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PART 1

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

Our AIDS education probably had utility early in the epidemic.  In 1994, however,  this is not the case because our ideas and approaches have remained largely unchanged since those early years, while historical, social, and psychological issues have converged to make the tasks of AIDS education almost completely new.  As a clinical psychologist, I must leave implementation of new approaches to those in public health.  But 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 nearly certain that it will be a lifelong event for most adult gay men.   Thus we must now provide education about a permanent form of lifeMedically, though we have developed some useful prophylaxes and discovered new and horrible ways to die in the bargain, we have been almost entirely unable to address the fundamental  process of HIV.  The burden thus placed on AIDS education is succinctly stated in a New York Times editorial of June 17, 1993:  "AZT apparently has little or no effect when given to people who are infected with the virus but have not yet developed symptoms . . . There is little choice now but to shift the emphasis to prevention programs." 

Socially - 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.  A shocking objective measure of the social realities with which we now live is revealed in some simple figures that one rarely dares utter.  To date, more San Franciscans (90% of them gay men) have died of AIDS than died in the four wars of the 20th century, combined and quadrupled.  Thirty percent of 20 year olds will be infected or dead of AIDS by age 30 and the majority will become HIV infected at some time during their lifetimes.  The mean life expectancy of a San Francisco gay man between the age of 16 and 24 is somewhere around 45.

In the context of these social realities, the psychological issues are necessarily profound, and our current circumstances are radical enough that, for the gay man, a complete reevaluation of our basic developmental schemes of human life is demanded.  Educators must account for who gay people are now when speaking to them about intimacy and "dangerous" behaviors.  Many gay men are now often rethinking the purposes and meanings of  their lives, and  feelings about everything - sexuality, human relations, and death not least of all - may be open for surprising revisions.

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Early in the epidemic, prevention efforts were assisted by the natural fear of gay men huddled over media reports of "gay cancer" and GRID.   While education 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."  Despite internal incentives, the practical information provided by education, and any incentives that education may have contributed, rates of HIV transmission among gay men began to rise almost as suddenly as they had plummeted only a few years before.  By 1988 studies of gay men in 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 onus of HIV transmission.  University of California at San Francisco epidemiologist Maria Ekstrand gave us such figures in early 1988.

We know from our considerable psychological experience with the anonymous self-reporting of severely stigmatized behaviors, that they are under reported  by as much as 30 to 50 percent regardless of data collection techniques.  Thus the real figures about unprotected anal intercourse are certainly higher than reported, and are likely to be about 45 to 53 percent.  Besides the potential for HIV transmission, there is something else very important about these figures.  In terms of the percentages of men practicing anal sex (though probably not in terms of numbers of occurrences) they are 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 our education may be of  little, or no value at all in motivating change in the behavior that we - and all gay men and their grandmothers - know to be the most dangerous for transmitting HIV.   

Unfortunately, a majority of AIDS educators continued to deny "relapse" through several years of soft and hard evidence.  They sought to defend the "reputation" of the gay community in order to procure funding, they said, and any public discussion of unprotected sex between gay men was criticized as "politically naive."   They also wanted to believe that their own work was on the road to ending the epidemic, and they experienced genuine consternation about what was going on.  After all, the word was out and gay men knew what was dangerous.

It was somewhere in early 1992 that AIDS educators finally "went public" with relapse.  This happened partly because the evidence had become overwhelming and had made itself obvious to any gay man who had been out of the house in the past four years.  But the years of educational "success" had unfavorably shifted an already marginal public opinion about what should be spent on gay men, and much of the funding for their education had been lost.  In California, about ten percent of state prevention money was being spent on the group that still comprised 80 percent of the epidemic.  Thus it was necessary to acknowledge "newly" increasing seroconversion levels among gay men to regain funding lost to claims of almost complete success in this heretofore thought "model" community.

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After nearly half a decade of hoping relapse was merely an illusion - "I can't believe men are doing this," a San Francisco educator said to me - it had become clear that relapse was not going to disappear on its own and that nothing could be done about a phenomenon that was not even being admitted.  Acknowledgment of the problem seemed an important start.  But the response to relapse over the past two years has revealed a disappointing, often dangerous paucity of insight about what men are doing, why they are doing it, and how to address it.  Educators have largely entrenched themselves still more deeply in earlier approaches in the belief that they worked at one time and should work again.  Expressing the frustration and inflexibility of many, an educator from San Francisco's STOP AIDS Project offered his solution to relapse at a 1993 meeting of AIDS educators:  "I guess we're just going to have to scare the shit out of gay men again." 

