Risk, Stigma, and Pleasure: The role of PrEP and Bareback Sexual Behavior among the Men who have Sex with Men in Amsterdam

Kevin Singh (10870555)

MSc Medical Anthropology and Sociology

Universiteit Van Amsterdam

Master Thesis 2016

Supervisor: Dr. Rene Gerrets

Second Reader: Dr. Eileen Moyer Acknowledgements

First and foremost I would like to thank all the respondents who participated in my research, their willingness to open up about such sensitive topics gave me the courage to continue through some of the harder days of my writing.

Next I would like to thank my supervisor and mentor Dr. René Gerrets, whose wisdom and encouragement kept me going through the worst of it.

Last I would like to give thanks to my loving Mother and beloved Brother for their continued love and support, I could not do this without them.

Table of Contents

Acknowledgements 1

1 Table of Contents 2

Chapter One: Introduction 3 1. Problem Statement 3 2. Literature Review 4 1.3 Theoretical framework 7

Chapter Two: Research Methodology 9 2.1 Introduction to Methods 9 2.2 Ethnographic Methods 9 Ethnographic Field sites 9 Interviews 11 CyberEthnography 12 Informal Conversations 12 2.3 Ethical considerations 13 2.4 Data Analysis 13 2.5 Obstacles and Reflexivity 13

Chapter Three: Risk and Health, Sexual Behavior of PrEP 15 3.1 Introduction to Risk 15 3.2 Risk Compensation 16 3.3 Risk Compensation vs Disinhibition 18 3.4 Risk and Biomedical Technology 19 3.5 Risk Behavior and Change 20 3.6 Conclusions and Reflection 22

Chapter Four: Stigma, Sexual Beliefs and Behavior 24 4.1 Introduction to Stigma 25 4.2 Stigma and HIV 26 4.3 Anticipated Stigma and HIV 26 4.4 PrEP and Stigma 26 4.5 Data: Experiences with Stigma 27

Chapter Five: In the Pursuit of Pleasure? 34 5.1 Introduction to Pleasure 34 5.2 Sexual Morality and Pleasure 34 5.3 Sexual Health Behavior and Condom Fatigue 36 5.4 PrEP and Pleasure 38 5.5 Conclusion: Pleasure 39

Chapter Six: Conclusion-Final Thought and Discussions 41

Bibliography 44

Chapter One: The Introduction

2 In conventional wisdom it holds that risk taking in sexual behavior can play a role in the high rates of sexually transmitted disease (STD) and the continued spread of the human immunodeficiency virus (HIV). Despite years of research, the psychosocial mechanisms that lead to risk-taking behavior are still not completely understood. Prior research has often assumed that sexual decision making depends on rational thought processes and has not adequately addressed the role that other factors, such as emotional state, attraction, arousal, personality, substance use, as well as social and cultural influences, may have on behavior (Bancroft., Janssen., Strong., Carnes., 2003; Watkins-Hayes 2014). More recent work has shifted to answering these deficiencies, however with mixed results (Watkins-Hayes, 2014).

Understanding sexual risk behavior becomes even more essential when considering the role it plays in safe sex practices. In their annual epidemiological report 2014, the European Center for Disease Prevention and Control (ECDC), indicate that sexual transmitted infection (STI) continue to pose a threat to the public health in Europe. Many sexual behaviors increase an individual’s risk of STI contraction. Having sex without a condom, having sex with many partners, and having sex for pay or paying for sex are especially risky (Campsmith et al., 2008; Workowski & Berman, 2010). In the Stitching HIV Monitoring (SHM) monitoring report 2015, sexually transmitted infections (STI), in particular HIV continue to pose a threat to public health in the Netherlands. At the end of 2014 19,773 people have tested positive for HIV in the Netherlands, of whom 18,355 are in care. It is estimated that there are around 2,800 people who are HIV-Positive and living in the Netherlands, but don't know it. Understanding the mechanisms around the negotiation and assessment to have safe versus unprotected sex is essential in high-risk populations, such as gay and bisexual men in whom nearly two-thirds of new HIV infections occur (Workowski & Berman, 2010; Parsons, Grov, Golub, 2012).

Despite the implementation of behavioral preventive interventions and technologies designed to slow the transmission of HIV, as well as the coverage of antiretroviral therapy (ART) among HIV infected men who have sex with men (MSM), HIV continues to spread among high risk populations of not only the Netherlands, but other countries throughout the world (WHO, 2013)(Parsons et al., 2012). In response to this, a new biomedical approach has been created to offer HIV negative individuals a chance to reduce their risk of HIV through the usage of low intensity ART, it is the hope of researchers that the usage of pre-exposure prophylaxis (PrEP) will act as a preventative form of treatment against the continued spread of HIV. The multinational iPrEX study has reported a 44% reduction in HIV acquisition among MSM using daily PrEP, when compared to placebo controls. They also found a 92% reduction in HIV infections among MSM who remained adherent to the usage of daily PrEP (Grant., et al., 2010). Overall the usage of PrEP represents a new tool within the arena of HIV prevention. However, while many researchers are optimistic about the role PrEP will play in diminishing HIV transmission, there are many who argue against the availability of PrEP and the subsequent consequences, such as the potential increase in high risk sexual behaviors (i.e. condom-less sex).

Bareback sex is a slang word for a form of sexual activity, commonly penetrative sex, done without the usage of a condom. The term originates in the gay community and comes

3 from the equestrian term bareback, which refers to the practice of riding a horse without a saddle (Berg R., 2009). Overall, the practice of barebacking is usually referred to as conscious choice to not use condoms during penetrative anal sex. As the potential sexual health repercussions of such a phenomenon are exponential, it is imperative we critically examine the nature of such a practice in order to better understand how we may better improve sexual health efficacy. As stated above very little has been done to understand how culture, society, and even individual factors shape the sexual risk taking subculture. To these ends we must ask the question of how intersectionality of so many factors shapes the practice of this phenomena, and how the introduction of PrEP as a new biomedical technology may shift the overall culture of sexual behavior for MSM, and in turn change the nature of this practice among the MSM of Amsterdam. To these ends, I aimed to conduct an ethnographic field study surrounding the MSM culture of the greater Amsterdam area. In doing so my fieldwork has been guided by the following research question:

How does PrEP as a biomedical technology, shape the psychosocial and cultural landscape of MSM who practice bareback sex behavior in Amsterdam, the Netherlands?

Literature Review

In order to understand the potential influence of PrEP on the bareback subculture, it is imperative to understand the individual and ecological (socio-environmental) motivations to have bareback sex. As stated above, bareback sex is a form of penetrative sexual activity forgoing the usage of condoms. As such, it is important to understand how condoms play a role in the individuals’ assessment to partake in bareback sex. Condoms, initially used for contraceptive purposes, quickly came to be used to limit or prevent sexually transmitted diseases. As the AIDS epidemic emerged and the transmission factors of HIV became known, the usage of condoms became even more prevalent as the principal tool in the prevention of infection. This was more so true for MSM who engaged in anal sex, the importance of the usage of a condom in HIV prevention helped to shape the role of sexual health and interventions in the fight against HIV, thus establishing its usage as a norm for sexual behavior. However, the choice to forego the usage of condoms itself is a complicated one with many factors, many studies have focused on this particular issue with various results.

Adam et al. (2010) also found that among many MSM who report unsafe sex scenarios, many involved the concept of being lost in the “heat of the moment”. As in many other studies, a common theme reported is the role of condoms and erectile difficulties, as well as the reported urgency of passion and opportunity to connect with a particular desirable partner accounts for some unsafe sexual encounters (Calabrese et al., 2012). In addition many studies have found a connection to the usage of drugs or alcohol as a facilitator for these heat of the moment scenarios (Berg et al., 2011; Grov et al., 2007; Watkins-Hayes et al., 2014). Furthermore, heat of the moment situations may further become compounded upon by trade- off scenarios, in which men may feel at a disadvantage with a particular partner, be it in terms of age, ethnicity, or attractiveness. There is a fear of not wanting to offend or insult the

4 desirable partner, thus leading to a trade away of safer sex implication in case it leads to an obstacle in having sex with this desirable partner (Adam et al., 2010).

The role of sexual compulsivity has also been associated with increased sexual risk behaviors among MSM. Often characterized as sexual fantasies and behaviors which interfere with an individual’s personal and often inter-personal well-being, these fantasies and behaviors can occur in both men and women and continue increase over time, leading to further disruption in an individual’s life (Kalichman & Rompa, 1995; Parsons, Kelly, Bimbi, Muench, & Morgenstern, 2007; Parsons et al., 2012). When comparing MSM without sexual compulsivity to MSM who do, researchers have found that those with signs of compulsivity report higher rates of unprotected anal intercourse, an increase in numbers of sexual partners, more instances of sexual intercourse under the influence of drugs, and higher incidence of HIV and STI. (Grove, Parsons, & Bimbi, 2010; O’Leary, Wolitsky, & Remien, 2005; Parson et al., 2012).

While there are numerous theories for why MSM may engage in unprotected sex, one constant among the research among MSM who self-identify as gay men, is the theme of feeling alienated from the overall gay community, or conversely strongly identifying with it (Adam et al., 2005; Adam et al., 2008 ). It is here that alienation from a community you feel you should belong to, can bring on an internal feeling of loneliness, researchers have argued that it is this need to be accepted into the community that sometimes drives men into taking unsafe sexual risks. The same could be argued to play a role among MSM who do not identify as gay. This also plays into the perception of intimacy, not only with one’s sexual partner, but with a community in of itself (Frasca et al., 2012). While it can be argued that various psychological factors as well as social factors shape these concepts, the possibility of an internal construct of these social values placed on community and intimacy help to shape the overall field of bareback sexual behavior(Adams et al., 2005).

Lastly, as stated before, the need to answer the loneliness in the individuals’ self may drive the intent of not using condoms in a sexual situation. Yet decision-making is a cognitive process in which a course of action is selected among many alternative possibilities. Every decision-making process should produce a final choice that may or may not prompt an action. The decision of whether or not to pursue a sexual encounter has intrigued many researchers. What can appear to be a simple choice of yes or no often involves a complex balance of short- and long-term potential benefits and costs , to both self and others. In answer to the question of how MSM weigh and out-weigh the risks and benefits of bareback sexual behavior may be tied to the final internal factor to be discussed, inevitability. Previous research has found that small portion of MSM have a preconceived sense of inevitability in that becoming infected with HIV is just a matter of time in the MSM community (Balán et al., 2013 ).

