Seattle King County
Department of Public Health
 Reinventing HIV Prevention
for Gay Men
Seattle, October, 1994

By Walt Odets

More than a decade ago, the gay and bisexual communities embarked on a sad and bewildering journey that would at every turn prove itself worse than our worst imaginations.  The solutions that might end this journey - the behavioral ones - seemed simple and within reach, and they are now a litany know to virtually everyone.  And it is true - simple changes in behavior might prevent HIV from ever again newly infecting a human body.  But we are here talking today because we seem destined to continue this journey - to further and to deepen it - and to be joined by many, many others, despite what we know .  What sense does this make? Certainly not common sense, or rational sense.  But it makes human sense, because human life is not only about what we know but about what we feel .  So it is simply feelings that I will talk about.  Without this understanding - of the profound and immutable importance of human feelings - how could we comprehend an epidemic that is a consequence of the undeniable and fundamental importance of lying together naked so that we can rub and suck and squeeze and lick each other?  So that we can enter another body or be entered?  So that we can exchange so-called "body fluids" as important gifts that express our most meaningful feelings for each other?  And all this, despite what we know.

What we feel as human beings is complex and often conflicted, and feelings have been made no simpler by the last 14 years of illness, death, loss, uncertainty, and fear.  In fact, within the shadow of the AIDS epidemic itself, we have allowed another epidemic to grow - a psychological epidemic - that is all by itself now a monstrous threat to gay communities.  This psychological epidemic is an epidemic of feelings - both conscious and unconscious - that threatens our capacities to live even marginally happy lives, and that, in many cases, threatens our will and capacity to survive HIV at all.

Although the HIV-positive people of our communities have had more than their share of psychological conflict and suffering, in discussing this psychological epidemic I am focusing on those of us who have remained HIV-negative so far.  Those without HIV - which, in fact, includes not only gay and bisexual men, but lesbians, and other survivors of AIDS - are survivors of the AIDS epidemic in some unique senses.  Those without HIV are also the purpose of our prevention work, if not always the entire method of that work.  But fortunate in escaping HIV, what are the HIV-negative among us so troubled about?  Why is their HIV-negative status so often subjectively experienced as tenuous?  And why are so many, as the organizers of this meeting ask, fucking without condoms and seroconverting?

Some simple epidemiology helps answer these questions: To date, more San Franciscans have died of AIDS - 90% of them gay men - than all the San Franciscans dead from the four wars of the 20th century, combined and quadrupled.  Nationally, 30 percent of 20 year-old gay men will be infected with HIV or dead of AIDS by age 30.   A majority of gay 20 year-olds will contract HIV during their lifetimes.  In San Francisco, our current rates of seroconversion will much more than maintain a 50% prevalence of HIV infection indefinitely .  So let me ask the question again: Why are the HIV-negative  among us having so much trouble?

We in the gay communities (and to a lesser, but important, extent in the lesbian communities) are the survivors of this horrible event and are reacting predictably and appropriately.  But many of us will not survive in any meaningful human sense - and many of us in a biological sense - unless we begin to acknowledge and address our problems.  Today, in virtually all large gay communities, we have a barely acknowledged and completely uncontrolled psychological epidemic characterized by mood disorders, including major, acute, and chronic expressions of depression and mania; anxiety disorders, including generalized expressions, agoraphobia, panic disorder, profound hypochondriasis, and post-traumatic stress-like syndromes; adjustment disorders; and extraordinary levels of sexual dysfunction, and social and occupational dysfunction .  In addition to these discrete psychiatric problems, we have two pervasive and powerful underlying psychosocial issues: The first is the gay community's unrealistic and destructive identifications with AIDS; and the second, survivor guilt.

