AIDSmap has a story up about a study just published about gay men, with the title "Having older sexual partners increases HIV risk for younger gay men." If you didn't read closely, you might think that the researchers had actually done a study that might buy them the cache to make such a claim. I thought I would take a moment here to dissect what the study actually found, and what we can(not) safely conclude based on those findings.

First, the study wasn't just about "gay men." Though many of the men involved did identify as such (74%), they recruited "men who have sex with men" - which includes a variety of other kinds of guys. Second, and more importantly in my book, they study involved a small sample of 74 men in North Carolina. That's right, 74 people are the basis for that rather startling headline. The meat of their claim is this statement here:

Men with PHI had partners on average 6 years older than themselves, whereas uninfected men's partners were 4 months their junior (P , 0.001). After adjusting for race, sex while intoxicated, and having a serodiscordant/serostatus unknown partner, a participant had twice the odds of PHI if his sex partner was 5 years his senior (odds ratio 2.0, 95% confidence interval: 1.2 to 3.3)

Let me try to translate that into slightly more clear English:

On average, the men that recently HIV-positive participants reported having sex with before they seroconverted were 6 years older than them. By comparison, HIV-negative men's recent partners were 4 months younger than them. When we take into account these guys' race, whether they reported being intoxicated while having sex, and whether they had sex with poz guys or guys whose HIV-status they didn't know, a participant was twice as likely to be in the HIV-positive group if he reported having partners five years older than him.

I hope that was somewhat more readable. In any case, what they're trying to say here is that because there is an association between having sex with older guys and being HIV-positive yourself, there may be causal relationship between those two things. But of course their data doesn't actually show this. Indeed, what there data merely says is that - of the 74 guys they interviewed - the ones who were poz were more likely to report having sex with older men before they were infected. The data they are relying on here is a survey asking men about their three previous partners before infection if poz or their three previous partners before their enrollment if neg.

But of course we can infer other possible theories here, and not just the causal link that they're alleging here. Or at least it could be missing pieces of the story. Now, importantly they did control for race, substance use, and sex with poz and unknown status guys. These are all important factors that should indeed be taken into account, so we don't mistake the difference in age between partenrs for the causal factor when it's actually other factors.

However, in a strange move that they don't explain, they actually don't include in their associative model condom use with their previous serodiscordant or serounknown partners, which actually varies considerably between the two groups (click to embiggen):

Just to clarify: This data isn't about condom use with any last partner, but only the previous partner who was either HIV-positive or for whom you did not know their status. That's a pretty important piece of data, and the different shown above is striking. But there's a bit of a statistical trick going on in their write-up. While the difference above is stark, non-condom use with a previous poz or HIV-unknown partner is not actually what they include in their model. Rather, for their odds ratio calculation, they include whether or not the participant reported having sex with a serodiscordant or serounknown partner at all. But this of course is the less meaningful datapoint -- what actually matters for risk is whether you used a condom with that last positive or unknown partner!

I don't like being duped, and seems to me to be what's going on here. They are using statistical trickery to manipulate our interpretation of their findings. What other conclusion can we reach? They have more meaningful data, and yet they willfully leave it out of the model and never address that exclusion. There is just no way that this was an accident -- they obviously ran the model with the condom use data and it was likely weaker than the one they decided on. Thus, I'm suspicious.

But beyond the statistical manipulation, this is a study of 74 men in North Carolina. Let's not get ahead of ourselves and start making any big claims about "gay men" universally or even across the United States.

Moreover, what is most troubling for me about this data is what they clearly want us to do about it: Prevent younger men from having sex with older guys. This to me is the next logical step in Public Health logic, and it's the one that had a bunch of us gay men's health activist up in arms a year or two ago when Michael Scarce reported on the Ning that STOP AIDS was working on an intervention research project that would attempt to do just that. It's important to know the ways in which HIV gets transmitted, and to be able to implement culturally tailored prevention efforts that come out of that knowledge. But dissociative mixing is not the answer.

Citation:

Hurt CB et al. Sex with older partners is associated with primary HIV infection among men who have sex with men in North Carolina. J Acquir Immune Defic Syndr, online advance publication, 2010.

"Risk" as a conceptual approach for much of the research on health has come under attack from many sides. Risk is everywhere and nowhere, it seems. When it comes to gay men's health, gay men's sexual risk practices have particularly been scrutinized by researchers who wish to stop gay men from doing such naughty things as having sex without condoms. Many have suggested that rethinking "risk" (traditionally conceived of through the lens of an isolated rational actor making complex cost-benefit analyses aimed at maximizing returns and minimizing harm for him/herself) as a concept is a necessary step towards creating a more effective / ethical / social public health.

As I was reading for my class today on the Sociology of Law, I came across this very interesting distinction between "risk" and "uncertainty" that gets made in the literature on organizational behavior:

"On the whole, then, high-technology start-up financing poses challenges not only of risk but also of uncertainty. Although lay parlance often employs these terms interchangeably, the organizational decision-making literature uses them to describe two distinct conditions. Under conditions of "risk," decision-makers may not be able to predict the future deterministically, but at least they can describe it probabilistically: with a little effort, individuals can identify the full range of options and outcomes, and they can determine roughly how likely it is that any given option will produce any particular outcome. Consequently, despite the presence of risk, decision-makers can still make rational choices based on expected-value calculations, and markets can still produce efficient coordination based on contingent-claims contracts.

Uncertainty, on the other hand, arises when decision-makers cannot determine either (1) the full menu of alterative behavioral options or (2) the relative probability of alternative possible outcomes. Unlike risk, uncertainty is deeply incompatible with the neoclassical model of fully rational decision-making. Instead of producing a careful expected-utility analysis of all lines of action, conditions of uncertainty tend to produce "boundedly rational" decision strategies, involving "good enough" choices, gut feelings, and rules of thumb. At a more macroscopic level, uncertainty elevates transaction costs and exacerbates intra-organization strains and power struggles. Consequently, unresolved uncertainty poses a fundamental cognitive and organizational obstacle to the formation and maintenance of stable markets for high-technology start-up capital."

-- Suchman, M. & Cahill, M. (1996) "The Hired Gun as Facilitator: Lawyers and the Suppression of Business Disputes in Silicon Valley." Law & Social Inquiry, 21(3): 679-712.

So my questions of the day: What would it mean to reconceptualize men's safer sex practices as enacted in an environment of uncertainty -- rather than in an environment of risk? Is "risk" really the appropriate concept for understanding these complicated, negotiated practices?

I was overwhelmed by the turnout last Friday night for the forum in Chicago, "What is justice for the black gay man?" I'm not particularly good at estimating crowd size, but the room was very spacious and it was standing room only. In attendance was a regular who's-who of Black gay men and their allies in Chicago, including a few local politicians and government officials. In this regard, I want to applaud the organizers of the event for bringing together a fabulous group of Black gay men and their allies for a discussion devoted to some rather difficult topics.

