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PART 2

AIDS & Public Policy Journal
SPRING 1994
Volume 9, Number 1


Aids Education and Harm Reduction
for Gay Men:
Psychological Approaches for the 21st Century

By Walt Odets

We must carefully examine the almost universal assumption among educators that if we give men "too much information" - which is to say something like the whole truth to the best of our knowledge - they will abuse it, exercise faulty judgment, or otherwise come up with unintended results.  "Directive education is necessary because men need to be told what to do," an educator at the San Francisco AIDS Foundation told me.  The most sacrosanct expression of this approach is seen in the absolute prohibition against saying that it is sometimes acceptable to have anal sex without a condom, which is when no one really has HIV - although it is often difficult to know when those times are.  As educators, physicians, psychologists, and gay men we all know - or ought to know - this is true.  Yet the nearly universal response to this assertion is that such an "admission" would encourage men to do dangerous things.  Part of the answer to this objection is obvious.  Some men are making such obvious decisions within like-antibody relationships; and, unfortunately, others are doing dangerous things.  One of the reasons for the dangerous behaviors  is our prohibition against discussing obvious possibilities.  Gay men do not, after all, need to be reminded of anal sex, and our prohibition does not allow them to have the information or develop the judgment to discern when a particular desired behavior is likely to transmit HIV and when it is not.  Our practice of simply instructing men in behaviors - "a condom every time" - actively obstructs the development of a capacity for informed judgment, and perpetuates society's homophobic desire to simply dictate behaviors to gay men.  People thus disempowered by directive instruction that contradicts their instincts - and often the truth - behave secretly, unthinkingly, and often self-destructively.  We cannot use these results to predict the behavior of an informed, educated, and respected population.

Education that recognizes these realities will truly help men educate themselves rather than instruct  them.  It will allow them to express their own values about life, sex, and intimacy, and to make their own decisions about what constitutes acceptable risk for themselves.  The idea that any level of risk is unacceptable is true only if the behavior in question is of no value or importance whatsoever.  The ease with which educators have been willing to make that assumption on behalf of gay men is an expression of homophobia.  It is not an assumption that all gay men would - or are - accepting.  New approaches to education will draw on our experience in the field of risk management which has clarified that an informed populace makes the best decisions and that the withholding or distortion of information almost always decreases the quality of decision making.   Most importantly in the human sense, new approaches to education will not homophobically dismiss the importance of gay sexual behaviors because there is any risk involved in them, but will authentically affirm the human importance of sexual intimacy and the same right to sexual expression for gay men that is so - relatively - easily granted heterosexuals.

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At the most pragmatic level, new approaches to education have much to offer by simply telling the truth about what we know - and what we do not.  We know that oral sex conducted in any manner whatsoever is hugely less likely to transmit HIV than receptive anal sex.  For those approximately 50% of gay men who are having anal sex without condoms despite what they have been instructed to do, it is important to know that, by conservative estimates, HIV is  transmitted to the receptive partner about 2.5 times more often than to the insertive partner, and that most studies have shown insertive anal sex to be a very low or essentially no-risk activity; that HIV is twice as likely to be transmitted if the infected partner is in very early or late stage infection;  and that rectal douching before receptive sex is correlationally and causally (Levy, 1993) riskier than fisting, ejaculation in the mouth, or oral-anal contact.  Providing such information does not encourage men to practice these behaviors, and for those who are already doing it, it is lifesaving information that cannot be withheld because as AIDS educators we would like to believe that "100% safe, 100% of the time" is more than a pipe dream.