Our model for prevention since the early days of the epidemic has remained virtually unchanged and should be briefly outlined.  It is a public health, social marketing model that espouses information and education as the foundation of behavior change, and the establishment of "social norms" or "community standards of behavior" to motivate implementation of the new behaviors.  Psychologically described, this has been an effort to provide people with sensible information and, for those not persuaded by good sense alone, to coerce behavior change with the power of social compliance.   While the social marketing model, in itself, may have utility, its expression in AIDS education has largely been simplistic and - according to some experts in social marketing  itself - incompetent.   At  best it is not a model traditionally brimming with psychological insight regarding sexuality, the most complex and subtle of human behaviors.  Nor has it been used to address the complexity of feelings, conscious and unconscious, that must inevitably occur during life in an epidemic.  In  more easily addressed human matters we can cite a roster of relative public health failures: unwanted pregnancies, heterosexually transmitted S.T.D.'s, and cigarette smoking to name a few.  If we add to this mediocre record the facts of life in a monstrous plague,  the need that AIDS education address a persecuted social minority whose core identity is intimately tied to the "target" behavior - sex in a sexually vectored epidemic - and that educators have taken publicly a "100%-safe-100%-of the time" approach, it is little wonder our efforts are lacking. 

My suggestions for new approaches to AIDS education fall into five rough subject areas.  These are, that we remove homophobia from our efforts; that we stop misrepresentations - withholding information and lying - to gay men; that we stop moralizing to gay men; that we begin to acknowledge the social realities of the epidemic; and that we begin to pay real attention to the specific psychological issues that arise in these most extraordinary circumstances.

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.  The condom provides an important example.  As an emergency measure in 1983 it made excellent sense, and it was reasonable to expect that men would adopt its use until we had better solutions to AIDS prevention.  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 adopt to condoms, ignore or fail to recognize their limitations, and, according to many educators, have fun with them is rooted in homophobia.  Also homophobic is the expectation that gay men ought to feel shame and guilt for not liking them and, often, not using them.   Homophobia lies in the 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.

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Thus educators told us - and continue a decade later to tell us - that if gay men 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.  The male heterosexual population would also not have accepted it, though gay men are publicly, if not privately, willing to espouse the idea of the condom as a reasonable lifetime solution.  In part this is because the condom, like "safe sex" in all its expressions, has provided gay men a means for having "good" sex. This is approved sex, sex that even (some) of the Federal government is willing to tolerate if not really endorse.  Ironically, this epidemic of a dreaded, sexually transmitted virus has provided a way to sanitize the whole idea of homosexuality by giving gay men a way of having "responsible," socially endorsed sex.  The condom, in particular, has become a way of making reparation for fundamentally bad sex, which in the minds of most means anal sex.

In a broader sense homophobia has generated the expectation that gay men  be better, more compliant, more motivated, and more competent  in this epidemic than any other population would have been expected to be.  This expectation is apparent in the idea, promoted in so many subtle forms, that the gay community is "doing well in the epidemic."  Why should gay men do "well" in this situation, and what could that mean?  Why would gay men not feel distress, anger, and hopelessness about what has happened to friends, lives, and the expression of sexual feelings?   These unreasonable expectations rest on the assumption that gay men are thought - and often feel themselves - to have something to make amends for.  The AIDS epidemic has been broadly exploited by homophobes both inside and outside the gay community as an opportunity for gay men to finally do good and be good .  The epidemic is not an opportunity to nurture homophobia and our education must not support that effort.

The issue of  misrepresentation - withholding information and lying - has already been touched upon in my discussion of homophobia.  It is misrepresentation of one kind or another that is used to promote homophobic feelings as education.   There are other important examples of misrepresentation that are perhaps less exclusively tied to homophobia and they too are destructive in many ways.  The misrepresentations of AIDS education, like most misrepresentations, can be sustained for only so long.  When they are finally discovered the useful components of the message will also be discarded with the untruths, and that now seems a reality among gay men considering the advice of AIDS educators.  

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Furthermore, the misrepresentations of AIDS education have often taken the form of  "erring on the safe side," an approach that may finally make the entire message seem an impossibility.  Again, the consequence will be a rejection of the whole message, not simply  because the message is distrusted, but because it is too discouraging.  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 - and the consequence 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 or anxiety in men receiving positive test results.

