The Psychological Politics of AIDS within Gay Communities

Having just flown in from California for the occasion, I would like to thank you for inviting me to talk on the subject of gay men and AIDS at one-thirty in the morning.  I have done this enough at International AIDS Conferences to know that Americans have spent much of the last decade-and-a-half jetting around the world telling everyone else what to do about the epidemic at all times of day and night.  I am not here to do that, and I would like to introduce my talk by laying the cards on the table and telling you why:  In the US, we have failed very badly at doing good and useful prevention for gay men.  Many of the reasons for that are not pertinent here in the UK, where I believe you have done much, much better.   In the US we are less respectful of human life as it is really lived – and particularly of human sexuality as it is really experienced – than almost any other people in the Western World.  We have thus sculpted an approach to AIDS prevention which is premised on dubious foundations: on the belief that we can help gay men learn to care for themselves by exploiting their shame and self-hatred to gain behavioral compliance; on the belief that we can keep gay men uninfected by lying to them about the facts and manipulating them with a weak amalgam of traditional public health and drugstore psychology; and on the belief that we can help gay men have long and happy lives by offering them impoverished visions of gay life that are hardly worth protecting from HIV.

The results of our decade-and-a-half of wisdom are – tragically – evident in every large city in America:  50% of gay men are infected with HIV – about five times the seroprevalence among gay men here in London.  On our current course, one-third of gay 20 year olds will be infected with HIV or dead before they are 30;  and more than half these 20 year olds will contract HIV in their lifetimes.   It now seems almost certain that this truly frightening picture – as compared to the relatively bright pictures here in the UK, in Canada, in Australia, and elsewhere – is not the consequence of differences in epidemiological timetables, but the simple, predictable result of  the kind of human values expressed by American society.

There are some issues that I believe we do have in common with regard to AIDS prevention in gay communities, and it is one of these that I would like to offer for discussion today.   This issue grows out of the peculiar, powerful, and destructive ways that AIDS has engaged gay communities.  This engagement is experienced in a number of ways by gay men, and is also experienced in the consternation that many of us around the world experience about how to construct prevention within a stigmatized minority community that seeks social, political – and, most importantly, human – unity, even as this community is, in reality, divided by an important fact centrally pertinent to prevention: a good number of us – in the US, half of us – are infected with a communicable, largely fatal virus, and the rest of us are not.

To make matters worse – very much worse – this virus is communicated almost exclusively among gay men by the very behavior that has most characterized us in the public mind for centuries, the very behavior that is most distinctive about homosexual sex, and the very behavior about which we feel the most shame, humiliation, and guilt.  This is, of course, anal sex, one man putting his penis, and often leaving his semen, in another’s rectum.  This act and all that it means and communicates is of profound human importance for many gay men.  We should make no mistake about it:  It is the coincidence at our tiny moment in history between the evolutionary whim of microbes and the importance of this simple, often magical, human behavior, that brings us an epidemic among gay men.

The conflict, shame, humiliation, guilt – and often, the unmitigated self-hatred – that gay men feel about being homosexual and about this fundamental human need for anal sex are all feelings that have become seamlessly woven into our experience of AIDS and our lives in the epidemic.  Referring to his parents contempt for his sexuality and his illness, a psychotherapy patient with AIDS described this process to me succinctly:  “One minute I want to defend myself and say, ‘Don’t treat me this way.  I have a viral infection and I have the right to be treated like a human being.’  And then a minute later, I say to myself, ‘No.  You’re a fag, you got fucked, and now you’ve got exactly what you deserve.  And that’s what my mother said to me when I first told her I was positive: ‘You’ve made your bed.  Now lie in it’.”  There is no hour of our lives in the epidemic that is untouched by these confusions.  Guilt, shame, humiliation, and self-hatred, now consciously and unconsciously pervade gay men’s experience of  being infected; of being homosexual and not being infected; and of being identified with a community which is now perhaps more commonly characterized in the public mind by the epidemic than by the act of anal sex.

One important consequence of these confused and entangled feelings is that quite aside from all the good, human reasons for protecting from stigmatization those dealing with HIV infection in their own bodies, we have found ourselves in the peculiar position of feeling that we have to defend HIV infection itself.  The largely unconscious cycle of feelings goes:

Being queer doesn’t feel O.K., and we got HIV because we’re queer.  But we want being queer to be O.K., and we say it’s O.K., so having HIV must be O.K., and we should say HIV is O.K., because otherwise being queer will feel even less O.K.