The idea that education with the whole truth will encourage unprotected anal sex is comparable to the idea that supplying sterile syringes and educating IV drug users about how to inject drugs with minimum harm will encourage drug use.  Like anal intercourse, those who want to inject drugs are doing it without our support.  If anal intercourse had only as much moral stigma attached to it as I.V. drug use, and if our own homophobia did not sensitize us to the stigma, I suspect we would have seen this analogy much earlier in the epidemic.  Like effective education for I.V. drug users, new approaches to AIDS education for gay men must be conceptualized as "risk management" or "harm reduction" approaches.  We cannot stop HIV transmission or end the epidemic through behavioral approaches without exacting catastrophic psychological and human costs.  And we cannot continue to burden every single gay man with that implied task.  Sexuality, regardless of how we would like to explain it - and often explain it away - is too central, profound, and complex a part of human life to allow such simplistic goals or the solutions that have been proposed to accomplish them.

A recognition of psychological and social differences between HIV-positive and HIV-negative men is another important reality that our new approaches to AIDS education must incorporate.  To date our education has largely expressed the political idea that all gay men are "equal" and AIDS education thus applies universally to all.  In most agencies the obvious idea that AIDS prevention is for HIV-negative men - those who do not presently have HIV - is a controversial, politically inflammatory assertion.  The confused retort is that AIDS education is for the gay community, because positive men are part of the solution.  It is little wonder that educators, often confused about the very identity of its target population (regardless of who is involved in the solutions), are producing equivocal, unclear, and misleading education.   If safe sex were common sense, could we expect gay men to buy the idea that it is the same common sense for positive and negative men?

Many  HIV-positive men quite understandably have different ideas and feelings  about life, and live with different values and objectives than HIV-negative men.  Despite what we would like to believe politically, many positive men are not taking responsibility for protecting negative men from HIV and do not see why they should.  Furthermore, many positive men - perhaps a majority - are not buying the "reinfection" theory (a speculation without a single study to support it), and have learned that opportunistic infections are often transmitted through what is "safe" sex in terms of HIV, the most fragile of organisms among the S.T.D.'s.  The assumption that two positive men should be enjoined to the same behaviors as a "mixed antibody" couple is largely the product of the homophobic appeal of "good" sex.   Our new approaches to education must recognize and address the differences between positive and negative men perceptively, unambiguously, and unhomophobically rather than blurring meaning to appease political anxieties and disguise confused conceptualizations.   

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Finally, our new approaches to education must recognize the broad human realities of life in an epidemic.  This means affirming gay men's complex and difficult experience rather than attempting to normalize life - or simply feign normality - in these most abnormal of circumstances.  In the San Francisco AIDS Foundation's "Outliving Forecasts of Doom" campaign, the advice offered for living in the epidemic is to "play it safe, make a plan, see it through."   The validating truth is that the epidemic is far from being merely a forecast .  It  has already exceeded our wildest and cruelest imaginations.   The campaign's glib advice to "make a plan and see it through" is a ridiculous prescription for a lifetime , is unvalidating of real experience, and is an effort to enlist denial against the substantial difficulty of creating a viable life in the circumstances many gay men find themselves in.  That AIDS Foundation educators would like to simply wish away the realities of life in the epidemic is seen quite explicitly in another model for gay life provided in the same campaign.  If one were to take its implications seriously, it would seem a prescription for mania:

    Got Places to go.  Single Gay Man with plans to make.  A few years ago, I couldn't think ahead to the next week.  Now, I'm organizing the first Queer Space Shuttle Voyage.  '10 . . .  9 . . . 8 . . . 7!  More than one way to get to heaven!'

