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The Office of AIDS
California Department of Health Services
Symposium
for HIV Prevention Professionals
April, 1998


Staying Negative in a Positive World:
HIV Prevention Strategies that Work

By Walt Odets

I believe our AIDS education for gay men had utility early in the epidemic.  In 1998, however, this is not the case because our comprehension of the problems has remained largely unchanged since those early years - while historical, social, and psychological issues within gay male communities have converged to make the tasks of AIDS education almost completely new.  I have now observed for several years the poor results - and psychological damage - our current educational approaches are producing, as well as many of the reasons this is the case.

Historically the epidemic has now spanned more than a decade and it seems almost certain that it will be a lifelong event for most adult gay men.   Thus we must now provide education about a permanent form of lifeSocially - and I am largely confining my remarks here to the "mainstream" gay male communities in the US, and especially those in larger urban centers - we have become habitués to a form of life completely unimaginable ten years ago: a 50% overall infection rate, 10 to 40% infection rates among segments of the young gay community, and 70% rates among older groups.  Such figures translate humanly into a huge accumulation of loss, grief, and its attendant depression, isolation, discouragement, and guilt.  And finally, in more specific psychological senses, it has become apparent that AIDS itself, the epidemic, and the form of life the epidemic has created all have special, humanly destructive entanglements for gay men who are accustomed to self-identification as members of despised, sexually identified communities that will be ostracized or punished for their behaviors.  These "special" entanglements, unfortunately, have not only gone largely unrecognized by prevention efforts, they have been homophobically, if unintentionally, exploited.  The result is a broad failure of prevention that we are, only now, beginning to acknowledge.

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Let me back up for a moment, to the earliest years of the epidemic.  At that time prevention efforts were assisted by the natural fear of gay men - many huddled over media reports of "gay cancer" and GRID.   While education at that time provided the information upon which behavioral changes were built, it is not clear that it ever provided the incentives or motivation.  In this sense it is not clear that our education has ever "worked" in the sense that we use that term when we speak of education's failure today.  By 1988 studies of gay men in several urban centers were being conducted and would be replicated all over the US  About one-third would self-report the practice of unprotected anal intercourse, a behavior heavily stigmatized traditionally and now also bearing the considerable additional onus of HIV transmission. Because self-reports of such behavior are notoriously low, the real figures are certainly higher, and are probably astonishingly close to the figures we had about anal intercourse (50 to 60% of men)  before there was an epidemic .  This leaves the possibility that today's education may be of  little, or no value at all in motivating changes in the behavior that we - and all gay men and their grandmothers - know to be the most dangerous for transmitting HIV.   

Unfortunately, educator's widespread denial that this was happening - denial that spanned a half-decade of data to the contrary - has been followed by a belated acknowledgment that demonstrates little insight about why it is happening.  As one example, an educator from San Francisco's STOP AIDS Project offered his solution to relapse in 1993:  "I guess we're just going to have to scare the shit out of gay men again," he announced to an astonished room of psychologists, physicians, and educators who were in the early planning stages of the now well-known "Dallas Prevention Summit" of 1994.  Although this educator's language was extreme, his conceptualization accurately characterizes prevention approaches that are sustained to this day: informational instruction enhanced with the coercive powers of social marketing.  In other words, most of us have still never seriously thought psychologically about why a gay man might expose himself to HIV despite "knowing better," and we have certainly never thought about why a gay might be ambivalent about not having HIV.  Today I would like to talk about a single aspect of this problem: the role of homophobia - external and internal - in the rising trend of new infections, and in the education that is supposed to address this.  