It has long been known that social factors such as race, and socioeconomic factors contribute to disparities in health. To this degree it can also be argued that sexuality can as well. At the widest level of social influence, factors such as heteronormativity may play a role in the alienation and rejection of MSM as a sexual minority. To this extent researchers

5 have viewed barebacking as a phenomenon which exists in an oppressive heteronormative society (Riggs, 2006). It is further argued that barebacking is a result of MSM asserting their expression of sexuality in an attempt to protest the homonegative views of sex (Holmes & Warner, 2005). The expression of homonegativity in society overall may act as environmental stressor, which in turn may be preventative in HIV reduction behaviors.

The internet has the capacity to provide a social network and environment to a unlimited assortment of social phenomena , thus providing endless opportunities. Yet how it does so is not yet clearly understood. While not having a hand in the creation of the bareback subculture, it has certainly has facilitated it. The internet serves as a medium in which MSM who bareback may be able to locate one another more easily. In research by Grov et al. (2006) it is estimated that there are about half dozen websites which exclusively target men who bareback seeking partners. According to cybercartography work on these websites and other bareback related sites, barebacking behavior was encouraged as an “expression of masculinity, courage, freedom and intimacy” (Carballo-Diéguez et al., 2006; Berg, 2009). Other research has shown that MSM find the internet as an easy medium in which to find partners who want to bareback (Halkitis & Parsons, 2003). Overall, research has found that with the rise of the internet as a sexual venue, the emergence barebacking related websites has potentially contributed to barebacking in of itself (Elford et al., 2007; Grov et al.,2007; Blackwell, 2010 ).

The role of community activism has also shaped the landscape of the bareback culture. Research has found that MSM who practice bareback sex have found themselves in a changed cultural climate, which was shaped by a sense of complacency and normalcy. A lack of social responsibility and reported fatigue with the AIDS epidemic and condoms, has resulted in the normalcy of bareback behavior (Carballo-Diéguez & Bauermeister, 2004; Halkitis et al., 2003 ). The assumption of bareback sex as a norm continues as men who practice it report lower perceptions of safer sex norms in their community, suggesting that in certain groups, the act of bareback sex has already shifted to a form of social structure which as affirmed and normalized bareback sex (Berg, 2008).

In general, with the improvements of HIV treatment and the increase in longevity of individuals living with HIV, as well as improvement of quality of life, there has been a shift in the perception of HIV infection. With these advances in treatment and medical technology it is possible to argue that the perception of HIV as a chronic debilitating death sentence has been shifted to one of a simple chronic disease manageable by daily medication. Many research studies have found that this view has contributed to MSM’s decision to bareback in decreasing their concerns of infection (Berg, 2013; Elford et al., 2007). In one particular study men reported the knowledge that fewer men were developing AIDS due to improved medical technology lead them to have more unprotected sex (Mansergh et al., 2002). In addition research done by Halkitis et al. (2003) found that nearly half of the MSM in their sample felt that barebacking increased in New York City due to advances in medical treatment of HIV. In London, Elford et al. (2007) found that barebackers where much less worried about HIV infection due to the availability of HAART.

6 With current public health and HIV prevention movements aiming to implement PrEP to the Netherlands in the near future, there continues to be concern over how such a biomedical technology can shape the lives of those it was intended for. Before implementation it will be necessary to assess how such technology can shape the already existing culture of bareback sexual practice. Recently work undertaken by Bil and colleagues (2015) attempted to examine the role of PrEP awareness and intentions among the MSM in Amsterdam, the Netherlands. They found that despite indications of an overall low intention to use PrEP among their sample, MSM who indicated a high degree of sexual risk taking were more inclined to be interested in the usage of PrEP. Similarly Golub and colleagues (2010) found parallel results among MSM of New York City as well as reported a decreased usage of condoms with intentions to use PrEP as well as an increase in sexual risk behaviors. Further research by Golub et al. (2013) later attempted to identify potential facilitators and barriers to PrEP acceptability as well as motivations for adherence among MSM and transgendered women in New York City. They found that while over half their sample were willing to take PrEP, the most common barrier to PrEP use were health concerns, including both long term and short term side effects, the impact on future drug resistance, and the overall concern that PrEP does not provide complete protection against HIV. Facilitators to PrEP were free access, followed by support services such as regular HIV testing, sexual healthcare/monitoring, as well as access to counseling. One of the most interesting findings of this study was that participants of color were more likely to rate barriers and facilitators of PrEP highly when compared to their white counterparts, due to social factors associated with disparities in access to prevention and care among MSM as well as disparities in access to or acceptability of PrEP. Based on these studies it is clear that the advent of PrEP usage among the MSM community will have an impact on sexual behavior and health practices. To these ends I have attempted to identify potential barriers and facilitators to use PrEP among the bareback MSM population in Amsterdam, Furthermore I have endeavored to observe the potential influence PrEP may have on long standing high risk behaviors. Finally, my overall goal has been to understand the psychosocial nature of bareback sexual practices as well as the psychosocial motivation to use PrEP.

Theoretical Framework

In an attempt to explore the dimensions of bareback sex as a sexual subculture among MSM we must first identify what forces shape the practice of bareback sex, and how it may be conceived as a sexual subculture. In using Bronfenbrenner’s ecological systems theory, which identifies ‘environmental’ systems in which an individual may interact. I will attempt to provide a framework in which I can critically examine the relationship of the individual with the surrounding community and overall society. In using the Ecological systems theory, I approach bareback sexual behavior from a multi systemic perspective. This theory emphasizes the reciprocal relations among multiple systems (the self, cultural, economic, and societal) of influence on a person’s behavior (Bronfenbrenner, 1979).

According to this approach, an accurate and comprehensive understanding of MSM sexual risk behavior must include knowledge of both the personal and environmental factors which may contribute to the decision to practice bareback sex. The overall goal will be to focus on

7 the social ecological influences, as well as psychosocial barriers and motivations, which may or may not play a role in the formation of this subculture/sexual practice. Very little has been done to understand how factors from multiple systems of influence can interact and/or combine with each other to shape a behavior. In using a multi-systemic perspective it is possible to identify the relationship between each system of influence, and how each may interact with the other, each playing a role in both direct and indirect effects on behavior. In a sense, one system may serve as a mediator of the effects of other systems/factors in terms of the behavior in question. Additionally, in accordance to this model, sexual behavior in of itself may hold some influence over each system in a form of feedback mechanism which continues to shape and reshape the interaction and relationships of each system(Kotchick, Shaffer, Miller, Forehand, 2001).

Conversely, using the Ecological Systems Theory in the study of PrEP’s influence on the established subculture of bareback sex will also provide a potential map of barriers and facilitators to its usage and implementation. Thus providing a map of what forces may play a role in the implementation among MSM in the Netherlands.

Chapter Two

Research Methodology

8 Introduction

To begin my study of MSM sexual practices in Amsterdam it was necessary to plan how to introduce myself to the community. Originally, during the initial planning stages of my thesis I had hoped to attach myself to a larger project aimed at examining the barriers to HIV prevention strategies (such as PrEP) among people from HIV endemic countries (PEC) living in the Netherlands. In doing so it was my hope to intersect with members of the MSM community, however as time went on it became clear that the needs of my research were shaped by access to the MSM community in Amsterdam. In order to understand how a biomedical technology such as PrEP can shape the psychosocial and cultural landscapes of MSM in Amsterdam, it would be necessary to systematically observe the culture in question. This is especially important in the study of bareback sexual practice, which in of itself can be seen as a subculture within the larger subculture of MSM. To do so would require an ethnographic approach, so as to immerse myself within that community.

A central tenet in ethnographic methods is that human behavior can only be understood within the context of which it occurs. In relation to understanding sexual practices, researchers often find themselves relying on self-reported data which may or may not carry certain biases. In the practice of a behavior (such as bareback sex) an individual’s behavior is linked to the context of the situation, this infers that people cannot always be studied independent of a situation (Baillie, 1995). In order to understand how bareback sex is practiced and shaped as a subculture I had to go where MSM practiced this behavior.

The first stage of my fieldwork involved identifying sites of interest. This involved identifying key stakeholder and informants within the overall MSM community in Amsterdam. Using various internet search engines, as well as social networking sites I identified various areas in which MSM congregated both socially as well as sexually. Each of the sites visited during my fieldwork was selected carefully based on areas of high MSM populations. My fieldwork officially began on the 29th of February 2016 to the 8th of May 2016.

Ethnographic Methods Ethnographic Sites The following sites where used as places for ethnographic participant observations as well as data gathering through the usage of conversations with patrons and key informants (such as bartenders or managers). Through participant observation I was able to interact with various people. In doing so I managed to identify key actors which in turn became key informants. By immersing myself in a site I managed to establish a presence, which in turn facilitated establishing rapport with key actors in the community. Site visits spanned the months of March and April, with at least one site being visited daily. A majority of the data used in this thesis are based on field notes taken while visiting each site.

Field Site A

9 Field site A is a gay bar with a large darkroom area in its basement. The basement consist of a maze/labyrinth type of design with various types of cabins and corners for men to have sex. The bar opens at 13:00h to 01:00h/3:00h, activity in the bar gets very busy in the early evenings during after work hours (17:00). This bar also provides free condoms and lubricant from dispensers in the bar area.

Field Site B Field Site B is a gay bar, similar to Field site A literally around the corner. Like the Field Site A, Field site B opens at 13:00 to 01:00/03:00. The ground floor consist of a bar, smoking lounge, coat check, and toilets. The upstairs of Field site B offers a sexual play area, with a dark room, multiple cabins and cubicles, as well as a sling and various glory hole areas. Like Field site A, activity will pick up after working hours, as well as weekends. Additionally, you can find free condoms and lube in the bar area.

Field Site C Field Site C is a gay cruise bar located in central Amsterdam, on a street well known for it leather scene (as well as leather wear stores). Field Site C itself is well known for its gay leather scene as well as various sexual fetish scenes. Split into two floors, the upstairs holds something of a rest area as well as bathrooms, a few dark corners for sexual activity as well as a sling and area for a DJ. The downstairs portion holds multiple darkroom areas, a smoking area, as well as a sling, glory holes, and a few cabins/cubicles. Field Site C has a late night opening times, from 22:00 to 04:00/05:00. According to key informants, Field Site C is most active on weekend nights, as its late night hours make it hard for many besides tourist and well known patrons from frequenting on weekdays. Solely a men’s bar. It is necessary to ring a door bell and be viewed by the bartender from a camera in order to gain entry.