American society as a whole has homosexualized AIDS, and gay and bisexual men  (and lesbians) - in our customary internalization of other's homophobia, sexophobia, and heterosexist prejudice - have AIDSified homosexuality.  The most extreme and explicit version of this process is seen in the accusation - and many gay men's unconscious internal conviction - that AIDS is retribution for homosexuality.  But most of our identification with AIDS is much more subtle than that.  It involves, as examples, an unconscious process of transferring the feelings about "sickness" from homosexuality to the literal sickness of AIDS; of transferring feelings about an unacknowledged, unvalidated, and hated form of life as a homosexual to a similarly reviled form of life as a participant in a semi-private plague; of  transferring feelings of inferiority about ones' homosexuality to feelings about having AIDS or being part of a community that is characterized by AIDS; and finally, of transferring feelings of guilt about being homosexual to feelings of guilt about having AIDS, not having AIDS, or not doing enough for those who do have it.  The transformation of traditional feelings about being homosexual into feelings about having AIDS - individually or as a community - is the product of compelling, but destructive, confusions.  The confusions come partly from the positive aspects of individual identification with a community that has provided an acceptable and meaningful sense of self, but a community that is now appropriately - if disproportionately - preoccupied with the AIDS epidemic.  This identification makes many gay and bisexual men - and not a few lesbians - feel that they have betrayed their true, gay or lesbian identity and their community by not having HIV.

These transformations of feelings about sickness, form of life, inferiority, isolation, and guilt are also based on the accurate perception that in many ways having AIDS is much more acceptable than being homosexual.  As a society we much more readily assist people with illness than with their lives, and we find disease much easier to talk about than human emotions, affections, and sexuality.  Many men thus find acceptance in having AIDS, acceptance that, with all the real horrors of AIDS, they have not found in gay or bisexual lives free of AIDS.  As one example, we would not be here tonight to consider the tortured lives of gay and bisexual men if they were tortured merely by homophobia, hatred, prohibition, and the malignant neglect of homosexual youth.

Survivor guilt - a term we now hear often but understand relatively little about - has become a major component of the psychological epidemic among HIV-negatives.  It is deeply rooted in the kinds of identifications I have just discussed, but also has distinct features that should be clarified.  According to Berkeley psychiatrist, Michael Friedman, survivors of the Nazi Holocaust

     . . . after struggling to begin a new life and often succeeding . . . succumbed to a variety of symptoms like depression, anxiety and psychosomatic conditions.  [These symptoms appeared] to be identifications with loved ones who had not survived.  Patients often appeared and felt as if they were living dead.  [The original researcher on this phenomenon] believed that these identifications were motivated by guilt, which he called survivor guilt.  The survivors experienced an "ever present feeling of guilt . . . for having survived the very calamity to which their loved ones succumbed."¹

I have told Matt's story, because he is among the many thousands of men who have serconverted because of what they felt rather than what they knew - in Matt's case, the serconversion occurring about a year after the negative test.  Matt was experiencing the combined sense of loss, depression, anxiety, confused identifications, and guilt now experienced by tens of thousands of gay and bisexual men and many lesbians in our diverse communities.  The man who has lost too many to AIDS and only anticipates losing more; the man who is too depressed to be able to imagine a future worth living for; the man who is too anxious to negotiate through the day; the man who is afraid to become friend or lover to another who might seroconvert or die; the man who is too convinced that regardless of what he does the outcome will be contracting HIV through fate, identification, or misunderstood biology; the man who is too homophobically self-hateful to feel worth taking care of; and the man who experiences being HIV-negative as a betrayal of lover, friend, or community - none of these men is likely to survive humanly, and many will not survive biologically .  The AIDS epidemic has now made a too difficult, painful, and empty life for too many - and HIV is too meaningful a way out.

What does this psychological and psychosocial catastrophe mean for the course of the AIDS epidemic and, in particular, for our prevention efforts?  It complicates the task immensely.  But are these complex issues ones that AIDS education can or should take responsibility for?  I say yes , because there is no other useful course.  The simpler educational approaches of the early years of the epidemic provided useful information, but its audience has been transformed by the epidemic itself.  This means that education appropriate to 1984 has little utility or purpose in 1994.  Unfortunately, we have barely recognized this fact, and much of our education has not only become substantially ineffective in reducing HIV transmission, it has matured into an inflexible and powerful force that is now often psychologically destructive, and often, I am certain, responsible for HIV transmission.  Only the epidemic itself - and a society that has exploited the epidemic to nurture and disseminate homophobia - now stand as more potent forces against the health and human welfare of gay, bisexual, and lesbian people.

Our AIDS education, though largely a product of gay and bisexual men themselves, is too often homophobic, dishonest, heterosexistly moralistic, and invalidating of gay and bisexual lives.  These destructive elements have come to permeate much of our education by exactly the means such forces always get into the homosexual communities - through the internalization and reexpression of the feelings and values of the homophobic majority of the larger society.  And just as homophobic, dishonest, moralistic, and invalidating warnings against homosexuality itself have never worked to make homosexuals live as healthy or happy heterosexuals, these elements within our AIDS education will not work to reduce HIV transmission.  If larger society, faced with the horror of AIDS, has exploited the epidemic to nurture homophobia, so have we within our various communities - and our AIDS education stands proof of that destructive fact.