Authentic validation will require that our education realistically acknowledge the complexity and depth of feeling of many men, even when that acknowledgment does not appear to immediately support the goal of reduced HIV transmission.  For example, there are many HIV-negative men whose feelings and values about life are so changed by a decade of life in the epidemic and the prospect of its permanence - so changed for worse and for better - that HIV infection and an earlier-than-expected death no longer seem like the worst possible events.  Men have not only become depressed and hopeless, many have learned to live life fully and intensely, a human capacity more commonly expected in the man who is dying than in the potential survivor.  Most AIDS educators will say that such men have become "complacent," that they are "coping with denial," or that they are members of a "fringe group" that is unreachable in its "psychopathology."  Some men with such feelings are probably exercising denial or might fall in the range of so-called psychopathology, but for many these are not accurate descriptions.  If some gay men feel that the fullest, richest possible life demands behaviors that may also expose them to HIV, who are educators to tell them they are wrong?  To attempt to morally shame such individuals who put no others at unwilling risk, or to attempt to coerce them into conformity to allay our own anxieties seems humanly reprehensible.  As educators we cannot propose that men live through this tragedy only to be told by us how to feel about it or to have their real feelings denied or dismissed as pathological by the wisdom of our education.  This is exactly how gay men's homosexual feelings are treated by the majority of society.

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In concluding my discussion of the realities of the epidemic, I must comment on the limitations of our knowledge about the key reality of  how HIV is transmitted.  Although receptive anal sex seems by far the most significant behavior is this regard, there is a small, inconclusive body of evidence that HIV is occasionally transmitted sexually by other behaviors.  We will never have absolute certainty about all the pertinent issues (and, incidentally, must stop trying to sell certainty as one of the rewards for following our instructions).  We could, however, know more about what sexual behaviors actually transmitted HIV and under what circumstances, and we would if we really cared about the behaviors.  With regard to sex we are a profoundly ambivalent society and more ambivalent still about homosexual sex.  It is accurate to say that much of American society would be pleased if gay men simply took their sexual behaviors and went away .   In a derivative dismissal of the importance of gay lives and gay sex we routinely make recommendations to gay men that we do not make to heterosexuals and have made some behaviors essentially impossible in any meaningful form.  In AIDS education to date we have been much more sensitive to the implications of protected sex for intimacy in heterosexual populations, and have never, to my knowledge, suggested that vaginal intercourse might be a dispensable part of the sexual repertoire.  New approaches to education must similarly value gay sex and its various expressions.  We cannot continue to rely on extreme, categorical instructions to gay men as a substitute for attempting to determine the facts.  Why have we not, as a colleague recently suggested to me, done a nationwide study of "sexual specialists," gay men who engage in single, exclusive forms of sex?  Why, indeed.

The importance of psychological considerations in AIDS education has already been largely elaborated.  This subject is the one most readily misunderstood and dismissed by AIDS educators.   In a June 1993 meeting of San Francisco AIDS providers to address HIV-negative issues - not the least of which is HIV transmission - an educator from the San Francisco AIDS Foundation talked about a series of focus groups conducted by media analysts to evaluate a new campaign on oral sex.  He reported that the "tag line" of the campaign was "Enjoy Oral Sex," but, to the consternation of the analysts, the men in the group almost universally objected to the line despite all "admitting" to the personal practice of unprotected oral sex.  I said it seemed late in the epidemic to feel "consternation" over the discrepancies between public statement and private behavior, and that those practicing unprotected oral sex would quite naturally be those with the most anxiety about the idea of enjoying it and saying so publicly.  The educator, little interested in this observation, replied that they had in any case solved the problem by changing the tag line to "Enjoy Sex" and this less specific statement was much more acceptable to the group.  I said they had not solved the problem of how these men felt, but skirted it.  His reply was that acceptance of the new tag line increased readership of the campaign, and in increasing "positive response," "we get more bang for the buck."

"That," he told me, "is what AIDS education is all about."

"Do you ever use psychological opinion when doing such campaign analysis?", I wondered..

"For what?" he asked.

"To help clarify people's feelings about sex and death."

"That," responded the educator, "is not what we're talking about.  You seem to want us to do psychotherapy from billboards.  We're doing education."

