Bareback sex: a conflation of risk and masculinity.

Bareback sex: a conflation of risk and masculinity.

Article Type:	Report
Subject:	Masculinity (Analysis) Masculinity (Social aspects) Anal intercourse (Health aspects) Gay men (Sexual behavior) Gay men (Health aspects)
Authors:	Holmes, Dave O'Byrne, Patrick Gastaldo, Denise Lombardo, Anthony
Pub Date:	06/22/2008
Publication:	Name: International Journal of Men's Health Publisher: Men's Studies Press Audience: Academic; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2008 Men's Studies Press ISSN: 1532-6306
Issue:	Date: Summer, 2008 Source Volume: 7 Source Issue: 2
Topic:	Event Code: 290 Public affairs
Geographic:	Geographic Scope: United States Geographic Code: 1USA United States

Accession Number:	186225544
Full Text:	From a healthcare perspective, there is an underlying assumption that most gay and bisexual men do not intentionally seek to have unprotected anal sex. This paper presents the results of a qualitative investigation conducted in three Canadian gay bathhouses regarding unprotected anal sex among men. It is our contention that much epidemiological research, though helpful, obfuscates essential factors in the practice of bareback sex. Consequently, the paper addresses two themes: the identification from the participants' perspective of the risk factors involved in the practice of bareback sex and the identification of specific risk-reduction strategies used by barebackers. Our research results indicate that the majority of the participants were informed about health risks and took steps to avoid harmful practices even when engaging in high-risk sexual activities. Many participants, regardless of their HIV status, used risk-reduction strategies because the majority wanted to protect both their partners and themselves. Keywords: bareback sex, masculinity, public health, qualitative research, risk ********** For the past few years, Internet access has facilitated casual and anonymous sexual encounters by increasing initial contacts between potential partners through the use of chat rooms and virtual communities. In Canada, however, although the Internet is considered an easy way for locating sexual partners, bathhouses remain the most popular and convenient way venues for men who have sex with men to meet (Ross, Tikkeanen, & Mansson, 2000; Somlai, Kalichman, & Bagnall, 2001). Bathhouses enhance desire and promote sexual diversity. Within their milieu, voluntary unprotected anal intercourse, commonly referred to as "bareback sex" is one of the choices available. The term bareback sex derives from the expression bareback riding (that is, riding a horse without a saddle). The usage acquired popularity about a decade ago (Scarce, 1999) and refers to a sexual practice in which condom use is explicitly and consciously eschewed during anal intercourse. Although unsafe sex has been identified and reported since the beginning of the HIV epidemic, the general assumption is that most gay and bisexual men do not intentionally seek to have unprotected anal sex. We believe that this conclusion obfuscates essential components powering the practice of bareback sex and that this understanding of unsafe sexual practices is superficial because it does not recognize several determining sociocultural and psychological factors (Holmes & Warner, 2005). The goal of this paper is to present the results of a qualitative research project on bareback sex conducted in three Canadian gay bathhouses and to attempt to fill a gap in the current scientific literature by addressing the following issues: the participants' perception of the risk factors implicated in the practice of bareback sex and the risk-reduction strategies (if any) used by the barebackers themselves. We contend that a better understanding of these issues is necessary in order to facilitate the implementation of healthcare interventions better adapted to the needs of this population. Background According to UNAIDS (2002), 75,000 people in high-income countries acquired HIV in 2001. Unsafe sex, reflected in outbreaks of sexually transmitted infections, and widespread intravenous drug use is propelling these epidemics. Despite prevention campaigns, HIV remains a challenge in most Western countries. The majority of new HIV infections in both North America and Europe are sexually transmitted (Health Canada, 2005). As a result, the relationship between HIV/AIDS and men having sex with men has been studied extensively for more than two decades. At present, the rise in the popularity of bareback sex has led to new research on this sexual practice (Halkitis, Parsons, & Bimbi, 2001; Suarez & Miller, 2001). However, a change in infection trends is neither able to determine the link between a particular sexual practice and HIV increases, nor to provide insight into how to develop healthcare interventions (Halkitis, Wilton, & Drescher, 2005; Halkitis, Wilton, & Galatowitsch, 2005; Wolitski, 2005). In the case of bareback sex, one reason that causation cannot be established may be that it does not constitute a new phenomenon. Sex without condoms was the norm before AIDS (Wolitski). A further confounding variable for determining the role of bareback sex in the recent surge in HIV infections is that while the public health literature claims that the number of men having sex with men who engage in bareback sex is a relatively small subset of the population, other sources indicate that bareback sex is practiced by individuals from every sociodemographic stratum and serostatus (Halkitis, Wilton, & Drescher, 2005) and does not occur because of poor planning or spontaneous decision-making (Dawson, Ross, Henry, & Freeman, 2005). In addition, there is no evidence regarding why some men engage in barebacking while others refrain or what differences exist in defining barebacking as a practice versus barebacking as an identity (Halkitis, Wilton, & Drescher, 2005; Wolitski, 2005). Based on research, men who have sex with men have indicated that bareback sex produces greater stimulation, heightens emotional closeness with a partner, and is a means of rebelling against established norms (Wolitski, 2005; Dawson, Ross, Henry, & Freeman, 2005). At this time, twelve theoretical factors have been implicated in the attitudes of gay and bisexual men toward this practice: (1) an erroneous perception of risk, (2) self-destructive impulses, (3) other destructive impulses, (4) AIDS fatigue, (5) a need for intimacy, (6) rational risk-taking, (7) diminished self-control, (8) a sense of invulnerability, (9) assertiveness failure, (10) a sense of fatalism, (11) condom-related erectile dysfunction, and (12) other condom-related attitudes (Shidlo, Yi, & Dalit, 2005). However, current public health strategies ignore the social context of sexual practices (Parsons, 2005) and many current models assume that unsafe sexual practices are the result of lack of knowledge and disregard the fact that individuals may intentionally engage in activities which put them at risk (Halkitis, Wilton, & Drescher, 2005), thus making these models inadequate for addressing the issue. Unfortunately, because of these limitations, interventions from outside the gay community may be perceived as thinly veiled attacks on an already marginalized lifestyle (Wolitski, 2005) especially since many reports identify bisexual men as vectors of HIV transmission into the heterosexual population (Bimbi & Parsons, 2005). Theorizing Risk and Masculinity A poststructuralist perspective supports the analysis of power relations at the individual and the collective level. In this paper we will apply this perspective to examine the conflation of risk and masculinity in the context of hegemonic male power using the lens of Foucault's (1991) concept of governmentality to examine bareback sex. Governmentality, a term coined by Foucault (1991), describes the general mechanisms of society's governance. It does not refer specifically to the term government, as it is commonly understood. As Gordon (1991) explained, "government as an activity could concern the relation between self and self, private interpersonal relations involving some form of control or guidance, relations within social institutions and communities and finally, relations concerned with the exercise of political sovereignty" (pp. 2-3). According to McNay (1994), Foucault considered governmentality as a complex system of relations that binds government in a tripartite manner involving three forms of power: sovereign, disciplinary, and pastoral. The idea of government implies all of the tactics, strategies, techniques, programs, dreams and aspirations by which authorities shape beliefs and the conduct of populations (Nettleton, 1991) and, in these terms, is an activity that aims to shape, mould, or affect the conduct of an individual or group. Furthermore, the notions of goverumentality and risk focus strongly on the subject's position within the discursive construction of risk, most specifically the manner in which individuals should be personally responsible for their well-being (Castel, 1991), and with this increased focus on individual responsibility, risk assessment has become a major industry (Ewald, 1991). This suggests that individuals are held responsible for avoiding risks based on established lists of perceived risky behaviours, lest they be considered "foolhardy, careless, irresponsible, and even 'deviant'" (Lupton & Tulloch, 2002, p. 114). By accepting it as a socially constructed phenomenon, risk can be considered as something to which we are all subjected in one way or another in our everyday lives. Lupton (1999) has suggested that these experiences are negotiated within and through contextual, dominant discourses, most notably those of medical science, industry and government. Such a concept relies largely on Foucauldian ideas of governmentality and the technologies of power that are seen to restrict or direct social agency. Individuals position themselves and self-identify through the dominant discursive constructions that are, at any given time, multiple and sometimes conflicting. Sexual risk-taking may also have important legal implications (Holmes & O'Byrne, 2006). Moreover, they may have an impact on health and may come to designate an individual as deviant because of a proclivity for risky behaviors. For example, since the early 1980s, a vast number of academic and popular publications exploring HIV/AIDS have considered and defined risky behavior and at-risk populations (Lupton & Tulloch, 2002) while emphasizing risk as something to be avoided, or at the very least controlled "as long as expert knowledge can be properly brought to bear upon it" (Lupton, 1999, p. 5). The social construction of masculinity is intrinsic to understanding gendered experiences of risk (Frost, 2003, 2005), and can be related to the notion of risk and social identity. The social constructionist perspective argues that gender is not an essential character trait, but is rather a summation of behavioural and bodily practices that are learned through interaction with others in various social realms. As such, masculinity and femininity are learned traits that have been assigned to individuals of a given biological sex. Expected gender performances are established as binary opposites--male or female, masculine or feminine (Butler, 1999). Green (1997) noted that an empirical study of children found that the perception of risk in boys as young as seven was different from that of their female peers. When the participants were asked to recount and react to accident narratives, the girls responded in ways suggesting traditional feminine constructs (concern, responsibility, and nurturing), but the boys were much less concerned about others and could be seen as willing participants in risky behaviour. Numerous studies on the construction of masculinity in boys propose that many different social milieus work in concert to construct this "appropriate" masculinity (Bramham, 2003). Other studies suggest that males are active participants in risk-taking behaviours and perceive risk differently than do females because of the expected performance of masculinity (Finucane, Slovic, Mertz, Flynn & Satterfield, 2000; Le Breton, 2004; Mitchell, Crawshaw, Bunton, & Green, 2001). Behaviour such as engaging in "unsafe" tasks, reckless driving or other breaches of legal or parental authority (Le Breton, 2004), participation in extreme sports (Laurendeau, 2004; Le Breton, 2000; Lyng, 2005), and even overtly aggressive play during sports and social games that both favours and puts male bodies at risk and has been created within hegemonic