I was excited to hear the panelists, of course -- particularly E Patrick Johnson and Keith Boykin, both of which have done some pretty groundbreaking work in their respective fields for advocating for LGBT issues broadly and for Black gay men specifically. Johnson's performance work, "Pouring Tea," I particularly love for the way it brings to life an extremely diverse set of experiences of Black gay (or otherwise same-gender-loving) men living and thriving in the South. Keith's critical work on the down low was also I think an incredibly important invervention into the stigmatizing discourses around this issue that became hyperbolic when writers like J. L. King (who went on Oprah to spread his pathologizing understanding of the phenomena) and Benoit Denizet-Lewis, who wrote a grossly distorted piece for the New York Times. Denizet-Lewis has actually made something of a career of pathologizing gay men, which probably explains mainstream media's love for his alleged "exposes."

So needless to say, I was eager to hear these thinker's thoughts about how best to advocate for and understand the experiences of Black gay men. I expected to hear about social justice rooted in a denial of access to social benefits, racism, pathologizing discourses about Black MSM's sexualities and behaviors, an HIV epidemic that is crippling agencies working with these populations and disproportionately infecting Black men, and an interwoven network of stigmas that makes daily life for these communities trying at best, and unbearable at worst. Alongside these problems, I also wanted to hear about the ways in which many Black gay men are surviving and even thriving despite these obstacles.

I didn't really hear either of these things. Instead, I was shocked and nearly appalled when it became clear that justice for the speakers was primarily about "loving yourself" and "being true to who you are." Indeed, the problem that was posited as the most trying for Black gay men was their own internalized racism and homophobia, a kind of pathologizing and psychologizing approach to social injustice that I found utterly baffling. No, it wasn't pervasive systems of racism, homophobia, sissyphobia, and pozphobia that are systematically embedded in social institutions and cultures that should be the focus of social justice movements -- but rather the internal psyches and emotions of Black gay men themselves.

This is not far from the latest self-help craze for Oprah to latch onto, "The Secret," which proposes that to succeed in life we merely need to imagine ourselves as successful, wish for that to be true, and think positively. If we aren't rich, then it's our fault for not wanting to be rich. If we don't have health care, then it's our fault for not wanting to become insured. This isn't just offensive, it's downright manipulative for the way that it seduces people into believing that the onus of achieving loosely defined "success" in life falls entirely on individuals. Nevermind the vast libraries of scholarship that illustrate the ways in which various forms of social inequality make achieving these markers of success difficult if not impossible for many social groups -- particularly those born into poverty but also those marked by certain socially ascribed characteristics such as race, gender, and sexuality. Under this individualistic / rational framework, you are a free agent whose choices in life are the only factor that will influence whether or not you grow up to be a CEO or a garbage collector. As a sociologist, this is the kind of ignorant, distorted, and highly conservative perspective on the world that erases the foundations for a politics of social justice.

I'd call attention here to two comments from the audience after the short presentations by the panelists that I think help illustrate the underlying politics (or lack thereof) in their comments. First, there was a question from a self-identified "successful" Black gay men near the front of the room who noted that he loved himself, his life, and his partner just fine -- but his self-love, well-paying job, and house didn't translate into his ability to formally marry his partner of many years. Thus, I read him as trying to point out the ridiculousness of the panelists' claims about what justice should mean for Black gay men -- it cannot be framed just in the terms of psedo-scientific self-help jargon, but rather must first and foremost recognize the structural and social injustices that make that self-love difficult to achieve. The self-love is the OUTCOME of justice, not the root CAUSE.

Second, a man near me later stood up to ask why it was that the panelists were defining homophobia as a kind of psychological problem, rather than as a pervasive social system of power relations that is embedded in institutions and cultures. Heterosexism, he posited, would perhaps be a better way to situate the claims for justice that could foment a Black gay politics. "No, no" the panelists said (I'm paraphrasing), "I don't think that's how we understand homophobia." But it was clear that this was EXACTLY how they were positing homophobia and more broadly the social justice politics that should stem from that form of social inequality -- as I hope is made clear by my (distilled) description of their talks above.

Don't get me wrong, I hope that Black gay men are happy. That's a good thing. But you just don't build a social justice politics based on psychological concepts like internalized homophobia and depression. That's the building blocks for a public health intervention, which increasingly are supplanting actual social justice movements for gay men in general -- Black, white, or otherwise. It's perhaps not a coincidence that these efforts are funded by state agencies that perpetuate these very injustices. The disease or problem in this model becomes not the system and the dramatic injustices it enables, but the various medical problems experiences by minority groups like "self-destructive behaviors" and "low self-esteem." It is precisely though this pathologizing reconfiguration that political movements become neutered and inequality gets perpetuated, reproduced, and made more insidious because these injustices come backed by medical authorities with so-called "evidence."

Let's take care not to fall victim to these alluring models for social change. They may make us feel warm and cuddly, but that isn't going to mean a damn when said happy person gets denied health insurance because he's HIV-positive. Or when he gets fired from his job because a co-worker saw him kissing his boyfriend at a local nightclub. Let's see how happy they are after that.

This is slathered all over CNN's front page today. Two things:

1) What does it mean that we are so ready to compare children to deadly weapons? Deadly not just to themselves, but the metaphorical comparison suggests also to others. Obviously, I think we need to be thoughtful about the way we create metaphors for understanding, and really think through the implications in making comparison. Bombs are weapons of destruction, engineered by man to kill others.

2) Moreover, if you look at the story's subhead, they're noting that "experts" argue that we need to "get our kids back on the playground." My problem with this suggestion is that it is backward-looking and nostalgic -- it imagines a time of yore when things were better, and suggests that we magically return to this era. I have news for you: It ain't gonna happen. Rather than viewing shifts in technology and childhood play as problems, we need to be invested in understanding how we can use them as assets. The Nintendo Wii is one great example of this and how we might think of applying it to the problem asserted in this article. Children aren't going back to the playground. Deal with it.

Just a few thoughts to start your day!

A few days ago, I published a piece that managed to re-posted on numerous blogs (here, here, here, to name a few) that critiqued the use of "serosorting" as a rationale for refusing to have sex with Poz men when condoms are used. A flurry of interesting and highly productive conversations came out of this piece that center around a number of problematics: Rationality vs. Emotionality (as noted in Daniel's response piece); Responsibility vs. Recklessness; and Individual Rights vs. Collective Ethics, to name a few.

But alongside these productive conversations came what I see as a highly vitriolic and slanderous response that emerged in the responses on Qweerty -- a kind of mainstream gay blog that gets quite a bit of traffic. I see a big part of the issue here as resulting from the title the folks at Qweerty assigned the repost:

As you can see, they've suggested here that I called people who refused to sleep with Poz men "assholes." I didn't, and I don't think that -- just to be totally clear. I don't know much about Qweerty, but in the past I've certainly seen comments there that suggest a pretty conservative readership when it comes to sex. But I had no way of anticipating the anger and vitriol that has spilled out in the comments against me and my arguments. I certainly understand that these issues are highly emotional, but most readers did not engage the arguments -- they opted instead to call me names. Ouch.

But I'm a big boy. I can take a bit of name-calling. You work long enough in HIV prevention, and you realize that someone's going to smear your name if you say anything that differs from the party-line prevention soundbites. So in the interest of making something productive happen out of this violence, I wanted to take a moment to see if there were underlying logics in the nearly 100 comments that were enabling the anger -- logics that anyone interested in unpacking the politics of prevention should be interested in. Here we go.

