Fridae

Since the early days of the AIDS epidemic, gay men have faced a perplexing question, how do I have a satisfying sex life without contracting or spreading HIV? In my practice as a psychotherapist, I've grown concerned with the increasing number of clients who are not using condoms (for a wide variety of reasons).

As I researched my latest book, Without Condoms: Unprotected Sex, Gay Men and Barebacking (October, 2005, Routledge), I discovered that anal sex without condoms what's now commonly known as 'barebacking' is the relatively infrequent act of a relatively large number of gay men. In other words, guys aren't necessarily barebacking night after night, but many are going condomless, and AIDS prevention efforts need to address this fact.

Clearly, the message of 'use condoms every time' is falling on many deaf ears. This prompts a very controversial question: Are there ways to minimise the damage of unprotected sex rather than eliminating the behaviour altogether? The variety of ways, short of using condoms, that most gay men use to avoid contracting or spreading HIV have become known as sexual harm reduction practices. These include:

� Negotiated safety. This is an agreement between two gay men in a HIV-negative, seroconcordant relationship to go through the process of getting ready to stop using condoms when they have anal sex.

� Serosorting. The practice of men having unprotected anal sex with other men of the same HIV status.

� Strategic positioning. Used by both HIV-positive and HIV-negative gay and bisexual men, this is the practice of infected men adopting the receptive bottom role during unprotected anal sex with HIV-negative men.

� Dipping. This is anal insertion for just one or two strokes without wearing a condom.

� Withdrawal. Pulling out before ejaculation.

� Assessing viral load. Using information that they or a partner have undetectable viral loads to make decisions about whether or not to bareback.

� Substitution. Opting for unprotected oral sex for unprotected anal sex.

Risk of HIV-infection is serious business. But I'm convinced that all political correctness aside including harm reduction approaches into existing AIDS prevention campaigns neither condemns nor condones unprotected anal intercourse.

It merely acknowledges that this behaviour is occurring and is merely another attempt albeit a controversial one to engage with men who are not using condoms.

Dr. Goldstone Responds...
"Though any dialogue on additional ways to prevent HIV transmission is helpful, I'm troubled by the issues of negotiated safety for many reasons," says Dr. Stephen Goldstone, Medical Director, GayHealth.com. Some of Goldstone's additional comments include:

� "There are far too many men who assume that they are HIV-negative when they have never been tested or not recently tested. I remind everyone that having unprotected sex with a partner who says he is 'negative' can leave you open to catching HIV."

� "Men do, in fact, catch HIV when they are topping a positive bottom. If another STD is present the risk of infection also increases."

� "Men with zero viral loads can also still pass HIV and HIV can be spread with oral sex."

� "Even if you are positive, unprotected sex creates the potential for contracting a more resistant virus."

� "I do agree with the notion that the protected sex all the time message needs to be reworked because too many people are not hearing it. I am all for harm reduction education, but harm reduction does not mean no harm or no risk."

� Concludes Goldstone: "As a friend of mine recently said: 'Having protected sex is no different than driving with your seat belt on; it's inconvenient, but well worth it.'"

Michael Shernoff is a psychotherapist in private practice in Manhattan and is on faculty at Columbia University School of Social Work.