gender constructs, (Young & White, 2000) work to gain young boys masculine capital, thereby constructing social identity both personally and with peers. In contemporary Western society, behaviours to which boys are expected to subscribe include assertiveness, competitiveness, independence, and dominance. Conversely, behaviors such as expressiveness, sympathy, passiveness and understanding should be avoided, lest one be thought feminine. Bodily practices include the development of hard, strong, muscled bodies that perform tasks that are acceptable within the range expected of masculine performance (Brarnham, 2003). There is an almost universal assumption of heterosexuality in this. When dealing with homosexuality and ideas of masculinity, there is an ironic relationship between sexuality and gender (Nardi, 2000; Pronger, 1990), even though masculine performance and homosexual behaviour have been considered in literature addressing socially defined risky sexual practices, especially in the era of HIV/AIDS. The following sections will address a specific form of high risk sexual practice: bareback sex. Method Some authors attribute the recrudescence of sexually transmitted infections (STI) and HIV to bareback sex (Condon, 2000). However, because there is very little relevant scientific literature, we chose an exploratory research design to help us better understand our topic. Bareback sex is commonly described as a gay sub-cultural trend that is practiced in public spaces; therefore, ethnography following the principles proposed by Hammersley and Atkinson (2004) seemed to be the most appropriate methodological approach. Contrary to the findings of many American authors, it was observed during a pilot study (Holmes & Warner, 2005) that men who have sex with men frequently meet each other at bathhouses. Consequently, we decided to situate our research and recruitment for the qualitative portion of the study in this environment. Note, however, that the objective of this paper is not to provide a thick ethnographic account of gay bathhouses (see Holmes, O'Byrne, & Gastaido, 2007), but rather to explore risk as it is perceived and enacted (or not enacted) by the participants in bareback sex in these milieus. Data Collection Following a comprehensive review of the literature relating to bareback sex, 28 structured in-depth interviews with barebackers were carried out in three Canadian cities. The participants were recruited while an ethnographic study in gay bathhouses was being conducted by the researchers (Holmes, O'Byrne, & Gastaldo, 2007), as well as through advertisements posted in gay bars in the cities of study. The resulting interviews, which were conducted in university offices in the three target cities, were audio-taped and then transcribed. The transcriptions were double-checked by a second researcher. All of the participants were of the age of majority according to provincial jurisdictions, and defined themselves as heterosexual, homosexual, bisexual, gay, or queer, and as regularly engaging in bareback sex with anonymous male partners. Interviewing continued until data saturation occurred. Data Analysis Content analysis was selected as the preferred means for exploring and analyzing the data (Denzin, 1998). During this process, knowledge of risk, risk representation, risk rationalization and risk-reduction strategies emerged as significant themes. For the purpose of this paper, our analysis will focus specifically on these four themes. In analyzing the data, we drew on the insights risk offered by poststructuralist theorists. Ethics The Canadian Tri-Council Ethics Policy (2005) was fully acknowledged and respected. We were well aware of the intrusive nature of a qualitative study exploring the personal sexual practices of specific individuals. Consequently, the rights and wishes of the participants were scrupulously respected at all times regarding content disclosure and any wishes to prematurely end an interview. The 28 participants who agreed to semi-directed in-depth interviews all signed consent forms. Rigour Applying the principles of credibility, transferability, reflexivity, and resistance ensured the rigour of this research project. The more traditional rigour criteria of dependability and confirmability were removed because they are incommensurate with the research paradigm of inquiry (critical theory). Credibility served to evaluate internal commensurability between the paradigmatic assumptions, theoretical framework, and findings. It is important to note that in this modified sense credibility does not refer to confidence in the truth of the data. The principle of transferability ensured that a thick description of the sample was obtained and displayed to allow findings to be applied to similar groups. Reflexivity forced the researchers to view the process as subjective and to acknowledge the effect of our personal, paradigmatic, theoretical and methodological biases regarding the research process. Thus, reflexivity promoted scrutinizing and evaluating our own behaviours, beliefs, and reactions in the same manner as we did the research data. The last rigour criterion was resistance, which views research as a means, rather than an end. Research should be evaluated in terms of its ability to act as a resource for understanding and for producing resistances to local structures of domination (such as certain ramifications of the public health dispositif). Results Although barebacking is a highly personal and intense activity, the research team's professional experience in sexual health clinics combined with in-depth knowledge of up-to-date research and theoretical sensitivity allowed for a sound and critical appraisal of the data collected. For example, we were always aware of our epistemological stand and, as a consequence, we acknowledge that, although we followed a rigorous data analysis scheme, this section is firmly rooted in the paradigm of critical theory (Guba & Lincoln, 2002). We also acknowledge that our personal experiences in the public health domain had an impact on the analysis process. This having been said, our research shows that risk is an important concept for the barebackers we interviewed. Almost all of them discussed the issue. At this point, however, we cannot assert that HIV+ individuals use pre-determined