1) "I take it this was written by someone Pos." & "hell no. he sounds like som sort of con man": A number of readers suspected that I must be HIV-positive for writing this. I think this is INCREDIBLY telling about the kind of divisive and polarizing kinds of conversations that are all too common in our communities. I'm not HIV-positive, but why does this matter so much? The subtle underhanded suggestion here is that I must be HIV-positive because I seem to be trying to coerce negative men into having sex with me.

2) "Trevor, you have no idea about the breadth of the stigma associated with HIV+ status; and only the few of us very long-term poz, and their friends and boyfriends, who witnessed and were subject to it do.": Let me try to translate: I've got the misery, keep your hands off. This is clear boundary-drawing, attempting to say that I have no right to discuss this issue because of my negative status. All too common when discussing issues of stigmatized minorities.

3) "What a nut. He seemed to also want to outright say -- but didn't -- that it was the duty of negative guys show their commitment to positive guys by fucking them.": Like the comments in #1, these readers presumed that I believed there was some kind of charitable commitment necessary for neg guys to be coerced into fucking poz guys. Again this is really not the point. The point is that there are prevention discourses circulating that making refusing sex with poz men seem entirely logical, and I'm challenging the logical bases by which that refusal becomes obvious or rational. Fuck whoever you want, but don't pretend like it's obviously just about self-preservation

4) "Hoppe is using the same tired rationalizations the community used in the eighties. I'm glan [sic] folks are seeing through this bulls-t. We have to stop aids in our community now. We've known the transmission method for years. And the available strategies have been obvious for years: positives only with positives, negatives only with negatives, honesty and caring for everyone, peer group pressure on thoughtless barebackers, condoms always for negatives except in a monogamous relationship when trust is rock solid. If anyone's feelings are hurt by this, tough s-it.": I think this comment speaks for itself. Here the claim is made that the only strategies for prevention transmission are 100% serosorting, shaming people who don't use condoms, and only allowing for unprotected sex within relationships. And I say: Tell that to the 68% of new infections that are estimated to be the result of condomless sex with people's primary partners. And obviously the pathologization of "thoughtless barebackers" is the kind of shaming that does nobody an ounce of good.

5) "I'm fed up with having to dance around the constantly shifting, ever increasing sexual minefield that horny, unconcerned poz men represent.": In this readers's mind -- and in many others -- the responsibility for transmission rests squarely on the backs of poz men. As if neg guys share none of that responsibility. As if the men leaving the backroom are akin to murderers. This is worse that stigmatization, it's criminal slandering -- and its the kind of hateful logic that Public Health scholars and institutions have too often served to promote and help disseminate in their efforts. I'm not saying poz guys are totally without any responsibility here, but c'mon.

and finally, my absolute favorite:

6) "Is it wrong to refuse to take a ride on a train you know has no brakes? Jesus, how can anyone write such a self serving, irresponsible idiotic article?": Wowzer! There's a lot going on here. First, it obviously equates having sex with Poz guys to getting on a train headed for certain death. I don't think I need to explain why that's the most disingenuous comparison I've heard in months.

Phew. I think I need to take a few days off from blogging. This was quite an intense ride. In the end, I'm reminded of something my mentor Eric Rofes wrote before he died (see pp. 6-7 of THRIVING, PDF found here):

I recently published on a gay news website an editorial viewpoint that attempted to open up new ways of thinking about HIV prevention, crystal use, and gay men who occasionally have sex without condoms. I was attempting to offer new vision. I understood the risk of attempting to offer new thinking and introduce complex concepts in a brief article on a popular website, but I did my best to inject some fresh thinking about risk-taking and the hazards of social marketing into a discussion which has become predictable and, at times, trite. At the same time, despite my awareness of the challenge I was taking on, I had not expected the rage reflected in some of the letters of response from readers. A sampling follows:

Patrick Syring from Arlington, Virgina, wrote:

"Your advocacy for barebacking and party drugs is abhorrent and disgusting. Gaymen like you tarnish the rest of us who play safe and cherish life more than you do. I hope you die painlessly but quickly."

Anthony Altieri wrote:

"Your article is one of the stupidest things I have ever seen in print. You are obviously a fucking idiot...You cannot blame people's self-destructive behaviors on prevention campaigns. Have you ever heard of a little thing called "personal responsibility"? Probably not. There are plenty of reasons people make unwise decisions: addictive behavior, loneliness, desperation, isolation, lack of purpose in their lives, lack of education, but I am confident you will NEVER find a case of 'I have uprotected sex and use drugs because I saw a poster telling me to use a condom.' The aids [sic] epidemic has been ongoing since the early '80s. DEAL WITH IT. USE A CONDOM YOU FREAKING MORON. Please do us all a favor, unplug your computer and refrain from subjecting the world to any more of your bullshit. Go sit quietly in your bedroom with the lights off, avoiding the realities of life. You seem to be pretty good at that anyway."

Why do conversations among gay men about HIV, barebacking, crystal use, and bathhouses get so ugly and divisive? Why are they argued in such a vehement manner? Are they simply another example of internecine warfare driven by personality conflicts, ego battles, and bad manners? How can we make sense out of distinct visions that seem to underlie these debates: one which argues that the crisis moment of AIDS has passed for gay men and one which berates gay men for taking a single step beyond the bomb shelter we've inhabited since the early 1980s? Why is gay men's sex so frequently the target of such contentious debate and demonization? How did we reach a point where there are such deep divisions among gay men about sexual health and safety? And in what ways do vehement responses to new vision effectively serve to keep out of our movement fresh, innovative thinkers offering fresh analyses?

Amen.

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.

It's been three weeks since I stopped buying cigarettes. It was a bit of a collective decision between me and three friends who decided that, at the very least, it was costing us a fortune and we would rather spend our money on champagne and foie gras than on the tobacco product. But more than just financial rationality, I think we all were grappling with a variety of concerns regarding our health / well-being. But I need to explain a few things first before I get there.

I started smoking when I was thirteen or so. Me and my cute neighbor snuck out to the woods behind his house to share a smoke. Ever since then, I've smoked to varying degrees -- sometimes going as long as six months without smoking, sometimes smoking more regularly. I never considered myself a "heavy" smoker, because it was primarily a social phenomenon in my life that was relegated to the weekends for most of these years.

From the beginning, smoking was closely tied in my life to a kind of rebellion against authority. The act of sneaking out, after all, was indeed the very method by which me and my similarly angsty neighbor enjoyed our first cigarette. Over time, as I became more of an "out" smoker, it became a way of signifying my disagreement with larger social norms about what constituted a morally acceptable lifestyle. Let me dissect this a bit more.

I believe that for me, smoking and coming out as gay were related processes for me that deserve a bit of attention here. By the time people started condemning me as "disgusting" for smoking, I had become quite accustomed to people accusing me as "disgusting" for having sex with men. Living in the South, it took much longer for Public Health's moralizing messages about tobacco use to disseminate in tobacco country than perhaps in other places in the US. But eventually it became agreed upon in white, middle class communities (e.g. where I'm from) that smoking was unseemly and morally suspicious. Smoking was something poor people or "deadbeat dads" did. It was a sign of moral failure.

