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Being Alive

GAY MEN AND UNSAFE SEX: Some Psychological Considerations


Being Alive 1993 Feb 5: 12

A recent article in Newsweek reported that surveys of young gay men indicate that an alarming number are ignoring safer sex guidelines. One study concludes that some 40% of San Francisco's gay men between the ages of 20 and 24 are HIV+. And experts estimate that some 40,000 gay men can still be expected to seroconvert each year in the US.

Why is this happening? For those of us infected with HIV and continually battling with its effects, high risk behavior seems almost inexplicable. Surely, gay men in the US know better. Word has been out for years now. How could you not know? At last summer's AIDS Conference in Amsterdam, a poster presentation by Berkeley psychologist Walt Odets tried to provide some answers to why some American gay men continue to practice unsafe sex. It is not, Odets argues, because of inadequate education about the transmission of HIV or its prevention. Rather, the root causes are psychological factors, unique to gay men, that contribute to high risk sexual behavior.

Odets based his conclusions on research conducted among presumed seronegative homosexual men in the San Francisco Bay area. Most were part of his own private practice of clinical psychology. From this study group, Odets isolated six contributing psychological factors.

THE DANGERS OF SURVIVOR GUILT Among some men, there seems to be a conscious or unconscious desire not to survive the epidemic. This could be because of depression, anxiety, loneliness or hopelessness about the future. Repeated losses leave some men uncaring about their own future; they are beaten down by the epidemic. And some are victims of an unconscious "survivor guilt." Too often, we see AIDS as a "gay disease." And this "homosexualization" of AIDS causes confusion between being gay and being HIV+. Such confusion, says Odets, may induce in some homosexual men a sense that to survive the HIV epidemic is to abandon their identity and community.

THE FORCE OF FATE Some men appear to believe that no gay man will survive the epidemic, so safer sex guidelines become irrelevant. The overwhelming nature of the epidemic and its decimation of the gay community lead some men to conclude that AIDS is their fate. They feel helpless in the face of so much loss. Odets suggests that unconscious internalized homophobia may induce some men to believe that because they are gay, they will get AIDS as a matter of fate, retribution or punishment.

DENIAL BY YOUNG AND OLD Denial, of course, can also play a part in supporting unsafe sexual behavior. Among younger men, there is the general sense of immortality found in those under thirty. AIDS is something that older gay men need to be concerned with. Stay away from old guys and you're safe. Older men, on the other hand, sometimes think that younger men are safe, because they were not sexually active when the epidemic began. This is a variation on the "stay away from old guys" rule. And then there are those men who do not identify themselves as homosexual, but who have sex with men. Often, these men deny that they are at risk for HIV because they are "not gay" and not a member of a "high risk" group.

THE CONSEQUENCES OF COUNTERPHOBIA Another factor that Odets identifies as contributing to high risk behavior is what he terms "counterphobia." Counterphobia motivates someone to engage in precisely that activity that he most fears. This may explain why some gay men, after years of following safer sex guidelines, revert to unsafe practices. As one patient related about his unsafe sexual episode, "I think it's the first time in years that I haven't felt like I was right on the edge of cracking up." Counterphobic behavior allows one to conquer feelings of helplessness and passivity and provides an opportunity to master one's anxiety.

THE DWINDLING OF SELF-ESTEEM Deficits of self-esteem are also a factor. All gay men, it seems to me, struggle to some degree or another with this issue. And when self-esteem falters, the desire to take care of yourself and others can also lessen. For many gay men who came out in the 70s and early 80s, self-esteem as a homosexual is derived from identity with a strong and vibrant gay community. But this community has been bashed by HIV and left weakened and struggling. Thus, the AIDS epidemic has in itself shaken the sometimes already shaky self-esteem of many gay men.

GAY MALE SEXUAL EXPRESSION Finally, there is the very basic issue of gay male sexual expression. For many homosexual men, the unsafest sexual practice of all is the one that is most satisfying, both physically and emotionally. Anal intercourse is a way of deeply bonding and for many is the expression of closest intimacy. Condoms can get in the way, as we often hear from heterosexual men. As one of Odets's patients told him, "it comes completely between you and your lover. And it says to him, `I don't trust you, and I hope you don't kill me tonight.'" Here again, both internal and external homophobia has tended to trivialize gay male sexual expression. Too many blithely dismiss the importance of anal intercourse as an expression of intimacy. And thus they minimize the problems associated with safer sex techniques.

PSYCHOLOGICALLY INFORMED AIDS EDUCATION Odets's work, it seems to me, is extremely valuable in developing AIDS education for the next generation of gay men. Such education needs to be psychologically informed and tuned into the emotional ravages that twelve years of the AIDS epidemic have worked on the gay community. Safer sex education also needs to value gay sexual behavior as the expression of the need for deep human intimacy that often is.

There is a complex of social, political and internal psychological forces at work today in the American gay community. These factors need to be understood and addressed, if we are to stop the spread of HIV and the further destruction of the gay male community. Until such AIDS education is developed and brought out to the community, the tragedy of seroconversion, it appears, will continue.

INSIGHTS FOR SEROPOSITIVES Odets's work on the psychology of unsafe sex is also relevant to those of us who are already HIV+. We too are suffering from the effects of watching our community be torn apart by this virus. Asymptomatics may suffer "survivor guilt" as they watch too many friends and colleagues succumb to AIDS. Any one of us can come to the conclusion that no one will survive this epidemic, that we are all going to die well before our time. Our self-esteem is precarious as we fight the indignities of disease and discrimination. All of us deal with the question of intimacy and its appropriate sexual expression.

DEALING WITH THE DECIMATION All of Odets's psychological factors are related to what the AIDS epidemic has done to the gay male community. Although we know that AIDS is not a "gay male disease" and that the population profile of those infected by HIV is shifting to other communities, in this country it is the gay community that has taken it on the chin these past twelve years.

I moved from San Francisco to Los Angeles in 1986. Whenever I go back up there, as I did over the recent holidays, I visit a city of ghosts. There is James who for years cut my hair, trying as best he could to make me glamorous, while regaling me with tales of his sexual adventures. He's been dead for years now. There is the guy at the flower shop on Fillmore who always warmly approved of my choices. One day, he wasn't there any longer and I didn't even have to ask why. And, of course, there is Gregory who taught me to stop worrying about being gay and to get out there and enjoy it. His ashes are scattered in the hills above Florence.

Most gay men have similar stories to tell. Many of us live among ghosts. It is impossible to ignore the impact of this decimation on those of us, both seropositive and seronegative, who survive. We need to understand how these years of loss have affected us, both as a community and as individuals. By being aware of the pervasiveness of these psychological issues in the gay community and by clarifying their impact on our own lives, we build up our ability to fight this virus and to prevent HIV from further damaging ourselves and our community. Without such insights, the destruction can only continue. 


Information in this article was accurate in February 5, 1993. The state of the art may have changed since the publication date. This material is designed to support, not replace, the relationship that exists between you and your doctor. Always discuss treatment options with a doctor who specializes in treating HIV.