risk reduction strategies that are different from those used by HIV- individuals; however, the serological status of participants will be made explicit when necessary to highlight differences between these two groups of barebackers. At this point, we will turn our attention to the results obtained from the interviews. Table 1 gives an overview of the demographics of the research participants. All individuals who engaged in the interview process (n=28) were asked to complete a brief survey describing their sexual orientation, age, socio-demographic status, average number of partners, and HIV testing history and results. One interviewee declined to complete the survey and two others were not practicing bareback sex; therefore, the results presented 1 are all calculated using n=25. The ages of the interviewees ranged between 22 and 54 years, with an average of 37.5. Under sexual orientation, 12 percent (3/25) defined themselves as bisexual, 52 percent (13/25) as homosexual, 24 percent (6/25) as gay, 4 percent (1/25) as queer and, finally, 8 percent (2/25) as other. No additional information, however, was provided in this category. For education, 32 percent (8/25) of respondents indicated high school as their highest level completed, 24 percent (6/25) indicated a college diploma, 28 percent (7/25) indicated a bachelor's degree, and 16 percent (4/25) indicated that they had attained a master's degree or higher. Respondents were also asked to check the income bracket that corresponded with their gross annual income, 24 percent (6/25) earned less than $15,000 per year, 32 percent (8/25) earned between $15,000 and $29,999 per year, 8 percent (2/25) earned between $30,000 and $44,999,20 percent (5/25) earned between $45,000 and $59,999, 8 percent (2/25) earned between $60,000 and $74,999, and 8 percent (2/25) earned more than $75,000 per year. In the space listing the number of partners in the previous six months, 4 percent (1/25) of respondents indicated none, 36 percent (9/25) indicated between 1 and 10, 28 percent (7/25) indicated 11 to 30 partners, 12 percent (3/25) indicated 30 to 50 partners, and 20 percent (5/25) indicated more than 50 partners. Of this group, 92 percent (23/25) had previously been tested for HIV and the remaining 8 percent (2/25) had not. Under the heading of last HIV test result, 8 percent (2/25) answered not applicable (no prior testing), 8 percent (2/25) did not answer the question, 44 percent (11/25) answered HIV negative, and 48 percent (12/25) had been previously diagnosed as HIV positive. Before we present our qualitative data, we would like to refute an assumption often held by professionals working in the field of public health. Some authors state that barebacking is more likely to occur in certain specific settings, gay bathhouses being targeted most often. Our previous research in three Canadian gay bathhouses leads us to conclude that, on the contrary, bareback sex can happen in any environment where men meet for sex (Holmes, O'Byrne, & Gastaldo, 2007). Our participants supported this assertion, as the following quote makes very clear: "Barebacking happens pretty much everywhere. It happens in the porn theatres, it happens in the bathhouses, it happens in the washrooms; it happens in the cars, it happens in the parks, beaches ... just everywhere" (PA 22, p. 19). While bathhouses are often under attack by public health figures for their involvement in the transmission of HIV and STIs, it is important to note that barebackers themselves report that bathhouses are just one location where this practice occurs. Furthermore, several studies have indicated that although a considerable proportion of men who engage in high-risk activities frequent gay bathhouses, only a minority of them report having had unsafe sex while there (Woods, Binson, Mayne, Gore, & Rebchook, 2000; Holmes & Warner, 2005). We agree with these researchers and gay activists that it is not where you have sex or the number of partners you have that is important, but rather what you do. In light of this, we will now explore the four categories that emerged during data analysis. C-1 Knowledge of Risk In contrast to public health claims that bareback sex usually occurs because of ignorance or due to the influence of drugs, it is essential to emphasize that the participants in this research project were well aware of the associated risks. We believe that the misguided public health assumption is highly problematic because it incorrectly frames several educational and prevention campaigns. For example, an HIV-negative participant who practices bareback sex as well as oral sex without condom states: Despite the fact that this participant practices barebakcing, he seems more concerned about the risk associated with oral sex if the mucosa is not intact. It is interesting to note that this participant's knowledge of the term "super seminal shedder" is in fact superior to the knowledge of many HIV clinicians and researchers who are un aware of the concept. The same interviewee was explicit in his description of the potential risk of HIV transmission via oral sexual contact: While the language used by this participant is not euphemized with medical jargon, an in-depth knowledge of risk is definitely present. In fact, this quotation illustrates an understanding of the location of possible infection (the oral cavity) and is aware that the likelihood of infection increases as the length of time of exposure increases. Another participant showed his knowledge and acceptance of risk relating to his practices. He did not act in a state of ignorance: Many participants were also well aware of the risks associated with drug use. One interviewee was able to clearly identify the licit source of the drugs he was using, the potential benefits of the drug, and the possible side effects of an overdose: In contrast to the assumption that drug use occurs strictly for the accompanying sensations, this participant provided a description of the source of the drug, the sensations produced, and a formula to ensure that an appropriate high is attained while the negatively reported "dissociative state" is avoided. In addition, most of the individuals we interviewed engaged in bareback sex despite knowing the risks. An HIV+ participant stated: Another HIV+ interviewee added: In fact, not