Among our most important and pervasive lies in 1994 is the representation that "most" gay men are having exclusively protected sex and regularly find it comfortable, satisfying, and unproblematic.  This is not true unless one is speaking strictly of a mathematical majority, and even that is in question.  Many gay men experience protected sex as restrictive, inadequate, or unacceptable, and in denying that we do not establish community norms of behavior, we force the issue into the closet.  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.  Gay men must be allowed to know that their conflicted feelings about protected and unprotected sex  are shared by many and that the transgression of "community standards" neither excommunicates them from the gay community nor makes their lives irretrievable.  Safe sex is anything but - as New York's Gay Men's Health Crisis has glibly told us - "just common sense."  

The other lies in our education largely serve to support the fundamental contention of new, "safe" community standards of behavior.  We have told gay men that condoms are fun, condoms are for lovers, and that mutual masturbation or frottage are universally satisfying substitutes for oral or anal sex.  We have also told gay men that if they do what we say they can "Be Here for the Cure," or that they can "Play it safe" by "making a plan" and "seeing it through" (both campaigns of the San Francisco AIDS Foundation).  In truth, very few are likely to be here for an AIDS cure and, for most men, life - and sexual life - in the epidemic are considerably more complicated than making a plan and seeing it through.  The slogans are more appropriate proposals for losing ten pounds and are an offense to the man dealing with the kinds of complex feelings that arise in the radical form of life the gay community is now conducting.

The list of lies is endless, and many, if not most gay men know what they are.  That such lies are the product of wistful optimism, of educator's own anxiety about the truth and fear for the futures of gay men, or are "just slogans to build community spirit" (as an educator at the San Francisco AIDS Foundation told me), gives them no useful place in public education.  It is my experience that the private anxiety of the educator about his life and his sexuality - and his difficulty in acknowledging these personal feelings - is a very good measure of how much lying he is willing to do to the rest of the gay community.  New approaches to AIDS education must, at a minimum, be held to the standards of commercial advertising in evaluating the truth of what is stated or implied.  Scrutinized in terms of Federal Trade Commission statutes - if not actual enforcement practices - for commercial advertising, much of our current AIDS education would be found deficient because of its misrepresentation of facts and the inability to demonstrate suitability of its "product."

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Moralizing in AIDS education is intimately tied to lying just as lying is to homophobia.   When the San Francisco AIDS Foundation wants to assert the success of new community standards of behavior, it tells us that the "Moral Majority is made up of . . .  men who express their sexuality in a healthy way."  Fortunately, such explicit, confused, and manipulative use of moral coercion is relatively rare in AIDS education, but from the beginning we have, at least by implication, promoted safe sex as a moral responsibility for the gay man, and treated any "unsafe" sex as a moral transgression against the gay community.  Like the lie about community standards of behavior, the most profound effect of this moralizing has been to keep unprotected sex and feelings about it unconscious.  Moral authority makes ambivalence or confusion about the issues or the occasional practice of unprotected sex a forbidden topic, and prevents men from consciously thinking about their sexual feelings, desires, and behaviors.  We cannot deal with a problem that "moral decency" forbids speaking about.

New approaches to education must encourage men to talk about "forbidden" subjects.  In pursuit of making thoughts and feelings accessible, we must speak about "protected" and "unprotected" sex.  Terms like "unsafe sex," and "risky behavior" are value judgments that imply that certain acts are "bad" and dangerous in themselves, despite our knowledge that they may be dangerous in the presence of HIV.  When we say that a man "is safe" we mean that he is "good," that he is a member of the San Francisco AIDS Foundation's new Moral Majority.  This is a distortion and confusion that can only be destructive.  Virtually all gay men are told as developing adolescents that homosexuality itself is dangerous, and as emerging, sexual adults must learn this is not true.  Having learned that truth, too many then throw out the body with the bath water, forgetting that some homosexual sex, like some of everything in life, is probably "dangerous" in some sense - medically, humanly, or otherwise.

When "relapse" first began to be acknowledged, it was called recidivism , a term borrowed from the field of criminology.  "Relapse" is hardly better in this regard, for it too implies failure, disappointment, and disapproval.  The idea of relapse also seems to imply to many educators that previously successful education needs to be reinstituted.  But it is not clear that old efforts were effective in the sense of motivating men to practice protected sex, and, even if they were, it is almost certain that approaches appropriate to 1984 are inappropriate in the radically altered social and psychological climate of 1994.

