AIDS Education: An American Decision

AIDS education in 1994 is conceptually almost unchanged from that of 1985.  In contrast, the gay and bisexual communities have lived more than a decade with AIDS and are socially and psychologically profoundly changed by the facts – as well as the forecasts – of the epidemic.  In the early years of the epidemic, the information provided by education was critical for a population almost completely ignorant of basic knowledge about HIV and AIDS.  While dissemination of that information was essential, it is not clear that education provided much, if any, of the impetus for actual behavioral change.  It seems likely that change was more a product of the natural fear of “at-risk” populations.  Since 1988, a consistent one-third of gay men have reported the practice of unprotected anal sex.  Corrected for typical under-reporting of such heavily stigmatized behaviors, these figures suggest that nearly as many men as reported the practice of anal sex before the epidemic (about 55 percent) are now conducting anal sex without protection against HIV (although probably with less frequency).  Thus our current education may be of little or no value in fostering useful behavioral change among well-informed populations regarding the practice known to be critical for HIV transmission.

AIDS education has been very seriously crippled by societal indifference, funding limitations, indiscriminate sexophobia, moralism, and homophobia.  In addition to these destructive “external” influences, a retrospective examination suggests that much of the public health-social marketing based education seen to date has not been adequate to address the needs of a psychosocial event as complex and sustained as the AIDS epidemic.   Information and the fostering of new social norms may provide a basis for behavioral change for motivated populations in the short term .  They have not, however, proven adequate in a lifelong event, especially for persecuted minority communities whose core identities are formed around precisely the complex behaviors in question – sexuality.  Although sexuality has always been the most difficult of health-related behaviors to change, the efficacy of AIDS education for the gay and bisexual communities has been further diminished because much of it has repeated the homophobia, moralism, misrepresentation, ignorance of realities, and lack of psychological insight traditionally directed at gay and bisexual men in the normal course of psychosocial development.  AIDS educators, too, experience conflict and ambivalence about homosexuality that is the internalization of larger societal values, and this is quite naturally reflected in their work.

Homophobia and Moralism

Homophobia and moralism are clearly explicit in the idea that “The Moral Majority of gay men express their sexuality in a healthy way” (a 1993 campaign of the San Francisco AIDS Foundation), and less explicitly in the related, widely promoted ideas that good gay and bisexual men have adopted condoms without difficulty, and are perhaps even enjoying them.  While condoms made good sense as a short term measure, in a lifelong event they have proved as problematic for gay and bisexual men as they have always been for all men since their invention in the 1870’s.  The idea that gay and bisexual men would – and ought – to use condoms without difficulty is based on the homophobic idea that gay sex is not “real” sex, that it has little or nothing to do with human issues such as intimacy, and that it is dispensable.  Such assumptions of dispensability about gay sex stop just short of the more explicitly moral idea that gay sex should simply not be going on anyway.  We would never expect heterosexuals to “simply” abstain from vaginal intercourse if they did not like condoms, though we have routinely had this expectation of gay and bisexual men regarding anal intercourse.

“Safe” sex, including condom use, has become a way for gay and bisexual men to have “good” sex and to behave in “approved” ways.  The human complexity of protected sex must be acknowledged, validated, and clarified in allcommunities, rather than denied in hopes that the denial will foster complex behavioral change.  Twelve years into the epidemic gay and bisexual men are not “relapsing,” but returning to ordinary human sex – albeit it, often with secrecy and shame.  When that is acknowledged, judgement-laden language like recidivism, relapse, safe, unsafe, risky, and responsible sex will be replaced with simple descriptive terms such as protected and unprotected.  Descriptive language conveys respect for the human importance of gay sex and provides an opportunity to examine the conflict so many gay and bisexual men actually feel.

Misrepresentation

Our AIDS education has become profoundly entrenched in numerous specific misrepresentations, including the ideas that gay and bisexual men are having fun with safe sex; that most are doing it; and that we can deal with the profound human complexities of the epidemic by “Playing it safe, making a plan, and sticking to it” or “Being Here for the Cure” (1994 and 1989 campaigns, respectively, of the San Francisco AIDS Foundation).  More broadly speaking, our most destructive misrepresentation has  been “erring on the safe side,” particularly with regard to oral sex.  This most universal form of sex among gay and bisexual men has been rendered essentially meaningless by recommendations of “safe” procedures that are nearly impossible and very rarely observed .  In actuality, we have virtually no research to support the idea that oral sex – conducted in any manner whatsoever – is a significant source of HIV transmission.  For example, in the San Francisco City Clinic cohort of 6,704 men, there were two recorded cases of possible HIV transmission over a five year period through oral sex with ejaculation in the mouth (an approximately .0003 risk over five years, or one-third the risk of death by driving an automobile on American roads for five years).

