Psychotherapy with Men who Bareback

The following is the follow-up article describing a talk I gave at the 1998 California Psychological Association convention in Pasadena, California. The article was written in a magazine format and intended for psychologists (and other mental health professionals)

Creating psychotherapists that are sensitive to and affirming of gay male sexuality was at the heart of my talk at the 1998 CPA conference in Pasadena. A 1997 study by Nancy Nystrom of the University of Washington found that 46% of lesbians and gay men have encountered a homophobic therapist, 34% stated that their sexuality was not acknowledged or was dismissed, and a surprising 7% had a therapist that made derogatory comments regarding his or her sexuality. It is my hope that education about the realities and variants of sexuality (here, gay male sexuality) will help therapists cope more sensitively and realistically when these issues are presented in therapy. But beware, my topic was controversial even to those who devote a majority of time with the lesbian and gay community, but downright shocking to those who are not familiar with sexual issues in general, gay male sexuality, and the long haul associated with the HIV/AIDS pandemic.

A February 1998 issue of the Advocate, a national gay and lesbian newsmagazine, called Internet on-line chat rooms "the new gay bars." For those who are unfamiliar with the concept, a chat room is a place in cyberspace which people access with their computers and a telephone line to meet others locally and around the nation who share common interests. Not surprisingly, the majority of these chat rooms are devoted to the areas of friendship, relationships, and sex. Chat rooms have replaced phone sex lines for many. They provide anonymity; a meeting ground for new relationships; and allow people to present their "darker" or "secret" sides. Chat rooms are supplemented by user profiles which list details about the user of the chat rooms including physical description and sexual interests.

A small but growing phenomenon in the gay male community, which grew out of computer on-line chat rooms, are specialty groups devoted to raw or bareback sex. Raw or bareback sex refers to anal sex without a condom. Currently there are groups in Los Angeles, San Francisco, and San Diego who seek out "fit, lean, and muscular" men to have bareback sex. The groups are not naïve men who have forgotten the ravages of HIV within their own community, but rather men who are HIV-positive or assuming the risks of becoming HIV-positive.

In order to explore this phenomenon further, I looked at personal profiles from America On-Line (or AOL), the nations largest on-line service with over 12 million subscribers and hundreds of active chat rooms at any one time. Limiting my search to profiles that indicate the user resides in San Francisco, I found that 90 gay men mentioned raw or bareback sex. Of those 90 men, 69 (77%) indicated a desire to participate in bareback sex, 13 (19%) stated they did not want bareback sex, and 8 were unclear in their reference. Men openly advertise in their personal profiles with quotes such as "Bend over boy: Condoms Optional" and "If barebacking bothers you, don’t bother me." Of those who indicated their HIV serostatus, 24 (35%) stated they are HIV-positive, the remainder made no reference to their status. Of those who indicated their sexual position preference, 13 (19%) stated they are a "top" (they enjoy inserting their penis into their partner’s anus) and 18 (26%) stated they are a "bottom" (they enjoy receiving their partner’s penis into their anus). Also, 20 (29%) stated they are "versatile" (they enjoy both positions) and 18 (26%) did not say.

Perhaps the most remarkable factor is not that gay men have sex without condoms. Anyone who does therapy with gay men (or anyone who works with sexually active clients of any sexual orientation) knows that relapse to unsafe sexual behavior is prevalent and the reasons are well researched. Rather, it is that some gay men are publicly and actively seeking partners with whom they can engage in premeditated and orchestrated high-risk sexual behavior. This dynamic echoes the phenomenon in the diet world as interest in a non-fat diet began to wane. The phenomenon was known as "Pleasure Principle Revenge" and was used to describe the reason for the failure of short-term fear tactics to maintain long-term behavior change. People decided that they missed the pleasures of more fattening foods and chose to eat them and suffer the consequences (e.g., heart disease, obesity), rather than compromise their quality of life. The dynamic in bareback sex may be much the same, but the consequences are different than those of eating an extra piece of cheesecake.