So when people started telling me I should quit smoking, it was rarely framed in terms of caring for my well-being. Not in the slightest. Rather, people took care to tell me how "disgusting" and "repulsive" my habit was, and that I should immediately stop engaging in this kind of repellent behavior. It is very clear to me now that being gay made me extremely suspicious and hostile to these messages. I knew from experience that "health" had been used to attack my sexuality and frame it as morally suspicious ("AIDS = God's Curse for Homosexual Promiscuity"), and so I was primed to be suspicious of anyone calling into question my character as person because of my taste for cigarettes. I distinctly remember someone in college remarking in surprise at my lighting up, noting that she didn't think I was "the kind of person who smoked." In that moment, I embraced her shock and dismay -- it was something of a badge of rebellion. Just in the same way that I might embrace someone being shocked when I describe a particularly slutty weekend.

I don't mean to say that being gay and smoking are actually in practice equivalent -- rather, I mean to say that people's telling me how disgusting I was for smoking actually prompted me to smoke more often, and for much longer, because of my already-antagonistic relationship to patronizing moral discourses on homosexuality. Criticizing me for smoking had the exact opposite effect of what was intended. After all, the way people reproached me for smoking was most commonly in terms of self-righteous snide comments that seemed aimed at serving the anonymous critic's sense of moral superiority -- rather than any actual concern for my own health.

I do not believe that I am a "better" person for not smoking. I do not believe that people who smoke are somehow more "damaged" than those who do not. These kinds of fucked up, pathologizing tendencies are exactly what prompts many of us who do smoke to come to identify as a smoker and thus make it much more difficult to consider stopping smoking. For me, quitting became synonymous with selling out to a "healthy" discourse that is riddled with problematic tendencies to associate "health" with "goodness" and "risk" with "badness." It took me years to feel comfortable deciding to quit for my own reasons, rather than feeling as though I had to proscribe to a presumed narrative of personal "betterment" that pervades popular discourses about "healthy behavior."

So please, for Gay's sake, don't congratulate me for stopping smoking. I don't feel better about myself for quitting. I'm almost a bit ashamed of it. It's just a decision I made, that took years of consideration and was informed by a complicated set of reasons. Congratulating me will actually make me feel like I made the wrong decision. And if you have a habit of self-righteously telling people that smoking is disgusting, cut it out. It's hypocritical. It's patronizing. And you're liable to make people who smoke only more committed to continuing to do so.

The San Francisco AIDS Foundation has just released their latest episode of their podcast featuring AIDS experts discussing hot topics of the day, this time around concerning the Thai Vaccine Trial showing a 30% preventative effect. The episode features SFAF staffer Erik Ireland and Executive Director of the AIDS Vaccine Advocacy Coalition, Mitchell Warren.

You can see here that "behavior change" is an issue, and that they regard this vaccine as not implementable because of this problematic. As Daniel Reeders has just recently argued here, implementing a 30% preventative effect among men who have no safer sex behavior to change would have a sizable impact on new transmission. But obviously the "public health nannies" (as termed by Elizabeth Pisani) don't agree.

The UNAIDS has just released a report (story | report) saying that "between five and fifteen men will need to be circumcised to prevent one HIV infection in the ten following years, at a cost of between $150 and $900 per infection prevented." Their conclusion: circumcision is a "cost-effective" intervention strategy for HIV prevention. In this report, there is no consideration for whether this procedure is ethical. Nor is there any consideration of what kinds of cultural meanings might be attached to the foreskin in communities they're ready to scalpel -- or how a mass program to remove their foreskins might be interpreted and expressed culturally.

I like to use the example that reader Thomas Kraemer provided a few weeks back in the comments: We could cure breast cancer tomorrow if we could just institutionalize double mastectomies for young girls. Or as my professor cynically joked the other day, "Why stop at the tip of the penis? If we could remove the whole shebang we could rid society of any number of not just medical, but social ills as well!" Oh, sure, some folks out there will resent the comparisons. "The breast is more important than the foreskin!" To this response, I have just one question: "Says who?"

I think we desperately need to be mobilizing against this movement towards circumcision. It's wrong-headed, poorly thought-through, and is really aimed at circumscribing any need for creative prevention approaches by creating a biomedical intervention. The crisis is clear: Prevention specialists -- trained in the too-often culturally incompetent fields of health and biomedicine -- are just downright flummoxed by the inability of their interventions to stem the rise in new infections. If you've ever worked in the field, you've undoubtedly seen their red-faced angst before: "Why won't these people just use condoms, goddammit?" Nevermind the structural constraints of poverty and gender. Nevermind the meanings implicitly and inadvertently attached to condoms by Western medicine (e.g. distrust, fear, etc.).

Thus, in an era when classical prevention strategies are failing globally, old-school prevention types have opted to search for a biomedical intervention that would avoid any need for dealing with the messy realm of the social. "If we can just chop something off, then we won't have to deal with compliance!" Ta-dah! The magical solution! Obviously, this logic is outrageously problematic. It presumes that circumcision will not be rife with cultural meanings and dilemmas, and it also presumes a hostile population that is "non-compliant." It never allows for the consideration that perhaps it is prevention that is the problem -- not the communities it seeks to change.

I am amazed by the number of studies in epidemiology -- the sheer mass of publications -- that continue to rely on behavioral survey instruments that unreflexively presume a set of concerns worth asking about that stem from an understanding of the epidemic in which it is people's behaviors that fuels the HIV/AIDS epidemic. This is downright shameful given the massive amounts of data that demonstrate how obviously correlated new infections are with social-structural factors like race, class, gender, and sexuality. It's like trying to telling people in Detroit to eat better when there is no grocery store -- not a single one -- within city limits.

It's past the point of naivety -- since the amount of data demonstrating the epidemic's social-structural roots is so compelling. It amounts to a kind of willful ignorance to continue trying what you know will likely fail because it is easily funded and requires little critical thought. It's easy. It's lazy. It would all be a bit humorous if it wasn't resulting in a body of prevention literature that does very little to actually work towards meaningful prevention. People are dying. Scientists are laughing their way to the CDC-NIH bank.

Removing foreskin in the name of health promotion is unconscionable. It amounts to a kind of cultural imperialism that will undoubtedly stir up backlash against Western Public Health. The idea is not seen as radical because we in the US already practice it so commonly. But believe me: If circumcision was virtually unknown in the United States as it is in other areas around the Globe, we would not be having this debate. But because it is such an institution here, the idea of promoting it elsewhere seems totally sensible. It's the worst kind of ethnocentrism, and it needs to stop.

In December of '08 I joined San Francisco's HIV Prevention Planning Counsel (HPPC) as a youth service provider and as a member of the TMSM community. The HPPC is made up of service providers, researchers, community members and other interested persons, who advise the SF DPH on how to create real-world prevention strategies and how to prioritize CDC funding in SF.

In January '07 the HIV Prevention Section of the SF DPH prioritizd the creation of an action plan to adequately address the HIV prevention needs of Latino MSM. In early '08, Oscar Macias and Erik Dubon of the SF DPH convened a group of Latino MSM and allies to discuss a local Latino action plan for SF. The group enlised Rafael Diaz and Jorge Sanchez as consultants to assist in the creation of the Latino action plan.

