The rise in unprotected sex among gay men is without precedent since the beginning of the AIDS epidemic—20 percent between 2005-2011 (1).

This rate was already impressively high. In 2005, nearly half of gay men had had unprotected sex in the past year. Add to this that while the number of new infections among gay men has stabilized, this figure approaches a shocking 30,000 new infections per year in the United States alone (2). Not only have HIV prevention guidelines reached their limits, but they’ve also become less and less effective.

The current impasse shouldn’t come as a surprise. The safe sex rhetoric is increasingly at odds with what many gay men experience in their bedrooms as well as the information that they receive. Real choice requires real information and yet we are nowhere near that today. Moreover gay men’s insubordination with regard to safe sex practices may reveal difficulties that many straight men experience also, although their sexual behavior is not as carefully scrutinized.

While fully acknowledging that I have limited background in the HIV prevention field, based on my personal experience and that of the many men I’ve had conversations with over the years, I would like to point to four significant shortcomings of the current safe sex rhetoric and suggest sensible solutions.

1. The first issue relates to the “fetishization” of unprotected sex.

In the early years of the AIDS epidemic, HIV prevention groups didn’t have many options. In order to enforce safe sex practices in a gay community that deeply identified as a sexual liberation movement, the message had to be strong and clear—having unprotected sex was not only stamped as unsafe, it was regarded as irresponsible and self-destructive.

Yet in the late 90s in the so-called POZ (HIV(+) gay men) subculture the symbolic meaning of unprotected sex underwent a startling transformation.

Unprotected penetrative sex became bareback sex, raw sex, uninhibited sex, breeding… it became a fetish. To receive the semen of another man anally became the ultimate transgression. (Bear in mind that in the gay world transgression is a historical habit. Luckily the reproductive imperative shielded the heterosexual world from such extreme.)

More difficult to explain is the immense attractive power of bareback sex beyond the POZ community. Bareback sex has been the fastest growing sub-genre in gay pornography for instance. In its laudable effort to turn protected sex into the “new normal,” the HIV prevention discourse championed an absolute moral polarization between safe sex and unprotected sex.

This polarization was as inevitable as it was logical. Along the way that same discourse forgot (or assumed that it would not matter) that for the great majority of human beings on the planet “normal” sex remained sex without condoms. Before the AIDS crisis—and apart from the very real risk of unwanted pregnancy—to ejaculate inside your partner was in the order of things. It was sex as nature intended.

The safe sex rhetoric, although straightforward and without a doubt life-saving, faced an inherent contradiction: the coexistence of two hardly reconcilable visions of sex, safe sex on the one hand and an erotic past that dated from prehistory on the other. This double standard was hardly sustainable. I belong to the very generation that was taught that safe sex could be sexy; I have yet to meet someone who agrees that condoms are sexy. The problem isn’t that condoms constitute an obligation. Lube for instance is just as much a requirement in gay sex, yet lube is sexy. Putting a condom on might be a loving act, yet it remains for most a parenthesis in the erotic process.

2. The second issue directly concerns the use of condoms and is twofold.

First the safe sex rhetoric has largely, if not completely ignored the fact that numerous men have difficulties using condoms. I am not referring to the 30 seconds of necessary interruption to put on a condom, which is classically mentioned as the major difficulty to overcome.

I am referring to what happens after: a significant decrease in sensation or no sensation at all during intercourse, making it difficult to maintain an erection. I am referring to the fact that many men, unlike video-edited porn stars and eager teenagers, do not sustain a fully erect state throughout intercourse.

When for one reason or another the erection diminishes, the condom lessens the sensation. The condom may even slip off, especially after following the guidelines that advise lubricating the penis prior to putting on the condom. And when that happens, a sexual encounter that started as promising can quickly spiral into an embarrassing moment. As a matter of fact, I have met numerous gay men who confessed to having given up taking on the top role only in order to avoid dealing with condoms.

There will always be men who have no problem whatsoever using condoms to corroborate the idea that those who do have problems with condoms indeed have a “problem”— whether it be attributed to a lack of confidence, anxiety, poor erotic skills, selfishness, lewdness, crudeness, or rudeness, you name it.

Unfortunately we tend to forget that penises—just like brains, nipples, and vaginas—are complex organs that are not all optimally stimulated the same way and equally sensitive in the same areas using the same movements. These individual variations easily explain, at least in part, why different people tolerate condoms differently.

Condoms don’t always work well with the foreskin either. Nor will I discuss here the discomfort that many bottoms experience due to condoms. In the process of creating a new, safer, sexual culture, we have left aside too many men who couldn’t fit in—measure up to—this “new normal.” And for fear of seeing the power of our safe sex guidelines undermined, we’ve collectively turned a blind eye and labeled anyone who failed to follow the instructions as irresponsible.

The second dimension of the condom issue goes hand in hand with the one above.

If penises are not all equal, neither are condoms. Condoms come in a limited yet significant variety—different sizes of course, but also lubricated, ultra-lubricated, ribbed, textured, ultra-thin, extra-sensitive, latex, polyisoprene, lambskin, and so on. And truth is, they do feel very different. For instance, I discovered that the supposedly “extra-sensitive” condoms, which seem to be made of a thinner but also more resilient and elastic material, drastically reduce my pleasure, while conventional condoms (although not ideal) remain manageable. One might think that the pros and cons of these various types of condoms would be critically discussed in HIV prevention guidelines and this information readily available on the internet, but to the best of my knowledge that is not the case. Instead we have marketing campaigns that consistently guarantee heightened sensations regardless of the type of condom. The highly publicized support of the Bill Gates Foundation to research projects aiming at inventing a “better” condom is a poor acknowledgment of this issue (3). I hope that their effort will be successful. In the meantime, we can no longer leave the concerns and difficulties of so many men both unheard and unattended.