No single issue testifies to these problems as clearly as our assumptions about the condom.  In 1982 the condom made good sense as an emergency measure, and it was reasonable to hope and expect gay men to adopt its use until we had other solutions.  As a permanent, lifelong component of sexuality, however, the condom has proven as problematic for gay men as it has always been for all men.  It interferes with tactile intimacy, prevents the exchange of semen - an important aspect of intimacy for many - and intrudes on lovemaking with a constant reminder that an expression of love, intimacy, or simple fun may turn into a reality of assault, illness, and death.  But we have told men that the "responsible" man uses a condom every time, that "condoms are for lovers," and we've even made condoms in party colors and told men they were fun.  And, indeed, most gay men now feel shame and guilt for having difficulty with condoms and for sometimes needing - not unsafe sex, not the pathological consequence of relapse or recidivism - but for sometimes needing ordinary human sex after more than a decade of waiting for other solutions.  That educators expected the compliance of gay men about unnatural and often unsatisfying forms of sex - and that gay men so easily internalized that expectation - is a product of the homophobic feelings that gay sex is not "real" sex, that it is not humanly important, and, indeed, that it all probably shouldn't be going on anyway.  Thus, the least gay and bisexual men can do is use a condom every time for the rest of their lives.  The directive routinely given to gay men - "if you don't like condoms, don't fuck" - is something we have never said to heterosexuals and never would, at least with any illusion that it was potentially productive, or respectful.  We have never, to my knowledge, suggested that heterosexual vaginal sex might be dispensable, and we have spent billions to make it possible without condoms.

Beyond the specific issues of condoms and anal sex, the entire idea of "safer sex" is a promotion of "good" sex, approved sex, sex that makes it acceptable for men to have sex with men.  And although this "approval" is at best don't-ask-don't-tell-tolerance rather than real validation, gay and bisexual men have easily taken to the idea of good sex, because we too, often feel we have something to make amends for.  By saying we have "safer" sex - a term that should be objectified and separated from moral implications by calling it protected sex - we "sanitize" the idea of sex between men, and homophobically exploit the epidemic as an opportunity to do good and be good in a way that we never thought seemed possible as homosexuals.

What else has our internalized homophobia and heterosexist morality brought to AIDS education?  It has encouraged us to dictate behaviors to gay and bisexual men - something society has always wanted to do - rather than help educate them with the whole truth as we know it and let them make their own decisions about what's worth what.  This is particularly apparent in our "erring on the safe side" about oral sex, which we know is hugely less likely - conducted in any manner - to transmit HIV than receptive anal sex.  The idea that no risk is acceptable is true only if oral sex has no value or importance whatsoever , and this is an assumption much of our education has homophobically been willing to make on behalf of gay men.  But oral sex is important, and as a psychotherapy patient recently said to me, "If you get it from that , then the only question for me is when, not if I'm going to get AIDS.  I'm not going to stop that for the rest of my life, and I might as well do anything I feel like doing in the meantime."   Such resigned, discouraged feelings are common among gay men because we have created a monolithic, lifetime prescription that feels impossible , and thus discourages men from any effort to avoid HIV - including efforts that really are possible, even over a lifetime.  On the subject of oral sex we have entirely failed to take leadership, and have allowed rumor and popular journalism to set educational policy, particularly in the last year in response to the Samuel study - a study that is anomalous in the entire body of research on the subject and that is, in my opinion, methodologically almost entirely indefensible.  If we valued gay sex and acknowledged that it was going to happen regardless of what we said, I suspect we would be promoting oral sex as a relatively harmless form of intimacy – including the intimacy of semen exchange. 

I have written in some detail on other very important things we must do to correct our AIDS education in a guest editorial in the Spring, 1994 issue of AIDS & Public Policy Journal , and copies are available here.  But before ending my talk I want to simply mention some of the important issues for education that I discuss in more detail there.

