The Bay Area Reporter - August 24, 2000
Terry Beswick

Anal intercourse, that much-maligned yet inexorably relished act, is not widely considered a topic for polite dinner conversation.

As a practical matter, it involves the insertion of an adult male's penis into the rectum of another adult.

The sexual act has been practiced not only among gay men the world over for all of recorded history, but by a significant proportion of heterosexual men and women as well, who attest to the physical sensations of anal intercourse or who simply use it as an alternative to penile-vaginal intercourse to prevent conception.

In the gay community, many men regard the anatomical structures which make anal sex not only possible, but deeply pleasurable, as one of nature's greatest gifts.

Nowadays, anal intercourse is increasingly regarded by scientists, physicians, and other learned people as a normal sexual act between consenting adults -- either between men, women, or a man and a woman. In our culture, modern intellectual understanding, acceptance, and appreciation of the act, its virtues, and hazards have grown commonplace.

And yet for centuries, the ancient method of coupling has been culturally condemned by religious zealots, with particular vehemence directed at its male practitioners, backed by laws of the state or various politically influential sects. In some parts of the world, men who copulate with other men may be imprisoned or even put to death, and in our own society, the act alone can justify expulsion from the military. In some states, "sodomy" is illegal for men, while in others, it is illegal for everyone.

And when practiced without the proper use of a condom, it is also one of the most effective ways to transmit the human immunodeficiency virus (HIV), the virus that can cause AIDS.

It is within this cultural and historic backdrop that health officials and the HIV and gay communities in San Francisco are being forced to revisit the old taboo in light of new scientific evidence of what has been widely known but little-discussed.

After nearly 20 years of living with the HIV epidemic under the mantra, "use a condom every time," more and more HIV-positive as well as HIV-negative guys are choosing to bareback, i.e. fuck without a condom.

Last week, in the wake of controversy over preliminary estimates indicating a significant rise in the number of new HIV infections among gay and bisexual men in San Francisco, the city's Department of Public Health issued a groundbreaking "11-point action plan," designed to turn this dangerous new trend around.

As reported in last week's Bay Area Reporter, DPH's new estimates of annual HIV infections in San Francisco, ranging between 750 and 900, were based on several key "indicator" studies, and almost all pointed to one inescapable fact: in the last few years, gay men have been increasingly engaging in unprotected anal intercourse.

Researchers point to various factors that may be feeding the shift in behavior, but the evidence all points to one underlying historic event: the introduction in the mid-1990s of HIV therapies, including protease inhibitors and other drugs which, when used in combination, can successfully reduce an HIV-infected person's viral load to undetectable levels.

In communities like San Francisco with relatively widespread access to advanced HIV care, the death rate from AIDS has dropped precipitously.

In short, people are not as afraid of AIDS as they used to be, and are increasingly willing to take the risk of HIV infection.

"Just last night, a friend and I had unprotected sex where he was the bottom and I was the top," one 24-year-old HIV-positive man, who asked not to be named, told the B.A.R. last week.

"[The bottom] didn't give a reason" for deciding to bareback, the young man, who said he has been positive since he was 16, continued. "It was a very spontaneous decision; there was no discussion. He's 20 and he's old enough to make those decisions. If he's that afraid then he shouldn't be having sex period. He can't hold me responsible."

His partner had previously told him that he was HIV-negative. The 24-year-old had also previously disclosed his status to his partner.

Interestingly, the HIV-positive man said that his doctor advises him to use condoms not only during anal sex, but during oral sex as well.

"I said, 'Well, I've never done that,'" he added.

The federal Centers for Disease Control and Prevention, which provides about $10 million of San Francisco's $16 million HIV prevention budget, "recommends sexual abstinence or sexual contact only with a partner known to be uninfected as the best methods of protection against the sexual transmission of HIV and other STDs." In addition, CDC recommends that male latex condoms be used consistently and correctly, with or without a spermicide. If for some reason it is not possible to use male latex condoms, CDC recommends using female condoms.

In the absence of hard data, and under pressure from funding sources, public health officials, HIV prevention organizations, and physicians have been reluctant to talk about the relative risks of infection among various sex acts, a fact that has unfortunately left gay and bisexual men to figure things out for themselves.

With their new action plan, DPH officials are acknowledging that gay men in San Francisco are "shutting down" to the old "safe sex" messages, and barebacking is a reality of daily life, requiring a new approach.

"Ownership," is the first point in the plan, which emphasizes the use of condoms for HIV-positive tops during sex with HIV-negative bottoms. "Take ownership of the epidemic, implementing culturally specific, community-driven responses. Prevention is not done to a community, but by and with a community."

A year and a half ago, in its February 1999 issue, POZ magazine published an article by University of California, San Francisco doctoral student Michael Scarce which listed eight different methods that men who had made the decision to bareback could use to reduce their risk of infection or re-infection.

Scarce told the B.A.R. that he took a lot of flak from HIV prevention organizations around the country after the article was published, and compared their concerns to those who suggest needle exchanges encourage drug use -- a contention that has been disproven by numerous studies.

In the context of HIV prevention, harm reduction, a model more commonly employed in the U.S. for drug addiction treatment, is seen as a realistic alternative to abstinence. The harm reduction model assumes thorough education of the known risks of various sex acts, and respects all parties concerned -- whatever their carefully considered choices. In other words, two well-informed, consenting adults -- whether both HIV-negative, both HIV-positive, or of different or unknown serostatus -- come to a mutual agreement of what practices they will engage in, and then stick to it.

With this series, "Barebacking, top to bottom," the B.A.R. next week will outline the methods used by men who bareback to reduce their risk of becoming infected or re-infected with HIV, or infecting or re-infecting their partner -- and what researchers and educators have to say about those methods.

And finally, the series will explore DPH's 11-point action plan and discuss community response to it.
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