This information is from their presentation to the HPPC on Sept. 10 '09. This will lay out an overview of their findings and their recommendations to the HPPC and SF DPH.

Final action plan N= approx. 239

Community Forum N= approx 45

Researcher Interviews N=6

Interviews w/ Latino MSM N=157

Dialouge w/ Providers N=31

Finding 1: San Francisco is a magnet for migration of young Latino men looking for sexual freedom and gender self-expression; they are treated as sexual objects and land in high risk contexts that put them at risk for substance abuse and HIV.

Recommendation 1: A guiding structure (perhaps a website online) that orients new waves of young Latino gay men who are newcomers to San Francisco; "landing pads" would be healthy and supportive contexts rather than situations of risk where Latino gay men are sexually objectified.

Finding 2: In San Francisco, it is very easy to find sex, but extremely difficult to find meaningful relationships. "Hot Sex" is the most valued commodity and men feel socially pressured to give up expectations of partnerships where they can integrate emotional and sexual satisfaction.

Recommendation 2: Programs that provide relevant and tailored education on the interconnection of sexuality, relationships, substances and HIV. Community building in context that emphasize a sense of familia.

Finding 3: Main reason for UAI (unprotected anal intercourse): perceived seroconcordance. Men are approaching HIV prevention by making assessments of HIV risk within particular sexual encounters - pursue risk reduction strategies other than condom use.

Recommendation 3: Programs that help men make sound and accurate assessments of HIV risk in different sexual contexts and situations, including knowledge of HIV status of self and sexual partners.

Finding 4: Stimulant use and participation in "Party and Play" (PNP) contexts are strong correlates of HIV risk. Sex under the influence is forced underground by stigmatizing attitudes and by health providers who do not address the issue.

Recommendation 4: Culturally relevant programs that address the functional use and impact of substances - emphasis on connection between stimulants and HIV. Need anti drug-stigma campaign and increased provider training.

Life Concerns and Priorities

Participants completed a brief survey listing 23 life concerns. They were asked to list and rank-order their 10 most important concerns:

Financial Well being 39%

Finding a good job 38%

Physical Health 34%

Depression/anxiety 24%

HIV/AIDS 21%

Having good friends 15%

Paying bills/debts 14%

Finding good housing 13%

Finishing school 13%

Emotional well-being 11%

Finding 5: Content of HIV prevention does not address the most pressing concerns of Latino gay men: Financial well being (#1) employment (#2) physical (#3) and mental (#4) health. Desire for improved physical and mental health is beyond issues related to HIV/AIDS (#5)

Recommendation 5: Programs need to address Latino gay men's concerns for job stability and financial well being; that is, connect HIV prevention with the existing with the strong motivation towards "Superacion" (improve one's situation - financial, educational, physical and emotional).

Finding 6: Latino English-speaking gay men have substantially lower rates of participation in Latino-identified HIV programs in the city - no HIV prevention programs specifically targeted to monolingual English-speaking Latino gay men.

Recommendation 6: Programs that welcome and target Latino English-speaking gay men need to be developed. However, this should not be done at the expense of existing programming designed for immigrant, Spanish-speaking men.

Finding 7: Riskiest group: older (over 35), English-speaking, unemployed, drug-using, HIV-positive, marginally housed, Latino gay men. Their risk is connected to poverty, social alienation, and social situation of vulnerability.

Recommendation 7: Create a program that targets the particular issues of older English-speaking Latino gay men of lower socioeconomic status who are marginally housed (mostly in SROs or shelters). The program should address issues of life stability, as well as access to culturally appropriate mental health and substance abuse services.

Finding 8: HIV positive men are reporting higher rates of risky sexual activity than HIV negetive men (59% v. 44%). Meanwhile, high rates of HIV stigma discourage disclosure.

Recommendation 8: Culturally tailored Prevention for Positives that addresses sexual behavior, HIV disclosure, and assessments of risk for HIV transmission among positive Latino men in a way that is non-stigmatizing. Campaigns aimed at reducing HIV stigmatization in the Latino gay community.

Finding 9: Non-gay identified men found in the social context that Latino gay men participate in: all (100%) straight-identified men interviewed were classified at HIV risk: these individuals unlikely to visit agencies or attend groups.

Recommendation 9: Programs tailored to MSM who identify as heterosexual should be developed, with targeted individual assessment and counseling by culturally trained prevention workers.

Finding 10: Many HIV prevention providers - often themselves members of the Latino gay community - are accomplishing very hard work under difficult circumstances.

Recommendation 10: Programs that address high burnout rates of HIV service providers. Existing Latino programs should be funded to carry out activites that prevent burnout and sustain the long-term, enthusiastic work of their front-line staff.

Whew! I know that was long, but it's good stuff. After some discussion on budget (pretty tall order for a city that just got it's state HIV prevention funds cut from 2.9 million to $500,000!) the HPPC voted unanimously to support the LAP recommendations.

The LAP team will be presenting they're more thorough data in a few months.

... sitting in a room full of epidemiologists going over a sexual history survey instrument -- being bored because as a gay man I have been subjected to these surveys dozens of times. I know exactly what they ask, at what point in the survey. My hetero classmates have never seen this before.

Today is the first day of classes here at The University of Michigan, and thus I begin my two-year adventure as a Masters of Public Health in the Department of Health Behavior and Health Education. Given my recent work, this may seem a bit contradictory. But I feel that if I'm going to engage in a serious critique of the field, I should get intimately familiar with its teachings.

So here I go! I just wrapped up my first seminar -- at the ungodly hour of 8:30 AM -- on HIV/AIDS. The professor began with the usual epi data, but moved on to a bit of Goffman, Foucault, and stigma. Hey, things are looking up!

Despite any evidence to suggest they are more susceptible to the disease, the SF Department of Public Health is advising that HIV-positive people take care to get the H1N1 vaccine when it becomes available:

San Francisco health officials stress there is no evidence to suggest that people living with HIV are any more susceptible to the swine flu than they would be for the seasonal flu. "They should think of it as the same as the seasonal flu. Whatever their reaction would be for the seasonal flu should be their reaction for H1N1," said Dr. Susan Fernyak, the health department's director of communicable disease control and prevention. "If they don't care about the seasonal flu, they shouldn't be up in arms about swine flu." Health officials have long advised HIV-positive people to get vaccinated for the seasonal flu each year, and that is still the case this year. Each year 6,000 Californians die due to influenza. "It is still a serious disease in California and people should get immunized for seasonal flu," said Amy Pine, director of the health department's communicable disease prevention unit. "Everyone should get [vaccinated], including people with weakened immune systems."

I teach 75 undergraduate students who will be prioritized in getting the vaccine. But I'm too old to be in the priority category. Hoping for the best!

Again, Via Joe. My. God.

I was shocked last weekend in Chicago at the LGBTI Health Summit when I began to cry in the middle of a workshop. It was my fourth session of the summit, and I was feeling a bit worn thin from the weekend's intensity. Nevertheless, I did not anticipate the power of the emotions I felt as I described my anger and intensity over Public Health's treatment of gay men's sexualities.