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Because the idea that psychological ideas might have a role in AIDS education is so controversial, I would like to comment explicitly on what role psychology might play in new approaches.  Public education is not a forum for conducting psychological treatment.  But AIDS education must incorporate psychological understandings into its conceptualization of the problem if it is to become effective with a problem as complex as a lifelong epidemic.  Education must eschew an exclusive belief in relatively simplistic schemes of behavioral change that persist in ignoring the role of feelings in human sexuality.  The idea that psychology has no role in explicating the educational demands of the epidemic makes as little sense as the idea that X-rays have no role in the diagnosis of gall stones because the treatment will ultimately be surgical.  This misperception is, in part, an expression of disciplinary territorialism; but in this epidemic among gay men, it is also because many of us are having feelings we are afraid to examine in ourselves: homophobic feelings, feelings about death and loss, and feelings about the old and new dangers of intimacy.  We are thus understandably reluctant to examine them in others or to acknowledge their relevance to our work.  AIDS education is significantly tied to psychological issues, because human life is filled with them.  No denial of this fact will eliminate the need to acknowledge complex, not easily addressed feelings when the issues are intimacy, sex, and death.  When, as educators, we understand this, we will not continue to pretend or to teach that protected sex is a matter of "common sense" and that anyone not practicing it is a fool or member of a "clinical" population.

If we could address only a single psychological issue in our education it would have to be the sense of inevitability that so many men feel about contracting HIV.  Although not in our standard nosology of psychiatric disorders, this sense of inevitability lies at the center of a constellation of recognizable problems commonly experienced by gay men living in the epidemic.   This sense of inevitability is the one important psychological issue that consistently spans a range of groups that, in other regards, present differing problems for AIDS educators.  Included are young gay men who have grown up into the epidemic, older men who have come out into the epidemic, and older men who self-identified as gay before the epidemic.  For the young this may be the crucial issue that education must address.

A sense of inevitability about contracting HIV - I shall simply call it inevitability from this point - is evidenced in a variety of forms.  It  expresses itself  in depression, in a sense of hopelessness, in feeling out of control about one's life, in anxiety, in the belief that one actually has HIV when this is not the case, in careless exposure to HIV, in the abandonment of any effort to protect oneself from HIV, and, on occasion, in the deliberate pursuit of HIV infection.  Inevitability is also expressed in HIV-negative men who visualize no future for themselves and live as if they had none.  Such men often live in a gloomy, unconscious assumption of a short life that pursues fulfillment of its own prophecy.

Feelings of inevitability are complex and are the product of many social and psychological forces.   Some of these, fortunately, are not entirely the product of our education, and could be partially ameliorated if our education would not exacerbate them and addressed them constructively.   Homophobia and hatred suggests that if you are gay, you get HIV because that is the fate of gay men, or, more explicitly, that HIV is what gay men deserve to get.  For the twenty year old, the developmentally characteristic feeling  that life beyond thirty is implausible, impossible or undesirable is given credibility and reason by the idea that one will eventually contract HIV.  For the man who has suffered many losses - personally or in broad identification with the gay community - contracting HIV is a way of sharing with those lost, and, often, of ameliorating guilt about survival.  For those who have suffered losses of very close friends or of lovers, the idea that one has HIV expresses the familiar conviction of surviving partners that they too are dying.

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What all these sources of inevitability have in common is that they are the product of a profound identification with AIDS, those dead of AIDS or those who are HIV-positive.  While the identification of gay men with AIDS is partially unavoidable because of the facts of the epidemic, much of this identification is an unconscious, confused, and illogical feeling that can be clarified in the context of other feelings.  New approaches to AIDS education must help gay men explore their identification with AIDS and the feelings that surround it.  Men will not contract HIV simply because they are gay, loved ones have died, or life beyond thirty seems impossible.  This clarification is especially critical for those who have never known a gay identity or gay community without AIDS - the young and those coming out later in life.