While there is no doubt that oral sex may – and probably does – very occasionally transmit HIV, the idea that nolevel of risk is acceptable is true only if the behavior in question has no value or importance whatsoever.  Were we to support gay and bisexual men in the practice of ordinary oral sex – with or without ejaculation in the mouth – it is likely that we would see an overall reduction in HIV transmission.  This probability rests on the probabilities that we would see a reduction in the incidence of anal sex; an even greater reduction in the incidence of semen exchange through anal sex; and would help place the task of protected-sex-for-a-lifetime back in the realm of possibility.  Current guidelines that classify unprotected receptive anal sex as “risky,” and unprotected oral sex as “possibly risky,” entirely distort the relative levels of risk for HIV transmission for these two activities; and they provide little or no incentive to practice a possibly alternative behavior that we know to be infinitely less likely to transmit HIV.  Too many men, now convinced that they are not and cannot sustain “safe sex guidelines” over a lifetime are simply resigning themselves to contracting HIV, and are abandoning any sustained effort to avoid it.  The man who practices unprotected  oral sex now very often feels that he has stepped over a line from which there is no return, and he might as well advance further into “self-destructive” – but important and rewarding – behaviors.  Men must be provided complete information that allows them to make behavioral decisions that reflecttheir values, rather than being provided instruction and simplistic guidelines that provide no realistic basis for lifelong decisions.  Current guidelines regarding anal and oral sex are distortions of the truth as we know it.  They are responsible for a poorly informed population and poor judgments, and are producing unnecessary HIV transmission.

Ignorance of  Realities

In glibly instructing gay and bisexual men to “use a condom every time,” we ignore the fact that, by in large, men are not doing this, and will not over a lifetime.  This is because the task is impossible stated that way; because ordinary, unprotected sex provides many rewards not provided by protected sex; and because most gay men know what education persistently denies: It is sometimes completely “safe” to have anal sex without condoms, which is when neither partner really has HIV.  That this determination is difficult for many men is partly the result of our refusal to provide them with the complete information – to the best of our knowledge – necessary to make such decisions.  That many men now make these decisions unsuccessfully – and contract HIV as a consequence – is not a predictor of how they would make the same decisions were they educated rather than instructed with global prescriptions.  Just as we routinely acknowledge the desirability of unprotected sex within “known” sero-concordant heterosexual relationships, we must support it within gay relationships and the heterosexual relationships of bisexual men.  Protected sex is often not necessary or appropriate within sero-concordant relationships – homosexual or heterosexual.  Withholding information for fear that men will “abuse” it is comparable to withholding syringe sterilization techniques from intravenous drug users for fear that the information will encourage them to continue or initiate drug use.

Another important reality of the epidemic ignored by our education is the surprisingly controversial fact that AIDS education is for HIV-negative individuals.  Though HIV-positive individuals may be part of the solution, they are not the target population for AIDS education.  Within the gay and bisexual communities, positive and negative men often have different medical, social, sexual, and psychological realities.  These differences become blurred and confused in the pursuit of “political correctness,” which is rooted in the psychological discomfort of educators about implying  that some gay men have “advantages” denied to others.  If education is to be effective with HIV-negative men, it must honestly acknowledge the advantages of not having HIV.  If this acknowledgment is experienced by HIV-positive men as a political affront or personal injury – and it most often is not – those problems must be dealt with separately, and without compromising education for HIV-negative men.  Discomfort and ambivalence about these issues has confused and weakened education, often rendering its purposes and meanings unintelligible to many men.  Why, as one of many examples, is  SPEAKING UP, “The Newsletter of the Men’s Prevention Program” (of the Cascade AIDS Project of Portland, Oregon) called “A monthly newsletter by, for, and about HIV-positive people and others affected by HIV.”  Why is this the newsletter of the prevention project; and why are HIV-negative men discretely referred as “others affected by HIV”?

Finally, regarding realities of the epidemic, is a general failure of education to honestly acknowledge the profound, often transforming experience that life in the epidemic has had on many gay and bisexual men.  That many men experience feelings and values –  and thus make decisions – we would not expect in “peace time” is a surprise only to those who deny the personal and social realities of the epidemic.  Education continues to deny these human realities by making simple prescriptions that promise to “normalize” life.  The implication that gay and bisexual men can return to normal lives if they only follow education’s simple guidelines on “safer” sex is not true.  Unless we are willing to attempt prohibition of important sexual behaviors – and thus pay immense psychological and human costs – no one can now expect the assurances and certainty about life that seemed possible for many in twentieth century America before the epidemic.