Field Site D Two doors down from Field Site C (Owned and managed by the same people), Field Site D is a self-proclaimed “sleaze” bar for men.. Open slightly earlier than The Eagle, 20:00 to 03:00/04:00, many men will frequent this spot before moving next door to Field Site C for one of their themed fetish parties. Two floors for sexual activity, once past the bar you will find multiple glory holes as well as dark rooms and stalls for sex, fetish-themed furniture such as a sling and St Andrews Cross, there is also an area set up for golden shower play. Upstairs is completely a dark room with a few more glory holes and a ‘shower fall’ for golden shower themed nights. Fetish-themed, this bar offers many different parties appealing to various fetish themes. Similar to Field Site C only doorbell access to the bar.

Field Site E One of the more popular gay clubs in Amsterdam, Field Site E offers a popular dance and cruise scene. Field Site E offers an assortment of themed parties from fetish-themed to normal dancing and drinking scenes. Open from Tuesday to Sunday ranging from 20:00 to 01:00/04:00/05:00 depending on the night and party theme. Some nights have a very strict entrance requirements dependent on dress code. Some nights are about certain themed gay

10 fetishes or men only action, while other days are co-ed and themed for simple parties and drinking. The club is split into three parts, the ground floor holds the main bar and dance floor. The upper floor holds a balcony which overlooks the ground floor bar area, as well as a dark room/cruise area with sling and couches. Condoms and lube are available throughout the club, the basement holds toilets, some private cabins and dark rooms as well as showers where you can rent towels. Field Site E has been the site of a few sex themed party to which I have volunteered at.

Field Site F Field Site F is a relatively new sauna to the gay scene of Amsterdam. Opened since the end of 2013, Field Site F is operated and managed by the same management of Field Site E. In the Sauna there is a capacity for about 260 men (260 lockers). The sauna has a large bar area with couches and lounges, there is smoking room right off the lounge/bar area. Next to the lounge is a hot tub, near a set of showers and a dry sauna. The sauna also holds a large steam room set up as a labyrinth. In the sauna itself there are 10 private cabins, A TV room, a sling room and a few open/ dark room spaces for sexual play. Overall the sauna represents a mix of both casual sex and relaxation. Open from 12:00 to 06:00 on weekdays and open 24 hours on weekends, the sauna attracts various types of men depending on the time and day. Free condoms and lube are distributed throughout the sauna, and safe sex is openly encouraged.

In my ethnographic approach I attempted to place myself as a man who has sex with men in an environment in which topics surrounding my research question would come to light. Often in anthropology, the researcher becomes a tool or actor in the very subject of study. My role as a researcher was well established among the various field sites well before my initial attempts at formal data collection, however it was well know that I was also a gay man, with a healthy sex drive and curiosity about practices taking place in these sites. While I will not denie the fact that I have been approached for sex on many different occasions, I have done my best to keep any such contact out of my data collection. I feel that it would be unethical of me to use any information gathered through sexual contact for the purpose of my research. All respondents be they formal or informal are men who I have not had any sexual contact with during the scope of my fieldwork. In addition all field notes where written down by me either in a journal after visiting a site or in a smartphone, as to disguise my note taking to potential respondents. It should also be noted that the primary language of my field sites is Dutch, yet due to the international character of Amsterdam, the widespread use of English, also by Dutch speakers, I encountered no difficulties communicating with respondents. In some cases I would say some native Dutch men had better grammar skills then myself.

Interviews In addition to ethnographic field observations, 20 men who identified themselves as having sex with men were recruited for audio recorded interviews on the topics of PrEP and sexuality from the greater Amsterdam area. Participants were recruited using various methods such as Internet based (Facebook and other social sites) as well as internet based dating apps (Growlr, Scruff, PlanetRomeo) On average interviews would take place in the place of the participants choosing, either their own home, a cafe, or bar. On average

11 interviews took about 1 hour to complete, leading to over 20 hours of recorded interviews. Topics covered included demographic/cultural background, opinions on sexuality among gay and bisexual men in Amsterdam, conversations about the participants own sex life, knowledge of sexual health information (access to, std’s and HIV), knowledge and opinions on PrEP, and finally attitudes and opinions on bareback sexual behavior. For the purpose of this thesis, most of the data from these interviews where rarely used due to their complex nature, length of interviews, and time constraints in terms of transcription and analysis. Future research opportunities will be used to analyze the data closely.

CyberEthnography The final addition to my data collection was around conversations and discussions generated among various social media groups surrounding the issues of PrEP here in the Netherlands. Using certain Facebook groups, as well as the internet hookup sites such as BullChat, I generated conversations on PrEP by posting requests for comments or interviews. Overall I have collected 10 short conversations about feeling and concerns to PrEP usage on BullChat, as well as observed posting on PrEP advocacy on the PrEPNu group on Facebook. Additionally, data was generated in my attempt to recruit participants for in-depth interviews through various dating apps. While not interested in meeting for a recorded interview, many men were willing to share their opinions on the topics of interest with me, thus providing additional insights into the role of PrEP here in Amsterdam. Many of these quotes where recorded in my field notes for analysis later on.

Informal Conversations Apart from my ethnographic work and formal interviews, I also managed to collect data from various Key informant and stakeholders within the MSM sexual community. Most of these conversations took place in informal settings, such as bars or clubs, or even over lunch and coffee. Most held positions among various research groups either within the GGD or other sexual health related organization. Some also included conversations with bar owners and managers, and even activists among the PrEPNu movement here in Amsterdam. Being as these conversations where informal, there is no audio recording of these discussions, all I have are essentially notes taken after each conversations. Overall I would have had the opportunity to speak informally to at least 10 Key informants, in which we covered topics about PrEP expectations and attitudes as well as gay and bisexual sexuality and MSM sexuality, and overall MSM sexual scene here in Amsterdam. A majority of my data present are based off of these informal conversations, as many came from a total of 52, men ages ranging from 22-68.

Practical and Ethical Considerations Potential risks to human subjects include breach of confidentiality which could occur if private and sensitive information regarding sexual health or use of HIV prevention strategies could be linked to an individual research respondent and if this information was obtained by person(s) outside of the research project. A breach of confidentiality could possibly lead to psychological discomfort or distress on the part of the research respondent. Decisions over sexual health and the use of HIV prevention strategies (eg. condom use) are

12 emotionally charged and may lead to conflict within relationships, MSM are at risk of being stigmatized by community members if they chose an HIV prevention strategy which does not conform to local societal norms. Participants who have jobs may lose their job if they articulate views about HIV, sexual health or HIV prevention strategies which are not considered acceptable from a normative perspective. Steps have been taken to protect participants against potential risks posed by their participation in this research. No personal identifying information has been collected through the ethnographic, qualitative and participatory exercises. After data collection, only I had access to the recorded MP3 data and field notes. All files were password protected. Any person participating in my research has been informed of all risks and protections in the verbal consent script. Participants, including both formal and informal have been informed of their right to withdraw from the study and to not answer any questions they did not feel comfortable answering. All respondents have been provided my contact information in case there are any follow-up questions concerning my research or their participation in it. All data based on this research has been reported in unique identify codes (methodology, participant category, interviewer, date). No individual respondents can be identified. The interviews have been conducted in either the privacy of the participants’ homes or in a location of the participants choosing. If other people were present in the interview space during the interview, permission was sought from the respondent to conduct the interview in a private part of the location. The recruitment and consent process ensured that the study participants understood the purpose of this study. If a respondent expressed any discomfort or stress during an interview or data-collection process, I would remind him that he did not have to answer questions which may make him uncomfortable and would give the respondent time to recover before proceeding with data interview. If a respondent expressed any mental or emotional anxiety, I offered to terminate the interview.

Data Analysis Due to the ethnographic nature of my research most of my data stems from my field- notes as well as informal conversations both in person and online. During fieldwork I digitalized all hand written field notes for analysis. Using the program NVIVO, I began to systematically code for themes using a grounded theory approach (Glaser & Strauss, 2009). Through coding and classification of my data, specific themes began to emerge. The most prominent theme to emerge from analysis was stigma followed closely by risk, and then pleasure. Other themes such as drug and alcohol usage, sexual health knowledge, health behavior, and health care dynamics also emerged. However, due to my own experience in the field of HIV prevention, I chose the three most prominent themes which I felt reflected not only psychosocial factors, but also held value to myself. As noted in many ethnographic based research, the role of the researcher holds sway over many aspects, including data interpretation. Thus, the themes reviewed in this thesis are a reflection of my own interpretations of the data, which are colored by my own experiences and perceptions. Segments of data used to support my claims came from multiple sources. Triangulation of these data granted more validity to my findings. However, as with the nature of such research

13 the validity of such statements is in question to how I as the researcher interprets them. This leads to greater subjectivity and is a limitation of this thesis.

Obstacles/Reflexivity Overall during fieldwork I encountered few obstacles in terms of accessing sites, however few informants permitted recording of interviews. Another issue that was my ability to be self-aware of my biases, while maintaining a professional line while interacting in sexual themed places. While neither of these required much work to deal with, it did provide me with times of stress and worry about the way I collected data and the validity of such data. As an openly identified gay man I tried to be actively reflexive in my approach to this study. I kept a diary during my time in the field, which aided in controlling potential bias during data collection and analysis. When approaching potential informants, I did my utmost to clarify the intent of this study, especially that I was not looking for sex. It is also important to consider how I as a gay male, may have unwittingly influence the responses of my participants, while peer to peer dialog may reveal hidden themes, it may also hinder them. I have attempted to be self-reflexive during the entire process of data collection through the usage of a diary, as unwitting biases could have been reflected in my tone or manner of speech. Lastly, questions posed to me about my own opinion on the subject matter of the interviews were handled with care and I have attempted to maintain a neutral ground in my responses to the best of my abilities.