Feelings of inevitability, unfortunately, are also severely exacerbated by our conceptualization of the epidemic and our current AIDS education.  This is accomplished largely by the implicit homophobia of much education and by the apparently intentional reinforcement of identification between positive and negative men.  These are immensely destructive forces that now often pervade - and sometimes characterize - our educational work.  There are important differences in the thoughts, feelings, and goals of positive and negative men, and generally it is positive men who most readily acknowledge this.  If our education blurs or obscures these differences we should not be surprised that many HIV-negative men develop feelings of inevitability about contracting HIV and no longer see real purpose in trying to avoid it.  In its 1994 campaign, the San Francisco AIDS Foundation tells us:  "Gotta Believe .  Single Gay Man outliving the forecasts of doom.  HERE WE ARE still pushing ahead.  Positive or negative, we thought safe sex was just about surviving.  There's more. . . [elipse in original]."

What does this mean?  That the Single Gay Man, positive or negative, is one in the same?  That positive and negative men are pushing ahead for the same things?  That protected sex  or survival mean the same for both?  That the "more" in the futures of gay men is the same regardless of antibody status?  These implications deny obvious truths, and they inappropriately entangle HIV-positive and negative men in common values and goals.  This is destructive work characteristic of agencies that do not even clearly recognize that their prevention work is for HIV-negative men.  In 1991 the San Francisco AIDS Foundation released a campaign which invited gay men to "Be Here for the Cure."  Though widely borrowed by other prevention agencies, many gay men expressed confusion about whom the campaign was for.  Were positive men being encouraged to hang on medically, or were negative men being told to stay negative, both waiting for "the cure?"

"I don't want the AIDS cure to be the focus of my life," an HIV-negative psychotherapy patient told me.

    Sure, if I were positive, I'd be waiting for the cure.  And I'd like that for all my positive friends because then I'd know they're going to be O.K.  But I can't sit around with them making that the big hope in my life.  I don't think it's going to happen and I feel like I've got to get on with my life.  If I wait for the epidemic to be over, that might never happen.

I related this story to an educator at the San Francisco AIDS Foundation.  "Your client is confused." he said.  "The real beauty of this campaign is that it works equally well for positive and negative men."

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Other sources of confused identification and feelings of inevitability arise from many specific educational recommendations that we routinely make to gay men.  The idea that HIV-negative men test for HIV antibodies at routine six or twelve month intervals is one such destructive practice.  To the extent that it is made explicit at all, the rationale for regular testing is generally three pronged.  A man will behave "more responsibly" if he knows he is positive; he can seek useful, "early intervention;" and men "want to know" and any psychological consequences of a positive result may be ameliorated through "counseling."  With regard to regular-interval (as opposed to one-time) testing, the truth supports little, if any of this rationale.  We advise men to "play safe" regardless of HIV status and research consistently shows little behavioral change consequent of HIV test results.  "Early" medical intervention might be useful three to seven years after seroconversion but is generally not appropriate for several years following conversion.  Knowledge of positive status many years before onset of clinical illness with no compensatory benefits has been immensely destructive for many gay men.  The idea that this situation is simply ameliorated through "counseling" is an expression of the denial that permeates so much of our education.

What recommendations for regular-interval testing do accomplish is keeping the HIV-negative man entangled in irrational fears of seroconversion because, by implication, he is being told that he should continue to test because he might have contracted HIV, regardless of his behaviors.  The back side of the implication is that eventually he will convert, because one repeats a test until the results are "satisfactory" and the subject "passes."  Regular-interval testing keeps HIV-negative men engaged in HIV-related medical services, by no coincidence, on the same six to twelve month interval that asymptomatic positive men are often advised to follow for CD-4 counts, and supports the feeling that seroconversion is an inevitability.  New approaches to education must inform men honestly about the sometimes useful purposes - and limitations - of HIV testing and permit them to make decisions that reflect the realities of their lives and their values. 