The workshop was titled, "Destroying Public Health: for the Good of LGBT Health: Critique. Alternatives. Discussion," and was a collaboration between myself and Bill Jesdale. He was going to do a piece on risk, and I was going to do an analytic-polemic piece on the need to destroy Public Health. I had given a similar presentation before at an academic conference (audio; slides), then-titled "Resisting Public Health." But I felt the need to rev things up a bit, so I opted for a more loaded verb.

No more than an hour before the workshop was to begin, I was fiddling with my Powerpoint slides. There was something missing. I had the analysis down, but there wasn't the personal-emotional component that I knew was key to the argument I was making here. I wanted to make first a structural critique about the field of Public Health's epistemological reliance on Psychology and Epidemiology -- and the kind of knowledge that these fields were most apt to produce -- and I also wanted to make a structural critique about the field's normative grounding assumptions about sex, desire, and risk. But what was missing was the personal piece about how these structures made me feel as a gay man. What was the impact on my life?

So I typed away, working up a slide that I knew was polemical, but that was coming from a real place of hurt and anger. I wanted to own that anger, to share it publicly in a way that I had not done before. I didn't realize then how painful and upsetting it would be to actual talk about these feelings. Here's the slide in question (click to embiggen):

You can see what I mean by polemical. In any case, no sooner than I started describing the ways in which Public Health scholarship on crystal-meth addicted, HIV-infecting, depression-ridden gay men made me feel, tears started running down my face. I could barely go on speaking. I had never cried like this in public before -- the only time I had come close was when I delivered a memorial speech for Eric Rofes some years ago. But this was even more intense.

I expected to feel anger, but I was struck by how overwhelmed I was by my sadness. Sadness over knowing that it was gay male scholars much of the time who were producing the research and interventions that made me feel so dirty and shameful. Sadness that my gay brothers -- my friends, lovers, and fuck buddies -- were being painted as uncaring and untrustworthy monsters. Sadness over how much damage Public Health had done to gay men's sexual cultures in the name of promoting health. Sadness over not being able to ask Eric what to do or what he meant when he said that Public Health was a "colonizing" force in gay men's lives.

I still cannot get over the intensity of the emotions I felt in that moment. I took me at least 45 minutes to stop crying. I did not know the level of hurt that was living within me, slowly building over the years, waiting for a moment like this to reveal itself.

If anything, my painful experience of presenting this material reminds me just how much I need to continue aiming my critique at Public Health. I want to take the lens away from Gay Men, and point it back in the face of Public Health. To reveal the ways it is structured around homophobic, heternormative, and anti-sex assumptions about what is "good" and what is "bad."

My life is now, more than ever, committed to destroying Public Health.

Finally! After months of anticipation, the LGBTI Health Summit is finally upon us. Tomorrow I'll be making the long drive from Charlotte, North Carolina to Chicago for a weekend of workshops and fun! I would LOVE to see you there! I'm particularly nervous / excited about debuting a monologue I've been working on for "The Bottom Monologues." We aren't premiering the show -- but instead having an interactive workshop where we'll show off two pieces in progress, get feedback, and test some ideas. As a special treat, after the jump you can find a sneak peak of the monologue I've been working on!!!

In the meantime, here's the 411 on the various workshops I'm collaborating on:

Saturday, 2:45 PM - 4:15 PM: "The Fine Arts of Queer Men's Health"

Co-Presenters: Erik Libey, Ted Kerr

This highly interactive workshop will explore the role that the creative arts can play in promoting queer men's health by highlighting two such projects. First, the artist-in-residence program at HIV Edmonton uses an innovative visual arts program that is sex-positive and harm reduction based. Second, "The Bottom Monologues" is a work-in-progress theatrical play that will use the art of storytelling to explore bottomhood in gay/bi/trans/queer men. Join us for this session which will provide a deeper look into both projects and will be rich in dialogue about how we can use queer men's creativity to build community and promote health in an affirming and holistic way.

Sunday, 1:00 PM - 2:30 PM: "Gay Men's Sexual Health: Adventures into New Cutting-edge Research"

Co-Presenter: Jason Mitchell

Many methodological approaches have been used to better understand sexual health among gay men. However, very few studies and therefore, prevention- type programs have investigated the sociological or interpersonal factors of gay men and how this may relate to their sexual health and well-being. This workshop will unveil findings from two new cutting-edge studies ("Meanings Behind Being a Bottom" and "The Boyfriend Study") and how these findings may be used in future programming for gay men, including gay couples.

Monday, 1:00 - 2:30 PM: "P-Values, Regressions, and Correlations, Oh My!: How to Read, Interpret, and Critique Scientific Research on LGBT Populations"

Co-Presenter: Jason Mitchell

Our newspapers are filled with new reports on scientific studies that claim to have discovered something new about LGBT health. Gay men and MRSA. Lesbians and breast cancer. LGBT teenagers and suicide. But rarely do newspapers critically interrogate the research. In this "how to" workshop, two Gay Men's Health scholars will present first an overview of typical research methods, as well as a glossary of the often confusing terms used to report new findings. Participants will then split up into small groups to analyze and critique some recent LGBT health journal articles.

Monday, 4:30 - 6:00 PM: "Destroying Public Health for the Good of LGBT Health: Critique. Alternatives. Discussion."

Co-Presenter: Bill Jesdale

We desperately need a radical restructuring of Public Health. In this workshop, we will briefly present a critique of Public Health and methods for resistance, leaving the bulk of the time to facilitate a discussion on the pain inflicted on LGBT people by Public Health and how we might envision its reshaping. Various viewpoints are welcome, but we will begin with one key assumption: Public Health as we know it needs to go. Now.

Hope you can make it! Oh, and jump on over for the preview of my bottom monologue!

[ Image redacted -- see here ]

(This image illustrates some of the backlash towards IML's new policy. Far as I know, only bareback porn is banned from IML's leather marketplace)

The tone of the online debate has been, well, impolite following the announcement by International Mr. Leather to ban the promotion and distribution of bareback porn at the weekend event's leather marketplace.

"Fascists. No wonder they like uniforms," wrote a man identified as Liam Cole reacting to the ban on Treasure Island Media's blog "You're just a bunch of sick people who need help," countered an anonymous poster on the same blog.

On August 17th at 6 pm at the Center on Halsted in Chicago, I will be sitting on a panel called "Risky Business? Reclaiming Pleasure," to discuss what effect bareback porn has on men's desires, fantasies and behaviors. The forum is not about IML's ban but will throw a wider net on the discussion of porn, sex without condoms and desire.

As a guest on Trevor's blog, I'd like to focus here on the IML ban that, once again, brought into focus the raw feelings that surface when gay men talk about raw sex. I should state my opinion up front: I disagree with IML's decision, don't believe it will affect behavior, and fear it will further marginalize a group of high risk men who need to be brought under the tent of community wellness, not banished.

"I never thought I'd see the day that IML is used as a vehicle for censorship," said one anonymous source at the Chicago Free Press website. "I don't like being treated like a child at an adult event." Disputing this charge was Colin at Gay Men's Social Crisis blog (GMSC) who said, "I have a hard time with this [censorship] argument. I find bareback porn in direct conflict with health education, even if it does present what can and should be recognized as a fantasy scenario."

Maybe the better question isn't whether or not IML's new policy is censorship - it is by definition - but whether censoring bareback porn from the IML marketplace, however offensively this may strike some of us, is worth the presumed outcome of "social responsibility" and health?