From the beginning of the epidemic our education has been laden with homophobic assumptions and has exploited the "internal" homophobia of gay men in an attempt to accomplish behavioral change.  For example, the condom made excellent sense as an emergency measure in 1983.  As a permanent, lifelong component of sexuality, however, it has proven as problematic for gay men as it has always been for all men.  The ideas that gay men would readily adapt to condoms, and ignore or fail to recognize their limitations - indeed, according to many educators, have fun with them - is rooted in homophobia.  Homophobia is at the root of feelings, often unconscious or unspoken, that gay sexuality is not "real" sexuality, that it is not humanly important, and, not uncommonly, that it probably should not be going on anyway.  Thus educators continue a decade into the epidemic to tell gay men that if they are going to have anal intercourse, the least they can do is use a condom, and "If you don't like condoms, don't fuck."  This would have been an absolutely unthinkable approach had the epidemic first appeared among heterosexuals, and no one would have proposed it as anything but a short term emergency measure: we know - and accept - that vaginal sex is not dispensable for heterosexuals .  Homophobia not only suggests that gay sex is dispensable, it also posits safer sex as a way for gay men to make amends for their sex - amends that many gay men feel, if not believe, they should be making.  The condom, like "safe sex" in all its expressions, has provided gay men a means for having "good" sex, approved sex, sex that even (some) of the Federal government is willing to tolerate if not really endorse.  The condom, in particular, has become a way of making reparation for fundamentally bad sex, which in the minds of many means anal sex.

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Misrepresentations about the viability of condoms for a lifetime is only one among a host of misrepresentations that express societal homophobia, engage internalized homophobia, and have become standard fare in education.  Some of the most destructive misrepresentations of AIDS education are expressed in the practice of "erring on the safe side."  For many gay men thinking about lifetime forms of sexuality our messages seem to demand unattainable standards of behavior that have contributed to a widely held sense that contracting HIV is inevitable - "not if but when " according to a psychotherapy patient.  The consequence of these feelings is unthinking or impulsive engagement in behaviors that really could be avoided, at least most of the time, even over a lifetime.  When HIV infection seems inevitable, many men derive comfort from contracting it now and thus eliminating anxiety about when .  This is one reason we often see a reduction of depression and anxiety in men receiving positive test results.

Among our most important and destructive expressions of erring on the safe side in 1998 is the idea that unprotected oral sex is dangerous, or dangerous enough that it ought to be routinely conducted with condoms.  We are alone in the Western World in this idea, and that is because there is no credible data to support it.  The single study we have to suggest a significant transmission potential for oral sex - the Michael Samuel study of 1993 - is riddled with methodological and conceptual flaws, is entirely unreplicated despite efforts to do so, is contradicted by all other data, and should not have been published if for no other reason than that 67 percent of the studied cohort had dropped-out for unknown reasons only four years into the six year study.  Ladies and gentlemen, I submit that among the most basic requirements of science is the requirement that you start over from scratch when two-thirds of your rats disappear for unknown reasons - and that you keep better track of your rats.

The Samuel study has nevertheless, become the backbone of US educational policy on oral sex.  Although gay men will - for any number of humanly good reasons - not use condoms for oral sex, many now believe they should.  And because they are not, they often feel, for these additional reasons, that contracting HIV is inevitable, and that there is no point in trying to protect themselves from any kind of sex.  A study by DeVroome, of Holland, in fact, found that those men who had the most anxiety about oral sex were those most likely to practice unprotected anal sex.  This "throwing in the towel" is a characteristic result of education that creates an impossible task in the name of erring on the safe side.  A psychotherapy patient expressed such feelings succinctly:

    I know that it's self-destructive, but so far as I'm concerned, it's perfectly natural to want to suck a guy off, and if that's all it takes [to contract HIV], I'm going to get it.  I know I'm not going to stop that for the rest of my life.  And then I think to myself, "Oh hell, why should I give up all the other things that are important to me - I should do what I want, live my life as long as I've got it, and get it over with."   I can't see trying to hang around for a long life sucking on rubbers.  I can't see how other guys do that.  Do they do that?  I'm asking, because no one I know does.  I guess we're all going  down the tubes together.

The most significant "behavioral" change of such education is that men do not honestly talk about what they are doing - in other words, they go in the closet about the kind of sex they are having.  There, like closeted homosexuality itself, the practice of unprotected sex develops a secret life with immense destructive potential.  The gay man practicing unprotected sex today is in the closet about it - often, unknowingly, with a majority of his peers.  Like the closeted homosexual he experiences shame, guilt, and a fragmentation of his life; and he begins to form an identity around his feelings and behavior that reinforces rather than inhibits the behavior.  Even those who only occasionally practice unprotected sex often feel they have crossed into forbidden territory from which there is no return and many do not even attempt to return.  These men are entirely lost to our education. 