only were the barebackers in our study not ignorant of risks, they were also highly involved in becoming more informed about HIV and STI risks. This knowledge came from several sources including the Internet. This participant illustrates that bareback sex in this case is not the result of ignorance. C-2 Representation of Risk amongst Barebackers The next category that emerged from our data was the representation of risk. Although it could be interpreted as barebackers exhibiting ignorance about sexual practices, in our view, this category represents a personal integration of knowledge of risk from a variety of sources. At a time when even organizations such as the CDC and Health Canada are unable to provide coherent and matching definitions of risk and transmission, it is an internalization of a variety of sources on the topic of HIV transmission rather than a recitation of all possible risk sources. In this context of anonymous bareback sex at bathhouses, the negotiation of sexual practices (including condom use) takes place within this personal representation of risk and because these encounters are often enveloped in an aura of silence, non-verbal communication is the norm (Holmes, O'Byrne, & Gastaldo, 2007). The following excerpt of conversation between the interviewer and a participant illustrates this vividly: Researcher: When you're having sex, how do you decide whether to use a condom or not? Participant: It's ... I leave that up to the discretion of the bottom. Researcher: Ok. So if he doesn't say anything... Participant: If I am the top and they don't say anything, I proceed. If I'm the bottom, I'm always very cautious and I am clear about the rules of engagement. It's like certain things are going to happen and one of them is you're going to put a condom on. But those are my decisions. If the other person doesn't want to or has made those decisions not to wear a condom, then that's their decision. (PA 18, p. 5) For a few, place is an important element in the risk appraisal equation, whether this be physical location or receptive versus penetrative status in the sexual encounter. For example, one participant clearly states that, for him, gay bathhouses are places where the risk of exposure to HIV and STIs is higher. While he admits to practicing bareback sex with anonymous partners of unknown serological status in various milieus, he believes that meeting another barebacker outside the bathhouse setting is safer: "if you don't go to bathhouses, then you are again going to cut the risk" (PA 11, p. 20). C-3 Rationalization of Risk among Barebackers The rationalization of risk was another factor involved in barebacking. This category signified that some barebackers rationalize the risk of the activities in which they engage. An HIV- barebacker states that: While this statement could be seen as ignorance of HIV risk, the participant states that his beliefs were developed through discussion. Another participant adds: For this participant, death is seen as a component of the life process, and the acquisition of HIV is not an interruption of the natural lifecycle, but one of its many facets. C-4 Risk Reduction Strategies Used amongst Barebackers All the barebackers we interviewed knew the risks associated with unsafe anal sex and the majority of them were practicing bareback sex with a harm reduction mindset. M were able to outline risk reduction strategies that they used with their partners; for example: (1) sero-selection of partners, (2) physical appearance of partners, (3) use of coitus interruptus, (4) pre-anal intercourse preparation, (5) self-awareness, and (6) decreased number of partners. 1-Sero-selection Some barebackers reduce the risk of their sexual practices by sero-sorting. Depending on whether the sexual partner is sero-concordant or sero-discordant, the likelihood as well as the type of sexual activity varies. Selection of partners according to HIV status is explained by an HIV+ participant: The intentional selection of similar HIV sero-status partners is a strategy of personal and public health risk reduction that is employed by many barebackers. 2-Physical Appearance Another strategy employed in the selection of partners relies solely on their physical appearance. Barebackers are cognizant of the physical changes caused by both HIV and HAART (Highly Active Anti-Retroviral Treatment). For example, changes such as lipodystrophy were discussed. Some of the participants would avoid individuals who have a typical HIV+ appearance: Therefore, according to some participants, assessing the physical attributes of a potential partner is another means by which risk is reduced. 3-Coitus Interruptus Withdrawal of the penis from the anus prior to ejaculation is another strategy used by several of the men. However, some individuals practice this method because they want to see the semen, rather than as a risk reduction strategy. An HIV- participant says: As a harm-reduction strategy, this participant describes an eroticization of ejaculate that is used to reduce the quantity of bodily fluids that are deposited within a sexual partner. A participant who is HIV+ states: Obviously, coitus interruptus serves as a means by which barebackers reduce their risk of HIV transmission regardless of the motivation. 4- Pre-Anal Intercourse Preparation: Foreplay Our results show that some barebackers insist on a preparation ritual to prepare the anus for sexual activity, thus reducing the risk of damage to anal tissue such as abrasions and open lesions. For some participants, extended foreplay constitutes part this preparation and, as such, involves oral-anal stimulation, digital dilation of the sphincter, and the use of a substantial amount of lubricant. The following quotes illustrate some of the various means of preparation used to decrease the risk associated with barebacking: In the last quotation, the participant describes a formulaic approach to bareback sex. In a fashion that resembles pre-operation preparation for cleanliness and sterility, appropriate foreplay is required by this participant to reduce the risk of transmitted infection. For some participants, the requirement and the type of foreplay depend on the location where bareback sex occurs. The following quote from a participant who often meets partners at the bathhouse, constitutes a good example: The preparation for anal sex is not undertaken using words. Body language, movement, and gestures set the stage. Another prevention ritual involved the state of the participant's nails: "Nails have to be trimmed" (PA 25, p. 14); and My nails are ... usually cut short anyway. Because you never know with me, I may walk to the store and end up meeting somebody and going somewhere. I have been meeting people; I have been meeting guys off the street, and gone back to their place. A few hours later, I'm heading back home or into where I had to go. (PA 22, p. 23) These quotes clearly demonstrate that barebackers do not engage in sexual practices that put them at risk for acquiring HIV out of ignorance. Most of the men we interviewed employed an array of harm reduction strategies. 