Chapter Three Risk and Health, Sexual Behavior of PrEP

Introduction

14 The ability to take risks is a hallmark of human nature. When facing uncertainty, humans often begin an internal calculation of various outcomes, which scholars define as risk (Baral et al., 2013). Risk is the consequence of an action taken in the face of uncertainty. In taking risks one has the potential of losing or gaining something of value. The values themselves are subjective to the individual, as each individual differs in the dimensions of social, interpersonal, and individual factors. Values such as physical/emotional health, social standing, and financial wealth are just few of the facets in which risks can influence. When it comes to the domain of sex, we can be faced with the consequences of contracting a sexually transmitted infection and/or experiencing unintended pregnancies through the uncertainty of risky sexual behaviors. To define sexual risk, we must first understand unsafe sex. Going into my fieldwork, I was already well aware of what I wanted to look at. Bareback sexual behavior, is often epitomized by sexual health care workers as one of the most unsafe forms of sex. Yet, apart from the biological associative risks involved with condomless sex, it was important for me to reflect on what constitutes risk. The uncertainty that a sexual partner carries a STI remains a pivotal factor in the definition of unsafe sex, the risk is the action, or choice to refrain from condom usage. To these ends, I began field work hoping to understand the pathways in which an individual may choose a given action or choice. Surely there must be more to the reasoning in the practice of bareback sex than simply making a choice in the face of uncertainty. As one respondent commented over a beer at Field Site A:

“Bareback sex is fantastic! I have only gone bare with partners in a long term relationship. I trusted him, but it’s still a risk.” “We play with other guys, but I trust that he doesn't go bare with them. I’ve had mistakes before, and you have to deal with the anxiety and fear that you may get something, you don’t ever know, right?” Chuck 32, 08-03-16

“You don’t ever know, right?.” This statement sums up the uncertainty that exist among MSM and condomless sex. An individual cannot know for certain that their sexual partner is without a STI. For MSM, the most important uncertainty currently faced among MSM is that of HIV and AIDS (Watkins-Hayes, 2014), although other types of uncertainty ranging from other STI are also relevant. The influence of the HIV/AIDS pandemic has had a collective effect on sexual health practices and beliefs worldwide. In the face of this uncertainty, the decision to eschew condoms during sexual intercourse remains somewhat a mystery. Previous research has attempted to understand the individual and situational factors that play a role in this risk behavior. Factors such as attitudes towards condom usage (Appleby, Miller, & Rothspan, 1999), as well as drug and alcohol usage (Grove, Parsons, & Bimbi, 2010) are but a few of the many factors which have been investigated, and some of which I came across during my time in the field. Examples of these can be seen in some of the responses to my question: What are your views on condoms?

“Well, I know that you should use condoms to prevent HIV, but I just can’t stay hard with them on.” “Condoms don’t feel good.” -Third, Grindr, 20-03-16

“Condoms make my dick go soft. I hate using them” -Seventh, Growlr, 11-03-16

15

“Do you use condoms for oral sex? No, right? So why would I use it when fucking?” -Mac, unknown age, Field Site D, 04-04-16

These responses where similar to others I received during my time in the field. Many of the men I talked to who practiced bareback sex shared similar views as the ones above. Conversely among informants who self-identified as inconsistent barebackers (men who indicated condom usage with only some partners), condom attitude was indicated as a factor, yet, the usage of party drugs, as well as alcohol consumption was in some cases also a factor.

“Usually I use condoms when I meet a guy, but sometimes I get so horny that I just need to feel the guy inside, feel him as I fuck him, nothing between us.” “Sometimes when I am high I forget to use a condom. The E [Ecstasy] sometimes gets me so hot I just want to connect with the guy” -Bart, 34, Field Site D, 17-04-16

“A little Speed and I get so horny, I’ll just fuck raw.” -George, 51, Field Site B, 22-03-16

“I always use a condoms, except, maybe I’ll be partying with some friends, and I’ll get high or really drunk, and, I like have sex with them, without a condom, but I’m not too worried, I know them, they get tested all the time, so do I, so I’m not worried about getting fucked without a condom by them, but I know better.” -Dan, 57, Field Site C, 12-04-16

“I know I know, its risky, but I just can’t stand condoms. I can always tell the difference when A guy is fucking me with one, it doesn't feel right” “…..Have you ever taken MDMA with some G [GHB]? It feels so good getting fucked, You can feel everything, even the guys heartbeat. If he is fucking with a condom you can’t feel anything, it sucks.” -Jelmer, 31, Field Site E, 24-03-16

These respondents indicated an awareness to the risks they were partaking in Yet it could be argued that their attitude towards condoms and their drug usage played a role in their risk assessment. Obviously these responses are but the tiniest indication of a larger theme, and further research will be necessary. Based on the responses above, I would posit that instead of being factors that enable risk behaviors, such as attitude towards condoms as shown by Bart, or drug/alcohol consumption as seen by both George and Dan, that it could be that these factors where simply in addition to the risk assessment of bareback sex. While I do not try to presume that these factors do not play a role in sexual risk taking and bareback sexual behavior, I believe the question should be asked - Why do they? Most importantly, with the advent of additional HIV preventative technologies in the fight against HIV these questions become increasingly important. However, the way we asses risk is also important, how do we compensate for things we know are risky, or protected, and how do we handle risk situations once we know they are not as risky?

Risk Compensation

16 In the health sciences, we see new technologies emerging in the fight again disease and disorders. In the realm of sexual behavior, new biomedical technologies in the fight against HIV/AIDS and other STI’s are imperative in our struggle to curb the ongoing spread of such diseases. With advances in such technology there is speculation about the possibility of unintended consequences, some of which are potentially damaging. In many preventive technologies and methods we find that these consequences unintended or otherwise stem from what is known as risk compensation (Hogben & Liddon, 2008). When defined, risk compensation is a theory which holds that an individual will change his or her response to a level of risk by becoming more careful in a more risky situation, while being less careful in situation which has less risk. It can also be operationalized as ones feeling of being protected against something, an individual may engage in other risky sexual behaviors. As it follows, in the realm of health, to be protected from a health related risk, it is possible that you may engage in risk taking behaviors which may put you at risk for the same or other problems (Cassell et al., 2006; Hogben & Liddon, 2008). Throughout health care history we can see various patterns of such thinking. For example, during the introduction over the human papillomavirus vaccinations for young women in the United States, There was fierce debate over concerns that once protected, young women would be more incline to have unprotected sex with more partners at an earlier age (Lo, 2006; Kapoor 2008; Kahan, 2010). Similar arguments were made with the introduction of condom distribution programs in the fight against HIV/AIDS (Cassell et al., 2006). Osorio and colleagues (2015) did a study which revealed that adolescents who believed sex with condoms are 100% safe, had a higher chance of having earlier sexual initiation, something of which is correlated with risky sexual behaviors later in life (Cassell et al., 2006). Furthermore, risk compensation in the form of increased sexual risk taking has been indicated among participants in HIV vaccine and microbicide trials (Chesney, Chambers, Kahn, 1997; Roddy et al., 2002), as well as among men living with HIV and on ARV therapy (Crepaz, Hart, Marks, 2004). To support these arguments I will attempt to explain how such a phenomena has occurred during my field-work.

My first run in with the concept of risk compensation came during a visit to Field Site F in central Amsterdam. An all-male sauna openly advertising to gay men, was one of my key field sites during my fieldwork period. Relatively new, having been opened at the end of 2013, the sauna has a capacity for 260 men. The sauna provides a rich environment for not only participant observation, but informal discussions, the sauna provides a spacious bar and smoking areas, as well as hot tubs and dry sauna (Further description in methods), as well as dark rooms and private cabins, Field Site F provided on of the optimal locations for my research questions. During my initial days there I struggled with myself and my ability to open up to members while being completely naked. Often when discussing my choice of field sites with colleagues, there would be some light banter about the sexual nature of the sites. A common misconception, while sexual contact and behavior does occur frequently at such sites, there are often times where in-depth discussions and debates may occur in common social areas. During my time at this sauna I was lucky enough to encounter an open discussion about sexual health risk among three members, this enabled me to drop my ‘shyness’ to the naked situation and quickly entered into dialogue with the men. One of the

17 discussions was about the seriousness of current STD’s such as chlamydia , gonorrhea, and hepatitis C. During this conversation I openly discussed with the men, my research interest in bareback sex and PrEP, and asked what concerns they may have regarding STD’s besides HIV, this was their response:

“I’m not all that worried [risky sex], you basically get an injection for everything nowadays.” “Yeah, I’ve had it before [gonorrhea], but it wasn't a big deal, I found out and got an injection. It hurt like a bitch though.” “They aren't a big a deal as HIV, but nowadays even that isn't so bad anymore. Guys are living a lot longer with new meds. I don’t want HIV, but its not the end of the world if I get it.” -Adam, Field Site F, 12-03-16

“I do bareback once in a while…[laughter] I did it just before you got here” “I only have sex with guys I know awhile, and it’s not that I worry, one guy he is undetectable so I can’t get it from him, He didn't come in me, you know? If I got something else they have medication for it. The GGD.” -Barry, Field Site F, 12-03-16

“I come here often, almost every week. It’s a nice place, you always meet new guys, it’s so close to Central there are always tourists or guys who live farther out stopping in.” “I always use condoms when I bottom [laughter] and I bottom a lot, but not when I top, I rarely use condoms then” “Topping is safer[seropositioning, you are less likely to get AIDS when you top. There are medications for STD’s too.” -Cade, Field Site F, 12-03-16

From the aforementioned quotes, we can postulate that the risk taking behaviors mentioned by these men (e.g. condomless sex, anonymous sexual encounters, seropositioning) are in relation to the premise behind the risk compensation theory. With the current ability to treat bacterial STI’s with antibiotics, respondents indicated very little worry in the possibility of infection. This line of thought is also coupled with the concept of anti- retroviral treatment, removing the ‘death sentence’ associated from the earlier history of HIV. The concept of taking a pill every day for the rest of one’s life seems to be mitigated in the face of sexual pleasure and disinhibition. The assumption that HIV viral load at an undetectable level creates a perception of protection enabling the practice of condomless sex with openly HIV positive individuals, without fear of HIV infection, despite the risk of other STI’s. To quote another man at the sauna, “I can’t get it if its undetectable” is just another concept of risk compensation.