Education mandating protected sex that does not acknowledge the facts of individual lives is another source of feelings of inevitability.  The ability to have ordinary (unprotected) sex with another HIV-negative man is one of the benefits of being negative (and perhaps of any sero-concordant relationship).  When we tell men that the rule is "a condom every time" regardless of circumstances, we deprive HIV-negative men of one of the most immediate and powerful incentives to remain negative.  We also create unconscious feelings that HIV is an inevitability.  "If neither of us really has HIV, why are we using condoms?", a psychotherapy patient asked me.  "Is it because I might really have HIV?  Or Steven might?"  Many men express such feelings, as well as the related feeling that every time they put on a condom the act makes them feel they must have HIV and are trying to protect their partner from it - why else are they putting on a condom?  We have "double-bound" men into such confusions with a remarkable show of bad psychology:

    Get tested and believe your results.  (But if your test is negative, don't believe your results: use a condom anyway).  Safe sex affirms your pride in being gay and loving gay men protect their partners (from what?)  But don't trust your "monogamous" partner (gay men lie and cheat).  Feel good about sex:  It's natural and it's your right.  (But don't floss your teeth before sex and get tested again in six months to see if you've finally gotten yourself into trouble).

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Such education is a prescription for madness, not AIDS prevention.  New approaches to education must tell the truth about these issues, must acknowledge that it is sometimes quite "safe" to have ordinary sex, and must help men develop the access to information and judgment that would allow them to make the best decisions reflective of their values and their appraisals of acceptable risk.  It is possibilities, not restrictions, that motivate a man to take care of his health.  The approach on oral sex taken by the California AIDS Office forecloses on an interactive approach to education and on the possibilities in a gay man's life by providing unqualified, restrictive guidelines.  These aggravate the sense of inevitability by not only creating impossible standards of behavior in pursuit of "erring on the safe side," but by making men feel out of control about some of the most important decisions in their lives.  Rote guidelines are disempowered and promote discouragement, hopelessness, and the sense that inevitably one is going to "make a mistake" and contract HIV.  They cannot be the foundation of education that serves a lifetime. 

In addition to the sense of inevitability, there are a handful of other important psychological issues that should be mentioned.  One is the variety of human meanings of sex, and, as one expression of those meanings, the meaning of semen.  What AIDS education has come to call "the exchange of body fluids" was once acknowledged as an important aspect of intimacy for many men.  There is no denial education can enjoin that will change this fact or experience.  In recommending oral sex with condoms - or in our more "liberal" jurisdictions, simply without ejaculation in the mouth - are we discouraging the most benign form of semen exchange?  Is a three-one-hundreths of one percent risk over five years a universally acceptable reason to preclude an important expression of intimacy?  New approaches to education must carefully consider the possibility that for men for whom semen exchange is an indispensable part of intimacy, oral sex with ejaculation might be an alternative of minimum risk, that it might reduce the incidence of anal intercourse, and, when anal sex does occur, that it might reduce the emotional need to exchange semen in this more dangerous way.

Trait behaviors are another psychological issue that new approaches to education must consider.  It is well established in psychological research that people are less likely to repeat undesired behaviors if they attribute them to "state" rather than "trait."  This is the difference between feeling you have done something because of a temporary state - a product of transitory external or internal influences - and done it  because the behavior is a natural expression of (permanent) character traits .  Behavior that is felt an expression of character traits is experienced as more compelling and  more difficult to change because character is perceived as relatively immutable - as who one is .  While AIDS education has sometimes acknowledged the importance of state-determined behavior (feeling in love, being influenced by a partner, or being under the influence of substances), it has at the same time focused on characterological issues.  As educators become more desperate about "relapse" this trend has intensified:  being a member of the Moral Majority is a trait and having common sense is a trait.

