choices to be made). People obviously have a "right" to have sex with whoever they choose. But don't pretend it's about promoting your health. That's just gross. It flirts at times with the logic that undergirds eugenics.
We need HIV/AIDS education. It's very important!! CDC has granted CSU $1.9M for HIV/AIDS education.
The number of members on the largest HIV dating&support site == Positivefish.com has reached 500,000 members
OMG! Why so many guys and girls on the site are very sexy? Why so many people are infected by HIV? There is no
doubt that we need SEX-ED
The real problem with this common reaction, "I won't have sex with an HIV-positive guy," is that it encourages everybody to lie about their HIV status. This makes so-called serosorting strategies worthless except for partners who have been together long enough to see and trust each other's HIV test results.
I think the risk of HIV is a rationalization for more complicated issues with ageism. Prior to AIDS, young gay men always said, "I won't have sex with any old troll or queen." (I plead guilty!) Today, a HIV-positive status correlates more with older men and it is too easy to equate the two.
I believe ageism is the root cause, and not the risk of HIV, because I often see young gay college men, with an anti-HIV-positive attitude, have sex with other young men whose HIV status was not disclosed nor requested to be disclosed.
Thank you for this insightful and limpid entry about "sero-sorting" and HIV stigma. Running a support group for young gay positive guys, and being 24 and positive myself, you quite adeptly nailed some points about stigma, sex and risk I don't generally hear often.
First off, whenever I've encountered this belief with someone about sex with positive guys, I always ask how they know when someone is HIV negative. It raises the point that even if someone is truly honest about saying their status, they could just be mistaken or ignorant--an HIV test several years old, or even one just weeks old may not be accurate if they are just newly infected a few weeks before the test or since. As well, the epidemiology of new infections is documented as happening most prevantly from people who are unaware of their status. Speaking from statistics, a negative guy is less likely to get HIV from a guy who tells him his HIV status.
Also I really want to give you kudos for highlighting the difference between *exposure vs infection.* Someone else commented about the need for more "sex ed"--but the content has to be changed too. With so much of the prevention messages rooted in fear (more and more I hear that youth just "aren't scared enough" about HIV to avoid infection though I think it is Fatalism...but that's another rant :P), a lot of information completely skips that just because you are exposed to HIV does not mean you are automatically infected. In fact a lot of messages "always use condoms", "it only takes one time" inherently imply and distort that any sexual risk is automatically consequential. I can't say how many youth I've come across that freak out and completely believe that they are positive because they didn't use a condom one time, or because a condom broke. Several even avoid getting tested, and sometimes justified that since they were already positive, they don't have to worry about HIV and condoms anymore. Others went through a more acute mental health crisis before finding out they are still in fact HIV negative. Regardless, all of them became more skeptical about what they were being "educated" about risk and STIs; this kind of result is dubiously helpful at best and counter-productive.
Personally, I feel that prevention is focused too much on these abstractions and numbers about risk and disease. Rather than a litany of pains, discharges, and discolorations, why not a list of all the different tests and locations available, how easy they can be to take, and their speed with results? Instead of 'always use a condom' rather 'what else besides a condom'; 'get tested' be 'what will your status mean to you'; 'choose safe sex' replaced by 'what makes you feel intimate, secure and loved' or 'what makes you feel sexy, satisfied and safe'? But I digress.
Disclosure remains one of the biggest barriers and difficulties with having HIV, and frankly I've been sharing for a while how the Public Health and medical establishment skew towards the positive person as having all the burden and responsibility for not infecting someone; this is especially reinforced with varying laws in different states criminalizing sex with HIV positive people (varying in charges, and varying to even being illegal despite consent, and/or condoms!). To be fair, the HIV positive community also tends to embrace that focus of responsibility, which I am not saying is a bad thing. Frankly though, instead of us being concerned about our status and telling, we should be more concerned about *the other's status and health*; medically, having HIV makes one much more susceptible to other STIs and things. I've been working towards having positive people change their perception of being so concerned about them transmitting to them being concerned about their own health, and a "negative" guy infecting them!