3. Interestingly, while some basic information remains hard to find, other information seems to spread like wild fire, and this constitutes my third point: the development of pre-exposure prophylaxis or PrEP (4).

The idea behind PrEP is to administer antiviral drugs similar to those prescribed to HIV(+) patients but now to non-infected individuals. Solid claims about the efficacy of PrEP at preventing HIV transmission remain rare, but results so far are incredibly encouraging. Despite the reluctance of medical authorities and many HIV prevention groups to recommend PrEP as an alternative to condoms, a fast-growing number of gay men today are opting for this strategy. Moreover, thanks to the Affordable Care Act (aka Obamacare) private health insurance providers are increasingly willing to cover it. Its cost reduced to a regular co-pay, PrEP has become widely affordable.

Gay men’s behavior is adjusting fast and this will only accelerate. If HIV prevention organizations don’t recalibrate their discourse accordingly, inclusively, and quickly, they will be taking the risk of generating even more disparities, between those who have the information and those who don’t, those who can afford the drug and those who can’t or don’t know they could, and those who are used to taking risks and those who aren’t. Having turned a blind eye to the struggle of so many men with condoms for decades, we don’t fully realize how much many of those men today are ready to not only transgress the guidelines, if they haven’t already, but to throw them away altogether.

4. My fourth point, perhaps the one that concerns me the most, involves the disclosure of one’s HIV status.

Thanks to efficient antiviral drugs and regular monitoring, the vast majority of HIV(+) men are now “undetectable,” which means that the production of virus, if any, is too low to be detected by the most sensitive methods. Because they are far less likely to be infectious, many HIV(-) men today opt not to use condoms when assuming the active role with HIV(+) partners. [Conversely anal penetration by an HIV(+) partner, even if undetectable and unless the HIV(-) partner is on PrEP, still seems unwise at this point, and ejaculation into the receptive partner even more.]

In this fast-changing landscape the most likely candidates for HIV transmission aren’t openly HIV(+) men, who are likely to be undetectable, but those who don’t know their statuses for they rarely or never get tested. I understand and agree that we should not force people to get tested for HIV.

However, in the same way that we have encouraged the use of condoms, couldn’t we also encourage men to show their most recent HIV test to each other in a systematic manner? I personally always keep a picture of my most recent test in my phone. That being said, men who get tested in private practices (as opposed to HIV prevention centers) are rarely handed written confirmations of their HIV(-) status, and not everybody thinks of requesting one. This unfortunate situation is often used to justify one’s inability (whether genuine or not) to present a valid test to his partner. [Now I am also well aware that an HIV(-) status is not a perfect guarantee. Virus production precedes sero-conversion, which means that recently infected individuals can be highly infectious while still testing HIV(-) on the basis of antibody detection, which is the most largely used method in prevention centers nowadays (5). However methods that directly detect the presence of the virus in the blood (e.g.:RNA detection tests) reduce this time window from 2-3 months to 10 days, which is far more manageable (6).]

Sero-sorting (a term that refers to men restricting sex to partners with the same HIV status, exempting HIV(+) men from using condoms among themselves) is increasingly the preliminary to unprotected sex among HIV(-) men too. Yet sero-sorting occurs far too often on the sole basis of mutual trust.

We could make it mandatory for medical labs to provide credit-card-size documents attesting of one’s negative, positive, or undetectable HIV status. If real gentlemen always carry condoms, why could they not carry proof of their HIV(-) or undetectable status also? Since an increasing number of HIV(-) men are sero-sorting and negotiating the use of condom anyway, they could at least do so on a more solid basis.

The mutual display of mandatory HIV status cards—in a systematic and yet consensual manner, even among couples—would offer multiple advantages: It would respect everybody’s personal freedom; it would empower gay men in their choice to use condoms or not; it would hopefully reduce prejudice against HIV(+) people; and it would probably make sexual encounters increasingly problematic to those who are unable or unwilling to share this information, which might be an efficient way to motivate them to visit an HIV prevention center.

By no means do I seek to denigrate the work and professional integrity of the many men and women in the HIV prevention field.

They have saved countless lives. Nor am I suggesting that the use of condoms and its enforcement should be abandoned. However because today the urgency and simplicity of the current rhetoric is longer legitimized by the threat of a quasi certain death, this rhetoric is slowly losing its power, inevitably. Many gay men are modifying their sexual behavior for the simple reason that the hurdles that they have endured for years have become even less bearable since the advent of efficient antiviral therapies and PrEP. Scolding those men as irresponsible is unlikely to help reverse the actual trend.

On the other hand we could manage this trend responsibly if we begin by acknowledging (1) that HIV prevention guidelines must take into account the recent breakthroughs in antiviral therapies, (2) that we have largely left critical information relative to the use of condoms in the hands of mercantile positivism, and (3) that we should urgently revise the way we encourage people to disclose their HIV status. If indeed real choice requires real information, this goes both ways.

Gay men need to be more outspoken about the difficulties and frustrations that they encounter; HIV prevention groups need to be less fearful of what might be revealed in that process and ready to adjust the way they operate accordingly.

The same trend has been documented in Canada, Britain, the Netherlands, France and Australia. http://www.nytimes.com/2013/11/28/health/unprotected-sex-among-gay-men-on-the-rise-health-officials-say.html?smid=fb-share&_r=0 http://www.cdc.gov/nchhstp/newsroom/HIVFactSheets/Progress/Trends.htm http://www.cnn.com/2013/11/29/opinion/gates-world-aids-day/index.html?hpt=hp_t4 http://www.cdc.gov/hiv/prevention/research/prep http://www.thebody.com/content/art5998.html?ic=4001 http://www.thebody.com/content/art6125.html?ic=4001

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