Risk Compensation vs Disinhibition

There are contextual differences between risk compensation and disinhibition, and it is important to conceptually understand them in relation to an individual’s interaction with risk. Overall, risk compensation is a cognitive perspective (Hogben & Liddon, 2008), a perspective which applies to the diminished susceptibility due to a preventive measure which

18 permits an individual to increase their other risk behaviors. As mentioned above, preventive measures such as condoms or medical treatment can create the perception of diminished risk, thus enabling the increase in similar or other risk related behaviors. Conversely, the concept of disinhibition is rooted in the foundations of psychological theory. To be inhibited is to have a mental restraint due to feelings of self-consciousness or unconscious restraint. When applied to risk, inhibition can be seen as ones restraint against a risky behavior. Such restraint can be conscious or unconscious. Thus, disinhibition is implied to make one less inhibited. In terms of risk, disinhibition occurs when an individual will stop trying to avoid risk either to themselves or others (Hogben & Liddon, 2008). When it comes to sexual behavior, examples of disinhibition can be seen in the effects of drugs and/or alcohol. As indicated in the quotes above, drug and alcohol consumption are frequently associated with increased sexual risk behaviors. It should be noted that the individuals constant interaction with their social environment will shape and influence their disinhibition in any given situation. Intra and interpersonal relationships will also play a role in how an individual may or may not respond. For example, when inebriated, a person may become sexual incautious and more inclined for risk and sexual exposure. Yet if in a situation surrounded by people who they may not feel sexually inclined they may not proceed to act on such feeling, or such feeling will not manifest. The following comment from a man whom contacted me through an gay internet dating app known as Growlr provides an example of disinhibition:

“ I don’t bother with condoms, honestly at this point I’m probably already positive. If not, It’s inevitable.” - Second, Growlr, 07-03-16

The respondent was responding to an open-ad I had made online for individuals to discuss motivations of bareback sex. His response is one example of many which reflects another aspect to disinhibition; when an individual feels that he or she cannot avoid a harm, then they no longer attempt to do so (Hogben & Liddon, 2008; Balán et al., 2013). From this quote I was quickly drawn to his indication of inevitability, something of which has been often reported on in previous research. As posited by researcher Balán and colleagues (2013), the sense of inevitability, that becoming infected with HIV is just a matter of time in the gay community. These responses along with the aforementioned alcohol and drug use are good examples of how two different factors can play a role in disinhibition. While previous research and literature has used the terms of risk compensation and disinhibition interchangeably, the lack of caring indicated in disinhibition is the primary difference between the two.

Risk and Biomedical Technology

As mentioned earlier, the role of biomedical technology on risk behavior has been well studied in the realm of HIV preventive technologies. From the initial concerns of the HPV vaccines on increased protected sex among young women (Lo, 2006; Kapoor 2008), to the role of condom distribution programs enabling increased sexual partners and possibly increased risk behaviors with the intention of condom usage (Richens et al., 2000;Starks et al., 2014; Mullan et al., 2016). Previous research has also found indications of risk

19 compensation among various HIV vaccine and STD microbicide trails (Chesney et al., 2000; Roddy et al., 2002). With the advent of PrEP and its impending introduction to the Netherlands and other parts of Europe, it has become increasingly important to understand how PrEP as a biomedical technology may play a role on the risk assessment of its users. A key point of debate among public health researchers is the concern that PrEP may lead to risk compensation, thus leading its users to engaging in more risky sexual behaviors. While there is evidence of risk compensation with the usage of preventive biomedical technologies in previous literature. There is little evidence among the various PrEP clinical trials to indicate risk compensation (Baeten et al., 2012; Liu et al., 2013; Guest et al., 2008; Marcus et al., 2013). On the contrary, researchers from the IPrEx and Partners PrEP studies found evidence that condom use increased and diagnosis of STI’s decreased during follow-ups (Baeten et al., 2012; Marcus et al., 2013). These findings are echoed by the few men whom are currently enrolled in the AMPrEP study As one participant indicated informally- “Instead of having more bare sex, I think I’m actually more aware of who I'm having sex with, and just more aware of using condoms.” This thought is echoed among the few men I had an opportunity to speak to enrolled in the current study. The impact of PrEP on the sexual practice of users outside of the clinical trials continues to be understudied. While researchers in the Partners PrEP study found no substantial change in risk practices (Mugwanya et al., 2013), It should be noted that such findings could be regulated by social desirability biases. That social desirability can shape interactions is illustrated in the following explanation by Johnny:

“I don’t talk about my sexual practice with my GP[General Practitioner], he knows I’m gay, he is gay himself, but I don’t tell him I fuck bare.” “Its hard to explain, I know I should let him know, I think its because I'm embarrassed.” Johnny, 38, Field Site B, 23-03-16

We could infer from this statement that individuals may self-report socially desirablabl outcomes to the respective clinical trials, thus creating inconsistencies or weak associations between risk compensation and PrEP. Overall, the degree to which risk compensation plays a role in the individuals risk taking decisions, as well as the role of biomedical technologies on behavior continues to remain understudied, however there continues to be indications that risk compensation varies as a function of perceived risk, dependent on the technology being perceived as well as the individual in question. As indicated by researchers in the San Francisco US PrEP Demo Project, risk taking behavior seemed to fluctuate among participants. Researchers found that sexual decision making was influenced by various factors including individual, psychosocial, and health related. They also found that risk behaviors were also associated with factors relating to personal relationships, substance abuse, and psychological distress. They concluded that the risk compensation may also be influenced by such factors, and that further research was necessary (Hojilla et al., 2015).

Risk Behavior Change

20 Among the theoretical models of risk compensation and PrEP users, researchers predict that an individual may only increase their sexual risk taking when there is opportunity and a perceived meaningful value in doing so, such as in creasing sexual pleasure or relationship satisfactions (Eaton & Kalichman, 2007; Hedlund, 2000). What this implies is that risk compensation will not increase sexual risk taking among individuals who lack opportunity or motivation. For example, among individuals who exclusively practice bareback sex, will not further increase their practice. Furthermore, it is unlikely that individuals who have already calculated their sexual risk in terms of decision about, frequency of sex, sexual positioning partner selection, or number of sexual partners, will increase their risks along those factors. Yet among my time in the field I came across many individuals who self reported this not to be the case:

“ I do not know if this is such a good idea. PrEP can lead to guys fucking around more, all the other diseases, and its not completely safe, what if you forget about taking it?” -Sixth, BullChat, 13-03-16

“Have you seen guys who say they use PrEP in their profile? All they want to do is bareback!” - Second, Scruff, 14-04-16

“My friend is taking PrEP and now all he does is go bare.” -Second, Grindr, 08-04-16

Conversely, others indicated less concern about risk:

“I don’t think guys are gonna just start having bareback sex, I mean you're gonna do it if you want to do it.”-Teddy,62,Field Site A, 31-03-16

“I think its a great idea [PrEP], some people are worried its gonna make guys have more sex. Then all the other STD’s will rise. Or some say that men will just become more promiscuous than they already are. But I don't think so.” First, BullChat, 08-03-16

These initial comments simply reflect the anticipation of PrEP usage among men in the Netherlands, yet when we take a look at the men already using PrEP, whether or not as a part of the AMPrEP study we find very distinct views. On participant of the AMPrEP study indicated how his involvement in the clinical trial has increased his own awareness of his sexual behaviors.

“In the study we have to use this calendar app to indicate when we take the pill, when we have sex, and what kinds of sex we have, that sort of thing. I notice the more I do it, the more aware I am of what I'm doing when I hook Up with someone, If anything I think I’m being safer than I was before.”

This AMPrEP participant’s views are similar to findings as reported above, that in some cases, PrEP usage has shown to decrease sexual risk taking practices. Conversely, one of my key informants, a well-known key figure in the LGBT community who I will refer to

21 as Jake, met with me multiple times over the course of my fieldwork. We began a dialog about his own impressions of PrEP and his feelings about it:

Jake: “So PrEP is now starting a big thing here in Amsterdam, there is already a movement to push it for release now instead of waiting for the study.”

Kevin: “How are you're feeling about it?”

Jake: “I think its a good thing, It feels like we are moving in the right direction.”

Kevin: “Any concerns?”

Jake: “No, not really. I’ve heard the guys say that guys using it don’t want to use condoms, so I guess people are worried about that. Maybe I could see it being a problem if there are guys on PrEP who only fuck without condoms, and won’t sleep with a guy who wants to use one, but no, honestly I doubt its gonna make that much of a difference, apart from the protective aspect.”

Kevin: “Do you think guys will be more inclined to choose condoms if using PrEP?”

Jake: “I think they will use it if they want to use it, I really don’t think PrEP will change my mind if I want to use a condom.”

What is interesting about this dialog is that at the time of this conversation, Jake expressed an interest in PrEP, yet was not enrolled in the study, and did not consider himself eligible for it. Working close to the sex club industry, Jake has come into many sexual encounters with patrons, yet always claimed to use a condom. It was only a few weeks later Jake managed to attain a prescription for Truvada from his GP. While Truvada usage for PrEP has not yet been cleared for usage in the Netherlands, it seems that his GP was willing to prescribe it anyway. Upon our next meeting he openly discussed its usage:

“Ive been on it for about two weeks now, and I can tell you, since you are interested. I haven't used a condom since. At least when I’ve been topping.” “You wanted to know if PrEP changes behavior? Well I can tell you, it does, I’m taking it everyday, and I just don't worry anymore” “I have had so much more sex since I’ve been on it. Its fun! I’m enjoying it a lot more, and I can just relax during a party.” “My partner knows I’m on it, and I think it may be a relief for him as well.” “I haven't really gone bare when I’ve bottomed, but definitely when I top.” -Jake, Key Informant, Date Redacted

From these conversations I shared had with Jake, we can begin to see parallels with the situational factors which may contribute to behavior change with risk compensation. First let us address the setting, from our conversations Jake mentions his involvement with the sex

22 club party scenes, as of such he identifies it as one of the few places he tends to have anonymous sexual encounters. Before his usage of PrEP Jake was always adamant about his condom usage in such liaisons, yet as we can see from his quotes, two weeks into PrEP usage and he reports condomless intercourse. Hojilla and colleagues (2015) reported that among the men in the San Fransisco PrEP Demo Project, that preventive decision making during an encounter was largely based on the context of said encounter. For example, bathhouse or online chat site. Additionally the assessment of a potential partner’s risk was also dependent on the context. These findings mirrored what I experienced in the field, not only from Jake but others as well. That the risk assessment and preventive strategies MSM use to reduce risk are complex and dependent on individual variation and context of the sexual encounter. In addition to context playing a role in risk assessment and behavior we must also take a look at role of PrEP in conjunction with other risk reduction strategies. While Jake indicates condomless intercourse, he also mentioned his sexual positioning as a factor. This is mirrored by other informants thought my time in the field. The usage of topping or being the penetrative partner is well documented in studies on preventive risk behaviors among MSM (Seropositioning), especially when negotiating the risk in bareback sex (Halkitis et al., 2008; Van de Ven, 2002; Grace et al., 2014). This assumption is indicative of the argument that risk reduction strategies are not simply discarded in the usage of PrEP, but rather incorporated into an individual’s existing prevention methods (Hojilla et al., 2015). Lastly, It should be noted the relief exhibited by Jake during our discussion about his being able to relax and enjoy the sex party more. Previous research on MSM sexual concerns has found that fears of HIV play a role in the physical and emotional aspects of sexual behavior and risk assessment (Rosser et al., 1997). From his statements and those of others I infer that PrEP usage provides some sense of relief against fears and stressors surrounding sex and HIV, and thus plays an additional role in how and individual may negotiate their risk assessment in the face of sex. Hojilla et at. (2015) found a similar result among the men of the San Fransisco PrEP Demo Project, in which they too suggest that PrEP plays a role in alleviating sexual anxieties, and enhancing intimacy among partners.