This is where the ban on bareback porn starts to appear arbitrary. On GMSC Colin observed, "I do love how bareback media is banned, and yet Mr. Renslow has made no mention of the bestiality porn that was quite prevalently displayed this year." Porn fetishizing shit was also available in the marketplace, according to online commentators who attended this year. If sexual ethics and health are what's at stake, then why ban barebacking but not bestiality or scat? At The Moby Files a man identified as J.P. added, "Perhaps IML should stop courting the alcohol company sponsorships and ad revenue if they were truly serious about setting a tone of responsibility for the community."

These arguments about the "gateways" to HIV infection (be they substances or images) are, it should be noted, of the same class of argument used largely by evangelical Christians and Republicans in their attempts to criminalize pornography, to censor sex and violence from TV and video games, and to shut down commercial adult establishments such as strip clubs and bathhouses. The business of protecting you from your untrustworthy self has historically been the province of the right wing.

Is viewing bareback porn a greater risk for HIV transmission than attending establishments and events (such as sex clubs or IML) where it is readily available? That's unlikely. There's a better chance of getting drunk by going to a bar than by watching National Lampoon's Animal House. But aren't these the wrong questions to be asking when we're talking about the purview of consenting adults? Deciding what is "advocating" versus "personal choice" at an event that celebrates sexual fetish is an exercise in tortured logic. Leave it to consenting adults to decide, no?

Interestingly, the question of whether or not we're even talking about adults is a major point of contention. "Imagine being a 23 year old kid and walking into that scene," said a man identified as Keith on Manhunt's blog. "You are being told that bareback is hot, bareback is masculine and bareback is acceptable. Is that the message we want to send?"

Chuck Renslow repeated this sentiment when he told me in an interview that a primary reason for IML's bareback porn ban was to protect leather newbies who might be uninformed about the continued dangers of HIV and misconstrue the display and sale of bareback porn at the marketplace as a sign that safer sex is no longer necessary. "If I can prevent even one HIV infection," he said.

To this, Paul Morris of Treasure Island Media e-mailed me: "Well, how will he keep the uninformed from walking around the hotel, where raw fucking and drug use are everywhere? The goings-on in the hotel exceed the imaginings of the sleaziest bareback porn producer (which would be me). So if he's serious about saving the innocent young'uns, Chuck would have to shut the whole operation down."

The "protect the youth" argument is a strange one to be having about an indisputably adult event and ironic considering this is the argument used repeatedly to whip up fear against LGBT people in our battles for civil rights. The right wing is, at least, actually talking about youth when, in an anti-gay marriage commercial, it casts an 8 year old girl telling her mommy she learned in school she can one day grow up to marry a princess. At the IML marketplace, not even 18 year olds can enter: 21 is the age limit.

Treating twentysomethings like children does not support them, it alienates them. Twentysomethings, like the rest of us, do not want decisions made for them. And like the rest of us, when it comes to health what they want is reliable information and the freedom to use that information by their own free will, even if we disagree with their choices. This has not changed since I was a twentysomething in the mid-90's and older activists at the time claimed the reason my generation was taking risks was because we didn't see all our friends die, the same reason given now about the latest batch of twentysomethings. If seeing our friends die is the only barometer by which you believe health promotion can be effective, you need to quietly retire yourself from this conversation.

The top reason cited for IML's bareback porn ban, stated in the letter sent to vendors, is that the CDC and local health officials informed Mr. Renslow that new HIV infections are on the rise. In graduate school I put together a list of newspaper headlines from the early 90's through the present (then 2004) that announced "alarming increases" in HIV infections among gay men. Every year, several times a year, the same headline. We should have all been infected by now.

This has never been new information. There are always populations of gay/bi men somewhere in the U.S. where infections go up (like young gay/bi African American men in Baltimore), while they go down in others (like older gay white men in San Francisco). HIV statistics are cited so frequently and confusingly and have been used so often to manipulate our fear and guilt that many gay men hear them like Bush era terror alerts.

I am not saying this to diminish the genuine concern of new infections. The best research I've read does indeed point to increases in infection rates especially among young gay men of color. What I question is the wisdom of banning, marginalizing and demonizing that our community practices when public health issues its press releases.

This, to me, is the saddest aspect of IML's decision to ban bareback porn, a decision that followed similar bans at Folsom, Dorey Alley and likely other venues I've not heard about. We know bans don't affect behavior but we ban anyway, perpetuating secrecy, lying and shame among gay men.

"What about our porn?" an HIV positive friend of mine said the other day when we were discussing IML's new policy. He was acknowledging the fact that bareback porn is largely (though not entirely) porn made by HIV positive men. Is it responsible to censor the sexuality of poz men in the interest of HIV negative men? Not if you respect HIV positive men, it's not.

I don't doubt that Chuck Renslow is "my people." He's a legend in the leather community, has owned bathhouses, sex clubs, fetish bars and has spent the majority of his life as an unabashed defender of the sexual subcultures that many gay men identify with more strongly than the mainstream LGBT movements that keep them at arms length. What I'm afraid Mr. Renslow doesn't realize is that his people have evolved, and that sophisticated understandings of safer sex without condoms (i.e. serosorting, strategic positioning) are widely practiced by gay men everywhere, and especially by those who attend IML.

Perhaps it's time that the leather community incorporate men who bareback into its credo of "safe, sane and consensual." Without these men as partners in health promotion, one of the community's most marginalized populations becomes disenfranchised from wellness altogether. This is neither safe nor sane.

I started feeling like crap on Saturday. The boys and I had just arrived home from the Russian River, where we spent the weekend with the bears for the annual "Lazy Bear" festivities. As soon as my friend dropped me off at my friend's house, I started to feel vaguely chilly and achy -- the kind of feeling you get when a bad cold or flu is just around the corner. I didn't think too much of it: All my friends had been sick the past week with strep throat that they kept passing around. Perhaps my turn was up. So after an episode of the Golden Girls, I passed out.

I'm not sure what time I woke up, but I immediately knew something was up. I felt feverish, with chills all over my body, and my muscles felt sore and stiff. I knew I had to get up and take some Ibuprofen to help check the fever, but getting out of my warm bed to venture into the chilly house seemed a challenge. After some procrastination, I managed the trek to the bathroom and downed some pills. And then back to sleep. When I woke up again in the afternoon I knew something was definitely the matter. I spent the day feeling terribly fatigued, feverish, and generally pretty gross.

My mind began to reel: What ailed my body? My friends had been sick with strep -- and this was definitely not strep. No sore throat. Perhaps the flu? Not likely -- I didn't have any nasal congestion of chest-cold symptoms. In the back of my mind, I knew that the last two times I had gay male friends who were struggling with flu-like symptoms in the summer months wasn't because of an unseasonable flu infection -- it was their seroconversion sickness. Essentially, it was their body sending them a memo that something was very wrong.

I began texting my friend who does HIV testing in the city, freaking out about how I needed him to bring an HIV test over immediately because I was sick and having seroconversion anxiety. He was in the East Bay, but luckily said he would try to bring one over a bit later. I tried to focus on the Golden Girls in the interim, but mostly spent my time recalling the past three months of my sexual life, detailing all the possible moments where HIV might have found its way into my body. The more time I spent crunching the possibilities, the more red flags I remembered / imagined.