As a consequence of such – may I call them,  “psychological politics” – we have constructed a very strange, largely unspoken protocol within gay communities.  This protocol is driven by our own, individual self-hatred, uninfected and infected alike, and it is born out of the unconscious cycle of feelings just cited, as well as elaborations of the feelings expressed by the HIV-positive psychotherapy patient quoted earlier:

He’s a fag too, and, if anyone deserves HIV, he deserves it as much as I deserve it, so how dare he experience me differently simply because I have HIV, because he could have it too, and probably will.

Or, from the uninfected man’s unconscious:

I’m a fag, I could have HIV, I probably deserve HIV, I don’t know why I don’t have HIV, and I don’t want anything to do with people who do have HIV because it reminds me that I’m going to get it or already have it.

And of course, the absolute unacceptability of such feelings among gay brothers then hatches the public protocol: I am living and thriving with AIDS, and I am proud of that.  And from the uninfected man: When I date a man, it makes no difference to me whatsoever if he’s HIV-positive or not.

Such protocol within gay communities, like all protocol, is erected against truths that are too harsh, too painful, and too disruptive of social life. Like all protocol, that arising out of our psychological politics, not only obscures the whole truth, it obstructs any effort to reveal the truth, an effort that might provide us the opportunity to deal with what is really paining us deeply.  Psychological politics within gay communities have prevented us from saying out loud that there are some real differences between positive and negative men in many interpersonal, social, and psychological needs and issues.  In the shadow of the undeniably pressing needs of infected men, we have to date been largely unable to acknowledge that uninfected men had any needs at all.   When a handful of uninfected men here and there have tried to assert needs, the response from others in the community has been badly distorted by both the unconscious components of our psychological politics and the protocol they have bred.  An HIV-positive AIDS activist was recently quoted in a San Francisco gay paper:

“I think it’s very important for HIV-negative folks to have a forum where they can share their concerns, but there’s a difference between creating forums of communication . . . and creating the perception of an exclusive entity that says to HIV-positive people, ‘You can’t come here; you don’t belong; you’re not good enough ‘ [italics added].”(1)

A decade and a half into an epidemic that has infected or killed half their community in San Francisco, HIV-negative men have pressing needs to talk among themselves about many feelings and issues that they cannot humanely discuss in the presence of positive men.  That these needs, including the need to discuss them away from positive men, might be construed as saying to positive men that they – positive men – are not good enough brings us right back to the roots of our dilemma:  I’m a fag, I got fucked, I got exactly what I deserved, and you who do not have HIV  may not imply that I’m not good enough.  And, again, the assertion of these psychological politics in protocol obfuscates what both negative and positive men are really feeling about the epidemic, themselves, those of the “other group,” and their social and intimate relations with each other.  Unfortunately, these are the very things we absolutely must talk about if we are to survive the epidemic not only as biological organisms, but as human beings.

Aside from helping destroy authentic, intimate, fully-lived human life, the psychological politics of our communities and their expression in  protocol have had another tragic consequence that I would like to examine in the remainder of my talk this morning. It is this: since April of 1985 when the ELISA first became available and we discovered that there were “positive” and “negative” gay men – and who they were, which is to say ourselves, our lovers, our best friends, or neighbor – we have been almost completely unable to do HIV primary prevention: prevention to help keep uninfected men uninfected.  Instead, we have done a kind of “undifferentiated” prevention that has insisted upon denying that there are any differences between positive and negative men that might be pertinent to prevention itself.  Undifferentiated prevention has thus persisted in doing prevention roughly as we did it before the ELISA.  This denial flies in the face of what men who know their antibody statuses – and even those who could know their statuses, but do not – are really experiencing.  As the epidemic has endured and deepened, positive men, negative men, and men who do not know have developed distinct social and psychological identities, and thus distinct needs, concerns, and issues, many of which are centrally pertinent to prevention.  In ignoring these differences, undifferentiated prevention has almost entirely failed to address anyone’s needs and concerns, and has largely failed to help accomplish the sole purpose of primary prevention: keeping uninfected men uninfected.