5-Self-Awareness "Some participants use discretionary abstinence as a method for reducing risk. They stated that they are aware of the risks associated with barebacking and that self-awareness of the physical condition of their skin is the most important aspect of harm prevention for them. Another added: These participants describe a reliance on their own physical sensations as a guide for transmission. In situations where the integrity of the protective skin layer has been compromised, cessation of sexual contact may ensue. 6-Decreased Numbers of Partners Limiting the number of partners is another strategy employed by barebackers, even HIV+ individuals who are concerned about the risk of super-infection with a different strain of HIV. In a state of self-awareness, some interviewees reported refraining from sexual activity with certain partners at particular times as a way of reducing their risk: Even if we're HIV, sometimes a guy could have a different strain of the virus, that could also be passed on to me or I can pass something to him. But now, I have three guys that I see that I socialize with. I go to their house and visit down, or spend a weekend, whatever. I bareback with these men only ... we are all positive (PA 24, p. 8-9) Discussion The interrelationships of men who have sex with men, risk taking, and masculinity are complex and paradoxical. It has been suggested, for example, that to a great extent, Western gay masculinity has evolved in response to traditional gender constructions that consider gay men as deviant or feminine (Pronger, 1990). Beginning in the 1950s, and evolving in the 1970s as a response to the drag queen image typically associated with gay culture, gay masculinity has now developed even further into its current form. Halkitis (2001) has labelled this current performance of dominant gay masculinity "the buff agenda" and argues that it is an embodied performance primarily in response to the HIV/AIDS epidemic of the 1980s, which worked to project an image of disease and frailty onto the gay community. Another aspect of the "buff agenda" is the gay poster re-used by a group of barebackers depicting the "Marlborough man" to promote the idea that real men like to ride bareback with its underlying message that real men are not afraid to take risks. Ridge (2004) suggests that there are multiple and complex meanings underlying participation in bareback sex, some of which are contradictory. However, one theme that emerged fairly consistently was that of masculinity, although even this notion was constructed in various ways. Primarily, participants considered masculinity as an embodied experience (Halkitis, 2001; Halkitis & Parsons, 2003). There were, however, contradictory considerations of this when discussing the active (penetrative) and passive (receptive) roles in anal sex: Ridge's work is an important contribution to the understanding of gay masculinity and its social construction in response to HIV/AIDS; however, what has emerged in more recent studies is not only the relationship between gender and sexuality, but also the role of masculinity in high-risk sexual practices. According to the Centre for Disease Control, the number of gay men who reported not using condoms with multiple anonymous partners increased from 24 to 45 percent between 1994 and 1999, and the statistics for other Western countries reveal that this phenomenon is not limited to North America. In a survey of more than 14,000 gay males conducted in the UK (Sigma Research, 2003), up to 60 percent of respondents reported having practiced bareback sex. Studies in Russia and in the cities of Budapest, Melbourne and Sydney have all reported increases in barebacking (Shernoff, 2006). An increase in the efficacy of anti-retroviral drug treatments has been suggested as a factor in this resurgence in high-risk behaviour (Halkitis & Parsons, 2003; Ridge, 2004); however, none of our participants offered this as a reason for engaging in barebacking. The relevance to men who have sex with men of public health discourses regarding HIV/AIDS awareness was also questioned, suggesting a rift between the dominant discourse and personal narratives (Ridge). When personal motivations for practicing bareback sex were explored (Holmes & Warner, 2005), reasons such as connectedness through skin to skin sex contact, the spontaneity and naturalness of barebacking, and a sense of completion (including semen exchange) were offered. Research conducted by Crossley (2002) clearly demonstrates states that expressing freedom, rebellion, or empowerment may also contribute significantly to a predisposition toward barebacking. Feelings of rebellion were also reported in earlier research conducted by Holmes and Warner (2005). These authors applied interporeted bareback sex as an act of resistance. However, despite clear evidence of patterns of resistance on the part of barebackers, we found that most of them employed a vast array of harm- reduction techniques to reduce the chance of infecting themselves or others with HIV and STIs. For example, "health status" was discussed by some of our participants who appraise or guess the HIV status of an anonymous bareback partner as a risk-reduction strategy. Other research findings have reinforced the observation that individuals often participate in potentially high-risk sexual practices after a certain level of trust has been established based on physical appearance. Consequently, some current American and Canadian prevention programs are now