Many clinicians and researchers are pointing the finger of blame at overconfidence in Protease Inhibitors, which have been inappropriately haled by some as a "cure" for AIDS. Other trends have emerged such as eroticizing the virus, where men desire both to infect others with HIV (if they are positive) or become infected (if they are negative) as a means of sexual and spiritual connection. Another is the "Sex Panic" political movement within the gay community. Sex Panic organizers are concerned about the "increased attack against marginalized sexualities" including the "anti-sex AIDS activism and education campaigns." Also, as previously mentioned the growing popularity of on-line information and entertainment services, which act as highly accessible and anonymous personal connection systems. Probably the most notable example of this phenomenon is a website called XTREMESEX. The website bills itself "for poz-hungry men into bareback sex." Please visit this site if you are interested in a frank and comprehensive presentation and discussion of the issues (including the risks). Please do not visit the site if you are unfamiliar with gay male sexuality and cultural norms, or are in any way uncomfortable with sexual issues.

As clinicians, we may wonder how we can stop this obviously high-risk behavior. But, with at least a segment of this population, stopping this behavior may be as futile as getting all heterosexuals to engage in birth control except when having sex for the definite purpose of having a child. Instead, a harm reduction model, as described by the Centers for Disease Control is indicated. This is much different than just safe sex education or outright discouragement of the behavior. Instead this starts with the acceptance that the client may not be willing to stop the behavior, but may be open to methods that will decrease likelihood of harm to himself and others. Much like any high-risk activity, there are methods one can practice during the act which limit harm. The following is a harm reduction sequence for clinicians to follow:

1. When talking about bareback sex behaviors, determine contexts and cognitions (thoughts) associated with the act of barebacking. When is the client more likely to bareback? What is happening just before? What are the feelings and thoughts during? What usually follows? What is the client's philosophy about sexuality and barebacking specifically.

2. Ask client about his understanding of risks and benefits (be sure that you also have an understanding of risks and benefits of barebacking).

3. Determine if there are aspects of your client's behavior that could be altered to reduce harm (e.g., ejaculation into a partner's rectum without partner's consent, barebacking when there is presence of exposed sores, cuts, or lesions, etc.).

4. Determine whether other aspects of his life could be focused on to improve health and enhance likelihood of behavior change (e.g., therapy for depression, encouragement of regular medical check-ups, nutrition counseling, etc.)

5. If client is ambivalent about changing behaviors, discuss consequences (benefits and losses) associated with new behavior. If consequences are unacceptable, brainstorm acceptable consequences.

6. Discuss switching to behaviors that are associated with less harm. Have client identify a goal of behavior change that is both desired by him and realistic to achieve. Have client come up with behaviors that may work to achieve that goal (e.g., sexual practices, substance use and patterns, etc.).

7. Discuss gradual reduction toward client identified goal (what the client wishes to achieve) as an alternative to prescribed behaviors (e.g., abstinence, always using condoms, etc.)

8. Discuss relapse prevention principles. Instead of pathologizing behavior client was attempting to change, help the client to gain understanding of the change process. Help client to understand that even when a client-identified behavior change is achieved, there may be times when he may engage in behavior that he was trying to change in the first place (or relapse). Help client to understand this is a normal part of the behavioral change process. Develop a plan for understanding the "relapse" and continuing with original change plan.

A note of caution: The methodology above is not a roadmap to make your client do what you want him to do. Rather it is a method to help your client achieve goals of his own choosing. The barebacking issue may bring up transference and countertransference issues and philosophical differences between clinician and client. It is important for the clinician to examine his or her own attitudes toward sexuality, gay male sexuality, and barebacking in general before engaging in such a dialogue. The clinician also needs to understand that after such a dialogue, some men will choose not to make any changes.

This is not a time for prudery. Clinicians who work with gay men need to become educated about the range of sexual expression and associated pleasures and risks. Educated clinicians can be instrumental in giving their clients accurate information that they can use in making informed choices about their behavior.