Remembering -- of course -- is a process fraught with imagination, and in times like these our imaginations runs wild. Usually I reconstruct hookups' faces into some frail-like memory, focusing on a zit that could have been a sore, or a skinny waistline that at the time I thought was the result of cardio, but perhaps was a sign of a disease-ravaged body. This time, however, I was mostly focused on a passionate but short-lived affair I had with a wonderful guy I found out later had a long expired work visa and was living the US without government sanction. "His access to health care was probably zilch," I worriedly rambled to my friend who arrived with the test. "Did he get tested anytime in the last year?" I kept thinking about our sexual encounters -- mostly about how we didn't use condoms.

What I was feeling wasn't regret, per se. To say that I regret our having sex without condoms would perhaps be to indicate that I expect to act differently in the future under similar conditions. Don't get me wrong: I have sex with condoms most of the time. But it's of course the "most" in that sentence that is most operative. What separates who falls in the percentile of scrutiny is a mushy calculus that I won't attempt to describe as rational or even reasonable. To say that there is some formula that we might apply to decide such matters is of course downright silly. There are a dozen kinds of reasons Public Health research might demonstrate in action for some set of guys or another, but they're not ubiquitous nor are they likely to stay static for one guy.

You might be thinking here that I've written all of this before. And you'd be exactly right. And this is where I get so frustrated with myself -- because this anxiety is like goddamn clockwork. Is this what it's like to be a sexually active, HIV-negative gay man? A three-to-six month cycle of negative tests and a hodgepodge of sexual encounters, followed up with a fresh batch of Paxil-deserving anxiety while painstakingly reconstructing every possible "mistake" you made since you last tested negative?

It seems to me that there are two possible ways to get out of this unhappy cycle. One -- testing positive -- is obvious. The other, I guess, is to be the perfect Public Health princess and manage to reduce your risk of contracting HIV to absolute zero. I shouldn't be so flip; this actually is feasible for many HIV-negative gay men and I know many guys who do in fact use a condom every time. I applaud their commitment! But -- for probably hundreds or maybe even thousands of reasons -- this goal has eluded some of us. Some wish they could achieve it, but for whatever reason find it difficult or impossible to do so. Others never shared this goal at all, and instead prioritize pleasure over risk (and I mean that in the most literal, non-judgmental of ways).

I guess I'm just frustrated to find that in the five years since I wrote a piece strikingly similar to the one you're reading, I still find myself in the same cycle of fear. Perhaps this is just the cost of being promiscuous in the face of a sexually transmitted disease. Perhaps it is just a reality of this thing we call risk. But I can't help but think that I have no similar anxiety about getting in my car to drive home at 2:00 AM, despite the fact that I'm taking a risk that I will be injured or perhaps even die in a car crash. I don't think I'm naive about the risks of driving at night, just like I don't think I'm reckless when it comes to HIV. All I know that of all the many risks I'm bound to incur in my life (driving, jaywalking, checking my luggage on a domestic airline, etc), only one seems to sit so close to home at the intersection of identity, health, and sexuality. And that is one messy fucking intersection.

Saturday I spent a lot of time thinking about what I would do if I tested positive. Who would I tell? Would I blog about it? I felt frustrated not by the immediate reality of the health of my body, but rather by the possibility of having to disclose that seropositivity to potential sexual partners in the not-so-Poz-friendly state of Michigan. Or better yet, of being branded HIV-positive and how that might inflect / affect my future identity, research, activism, or employment.

After another negative test, I find myself back at square one. What I want is a sexuality without this kind of maddening, cyclic anxiety. A way to live my life, have great sex, and quit spending days or even weeks freaking out about seroconverting. Perhaps that's too much to ask.

Eek! So creepy!

(Via Gizmodo.)

As a follow up to Trevor's post on the exciting new study about MSM and barebacking, I'd like to call attention to two less exciting publications about gay male sexual health released on the American front. On June 8, the CDC published a new fact sheet on oral sex and HIV risk. Unsurprisingly, it emphasizes the risks of oral sex without exploring the social meanings that lead us to practice it in the first place. The jist of the fact sheet is summarized in this quote:

Even though the risk of transmitting HIV through oral sex is much lower than that of anal or vaginal sex, numerous studies have demonstrated that oral sex can result in the transmission of HIV and other sexually transmitted diseases (STDs). Abstaining from oral, anal, and vaginal sex altogether or having sex only with a mutually monogamous, uninfected partner are the only ways that individuals can be completely protected from the sexual transmission of HIV.

Just as positing abstinence and monogamy as the only safe sex practices is unhelpful advice for the gay community, so too is the fact sheet's recommendation that participants use condoms to reduce the risk of HIV transmission through oral sex. Nobody uses condoms for oral sex except that married guy I met at a bar last year in Paris. In the real world, both these strategies are often unrealistic in developing a culture of safer sex. Ultimately, they function merely as a punitive criticism of the sex practices in which many gay men engage. The development of a gay male culture that values safe sex requires us to explore how gay men associate their sex practices with the experience of pleasure, love, self-affirmation, joy, fulfillment, and other feelings that lead many of us to "irrationally" throw caution to the wind when we're having sex. Whether or not one feels comfortable with the culture of hooking up, it is irresponsible to discuss any sex practice without considering the social values of which it has been made expressive.

In a similar vein, the Chi-Town Daily News recently ran an article on a study showing half of HIV+ gay men in Chicago were unaware of being infected. Although the article emphasizes the need to develop a holistic approach to gay men's health that considers more factors than just serostatus, it also comes down hard on online hookup websites, quoting one man as saying, "'We need to know who makes up these social networks,' which include men who meet other men over the Internet or through phone networks,' [...] 'You're kind of playing Russian roulette.'"

The metaphor of Russian roulette suggests the possibility of a 1/6 chance of sudden death by having unsafe sex. This statement is unproductive fearmongering. It is true that hookup websites like manhunt.net and gay.com are one conduit through which some gay men have unsafe sex and contract HIV. But the gay male sexual universe would not be made any safer if these websites were to be eradicated, as the speaker seems to imply. We would do well to remember the lessons learned by earlier generations with the closure of the bathhouses in San Francisco after the outbreak of HIV/AIDS. As Gayle Rubin wrote in her 1990 essay, "The Catacombs: A temple of the butthole,"

The closure efforts set dangerous precedents for state harassment of gay businesses and gay behavior. Wholesale closure eliminated opportunities for sex education along with opportunities for sex. Closure drove men to the streets and alleys and parks, which were arguably less safe and clean than the clubs they lost.

In the last decade or so, hookup websites have become a major site of gay sexual activity and community life. These websites are often considered a realm of disease and lack of intimacy. While the dangers of hookup websites are real, they also serve as one of the only places in which the many varieties of sexual expression that have been rejected by society can exist. The discourses on safe sex would do well to consider the unique value of sexual and social network sites before condemning them wholesale.

Conference organizers have just posted audio recordings of from the LumpenCity conference I attended in Toronto earlier this year (see my abstract here; see the conference website here; find my Powerpoint slides here). Here's the audio!