Conclusions and Reflection

The role of risk in sexual decision making behavior is a complex one. Research has shown the influence of social and structural level factors play a role in the assessment of sexual risk in the areas of social, economic, organization, and history of sexual risk taking and HIV acquisition (Baral et al., 2013). Yet it is important to understand the individual level forces at work in any new HIV preventive strategies for these to be successful. Sexual Risk taking is a complex phenomenon that should be examined at an individual’s risk threshold and sexual health goals. If we are to strive towards the goal of an HIV free generation it is imperative that we look at how individual factors shape the efficacy of PrEP not only for the individual, but for the community overall. In writing this chapter, I often thought back to my own sexual encounters, both before fieldwork and after. As a gay man, living with the fear of acquiring HIV has played a large role in my own sexual initiation as well as behavior over the course of my adult life. The

23 longer I seem to work in public health, the more judgmental of certain things I become. My initial thoughts into the usage of PrEP mirrored those of some of my respondents, that PrEP was a dangerous tool. Ingenious, yet dangerous. I did not believe that our current societies where capable of using such a tool appropriately. That the goal of HIV elimination was fool hardy without a vaccine or cure. Yet the more I delved into the MSM party and club scene, the more I began to see the appeal of PrEP. The constant fear of HIV has long shadowed many lives since the initial onset of the epidemic, factors such as stigma hold sway over our sexual lives(See corresponding chapter). The advent of this biomedical technology has the power to change all that. Yet, are we as flawed social beings capable of using it properly? What does it mean to be proper? I have no answer to these questions, yet all I know is that my views on risk, and sexual behavior in the coming of PrEP have changed. Perhaps it would be nice to live and love without fear?

Chapter Four

24 Stigma, Sexual Beliefs and Behavior

Introduction

What is Stigma? I asked myself this question many times, over the course of my fieldwork. Yet when trying to put into my own words, often the definition seemed to allude me. Why do we place meaning on the actions of others? How do we brand those with differing behaviors in negative light? Originating in the late 16th century, this Latin term of Greek origins denoted a mark being made by pricking or branding (Merriam-Webster Dictionary). A stigma was commonly cut or burned into the skin of criminals and slaves, in order to mark them as polluted persons. These individuals were actively shunned and avoided, looked down upon, and lowered to the lowest of classes. It is known commonly in the present that the word stigma, when used as a noun, functions to name a specific type of label of status. Stigma is often used to indicate a mark of disgrace, usually associated with a particular circumstance, quality, or even a person (Oxford Dictionary). Synonymous with words such as shame, disgrace, and dishonor, conversely the term stigma may also be used to identify visible signs or characteristics of disease. In his book Stigma: Notes on the Management of Spoiled Identity (1963;2009), famed sociologist Erving Goffman describes stigma as “an attribute that is deeply discrediting” by other people and results in a degree of social rejection, often in the form of discrimination or disrespect; it exists when an attribute is linked to a negative stereotype. According to Goffman, stigma may be categorized into both discredited and discreditable attributes such as behaviors, physical conditions, or reputation. A discredited attribute can be perceived by others, while a discreditable one is not as obvious. It is in this distinction that an individual may manage a stigma dependent on how noticeable the stigmatized attribute is (Goffman, 1963). When applied socially a stigma can take many different forms. Often dependent on the cultural and societal sphere of influence, stigmas can be dependent on cultural values, gender, race, illness, and disease. Stigmas in today’s world can often occur in everyday settings, such as the workplace, educational institutes, within health care, the criminal justice system, and even with a family. It is also possible to conceptualize stigma as a process of interrelated components. According to research by Link and Phelan (2001), these interrelated components include:

1) The labeling and differentiating of attributes prevalent among certain groups of people 2) The association of negative stereotypes to those attributes 3) Placing the individuals possessing the fabled attributes into a separate category from the group 4) Employing strategies against separated individuals to the extent that they experience social loss and discrimination.

It is through this process in which stigmatized individuals may experience the perceptual and social components to stigma.

25

Additionally, in recent research by Ramdas and colleagues (2016), health related stigmas are conceptualized and categorized into four main types:

1) Experienced or Enacted 2) Anticipated or Perceived 3) Internalized or Self 4) Aesthetic

Experienced or Enacted health related stigmas are usually classified when a person experiences overt acts of discrimination, abuse, or negative attitudes in relation to a illness. For example, such experienced stigmas are prevalent among individuals living with HIV/AIDS and mental illnesses (Van Brakel, 2003). When a person or individual is afraid of encountering/experiencing stigma, or feels shame in association to a particular illness, they may begin to experience anticipated or perceived stigma. This type of stigma is also known as hidden distress (Scrambler, 1998) and may have more of an impact on quality of life than that of experienced stigma(Van Brakel, 2003). Internalized or self-stigma arises from the acceptance of a social stigma by those whom are targeted, thus self-stigmatizing themselves (Boone et al., 2016). Self-stigma is much harder to identify than experienced or anticipated stigma, yet it sometimes can carry the same level of distress, if not more (Burnham et al., 2016). Finally, the last type of stigma is the Aesthetic, when an individual or group is stigmatized due to physical bodily deformities which are visible (Ramdas, et. al. 2016). It is through the process of stigmatization that the association of unwanted characteristics form stereotypes. Once differences are labeled in such a fashion, an individual can remain stigmatized until the stigmatizing value is undetectable (if ever). Once stigmatized, individuals may also shape their emotions, behaviors, and beliefs according to the stigma (Major, 2005).

Stigma and HIV Stigma has been tied to the HIV/AIDS epidemic since its early onset in the mid 1980’s. The World Health Organization’s Global Program on AIDS, once described three phases to the epidemic, the last being the stigmatization and discrimination of individuals living with or at risk for HIV. This would in turn lead to a collective denial and further hinder prevention efforts (Parker & Aggleton, 2003). In general, the MSM community has continued to endure stigma and discrimination since the early onset of the HIV/AIDS epidemic (Boone et al., 2016; Garett et al., 2016; Earnshaw & Chaudoir, 2009). It can be argued that this stigmatization stems from the fact that male to male transmission carries a historical overtone of having been a major cause of the spread of HIV (Centers for Disease Control and Prevention, 2004). Over the years, research studying HIV related stigma has focused on the effects of such stigma on the health and behaviors of already infected populations. This research has helped to shape the knowledge of how social distancing and its consequent detrimental outcomes can affect those who are infected, particularly infected MSM (Wolitski et al., 2006). Researchers in collaboration with the Seropositive Urban Men’s Study Team (2006), found that HIV

26 related stigma was associated with depressive symptoms, avoidant coping mechanisms, and high risk of anonymous sex, among HIV positive men (Wolitski et al., 2006). Other studies have reported similar results across various HIV positive populations (Grove et al., 2010; Wohl et al., 2013; Earnshaw & Chaudoir, 2009). A primary point of concern among public and global health stakeholders, is to the consequence of HIV stigmatization and its potential impact on safer sex decisions and practice. Research has shown that stigma may prevent people with HIV/AIDS from disclosing their status to potential sexual partners (Ciccarone et al., 2003; Derlega et al., 2002), thus creating barriers to safer sex negotiation. Stigma can also interfere in the acquisition and dissemination of safer sex knowledge and education, as researchers have found that stigma may prevent individuals with HIV/AIDS from discussing with health care professionals how to practice safer sex (Makadon & Safren, 2007). These findings suggest that both the experiences of enacted stigma, and the awareness which comes from a stigmatized status can result in risky sexual behaviors among individuals living with HIV/AIDS. However, previous research that has attempted to examine this issue have not found any consistent relationships between stigmatization and sexual risk taking (Wolitski et al., 2007; Wolitski et al., 2009). In a study conducted among heterosexuals and intravenous drug users living with HIV/AIDS in France, researchers found that individuals reporting stigma from friends, family, or colleagues because of their HIV status were more likely to report unsafe sexual behaviors than those who did not (Peretti-Watel et al., 2007). Conversely, another study (Courtney-Quirk et al., 2006) found no relationship between HIV/AIDS stigma and sexual risk taking among homosexual men. Additionally, further studies on both homosexual and heterosexual populations have shown other factors besides HIV/AIDS stigmatization to be predictors of sexual risk taking among individuals living with HIV/AIDS (Golub et al., 2010; Vanable et al., 2006).

Anticipated HIV Stigma When it comes to populations at risk for HIV, there is very little research done on the effects of anticipated or perceived stigma on sexual risk behaviors. Most recent work on the effects of anticipated stigma covers the role of HIV testing practices among at risk populations such as the MSM community. In the case of anticipated stigma, HIV negative individuals may or may not endorse stigmatizing beliefs or stereotypes about individuals living with HIV themselves (Earnshaw et al., 2013). However, Golub et. al. (2013) theorized that the knowledge of negative societal attitudes towards an HIV infected individual may cause concern about experiencing negative consequences such as rejection, discrimination, or shame in the event of a HIV diagnosis. It is through this concern of future stigmatization that an individual may form a psychological barrier to finding out ones HIV status. Previous research has shown the relationship between HIV stigma and negative believes (stereotypes) and testing behaviors has led to distancing and reduced risk perceptions. For example, individuals may avoid HIV testing because they do not identify with their stereotyped perception of what kind of people are HIV positive, and thus are not at risk. However, researchers theorize that in anticipated stigma, the risk perception is not disrupted, but instead individuals choose not to test because they fear the negative consequences of a positive result (Golub, 2013).