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But why has the risk of oral transmission of HIV so grabbed the attention of educators?  And why has the possibility of oral transmission - a possibility that the MACS study in Chicago, in attempting and failing to replicate Samuel's findings, termed "a rare event occurring below levels of statistical detection" - why has this possibility so engaged gay men themselves?  Genuine, if largely misplaced, concern about anyone else contracting HIV is one reason.  But another, very important reason, is that oral sex between men is not valued, and it is simply easier to tell men what to do, to use condoms - even if we know they will not do it.  Education that truly valued gay lives would help men educate themselves rather than instruct them.  It would assist and allow gay men to express their own values about life, sex, and intimacy, and to make their own decisions about what constitutes acceptable risk for.  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, although many - dealing with their own unclarified  homophobia - are feeling pretty anxious and guilty about rejecting it.

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.

Before I conclude, I would like to examine more fully the feelings of inevitability about contracting HIV that I referred to earlier.  I believe that the experience of inevitability about contracting HIV is a central issue that education must constructively address - and must certainly not exacerbate.  This experience 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. 

Feelings of inevitability are the product of many social and psychological forces.   Some of these, fortunately, are not the product of our education, and could be partially ameliorated if our education would not exacerbate them.  As examples, homophobia, hatred, and self-hatred suggest 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 gay twenty year old, the 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 gay communities - 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 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.  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 now critical for all gay men, but 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 much of our current AIDS education.  This is accomplished partly by the implicit homophobia of much education, which I have discussed.  But it also accomplished by the intentional reinforcement of identification between positive and negative men.  To date our education has largely expressed the political idea that all gay men are "equal" and AIDS education thus applies universally to all.  At San Francisco's STOP AIDS Project, as 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 idea.  Their confused retort is that AIDS education is for the gay community , because positive men are part of the solution, and that services or education specifically for HIV-negative men would be "divisive."  A recent Reuters wire story carried the following headline about a new prevention campaign at Gay Men's Health Crisis, a campaign that I helped develop:  "Nation's Oldest and Largest AIDS Agency Launches First Prevention Campaign for HIV-Negative Men."  One must wonder about what kind of "prevention" preceded this campaign.  It is little surprise that educators, confused about whose outcome education must change (regardless of who is involved in the solutions), are producing equivocal, unclear, and misleading education.  Our traditional forms of education have played an important role in creating common feelings that contracting HIV is inevitable, because they have failed to distinguish the different concerns and problems of positive and negative men, and have encouraged the identification of negative men with positive men.   

In truth, there are important differences in the thoughts, feelings, and goals of negative and positive men, and it is usually positive men who most easily 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 a 1994 primary prevention campaign, the San Francisco AIDS Foundation told the reader: "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. . . [ellipse 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 where those values and goals are and should be different.

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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 backside of the implication is that eventually he will convert, because one repeats a test until the results are "satisfactory" and the subject "passes."  As a physician recently told a psychotherapy patient of mine:  "If you're negative, don't worry.  Come back in six months and we'll test again."  Regular-interval testing keeps HIV-negative men engaged in HIV-related medical services, by no coincidence, on the same six month interval that asymptomatic positive men are often advised to follow for blood 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 contracting HIV is inevitable.  "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 (but from what?)  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 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.  Rote guidelines are disempowering 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. 

I realize that even with the few specific issues discussed here I have placed expectations on AIDS education that go far beyond simple instructive approaches to reducing HIV transmission.  But why should AIDS prevention be saddled with the responsibilities of excising homophobia from education, pursuing honesty, acknowledging realities, and validating complex feelings that are not directly connected to reducing HIV transmission?  Is such work the responsibility of AIDS education?  Am I not suggesting that AIDS education do the work of others, perhaps psychotherapists?

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.

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The second answer is that AIDS education must broaden its purposes because of 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 . 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 like doing 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.

1998 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 social marketing specialists 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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