Undifferentiated prevention is now so familiar to most of us, that the idea requires some clarification.  Most simply put, undifferentiated prevention is doing AIDS prevention for “gay men.”  As one example, it is exhorting men to Stay Healthy, without saying if we mean uninfected or asymptomatic.  It is, in another notorious expression, A Condom Every Time.  A Condom Every Time was a sensible instruction – indeed, the only possible instruction – before the ELISA.  But in the current age, when many men know if they are infected or not – and many others would know, if prevention provided reasons to know – it is an instruction that ignores or denies an obvious fact.  Infected and uninfected men use – or do not use – condoms for very different reasons.  After all, the potential consequences of not using a condom – and the potential benefits of using one – are entirely different for the two groups.  The reasons men do not use condoms run the gamut from the important desire for unencumbered, intimate sex, to problems communicating, to complex psychological and psychosocial issues.  In 1996 the task of prevention is no longer to tell men to use condoms, but to help them understand why they are not using them when there is risk of transmitting HIV.  If we are to do that, rather than mindlessly persevere in telling men to do what they are not in fact doing, we must know to whom we speak and about what.

Before I explicitly discuss the role of our psychological politics in undifferentiated prevention, I would like to provide a more detailed example of the undifferentiated approach, in this case from San Francisco’s STOP AIDS Project – one of the world’s most widely copied primary prevention programs.  A 1995 brochure inviting men to its small, peer-led meetings tells us that,

[STOP AIDS offers] a one-shot evening with other gay and bisexual men like yourself who want to explore what good sex – safe and satisfying sex – is all about.  A lecture?  No way!  Everybody talks.  Everybody listens.  After all, everyone’s experience is different.  It turns out we all have a great deal to learn from each other about dealing with fear and frustration.  And a great deal to teach one another about what getting close really means. . . . You’ll hear the latest facts about the risks of different sexual practices and how you can stay safe.  You’ll have a chance to talk about how AIDS has changed more than our sex lives – it shapes our friendships, our community, our personal sense of the future. . . . Best of all, the evening is a time for all of us to renew our commitment to protect ourselves and care for others in the ways that mean the most. (2)

The language of this very typical piece simply begs the issues of primary prevention.  The purpose of the meeting – to help keep uninfected men uninfected – is hedged from the beginning by the idea that men are getting together to “explore what good sex – safe and satisfying sex – is all about.”   And the hedging continues throughout.  Are the other men in the group really “like yourself,” or might HIV status have something to do with that in the context of prevention concerns?  Could differences in the ways men experience sex and the epidemic have anything to do with HIV status?  Might HIV status contribute, in a number of ways, to problems with “getting really close?”  Are the risks of “different sexual practices” and “staying safe” unrelated to HIV status?  Could the nature of men’s “fears and frustrations” have anything to do with HIV status?  Might HIV status have something to do with the ways that AIDS has changed our “our sex lives, our friendships, our community, or our personal sense of the future?” And, finally, who is renewing his commitment to protect whom from what and whom “in the ways that mean the most?”

In this very typical presentation, differences between positive and negative men are deliberately blurred on the most obvious issues, and, indeed, HIV-negative men – who are the outcome population for primary prevention – are mentioned only once in the brochure:  they are told that by attending this meeting they can find out where to go – meaning elsewhere – to talk about what it means to be HIV-negative.  Nowhere else in the brochure are the words HIV-negative or uninfected even used.

In intentionally obfuscating the outcome population for primary prevention – uninfected men – STOP AIDS eliminates any possibility of addressing this population’s specific issues and needs.  Nor can STOP AIDS address the issues of infected men which might help them contribute to keeping uninfected men uninfected.  By its very nature, undifferentiated prevention can talk only about issues that can be presented equivocally.  As soon as prevention speaks to the purpose of staying uninfected, those who are already infected are excluded.  And this, of course, is precisely where our psychological politics first reveal themselves: undifferentiated prevention is what it is, in part, because we cannot bear to exclude positive men, cannot bear the possibility of making them feel that they do not belong or are not “good enough,” even when the subject is, or ought to be, keeping uninfected men uninfected.

This humane, if ill-clarified, concern for the feelings of positive men is revealed in an obvious, but startling observation:  primary prevention has changed in one important regard since the ELISA.  Although we still address the undifferentiated group of “gay men” that we spoke to before the ELISA, we have stopped explicitly encouraging them to stay uninfected, and we have entirely stopped talking about the horrors of HIV infection that might serve as one incentive.  We have reduced prevention to a set of concrete, universal instructions that never speaks – that cannot speak – of motivation, purposes, or outcome.