27 Often the conceptualization of stigma as a social process does not always distinguish between prejudice, stereotyping, and discrimination. As mentioned earlier in the work of Link and Phelan (2001), as well as Parker and Aggleton (2003), most work focuses on how all three work in tandem to create a societal stigma influence/outcome. However, while they may work in tandem, each represents a distinct psychological and societal response that may effect the outcomes individually. Prejudice is often experienced at the individual level as an emotion, while stereotypes are more a cognitive script, and discrimination a behavior (Brewer et. al., 1988). Thus, because they are separate processes, they can be experienced in varying degrees dependent on the individual. In conclusion, the perceptions of stereotypes may play a larger role in the effect of anticipated stigma on HIV testing behavior, rather than prejudice or discrimination.

PrEP and Stigma With the impending implementation of PrEP in the Netherlands, we have already begun to see shifts in opinions and behaviors surrounding its usage. Hotly debated among various circles, the concept of PrEP has become a keystone in sexual health practices. PrEP in of itself has become a brand, a mark on the user or advocate of it usage. Within the overall debate about PrEP, the practice of condomless sex is at the forefront. Multiple articles and commentaries have labeled the usage of PrEP to enable condomless sex as negative, unacceptable, and dangerous (HuffPost Gay Voices, 2014; US News World Report, 2012; Weinmeyer, 2014). Among health care providers, there is a concern that PrEP usage will increase HIV risk behaviors (Bareback sex) due to the perceived decrease in danger to HIV infection, this view is in line with risk compensation theory (See theoretical framework) and continues to be widely debated among health officials and other key stakeholders in public health (Wheelock et al., 2012). With the initial onset of PrEP in North America, one can see the onset of labeling, or marking of PrEP usage in a negative light. “Truvada whore” first mentioned publicly in a article on Huff-Post Gay Voices (2012), shows the negative assumption association to the usage of PrEP. This sentiment is echoed among many key figures in the LGBT and Public Health sectors, to the extent that fears of risk compensation have created barriers to PrEP implementation and access. The question of whether or not PrEP increases risk compensation is not important here (See Chapter Risk), but more the role of the stigmatization of PrEP usage, and the subsequent consequences to the MSM community in Amsterdam. The unsupported association of PrEP with sexual risk taking is widely debated among networks interwoven with the public health and MSM communities worldwide, this in turn has led to the usage of the term “Truvada whore”. Thus, decreasing the motivation to use PrEP among potential users, as many may have experienced or witnessed the usage of such terminology among their peer social groups, and fear stigmatization (Calabrese & Underhill, 2015). The internalization of negative associations about PrEP may in turn play a role in the perceptions of potential users, as their own perceptions of eligibility may become skewed, indication a self-stigmatization of PrEP usage (Perez-Figueroa, 2015). Researchers of the iPrEx clinical trial in France, found that among MSM nearly 80% of men who qualified for

28 PrEP usage according to their sexual histories, 78% of the group did not believe they were at risk or in need of PrEP usage. While negative association towards sexual behavior were not found, the stigma associated with the taking of a prophylactic medication was found to be an indicating factor among the men (Gallagher et al., 2014).

Labeling the Whore “PrEP whore” synonymous with “Truvada whore” was first indicated among the initial PrEP studies to take place in San Francisco USA (Spieldenner, 2016). This labeling could be seen as a form of slut shaming, as the term slut has a devaluing/stigmatizing label one one character (Spieldenner, 2016; Associated Press, 2014). The terms itself indicated that those who use PrEP are being labeled as sluts, due to the association that PrEP equals condomless sex. To be a PrEP whore is to be a copout, no longer responsible for the usage of condoms (Bellus, 2014). This is reflective of the whore labeled used among men with HIV, as they are usually stigmatized for their infection from a perceived lack of condom usage. These associations lead to the framework that PrEP users like men living with HIV should be labeled and avoided both sexually and socially (Belluz, 2014; Spieldenner, 2016). Often the usage of both ‘clean’ and ‘dirty’ binaries shape the sexual social values of the MSM community, as those terms are used to indicate sexual health status and practice. Often online among gay dating apps or websites we see men who identify as HIV negative indicate they are “clean”. This in turn creates an association to HIV as being “dirty” (Spieldenner, 2016).

Experiences with Stigma My first run into the concept of stigma began early in my fieldwork with my initial attempts to understand the culture of bareback sex in various sexual clubs and bars. the following is a detailed account from those early days put together though notes taken in the field:

Bareback Sex Over the course of my fieldwork, a majority of my exposure to the culture surrounding bareback sexual community took place among the many cruising/sex bars and clubs of Amsterdam. Among my peers and colleagues, the thought of me entering a sex club often brought snide remarks, “So lots of participant observation, eh Kevin?” was one of the less crude remark I received when describing the ethnographic field sites. Yet what is often misunderstood about these bars and clubs is that it serves more than just a place to take part in a quick sexual escapade. Often between the sounds of music and sex, one can find in-depth conversations taking place at the bar or smoking areas. It is among these areas that I made first contact with my key informants.

Unspoken truths My first introduction to discussions of bareback sex took place at Field Site A (Further description of site see methods), located in center city Amsterdam. My key informant, a regular who I will identify as Clark, openly began a dialog with me on a early Tuesday afternoon, right around 14:00 hours, just before the after work rush. Clark was rather

29 open to discussing my research interests, as I approached him by openly discussing the bar itself. When asked to describe the bar, Clarks definition opened the door to discussions on bareback sex. “This place is primarily for sex, go downstairs and you can find whatever you want.” This statement further piqued my interests. What more could one expect in a cruising bar with a large underground play area? Obviously the concept of sex was openly displayed in the bar, with dispensers of condoms and lube located throughout the building. My further discussions with Clark lead to a tour of the underground labyrinth, as we walked through the poorly lit maze filled with nooks and cabins the sounds of sexual contact filled the air. Groans, moans, slurping, and panting, the smell of poppers high in the air. As we walked around smaller ‘rest areas’ actively displayed porn as men relaxed with their drinks, small conversations taking place quietly beneath the sounds of sex. “Men who come here always get more than they expect, it’s the environment, the dark, the smell” Clark stated and we sat down in a corner, watching two guys having sex in a nook. “Men will come here after work, or tourists will come during the afternoon and early evenings looking for a release” Clark stated somewhat dispassionately as we sat watching the scenes of sex taking place around us. At this point I felt rather voyeuristic, hesitant to draw my eyes to the somewhat passionate scenes before me. Yet as I sat there, my drink in hand trying to maintain eye contact with Clark alone, or shifting my gaze to the porn being displayed on the TV screens, I began to realize the normality of the situation I found myself in. Men openly had sex in these spaces, there was no expectation of privacy, thus, no reason to be embarrassed. No doubt sensing my somewhat shy mood, Clark engaged me in asking more about my work, and my reasons for coming to the bar. As I explained my interest in the motivations and barriers to bareback sex among men in Amsterdam, Clark laughed and stated “If you want to talk to a barebacker, you have one sitting right next to you!” I struck gold! I thought, as I proceeded to ask him- Why do you practice bareback sex? Clark took a moment to answer, as he sipped his beer and stared at a particularly aggressive couple in the corner. “I bareback because it feels good.”

Anonymity and Stigma That evening Clark’s responses to my query shaped the remainder of my fieldwork in how to approach questions on bareback sex. If the motivations for bareback sex where pleasured based, would there be any barriers? (see Behavior and Risk chapter for more on motivations), Would it really be that easy to discuss? Despite Clark’s openness to discuss his bareback sexual behavior, I wondered if it was due to the fact that we only met in the bar, sitting in a shadowy corner with men having sex around us. I could not help but to wonder if the scene enabled his responses. When facing anonymity my respondents both formal or informal where rather frank with their discussion of bareback sex. Yet in certain medias such as the Internet based application, where anonymity is somewhat implied, men who openly identified themselves as barebackers or practitioners of raw sex, continue to expect a negative response to their status.

A respondent on a Reddit subforum about barebacking stated- “I’ll be waiting for the flood of hate mail after this but…..I only Bareback”

30

This response was similar to ones I faced in the field, particularly in my conversations with Clark.

“No, I don’t tell my friends I fuck bare. If they knew they would think I’m poz” -Clark, 55 Field Site A, 02-03-16

“I sometimes tell guys I only do safe sex, because if I don’t, sometimes guys block me” - Grindr Respondent, 10-03-16

“When I think of bareback sex, people think of AIDS, and if they don't think AIDS, they think I have something else. They think I'm dirty.” “I only will talk about this to guys I have sex with, not my colleagues or friends.” -Rick, 30, Field Site A, 03-03-16

These snippets of conversation indicate the notion of bareback sex carries similar stigmatizing features found in HIV related Stigma. Yet what is most interesting about these comments is where and from who such negative associations are from.

“I would never tell my friends I bare. They don’t like that kind of thing.” “I don't know if they practice bare we don’t talk about that.” “They look down on guys like that” -Clark Field Site A, 02-03-16

Clark’s worry that his friends, who he specifies are also gay men would have some sort of judgment on him if it was known that he practices bareback sex. Yet what is further interesting is whom he does not have a problem knowing.

“Guys in places like this, and [Field Site B], sometimes we come down here and we don’t even talk about using condoms, we just start fucking.” -Clark Field Site A, 02-03-16

“One time a guy asked me to do it bare, before we came down here.” -Clark Field Site A, 02-03-16

“I think its easier to talk about this in a place like this, sometimes you make friends with these guys, but its not like my friends outside this place, we come here for a reason, we come to enjoy sex. When we take a break, we talk about bareback sometimes between drinks or something, like its normal. Outside with my other friends, no, no, we don't talk, and I don't want them to know.” -Clark Field Site A, 03-03-16

These conversations indicated that stigma both enacted and anticipated exists among men who bareback in Amsterdam. Yet this stigma itself is overshadowed by the HIV related stigma attached to sexual risk taking in general. I would posit that Clark’s need to keep his social circle separate from his socio-sexual circle indicates a worry of rejection from those he

31 cares for. Yet as indicated earlier in the methods section, the usage of these field sites appeal to a small sample of MSM living here in Amsterdam. I would also posit that the information gathered in cruising bars and sex clubs, as well as hook up apps, may have drawn men who have separated both their everyday social circles from their sexual circles. Particularly among the men who practice bareback sex. However, further research into these field sites would be necessary to argue this claim. Conversely, as stated previously, motivations to partake in condomless sex may include the need to bond closer with others due to stigma related to either sexual minority status or HIV. As seen in the following conversations about motivations of bareback sex.

