The Sixth International Conference
on AIDS
San Francisco, 1990

I am speaking today about the psychological impact of AIDS on uninfected gay and bisexual men, the group that to date we have called the "worried well."  One third of my private practice of psychodiagnostic assessment and individual and group psychotherapies is still involved with the uninfected, but it is my observation in this work that we have seriously misassessed the problem.  If we accept Mayor Agnos' figures that to date more San Franciscans have died of AIDS than died in the four wars of the 20th century - combined and tripled, how could it be that the survivors of this event would be merely worried, or be well?  In my opinion, there is now a psychological epidemic among HIV survivors, and it is and epidemic dwarfed only by the HIV epidemic itself.

My subject concerns some unknown percentage of the population of gay and bisexual men in the US who are HIV-negative, or reasonably believe themselves to be so, and who have no significant pre-HIV epidemic histories of mood, anxiety, or obsessive-compulsive disorders.

The problems of the uninfected have been hard to discuss for many reasons.  Appropriate attention to the problems of HIV-infected people is one; but other less healthy reasons include shame about having apparently escaped the virus and having problems despite that good fortune; and guilt about surviving at all.  While I cannot imagine directing resources away from HIV-infected people to the uninfected at this time, I do think it is time that we clarified the problems of the uninfected.  Most importantly, we must begin to address the continuing seroconversion among gay men.

The psychological epidemic among uninfected gay and bisexual men is, in many ways, familiar in its clinical presentation.  The most prominent features are serious mood and anxiety disorders.  One New York study suggests that fully 39% of HIV-asymptomatic, presumably healthy gay men qualify by structured interview for DSM III mood- or anxiety-related Axis I diagnoses.

Also commonly seen in clinical practice, though little discussed, are the traditional male sexual dysfunctions: disinterest or aversion, impotence and inhibited orgasm.  In this population, however, there is much evidence that these functional problems are based less in interpersonal dynamics, and more in phobic anxiety.  For many gay men conscious and unconscious associations of sex and AIDS has made it difficult or impossible to achieve orgasm while there is physical - especially genital - contact with another man.

Another common problem - among the "miscellaneous" on my [slide] screen outline - is hypochondriasis.  Again there is a special clinical twist, which is that the complexity of epidemiological and biological models - including many new questions about the reliability of the ELISA - make some apparently hypochondriacal concerns more realistic than we are comfortable admitting.

Finally, among the miscellaneous features of the clinical picture is survivor guilt.  Guilt is often an important mediating element in both depression and anxiety. Such unconscious guilt was first described by Niederland in survivors of the Holocaust.  Struggling for and succeeding in having new lives, they then succumbed to depression, anxiety and psychosomatic conditions.  Such symptoms, said Niedlerland, arose from identifications with loved ones who had not survived.  Survivors experienced persistent feelings of guilt for having survived the very calamity to which their loved ones succumbed. 

Such survivor guilt is now a pervasive psychosocial issue in the HIV epidemic, and a complex one.  I will simply introduce the subject here by saying that I find a "developmental predisposition" for such feelings in some men, in the form of much early psychological conflict characterized by guilt and loss.  Survivor guilt is one of the most destructive of the psychological phenomena we are now seeing, but it is also one of the most responsive to psychotherapeutic intervention.

Many of the psychological issues I have just discussed are clinically intelligible responses to the horror of the HIV epidemic.  But in the case of guilt and guilt-mediated depression particularly, they are often exacerbated by a confused identification with AIDS.  Certainly we in the gay community are deeply involved with AIDS because we must be. But gay men now often "come out" as gay by talking about AIDS rather than feelings, relationships, or sexuality.  When we thus speak of AIDS instead of homosexuality, it becomes apparent that the psychological and social meanings of AIDS  as opposed to its realities  have engaged us to an extent not explained by the facts alone.

This "homosexualization" of AIDS - which is to say, the unrealistic psychological entanglement of the gay identity with AIDS - becomes more intelligible when we consider homophobia.  Homophobia - internal to the gay man, as well as societal - has facilitated the shifting of familiar psychological conflicts from homosexuality to AIDS.

Once isolated for our sexuality, we are now threatened with isolation for our virus; considered "sick" for our sexuality and homophobically concurring, we are now sick with AIDS; threatened with punishment and homophobically expecting it, we now, often unconsciously, feel punished with AIDS; shunned by society, many gay men now shun others because they are sick; and, finally, having suffered guilt about sexuality, many of us are now feeling guilt for having AIDS, for not having AIDS, or for not doing enough to help others survive.

One reason many gay men have thus shifted familiar psychological conflicts from homosexuality to AIDS lurks in the fact that 12,000 of us have gathered here to discuss, not gay lives, but AIDS.  We never gathered in these numbers to address the crippling psychological toll exacted by society from men when they were merely homosexual.

We can be here, in part, because AIDS has the respectability of science and medicine; it allows a man to have a disease rather than be and live one; and, finally, it allows us to talk about everything except the emotional, sexual, and interpersonal issues that are for so many too painful and too difficult.  For those gay men accustomed to life on the fringes of a rejecting heterosexual society, the acceptance gained by having AIDS can feel irresistible.  Many are finding it easier to be threatened by AIDS, to die of AIDS, or to be guilty for not dying of it, than it has ever been to be gay .  Despite all its horror, AIDS has given many gay men an identity that is easier than that of being homosexual.

The costs of such acceptance for the infected man is obvious; but for the uninfected, the entanglement of gay identity with issues of AIDS exacts serious costs of a different, less obvious kind.  Survival may be experienced as a betrayal and abandonment of those who are sick; the gay man may feel that in survival he is betraying his personal identity as a gay person; and he may feel that he is no longer part of the community - now, so it often seems, all sick or already gone - which is the only human community in which he has ever been able to be who he truly is.

Such feelings prompted a psychotherapy patient after a negative HIV test, to say to me, "I wonder if it is really O.K. with my positive friends that I'm negative.  I'm thinking particularly of Robert and I wonder if he could ever forgive me.  I feel as if I've abandoned him."

I have saved discussion of safe and unsafe sex to now because it is truly the bottom line for the uninfected man: The practice of safe sex is his statement of commitment to biological, if not psychological, survival.  Yet the facts about the forbidden topic of unsafe sex are alarming.  One third of gay men in this country are now reporting regular unsafe sex, and the CDC reports that 40,000 gay men are seroconverting annually in the US 

In safe sex-educated 1990, ignorance no longer explains the whole problem, and I think we must look elsewhere for insight.  Among other things, we must begin to think about the potential lethality of unsafe sex as not only a deterrent, but, for many, a motivation to practice it. 

The unconscious desire to not survive - because of depression, loss, and guilt about surviving - is surely an important, not uncommon motivation for unsafe sex.  Also important is the unconscious belief that one will not survive - an expression of helplessness and resignation.  Denial, counterphobia, poor self-esteem, and the experience of desirable intimacy in unsafe behaviors, are also all significant contributors to the motivation to practice unsafe sex. These are issues we can address and we must overcome the politics and prohibitions surrounding the subject so that we may do so.

In closing, I will quote a remarkable 23 year old gay man who had, a few weeks before, received a positive HIV test result.  He said:  "I'm sometimes glad to think that in ten years I'll be dead.  By then the only gay people left will be those whose lives were ruined by watching the rest of us die."

This is an exaggeration, surely - but there is also much truth in his words.  I hope that we are able to work against the very possibility.  Thank you.

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