If undifferentiated prevention cannot speak to negative men about getting infected – or, as another approach to primary prevention, to positive men about infecting others – how has primary prevention even attempted to address its purpose at all?  The answer is that undifferentiated prevention has relied entirely on the paradoxical instruction developed in pre-ELISA days, an instruction best exemplified in the idea of telling “gay men” to “use a condom every time.”  The paradox in the instruction is that for purposes of protecting himself, every man must assume himself uninfected and all others infected.  And for purposes of protecting others, he must assume himself infected, and all others uninfected.  In other words, undifferentiated prevention has every gay man both coming and going regardless of what he knows, does not know, thinks he knows but does not know, or thinks he does not know but knows.  While this paradox was a necessity before the ELISA, we now have at least the possibility of knowing antibody status.  And, unfortunately, the paradox has increasingly separated gay men from prevention for various important reasons.

Firstly, the paradox is responsible for separating gay men from what, in the US at least, has been the very backbone of prevention, HIV testing.  In denying that differences in antibody status exist in practice, the paradoxical instruction has prescribed a single behavioral code – a condom every time – without regard to the actual HIV condition of sexual partners.  Given this instruction, the very best that a gay man can hope for from an HIV test is to find he is uninfected, but is expected to stay that way by acting as if  he and his partners were actually infected for the rest of their lives.  The consequence is not only that there is little incentive for testing – and little sexual benefit for being and staying uninfected – but that a “cognitive dissonance” is created.  The uninfected couple must wrestle with feelings that either some prevention instructions are wrong and unnecessary or that one or both is not really HIV-negative.  This is very much like asking a man to take an antibiotic every morning “just in case” he has an infection.  He soon comes to feel that either the prescription is unnecessary, wrong, and implies an untruth – or that perhaps he has an infection after all.  Neither resolution of the dissonance supports prevention objectives.  Too many men now simply dismiss the pertinent messages of prevention as irrelevant to their circumstances.  And too many others feel that infection has, somehow, already occurred or surely will.  It is of  little wonder that few countries have encouraged testing to the extent the US has, and that in the US, testing is now on the decline among gay men.  As a great American, Bob Dylan, once said, you can’t fool some of the people all of the time.

The second way in which the paradoxical instruction separates gay men from prevention ought to be obvious.  The very form of the message – which must adhere to the cardinal rule of speaking “equitably” to all gay men about presumably universal issues – does not allow us to address the particular issues of negative and positive men, and thus bring relevance to prevention.  Contrary to the assertions of many AIDS educators, gay men have not grow “complacent” in the epidemic; they have simply become acclimated to the personal irrelevance of prevention’s “universal” messages.

While our psychological politics are very leery of excluding or stigmatizing positive men by speaking explicitly to negative men, there is a second, important reason that we have kept prevention messages universal.  If we do the obvious and speak specifically to the outcome population for primary prevention – HIV-negative men – we simultaneously open the possibility of speaking explicitly to positive men.  We have almost completely avoided doing this, for we fear stigmatizing positive men not only by excluding them, but by placing an inordinate burden of responsibility for the transmission of HIV on them.  I believe there are many important human, as well as simple, pragmatic reasons not to use primary prevention to burden positive men with exclusive or inordinate responsibility for HIV transmission.  But it is curious – and an anomaly in the history of public health – that we have constructed a prevention approach for gay men that treats public health’s traditional “carrier” and “public-to-be-protected” with absolute equity of responsibility for avoiding transmission, even when the infected man is aware of his condition.  It is, after all, almost certain that all new infections do not occur accidentally or unknowingly on the part of the infected partner.  And while in 1996, the HIV-negative gay man ought to know that he may be risking transmission in a sexual act with an unknown partner or partner of unknown status, the knowingly infected partner has certainty that this is the case.  These observations suggest that positive men have a role in primary prevention as a target – as opposed to outcome – population, and any authentic primary prevention will have to address this possibility with respect and cognizance of the social and psychological realities within gay communities.

Finally, undifferentiated prevention distances gay men from prevention by unavoidably positing a monolithic, impossible task.   The paradoxical instruction was hatched early in the epidemic when it was the only possible instruction, and at a time when we expected the epidemic to be over in a few years.  But in 1996, we are asking 20 year olds to somehow envision success in using a condom every single time they have sex for the next half century; and we explicitly forbid latitude for knowledge of antibody status, context, or partner.  If that task feels impossible – and perhaps a majority of young men today have never even dreamed it possible – contracting HIV becomes plausible or, worse yet,  inevitable.  In the face of such uncertainty or hopelessness, there are too many powerful incentives to accept ones fate as a gay man, throw in the towel, and get it over with now.