addressing this assumption of security and trust based on uncorroborated visual assessments. The San Francisco prevention campaign entitled "How do you know what you know?"' is a good example of this. It is designed to challenge unexamined assumptions based on visible physical characteristics and targets men who have sex with men of either serostatus who are engaging in barebacking with anonymous partners. Voluntary risk-taking can be connected to personal determination of one's self and suggests that participation in activities such as barebacking can be seen as identity forming because successful completion of an activity defined as risky within one's social milieu has an impact on social identity (Lupton & Tulloch, 2002, 2003; Lyng, 2005). While gendered subjectivities are key factors in both risk-taking activities and discursive constructions of risk, and while studies have suggested that subjectivities of race or ethnicity, class and ability undoubtedly influence experiences of risk, we also recognize the multiplicity of individual subjectivities that work to create an individual's sense of "self." Our data and other studies (Holmes & Warner, 2005; Holmes, O'Byrne, & Gastaldo, 2007) suggest that the construction of risk is highly personal, hence subjective, and influenced by socio-cultural factors and knowledge gained regarding HIV and STI. The majority of our participants were informed mainly on the basis of accepted scientific evidence about risks and took steps to avoid harm, even when engaging in high-risk sexual practices. In fact, risk-reduction strategies were implemented by many barebackers regardless of their HIV serostatus. Consequently, although we acknowledge that this might not be true in every barebaker's case, we believe that our research results call for a rethinking of current public health campaigns that target sexual health. Conclusion The research results presented in this article are important because they constitute a necessary step in closing a current gap in gender studies and public health literature by proposing a better understanding of risk representation and by identifying ways in which barebackers reduce the risks associated with STI and HIV transmission. As such, these results, by promoting a clearer understanding of the individuals who engage in risky sexual practices may help healthcare providers to develop new intervention tools in clinical settings. The current belief in the public health domain that individuals engage in unsafe sex because they are not aware of the associated risks, is questionable, misguided and therefore ineffective. Barebackers know the risks associated with their practice and engage in it nonetheless. Consequently, we strongly believe that HIV prevention campaigns must experience a paradigm shift if they are to reach this rapidly expanding population. By taking various complex concepts of risk as a starting point and by considering different theoretical points of view and existing empirical research, we can see that risk exists in multiple forms and is socially constructed through contextual, dominant discourses. Rather than being a global experience as suggested by the paradigm of the risk society, risk and risk-taking (both voluntary and in terms of risk-management) are negotiated through the localized experiences of individuals and need not always be seen as something dangerous or negative. In fact, it has been suggested that voluntary risk-taking can be seen to have positive effects in terms of personal agency and the development of social identity. However, even voluntary risk-taking is still very much governed by discursive constructions of risk, which are then experienced by different subjectivities including gender, sexuality, ethnicity and race, class, and ability. In consequence, we conclude that according to the relevant literature, barebacking is gender-specific, and is tied to constructions and performances of masculinity, and to representations of risk. References Bimbi, D., & Parsons, J. (2005). Barebacking among internet based male sex workers. 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Sabo (Eds.), Masculinities, gender relations and sport. (pp. 108-125). Thousand Oaks, CA: Sage Publications, Inc. DAVE HOLMES University of Ottawa, Canada PATRICK O'BYRNE University of Ottawa, Canada DENISE GASTALDO University of Toronto, Canada ANTHONY LOMBARDO University of Toronto, Canada Dave Holmes, School of Nursing, Faculty of Health Sciences, University of Ottawa; Denise Gastaldo, Faculty of Nursing, University of Toronto; Patrick O'Byrne, School of Nursing, Faculty of Health Sciences, University of Ottawa; and Anthony Lombardo, Department of Public Health Sciences, Faculty of Medicine, University of Toronto. The authors would like to thank the Canadian Institutes of Health Research--Institute of Gender & Health and Institute of Population Health--for funding this research. Correspondence concerning this article should be address to Dave Holmes, School of Nursing, Faculty of Health Sciences. University of Ottawa, 451 Smyth Road, Ottawa, Ontario Canada, K1H 8M5. Electronic mail: dholmes@uottawa.ca For me, it's the state of my oral hygiene, "Did I brush my teeth before I went out?" Yes ... then no oral sex is going to happen.... That's in case someone has a lot of pre-cum, because pre-cum can be very heavy with HIV. I was just talking to a friend of mine who's very into the HIV policy thing at Health Canada, he came across a new term he's never seen before, a "super seminal shedder". Someone who secretes a lot HIV in the semen, the pre-cum, and it's particularly prevalent in older men. (PA 18, p. 8). Sucking is as sate as the cock you're sucking and the state of your mouth ... people just doesn't [sic] understand the dangerous place for a potentially HIV-infected cure is actually your mouth. I mean, the obvious thing is to not let someone come in your mouth but if it does happen.. . well, get it out of your mouth, so if that swallowing it, then swallow it, if it's spitting it out, then spit it out, but get it out. That's where the important potential risk of infection is, it's actually in your oral cavity. (PA 18, p. 21) And probably there's always the risk they say of cross infection or maybe another strain of the virus and whatnot and I think that maybe the risk is a