Such presumed foundations for behavior change imply character traits, and in the case of those who find themselves even occasionally practicing unprotected sex, character defects.  Educators seem to hope for permanent changes in behaviors by connecting behavior to character and then changing character (or molding it into conformity with community standards).  Unfortunately such efforts encourage occasional behaviors to become characteristic ones, because, for those compelled to practice unprotected sex for reasons they do not understand, character-based education colludes with the rationalization that "I guess it's just in my nature."   People become committed to behaviors that express character, just as men become committed to homosexuality when they begin to conceive of themselves as gay.  A characterologically focused, educationally induced polarization between "good gays" and "bad gays" will accomplish nothing and destroy much.   New approaches to education must be very careful in their use of character issues.  They must acknowledge the complexity of  feeling about sex and must acknowledge that many men occasionally engage in sexual behaviors they wish they had not.   It is only in this acknowledgment that the reasons may be understood.

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Next among the psychological issues is that called off line-on line by Australian psychologist, Ron Gold.  Put simply, this is the readily observed idea that people exist in different "states" of consciousness when they are being educated and when they are having sex.  In neurophysiological terms this is the idea that people are educated "with" their cortexes and have sex - at least substantially - with their brain stems.  Gold makes a convincing point:  Our education is aimed at the cortex with little regard for how the cortex and brain stem interact during sex .  Gold proposes that the two can be taught in the "off line" (cortical) condition to interact more effectively while "on line."   Most acculturation and socialization involve establishing "communication" between these two states of consciousness, and this can be done in the context of AIDS education if we stop educating the cortex as if it were the source of all human feeling and behavior.  The idea that human life is primarily - or most importantly or desirably - a cortical experience is the vain hope of an erotophobic society.  It is not true that we live primarily in our cortexes and we have an epidemic to prove it.

In affirming the reality and human importance of our subcortical lives, new approaches to education can teach people the skills that allow "on line" communication, and this can be done without destroying the altered state of consciousness that makes sexual experience important and compelling.   New approaches to education must also affirm the importance of erotic life by showing it realistically integrated into other aspects of life:  intimacy, friendship, love, and human communication.  Remarkably, education to date has show almost exclusively "recreational" or casual sex, and in doing that destructively supports societal beliefs that sexuality has only a special - relatively superficial and segregated - place in human life.  The integration of erotic life into the totality of human life is especially important because numerous studies have suggested that HIV-transmission is now occurring more commonly within relationships than through casual sex; and it is important because the recognition and integration of our erotic lives is a necessary component of self-respect and thus the capacity to respect and love others.  That latter capacity is the foundation of a life worth living.   

Finally, among this small sample of psychological issues is substance use and abuse, one of the most discussed and apparently least understood in AIDS education.  In some populations research has established a correlation between substance use and unprotected sex.  But our education has persistently confused correlation with causality.  The correlation between substance use and unprotected sex is generally interpreted to mean that people have unprotected sex because they use substances.  Thus, the reasoning goes, we can reduce unprotected sex by reducing substance use. 

Alternative explanations for this correlation - and ones that make more psychological sense - will be much more useful to our education efforts.  These include the insight that people are not having unprotected sex because they have been drinking, they have been drinking in order to have unprotected sex.  This explanation recognizes that unprotected sex is often important and compelling and that the disinhibition provided by substances is often necessary to act out the desire.  People are also using substances to have protected sex, either because they have long-standing anxiety about sex or - quite commonly - because our education has fallen seriously short of doing its work in a way that might allow genuine confidence about the reasonable safety - and human value - of  protected sex.  Our current education's homophobia, moralism, directiveness, erotophobia, and penchant for "erring on the safe side" are important contributions to many men's need to use substances to engage in sex of any sort.

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Poor self-esteem is another common underlying motivator for both excessive substance use and unprotected sex, and depression may underlie and motivate both.  Such explanations include the rudimentary psychological idea that drinking is not simply the source of behaviors but also the consequence of feelings.  This insight has been obscured by medical models of substance abuse because such models define abuse as the primary problem, thus eclipsing psychological meaning.  It is feelings that are responsible for unprotected sex, and they must be addressed if behavior is to change.  These feelings are evidenced, not at the substance-impaired moment that the sexual activity takes place, but at the moment the individual decides to use the substance.  Thus the response of men who report having unprotected sex "because I was drunk," is not an adequate understanding.  The real question is, "Why did you get drunk?  There is no utility in trying to treat one symptom - substance use - to get rid of another - unprotected sex.  New approaches to AIDS education must help men understand why, in a psychological sense, they use substances and what the consequences can be.