In sum, undifferentiated prevention offers gay communities a constellation of troubling instructions and results: paradoxes, a denial of obvious incentives, apparent untruths, persistent doubt about really being uninfected, irrelevance, and feelings of  uncertainty or hopelessness about the possibility of being gay and staying uninfected. Given these shortcomings, why have we persisted in – indeed, usually insisted upon – such an approach?  Because our psychological politics have demanded that we defend homosexuality by defending not only the lives of those with HIV, but HIV itself.  If we are all gay and all deserve what we already got, might have gotten if we hadn’t been lucky, or will get when our luck runs out, it feels unacceptable – even dangerous – to assert that there might be any differences at all in the experience, hopes, or futures of infected and uninfected men.  If we explicitly assert that it is better – much better – to remain uninfected, are we not implying that there is something “wrong” with being infected?  If a large segment of our community speaks openly about plans to survive the epidemic – and how, and what for –  are we not abandoning those who probably cannot survive and for whom such hopes seem futile?  Dare the uninfected man, who is a fag too, risk pushing his luck by hoping for a future and thus tempt a fate he half feels he deserves?  Can the “fortunate” among us hope for things that are impossible for those whom we cannot bear to acknowledge are unfortunate?  If we insist on the hope and importance of remaining uninfected, are we not implying that the lives of those already infected are hopeless?  In other words, can we really assert that it is better to be thriving without AIDS than with it, and not feel as if we are selling ourselves, our brothers, our community, and homosexuality itself down the river?

Such feelings and the protocol of gay communities that hides these feelings are preventing us from recognizing, clarifying, and addressing obvious, often differing, realities in the lives of infected and uninfected gay men – realities that play central roles in the ongoing toll of new infections. These include the realities that “safer sex” is not a condom every time, but any sex that does not transmit HIV; that HIV infection cannot occur between two uninfected men or two infected men; that all gay men need not, and cannot, bear the burden of living lifetimes as if they or their partners were infected; that there may be possibilities in the lives of uninfected men that do not exist for men already infected; that uninfected men who are hoping to stay uninfected are hoping for futures that most infected men cannot have, and that we must nurture those hopes in order to help men stay uninfected; that if “being healthy” in gay communities has come to mean “HIV-positive but asymptomatic,” being “healthiest” means being completely free of HIV; that we have complex, often troubled feelings about ourselves and each other, and these feelings motivate some men to knowingly transmit HIV, and others to knowingly expose themselves; that we are often guilty about each other, often frightened of each other, and that we hurt each other because of how we feel about ourselves; that we are already deeply divided because we misrepresent and deny our differences rather than confront, clarify, and negotiate them; and, most importantly, that if our need to feel authentic acceptance of our lives as gay men cannot be disentangled from compensatory, false “pride,” including pride about HIV itself, then we will lose even more to the epidemic than we have already – perhaps everything.

Unless the uninfected gay man’s hope to survive, per se, is experienced as betrayal, primary prevention unfettered by the psychological politics of our communities need not betray, abandon, or accuse those with HIV.  Authentic and explicit primary prevention can acknowledge the differences between infected and uninfected men without implying that one is not good enough or is culpable. And authentic primary prevention can respect the desire for unity among gay men without denying the truths of our lives. If the feelings that mislead us on these truths cannot be examined and clarified, we will not be able to make a decision to do primary prevention, or not do it because it is too humanly destructive and painful for those already infected.  Our misrepresentations and lies have accomplished little good, and today, the epidemic in gay communities is already the product of a decision, if an unconscious one, to not do primary prevention.  This is much too important a decision to have made unconsciously.

NOTES

(1)  “Is HIV Tearing Us Apart?”, Tim Pfaff, San Francisco Frontiers Newsmagazine, vol. 14, no. 22, pp. 24-25.  The man being quoted is Bill Hershon, who is cited as a law student who also serves as the consumer advocate on the San Francisco Mayor’s HIV Planning Council.

(2)   “You’re right.  A Small Group of Powerful People Can Stop the Spread of AIDS,” the STOP AIDS Project, no publication date.  The brochure is funded by the California Department of Health Services, Office of AIDS.