We must clarify the objectives of our education - it is for those who do not now have HIV - and stop nurturing the social and psychological identification of HIV-negative and positive men.  In a prevention campaign this year, the San Francisco AIDS Foundation tell us: "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. . ."  What does this mean?  That the "single gay man," positive or negative is one in the same?  That, positive or negative, he finds the same meanings in protected sex, is pushing ahead for the same things, the same future, the same "more" in his life?  The encouragement of this kind of confused identification is responsible for the sense of inevitability that so many gay and bisexual men feel about contracting HIV.  It is now significantly a product of much of our education, and it is a central, immensely destructive issue that must be addressed immediately .  Primary and secondary prevention became – potentially - distinct and separate tasks in April, 1985 with the advent of the ELISA.  The undifferentiated, "hybrid" education that we continue to this day - education that addresses "gay men" without regard to antibody status - is not true primary prevention.  We must now actually do primary prevention for gay men who do not have HIV.  And if we do not we should not be surprised that many HIV-negative gay men experience themselves on a life continuum that terminates with death by AIDS.

We must examine both unprotected sex and substance abuse as effects of depression, hopelessness, poor self-esteem, and anxiety about sex - protected or not - rather than continuing in the psychologically naive idea that substance abuse causes unprotected sex.

We must acknowledge - as we routinely do with heterosexual populations - that it is sometimes perfectly "safe" to have ordinary human sex within like-antibody relationships, and thus provide men with incentives rather than merely prohibitions.  The global rule, "a condom every time" means that today we are telling the gay man and his partner to test, and if they are negative to spend the rest of their lives behaving - and feeling - as if they might have HIV.  Clear distinctions between the issues and needs of negative and positive men will be a hallmark of true primary - and true secondary - prevention efforts.

We must tell the truth about what we know about sexual acts and their transmission of HIV, and we must value these sexual acts enough to learn more about them with regard to transmission.

We must divorce the issue of HIV testing from prevention, and return it to medicine and individual consideration where it belongs.

And most importantly, and broadly, we must produce education - not instruction - that is authentically validating of homosexuality and homosexual lives.

My suggestions clearly leave us with educational approaches rooted in relatively complex social and psychological understandings.  But should education be responsible for dealing with these understandings?  Is this not properly the work of others - perhaps psychologists?

My first answer is that AIDS education for the gay, bisexual, and lesbian communities - education for a lifetime - has a responsibility to not do psychological harm, and it has failed in this responsibility .  In its obfuscation of facts and feelings alike, much of our education is now a major source of psychological damage for our communities and, like the epidemic itself, is thus often contributing to the transmission of HIV.

The second reason that education must embrace more complex social and psychological understandings is found in the nature of denial and repression.  The man who is not permitted by the denials and misrepresentations of education to really contemplate why he might not feel like surviving the epidemic cannot authentically think about why he might want to survive; and the man who cannot authentically think about why ordinary human sex is of profound importance, cannot think authentically about why it might not be important enough on a particular occasion to contract HIV for. 

The third reason is that AIDS education must reevaluate its fundamental purposes.  In a event of this destructiveness and duration, education will accomplish little by promoting - or insisting upon - biological survival as a sole and adequate objective.  Lives must be worth living.  Survival must include the idea of meaningful human survival, which includes a capacity for love, intimacy, and the sexual expression of such feelings.  AIDS education must take as its primary task such human purposes.  The effort to reduce HIV transmission can only be secondary, for it can only build on lives experienced as worth the trouble to protect.

Finally, some objections to more complex approaches to education - which is to say, validating, useful, psychologically informed education - are based in the desire to withhold "mental health" services from gay men and women because these services might nurture and support happier, more viable lives - lives that are prohibited because they are homosexual.  The Department of Health and Human Services – as a condition for providing its much needed funding for this years American Association of Physicians for Human Rights prevention summit in Dallas  had to approve every piece of literature distributed there to assure that it would not be construed as "promoting" homosexuality.  Well, I am promoting homosexuality - happily lived, humanly important, sexually expressed - and HIV-free for as many of us as possible.  And I am promoting it for all who know that, for them, it is the truth .  Regardless of what homophobes might wish, we will not be able to spare the United States the public cost of HIV disease - 100 billion dollars for every million dead homosexuals - if homosexual lives remain invalidated, unrespected, and unfulfilled under the hand of a hateful society. 

For those who are more concerned with money and with who people appear to love than with any real capacity for love, and for those would deny services for fear that they will make our lives viable, there is one honest response that we must voice: you can pay for our deaths or you can help us - indeed, just let us - deal with making our lives worth living.

Thank you.

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