I have proposed an approach for AIDS education that goes beyond simple, direct, instructive efforts to reduce HIV transmission, with or without the adjunct of social marketing.  Unlike responses to acute emergencies, comprehensive approaches are necessary in a lifelong event.  But why should AIDS prevention be saddled with the responsibilities of  excising homophobia and moralism from education, pursuing honesty, acknowledging realities, and validating complex feelings that are not directly connected to reducing HIV transmission - indeed, feelings that, in the short term, may appear to encourage transmission?  Is such work the responsibility of AIDS education?  Am I not suggesting that AIDS education do the work of others, perhaps psychologists?

The first answer to these questions is that education has a responsibility to not do psychological harm and it has failed in this.  In its denial and obfuscation of facts and feelings alike, AIDS education is now responsible for a considerable amount of psychological damage to gay men.  Along with the epidemic itself and its attendant experience of loss, depression, and anxiety, AIDS education taken on the whole is now a major psychological liability for gay men.  Like all destructive feelings arising out of the epidemic, some of those nurtured by our education are now responsible for a considerable amount of HIV transmission.  To the extent that education is compounding the psychological damage wrought directly by the epidemic itself, it must stop for human reasons as well as for the effort to reduce HIV transmission.

The second reason that AIDS education must broaden its purposes is to be found in the nature of repression and denial.  The man who is not permitted to think about why he might not feel like surviving the epidemic cannot think authentically about why he might feel like surviving it.  The man who is not allowed to acknowledge his feeling that the richest possible life may demand behaviors that  expose him to HIV cannot clarify why he might not feel those things.  The man who is not permitted to think about the personal meanings of sex and the special meanings of ordinary, unprotected sex cannot think about why those meanings may not be an adequate incentive to contract HIV.  In enlisting, rather than suppressing, individual contemplation and insight, new approaches to education can help nurture the most powerful - perhaps only - forces we have against the epidemic.

Finally, AIDS education must reevaluate its fundamental purposes.  In a lifetime event of this destructiveness we are not addressing the human needs of the gay community by offering - or insisting upon - biological survival as an exclusive and adequate purpose for human life.  Lives must be worth living, and the epidemic itself  has only complicated this perpetually difficult effort.  Survival must include the idea of meaningful, human survival for a community that has traditionally been scorned or punished for the way it makes love, communicates intimacy, and creates human bonds.  New approaches to education must take as their primary task such human purposes.  The reduction of HIV transmission can only be the secondary task because it must be built on the foundation of  lives experienced as worth the trouble.

1994 demands an extensive reconstruction of what we now call AIDS education.  This is because we do - or ought to - understand more than we did in 1984; because the epidemic is not an aberration in our lives, but a permanent form of life; and because those who have lived through the epidemic are understandably no longer who they were before it started.  What we have traditionally called public health may be a vehicle, but cannot be the whole content of new approaches.  Public health experts and media analysts who now direct our educational efforts must begin to understand and include the facts of human experience.  An educator, explaining the necessarily directive nature of AIDS prevention, once said to me, "If you want someone to buy a Chevrolet, you don't tell him he might want a Chevrolet."  My answer was that for a man living in a lifelong epidemic in which intimacy might become assault and love death, we had no Chevrolets, we had only contemplation itself: the internal space for each man to think and feel and thus make for himself the best possible decisions that he might.  We cannot tell people how to act in the epidemic any more than we can tell them how to feel about it.  It has not worked and will not in the future, and if we are concerned with the quality of gay life in America, rather than merely the quantity, that sort of instruction is something we should not even be trying.

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