Other American communities – particularly poor people of color – have never lived with assurances or certainty about life.  We are failing to acknowledge that many gay and bisexual men are the product of both the epidemic and longer-standing sources of doubt; and that even those gay and bisexual men born into American middle class expectations are now experiencing what more broadly disadvantaged populations have always experienced.  Just as it has with other disadvantaged populations, American society as a whole is now waiting for the gay and bisexual communities to bury themselves, and it is doing this as it has always done it – by denying other’s realities.  Our education’s denial of real life in the epidemic colludes with societal.  Denial of life’s realities is not “optimistically” supportive, but profoundly disempowering for gay and bisexual men, just as it is for any community living with such life-distorting problems.  By creating distrust of authentic feelings, denial heightens dependency on (often unfounded) educational prescriptions and encourages lives that are subjectively unconvincing, rather than an expression of authentic individual and social values.  Lives ultimately experienced as inauthentic will be experienced as less worth saving, and less worth protecting from HIV infection.

Psychological Insight

AIDS education has failed to incorporate numerous psychological insights pertinent to addressing communities affected by AIDS.  These include the complex interaction of rational (cortical) and irrational (unconscious or subcortical) human thoughts, feelings, and beliefs; the complex, frequently non causal relationship of substance abuse to HIV transmission; the consequences of using character-based models to attempt behavior change or explain the inability to change it; and the use of “moral persuasion” in communities whose very identity is considered a moral transgression by the larger society.

A central psychological issue – and one perhaps unique in crossing generational lines within many gay and bisexual communities – is that of identification .  There are historical and social reasons that so many gay (and some bisexual) men identify strongly with AIDS.  But when that identification is so powerful that contracting HIV seems an inevitability, we are dealing with special psychological problems that our education has ignored and often exacerbated.  Young gay and bisexual men, as well as those “coming out” later in life, have never known a personal identity or community without AIDS as a central feature; and many older men have lost so many friends to AIDS that it often feels impossible they could be excluded.  All these groups are subject to the feeling that contracting HIV is inevitable because gay men get AIDS, which is often a euphemism for the more explicitly homophobic idea that AIDS is what gay and bisexual men deserve to get.

Unfortunately, much of our AIDS education has actively reinforced these confused and destructive identifications by blurring the differences between HIV positive and negative men.  A 1994 campaign of the San Francisco AIDS Foundation tells men:  “Single Gay Man outliving 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].”  The implications of this campaign include the ideas that, positive or negative , the “single gay man” is one is the same, and that he is pushing ahead for the same things, finding the same meanings in “safe” sex, and anticipating the same “more” in his future, regardless of antibody status.   The reinforcement of such specious identification exacerbates the common feelings among HIV-negative men that contracting HIV is not only inevitable, but that the avoidance of HIV may be an effort – if a vain one – that betrays ones true identity and community.  Our education must be carefully examined to excise such implications, for they are now pervasive and destructive.

Conclusions

AIDS educators are as much heir to the moralistic, sexophobic, homophobic, and psychologically naive traditions of American culture as any other acculturated individuals.  If our AIDS education has been lacking for “internal” reasons, that is because it accurately reflects larger societal values.  But AIDS educators – most gay or bisexual men who would like nothing more than to see the end of this epidemic – hold a special trust for the gay and bisexual communities.  This trust must include every effort possible to address people at risk for AIDS with honesty, respect, acknowledgment, and empowering education.  This is true for human reasons, as well as for the effort to reduce HIV transmission.  Certainly AIDS education must not do psychological harm, and it has failed in this responsibility.  Education must, in a complex, lifelong event, support individual understanding and decision making rather than suppress them with directives.  The gay or bisexual man who is not allowed to think about the compelling personal value of unprotected sex cannot think authentically about why that sex may not be worth contracting HIV for.  Gay and bisexual men must be supported in discovering and rediscovering lives that are worth protecting, even in the unbearable grip of an epidemic.

With the AIDS epidemic still – unabated – at the door, American society must make a decision.  As a nation we have almost never been willing to pay for the subjective well being of our citizens, even when they were notmembers of despised minorities; but we have very occasionally exercised financial foresight, and paid to reduce future public costs.  For minority communities  now living with AIDS – a nightmarish form of life in which intimacy might become assault and love become death – only authentic empowerment and a clarification of the meanings of life can provide solutions for either subjective experience or public cost.  Human concerns entirely aside, America now faces a decision about AIDS education for gay and bisexual men – and others – that it has also faced on behalf of other disadvantaged communities:  Is the opportunity to deny empowering and humane education for feared and despised communities worth 600 billion dollars in medical costs for the 6 million gay and bisexual male citizens who will become infected with HIV if our education is not made relevant, humane, and honest?