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The "Moral Majority" campaign of the San Francisco AIDS Foundation bears closer examination.  The campaign tells the gay community to be "proud" of its efforts in fighting AIDS and to "take back the phrases" used to hurt it.  In addition to the "the moral majority," the gay community is to recoup and presumably  revitalize for its own purposes the phrases "family values," and "the right to life."  But, except that such language is now being proposed to promote different ends and injure different enemies - mostly ""noncompliant" gay men - how is this use of ad hominem moralism any different from that of the Religious Right?  Is it acceptable for this largely gay-staffed agency to invoke such language to ostracize, shame, and attempt to coerce the 45 to 55 percent of gay men who sometimes engage in unprotected sex or simply have complex feelings about the subject?  The effort is destructive and divisive - both of men within themselves and of the gay community as a cohesive social force - and it seems an act of desperation by educators who are troubled by what they see and understand very little about it.  Like all moralistic assaults, it will ultimately exclude and help solidify the maverick identity of those it hopes to convert while including only those who allow themselves to be told what they feel, desire, and experience.  Most gay men have already been subjected to such efforts and know their power to confuse feelings, distort and fragment lives, and produce impulsive and destructive behaviors .

My fourth subject area, acknowledging the social realities of the epidemic, provides a glimpse of education relatively free of  homophobia, misrepresentation, and moralization.    This acknowledgment must be centered on education that tells the truth about what we actually know about HIV transmission, which is not now the case .  The chasm between what we know and what we tell gay men is immense and bewildering.  While we have virtually no significant research from the last decade to support HIV transmission by anything but receptive anal sex, we continue to force upon gay men unrealistic and exaggerated doubt and anxiety about oral and other forms of sex.  

The California AIDS Office released guidelines on oral sex for the first time in February 1994.  What is remarkable - and typical - of these guidelines is how little research of existing literature went into their formulation, and how marginally the guidelines reflect the research  that did actually take place.   Important pieces of work like the New York State Department of Health AIDS Institute study (Risk of Sexually Transmitted HIV Infection , December 1992) and Jay Levy's recent piece (The Transmission of HIV and Factors Influencing Progression to AIDS, The American Journal of Medicine, July 1993) were apparently unknown to the office when I inquired about research background for the guidelines.  The New York study suggests in its analysis of one study (of gay men in the San Francisco City Clinic Cohort) that among 6,704 men followed for five years there were two seroconversions that might be attributed to oral sex with ejaculation in the mouth.  This represents approximately three-one-hundreths of one percent risk of HIV transmission over five years, or about one-third the risk of dying in an automobile accident over the same period of time.  Levy, having conducted a long, detailed discussion of the dangers of anal sex, and speaking of all forms of sex other than anal-receptive intercourse, reports simply that they "carry a low but still potential risk of HIV transmission."  Even ignoring such literature, an internal memo summarizing the research circulated within the AIDS office (and supplied to me in response to my inquiry) stated

    To date, researchers have been unable to conclusively categorize the degree of risk from receptive or insertive fellatio . . . Increasing awareness of HIV risks have led some high risk populations to reduce the frequency of unprotected insertive or receptive anal intercourse and has led to an increase in sexual activities considered to be of lesser risk (i.e. oral sex) . . . Until researchers provide a better understanding of the variables and probabilities of oral transmission, we must rely on common sense.

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With this background, the guidelines released to the public recommend that men "take a moment before and after oral sex [with a condom ] to wash the penis . . . with mild soap and towel dry;"  "cover your partner's penis . . . or anus with a protective barrier before any mouth contact;"  "use only water-based lubricants;" and "avoid rough or vigorous oral sex and check for breaks or cuts in the skin periodically [presumably in the mouth, since there is a condom on the penis]."  Additionally, there are four other recommendations and an appended discussion of the relative merits of  plastic "wrap" (as opposed to plastic "bags") as barriers to HIV.  These guidelines - as well as those published inaccurately (and implying even more danger) in the San Francisco Chronicle - essentially banish to history oral sex as we have known it.  It is little wonder that in the following weeks a half dozen psychotherapy patients mentioned the regulations as impossible to adhere to and discouraging generally, and cited them as support for their feelings that the question was not if, but when they would contract HIV.  One man said to me, 

    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 [sexually] - 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.

This seems an intelligible and obvious response, but it is, assuredly, not what the AIDS office had in mind.  "There does seem to be a risk . . . We don't know how small it is .  We want to err on the side of being too safe," Debbie Cohen of the AIDS Office told me on the telephone.  "I would hate to think that our guidelines simply generated discouragement that might cause even more risk, or that they implied that we don't value the importance of oral sex for gay men."   Her concerns were unquestionably sincere, but the public education that actually took place demonstrates an approach to AIDS "prevention" that has become destructive - biologically and humanly - and must be replaced with new thinking.

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