It helps for someone to pick up that self worth again, because the most common and most difficult form of stigma is self stigma, very much what you described with that young man on the dance floor. And the worst we think of ourselves the more likely we are to do something that we will regret later, and the downward cycle continues. Yet, overcoming self stigma is a personal process, so like with your example positive guy, there is not too much you could do to rid that stigma right away; sleeping with a positive guy won't cure all the fears, shame or self worth, but being embraced and supported is always helpful in the end. And no, I am not saying you have to sleep with a poz guy in order to be supportive :-P
So in the end, I was thoroughly heartened and impressed by your posting. Thank you again :)
Thanks Larry for your comments! It's very intriguing that we're both quoting the same figure yet coming up with such radically different numbers. I'm quoting the Aust Soc HIV Med (ASHM) lit review and PEP guidelines at http://www.ashm.org.au/default2.asp?active_page_id=251 and as you guessed, they use the Vittinghof paper. There's a good reason why they've chosen the upper bounds estimate, because they're leaning towards prescribing PEP and the higher the risk, the stronger the justification. However, I'm not sure it's as justifiable to choose the lower bounds estimate when we're trying to criticise a neg man for badly managing an otherwise legitimate fear of HIV infection. The huge difference between those numbers points to the enormous uncertainty involved and that's an argument in his favour, not ours. It would make a lot more sense to argue this issue in terms of how confidence and skills in condom use might benefit him, and what lacking them might lead him to miss out on -- great sex and a long relationship with the man of his dreams, who may just happen to be HIV-positive.
yet it continues, no matter how they try to explain or rationalize behavior and consequences.
>"Refusing to Have Sex With HIV-Positive People: Why It's Not a Prevention Strategy, and Why It's Harmful to Our Communities"
Not having sex with HIV+ people causes AIDS? Not getting AIDS is harmful to the gay community?
>"Obviously, if we extend this risk over time, then we run into increased risk of transmission for a variety of reasons -- namely condom fatigue reported within serodiscordant couples. But if you use condoms, your risk of becoming infected from hooking up with a HIV-positive guy is probabilistically very low. Thus, excluding them from your dating pool cannot and should not be considered a risk reduction strategy -- unless you are having unprotected sex."
Disturbing question to insert (pun intended) into the conversation at this point: do condoms ever fail? do people ever claim to use condoms, but don't? will either of these questions cause anyone to get AIDS?
>"I'm worried that health is becoming a new way of justifying discriminating sexual practices -- which I think extends often to areas of race and class. I don't know that many would consciously admit it, but I'm sure that some guys refuse to have sex with Black men because of statistics saying they are much more likely to be HIV-positive. There's a kind of perverse use of statistics in these scenarios to map out risk reduction strategies -- strategies that may fly in the face of reason. I'm not trying to make people's DESIRES problematic here -- but rather their use of discourses of health to justify discriminatory practice. Public Health's silences and failures to communicate meaningfully and effectively in the HIV prevention arena are a gigantic piece of the problem -- I'm not just indicting individual CHOICE here (in fact, I would be more apt to defend choice - and more invested in critiquing the kinds of discourses that enable those choices to be made). People obviously have a "right" to have sex with whoever they choose. But don't pretend it's about promoting your health. That's just gross. It flirts at times with the logic that undergirds eugenics."
Everyone who engages in sex is engaging in eugenics (except for the homosexual part of the transaction). Selecting someone to mate with is influencing the future of the species.
There were slaves who were against the Emancipation Proclamation and women who were against the Right to Vote. It depends on how you're wired. It's one of the mistakes that nature can make. Is it nature's way of weeding out the population? How is it there's a fixed percentage of homosexuality? even in other species. there are, even in this country, people who do things counter to their own interest like being against universal healthcare. They die off leaving those who don't do things counter to their own interest.
>"This essay is just a gloss on these issues -- it admittedly raises more questions than it answers -- but I desperately think we need to think critically about the way we (I mean both we as gay men, and we as people invested in promoting Public Health) allow stigma to continue operating in our communities through the lens of "health" and "risk reduction."
Thanks for your interesting observations; I especially also appreciate zanderupin's remarks. A few things:
--Risk calculations that you note here rarely if ever circulate in communities of gay and bisexual men and other men who have sex with men. While it's conventionally or tacitly understood that condomless receptive anal sex is the 'most risky' practice, the kinds of calculations of riskiness you cite are almost never advertised or even told to relevant populations; they remain hidden. I suspect that public health and STI prevention folks tend to hide these sorts of numbers because they go against the prevailing ethos that attaches fears of 'threat' or 'danger' to each and every act of condomless sex; in their view, to make this information part of prevention would potentially license or enable 'irresponsible' behavior.