little bit less when they don't cum inside you. The risk is still there but in my own mind the risk of cross, whatever you call it, contamination or receiving another virus is probably less if you don't have the person ejaculate inside you. (PA 19 p. 17). Ketamine--it's an anesthetic that's used in veterinary. And it produces a sense of euphoria. I don't like it, and that's why I don't do it, but people do it on bumps. So they'll be on ecstasy and they want to, get higher, they'll do a bump on the dance floor, it can, if you do too much of it can lead to a 'dissociative' state and that's what I don't like. (PA 2 p. 12) I'm fully aware of cross-contamination, cross-infection, re-infecting yourself, you know. Radical viruses, things like that. I take the risk. (PA 20, p. 7) I don't have to worry about catching HIV; the only thing I have to worry about is the different strains of the virus and the other STDs. I've had many a discussion with my doctor about this, and the one doctor finally said, you know the risk, so that's it. (PA 22, p. 5-6) Actually I have a friend, who has a number of listservs she organizes, and one of them is a daily popular press email on HIV-related issues, and so she sends me that. I'm always reading and put the little the pieces together. (PA 6, p. 12) As a top, barebacking is to me not a particularly risky activity, that's my own personal line that I've drawn. As a bottom, it's a very risky activity. The rationalization that I've come to in that decision is, I'll let someone suck me without a condom and it doesn't matter ... I don't ask whether they're HIV positive or not, to me that's an acceptable risk in my world. I've talked to a lot of people, and eventually came to the conclusion for myself that to be a top, all things being equal, the state of my penis is healthy, then to me it's as risky as oral sex. It's the same level of risk, and if I've made that rationalization for oral sex, then what's the difference for anal sex? (PA 18, p. 2) I bareback because we all die from the time we pop out. And I feel like I'm a little more spiritually evolved, than I was before. I believe that death is just an extension or a continuation of life. (PA 20, p. 22) Well, I am HIV+, and if I'm going to be a top, then I won't bareback, I'll use a condom, because I don't want anyone else to contract HIV, and if I'm going to be a bottom, it's usually with people who are HIV+, so no condom, it's consensual. (PA 10, p. 1) If I see someone who looks sick, etc. You must stay away from him. But if another guy looks healthy; I am ready for barebacking (PA 23, p. 36) I don't mostly cum inside. Because I like the feeling of seeing cum. I Like cumming on someone's chest. Mostly people like to see cum. That's what sex is about. Sex is about the cum. People are always curious ... they just want to see it. (PA 23, p. 28-29) When I am being fucked bare, I ask them not to cum inside me. There is always the risk of cross infection or maybe another strain of the virus and whatnot and I think that maybe the risk is a little bit less when they don't cum inside you. The risk is still there but in my own mind the risk of cross ... contamination or receiving another virus is probably less if you don't have the person ejaculate inside you. (PA 3, p. 8) Lots of lube, lots of ... sort of assplay, just sort of making sure that they're ready to have sex. It's pretty bad to slam your cock into someone's ass, that's just not the way it goes. It's like having sex with a woman, you can't just shove it in. I use water-based lubes. 1 find a little bit of lube and saliva is the perfect mixture ... keeping things lubricated. (PA 18, p. 7) Well, usually just, you know, like some Vaseline, usually and then just loosening it up a bit with the fingers while you're having fun and doing certain things ... and then having anal sex afterwards. (PA 8, p. 15) Usually there's always, urn, rimming involved prior so that provides some lubrication and there's all part of the foreplay before the fucking. (PAl 9, p. 9) The top introduces his finger to apply a bit of lube ... Direct skin-to-skin sex, is supposed to hurt good, not hurt bad. And ... not using lube, I mean, one could run the risk of getting torn, damaged, and it's not very pleasurable. And you can't endure, or continue for a long time. (PA 20, p. 19) If it's a bathhouse I won't rim him. Usually you just start by fingering him, and usually you just use actions to describe what you want to do next (no verbal communication) ... so you finger them right, and if they let you, and you keep going, and they don't move your hand and everything, then you can slowly move their body towards you. So, it just generates, it just starts the anal sex. (PA 9, p. 19) I won't give a guy a blowjob if I had a meal within the last couple of hours. I'm a lot more in tune ... I pay a lot more attention to my own body and where it's at. And if I have any doubt that the skin on my penis has been compromised, that's it, it's over. (PA 18, p. 5) Let's say I've been at a bathhouse for a while, and I've had a lot sexual encounters, and there was a particularly rough blow job or handjob, then I just won't take the chance that there's been any abrasions. (PA 20, p. 6) The narratives suggest that sex, including anal penetration, does not have fixed meanings based on dichotomies such as active/passive. On the contrary, accounts of informants have confirmed that sex is a repository for a range of meanings (Ridge, 2004, p. 274). Table 1 Description of Sample Age (M [+ or -] SD) 37.6 [+ or -] 9.5 (range: 22-54 years) n % Sexual orientation (Self-defined) Bisexual 3 12 Homosexual 13 52 Gay 6 24 Queer 1 4 Other 2 8 Education (Highest diploma) High school 8 32 College diploma 6 24 Bachelor diploma 7 28 Master's degree 4 16 Income ($) <15,000 6 24 15,000-29,999 8 32 30,000-44,999 2 8 45,000-59,999 5 20 60,000-74,999 2 8 >75,000 2 8 Number of partners (Last 6 months) None 1 4 1-10 9 36 11-30 7 28 31-50 3 12 >51 5 20 Previous HIV test No 2 8 Yes 23 92 Result of last HIV test No Answer 2 8 Negative 11 44 Positive 12 48 N = 25 Note: Twenty-eight men agreed to be interviewed; one declined the socio-demographic questionnaire; two were not considered barebackers as they always engaged in protected anal intercourse.
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