--Globally, HIV+ gay men, and other MSMs, are also rarely explicitly addressed with respect to varying levels of their own infectiousness. The general assumption, I think, tends to equate HIV+ status with 'infectiousness.' There is some movement here, especially following the 2008 Swiss statement on ARVs and infectiousness, but overall an absence of discussion on this issue, especially in medical circles.
--Everyone has an HIV status.
--I do think you are policing desire here, despite your stated intention. But rather than the question of whether or not HIV- men who refuse sex with HIV+ men who are open about their status are 'discriminating' or using public health discourse to justify practices of marginalization, it is perhaps a more fundamentally interesting exercise to consider the mechanisms by which sexual desire and subjectivity become tightly interwoven with questions of risk and what this means for gay and bisexual identity today. While I partly appreciate your rush to condemn what seems to be a mis-guided set of presuppositions, I would be more interested in a sympathetic reading or interpretation of the phenomenology (or something!) of HIV- sexual being. It would be interesting to know *how* it is that public health rationale governs sexual desire in contemporary gay worlds and the material-cultural circumstances through which this sexuality is (re)produced. In other words, we should make abnormal the ostensibly 'common sense' public health Reason or rationality that seems to shape what the gays want to do in bed. In a way, your critique here ends up reinscribing the public health discourse of risk calculation rather than putting it in question.
--Discussion above and at Queerty leads me to believe that gay men are still struggling with the loss of sexuality under the sign of HIV; there is little discussion of this loss and I sometimes think that the psychic consequences of this loss are that the anger that accompanies it is directed inward at gay men and gay selves, i.e., that the energetic condemnation of risk-taking by gay men today (stuff like: dumb asses! use a condom all the time!) conceals an underlying anger about the loss of sexual freedom that HIV/AIDS represented and represents.
--I'm surprised that you make little reference to the relative difference in risk calculation that being 'top' or a 'bottom' makes.
Thomas: THANKS for your extremely helpful comments. They really I think help to illuminate a problem I feel with regards to this piece -- indeed, I feel caught between a rock and a hard place. On the one hand, I want to be highly critical of "rational" decision-making processes that are so highly valued within Public Health discourses. On the other, I want to value lay strategies for minimizing risk while maximizing pleasure that exist within gay men's communities. In this essay, it indeed may seem that I am doing quite the opposite: critiquing the latter, while valuing the former. The last thing I want to do is to make gay men feel shittier about their sex lives. The real target here -- in my mind -- is Public Health institutions and the kinds of strategies they offer gay men for being whores in the face of an epidemic. In the US, sadly this is not something that happens. Indeed, ASO's have been EXTREMELY mum when it comes to serosorting practices, and it is this ambivalence / silence that I think that is partly to blame. Obviously, though, stigma is playing a large role in this game as well.
Daniel has what I see as a follow-up piece on the blog right now. I disagree strongly with his alternative approach, but will leave my comments for that entry.
For me, it's impossible to talk about discrimination when one is talking about sex. One's attraction or lack thereof to a person is so personal that I find it laughable to suggest that someone is wrong to turn down a potential sexual partner for ANY reason.
Fear of HIV positive partners may be irrational. Just as not being attracted to someone based on skin color, religion, or even height may be irrational.
But it is what it is. If a person fears HIV, and doesn't find that fear sexy, then how can you expect someone, especially someone you've just met, to get over it and have sex with you? It's unrealistic to expect this or ask this.
Attraction is only one part of the equation when it comes to sex. Being uncomfortable or fearful of your partner, no matter what the reason or irrationality of that fear, is not sexy.
Hello Trevor!
Thank you very much for this essay! It was very helpful for me to understand myself and reasons of possible rejection from other HIV neg guys.
I am positive newly, well relatively, 6 months now. And it has happened for the first time that someone rejects me (at least directly) due to my status.
It really hurted, it did especially because I really like the person and all was going on so well.
Anyway I can spare you the details. I started a blog (encouraged by yours here), which anonym will relate how I'll be dealing with the status:
http://pozzed.blogspot.com/2010/03/stigmatized-fancy-raw-start.html
Big hug!
N.