“I bareback because it feels good, I almost never use condoms unless the guy asks. To be honest, not many ask in a place like this. They either put it on themselves, or just fuck bare” “When you use a condom, I feel like there is no connection” -Clark Field Site A, 02-03-16

“I can't have sex with a condom, It just won’t work. I need to feel my partner” “Its more pleasurable without the condom….and it feels good to get a load inside”- Fourth, BullChat, 10-03-16

“When we bareback, it feels so good, like a connection. I feel close to my top when he comes in me, I feel his seed inside, I feel like I belong” Jay, 29, Field Site C, 23-04-16

“I fuck raw because it feels so much better than with a condom. I stay hard and it feels so good to cum in a willing bottom” -Ninth, Grindr, 02-05-16

These responses to my question of “Why do you Bareback?” indicate similar findings as found in other research by Smith et al. (2008) where condom usage indicates distance from ones sexual partner. Another similar finding is the increased perception of pleasure and intimacy with one’s partner (Golub et al., 2012; Schilder et al., 2008). Furthermore, as indicated in Starks et al. (2014), such perceptions of intimacy and pleasure may be mitigated by gay related stigma.

While my work into why men who practice bareback sex continued, I began to become a regular at many of the sex related bars and clubs in Amsterdam. This enabled me to form a rapport with bartenders and managers as well as other regular patrons. Yet as I continued on in the field, I realized that it was necessary to understand the views of bareback sex from men who do not practice it. Through the usage of various mediums, such as the internet forums and dating apps, I managed to gather additional information about the perceptions of bareback sexual behavior.

“Before ARV’s, it was considered pretty stupid to fuck without a condoms. I really didn't start sleeping with men until the early 90’s, and then condom usage was non-negotiable. Nowadays, not so much” -Unknown, Field Site F- 12-03-16

32

“It’s so hot watching it on porn, but in real life its way too risky. I would never fuck someone without a condom.” “I would only do it if i was in a monogamous relationship” Caleb, 27, Field Site E, 24-03-16

“I refuse to have bareback sex. I am terrified of HIV” Anonymous, BullChat 30-03-16

“I have never done it myself, I think people who do really just don't care about themselves” - Sixth,Growlr, 10-03-16

“ i am afraid to have sex without a condom.....after 34 years safe sex....i am used to it….” “because there is always a small voice in your head when you have sex.....maybe it is more relaxed with prep...... but still i am aware of hep c and other std’s…”-Second, Bullchat 08- 03-16

From this perspective we see the echo of fears over HIV, leading to the stigmatization of the sexual practice. The assumption that men who bareback don’t care about themselves, or are ‘stupid’ are just some of the assumptions made by non barebacking MSM. As my interactions with men in Amsterdam continued I began to see a shift in the usage of the term barebacking to other terms such as raw or bare sex. Astoundingly one of my key informants summed it up as such.

“I don’t like using the term barebacking anymore. It’s just feels wrong, I just say raw or bare, sometimes I think there isn't even a need to identify it anymore. ‘Do you want to use a condom?’ I guess thats all there is to ask.” -Key Informant Jon, 16-04-16

“Raw sex is very hot, It feels so good to feel the guy without something in-between. Sure it’s risky, but everything has a treatment now.” -Mac, 41, Field Site A, 27-04-16

“I only go bare with people I trust. I have to know they get tested regularly and are negative.”- Unknown Grindr, 01-05-16

This aversion in terminology can be the attempt of individuals to avoid the stigmatization associated with the term bareback. As stated before, the long association of condomless sex with HIV infection, has led to the term bareback to become a stigmatizing mark in of itself. I posit that the usage of terms such as bare or raw sex have less of a stigmatizing effect than that of bareback. Though the behavioral component of condomless sex still holds a stigmatizing feature, it should be noted that the negative association of the behavior is not found in the usage of the terms bare or raw sex. I am of the opinion that the sexualization of these terms has become erotic, thus covering the previous stigmatizing association, at least on the surface. Overall, further research on this discourse is necessary.

33 Barebacking and PrEP Throughout the various conversations I had about bareback sexual behavior, I also had many conversations about PrEP and its role within the sexual practice. While further in- depth discussion of the findings can be found in the Risk chapter, It’s important to note the negative association PrEP has gained with bareback sex.

“I got single about 1,5 month ago and ever since i have spoken to sooooo many people online that just want bare sex, that say they are on prep so it doesn't matter. I've spoken to a guy who only wants bare since there is less chance on std's since guys using prep get tested more often than other guys.” “….and another guy was like, yeah i'm on prep like half of Amsterdam.. but i heard from a friend and the ggd lady when i got my std hiv test, that only about 350 guys are in the trial. but when i'm online i feel like so many guys are on prep, and they see it like the solution for stopping hiv and having bare sex with everyone. which obviously is not the solution when people are not safe doing their condoms, how are they going to be safe taking a pill every single day just to have slut sex.” -Third, Bullchat, 09-03-16

“Im against PrEP, especially for those who use it to fuck bare, hepatitis C is dangerous.” “Guys fuck around in Church, darkrooms, and here, they sometimes say they use PrEP and fuck without hesitation of disease. It’s ridiculous, they think it’s a free ride.”Leslie, 46, Field Site A, 19-04-16

Further responses from various sources mirror those above. The discussions on PrEP when on the cautious side exhibited signs of stigma similar to HIV related stigma. Often coupled with the act of forsaking condom usage, or to proliferate the practice of bareback sex. Yet the HIV related stigma influence on PrEP is only one part of the issue revealed to me over the course of my fieldwork. Stigma attached to PrEP usage seems to stem from two types. The first, a social related stigma attached to PrEP users as being promiscuous, being label “sluts” or “whores”.

“Why would I use PrEP? I’m not a whore!”-Anonymous, Field Site F, 12-03-16

“I’m fine with my sexual partners knowing I’m on PrEP, but I do not want anyone else to know [laughter] They will think I am a slut.”Larry, 40, Field Site D, 09-03-16

These respondents indicated a duality apparent among the MSM community. The anonymous respondent who walked away before I could get more information, indicated an aversion to PrEP usage, as he found himself identifying its usage with the negative association one uses in the term ‘whore’. Larry indicates the stigma attached to men who want to use or are already on PrEP. Over the course of drinks in a sex club called Field Site D, an informal respondent replied to me that he was on PrEP, and that its usage for his sex

34 life was welcomed, yet he still held concerns over being seen as a slut, or overly promiscuous among his non-sexual peers. One of the most impactful response I received came from a key informant who is a active member of a HIV related organization. This organization which will remain nameless often promotes the usage of PrEP in its social out reach. My key informant is a member of the board comprising mostly of gay and bisexual men, over coffee he confided in me about his own PrEP usage.

“I am on PrEP, but I haven't told my partner or any of the guys I’m working with.” “I don’t know why, with my partner, we are in a open relationship, but I’m worried if he knows I’m on PrEP he will think I’m fucking a lot of guys, and doing it bare, even though I’m not.” “I work with a bunch of gay men, and you can see we fight for PrEP usage in the Netherlands, but I don’t want them to know I’m in the study. They know I have a partner, I don’t want them to know my sexual behavior” -Key Informant HIV Org, 29-04-16

His responses somewhat astounded me. I could not believe that a member of an organization fighting for PrEP usage in the Netherlands was showing concerns about what others might think if he was one PrEP. His response mirrors concerns over being known as or labeled as promiscuous, and/or a sexual risk taker. The responses are but a few of many that I came across during my work. Its shows that the social related stigma of PrEP lies further in the realm of sexual morality (See chapter Stigma). This in turn is mirrored in the discussions of what compromises good versus bad sexual behavior. Finally the second type of stigma I have come across in my work is also reflective of social stigma properties, yet would be closer to health related/epidemiological stigma. The indication of PrEP users being coupled with increased rates of STI’s.

“I am a bit concerned about using PrEP, I heard guys tend to have more syphilis or that other one…gonorrhea, when using PrEP.”-Danny, 23, Field Site B, 20-03-16

“Guys use PrEP and their getting all these other diseases, you know? Because it only protects against HIV. So guys are now getting all the other ones and spreading them to others”-Eric, 29, Field Site F, 12-03-16

“A friend of mine is a GP, he said that I shouldn't sleep with guys on PrEP, they may have some disease.” -Fifth, Bullchat,13-03-16

These responses indicate the association of a disease, in this case a sexual transmitted disease, to individuals who may be using PrEP. Among my time in the field I found that concerns for other STD’s was a barrier to PrEP usage among MSM. Also indicated is the assumption that PrEP users are more likely to carry an STD because they are more likely to engage in high risk sexual behaviors. While misinformation about PrEP continues throughout the world, knowledge of PrEP is just beginning to make its way to the MSM community here in the Netherlands. I believe that continued research must be undertaken ignorer to

35 understand the role stigma plays in MSM sexual health practice, and how such a role influences the motivations and barriers to overall PrEP usage.

Chapter Five In the Pursuit of Pleasure?

Introduction

Throughout the previous chapters of risk and stigma, there has been an underlying theme when examining the motivations to PrEP and Bareback behavior. The role of sexual pleasure is a constant in both my fieldwork and corresponding interviews. If we are to operationalize the concept of pleasure in terms of a physical sensation or the subjective enjoyment of sexual behaviors then we can begin to see how it plays a role in the overall motivations surrounding both PrEP and Bareback behavior. As stated in earlier chapters, the concept of pleasure seems to be an argument against sexual risk taking practices, and more so has been openly acknowledged as a benefit of both condomless sex and PrEP usage. Conversely the concept of pleasure has also been an argument against condomless sex. Often being framed as a unacceptable and even dangerous motivation for bareback sex, or PrEP usage. The question I must then ask is, why? When did pleasure become such a forbidden taboo in the really of sexual/public health? Why does the concept of sexual pleasure carry such heavy overtones of risk and stigma among the MSM community? The answers to these questions are not easily answered in the scope of this research. Yet, they provide a framework for my investigation into the role of sexual pleasure in both MSM who practice bareback sex and those who do not. The role that the condom has played as an icon of HIV prevention, is pivotal to understanding motivation to further preventive strategies such as PrEP. The role of pleasure is pivotal in sexual health ideology and STD prevention strategies. From a HIV prevention perspective, the concept of pleasure is often seen as sacrificed in-order to prevent risk taking, for example, the diminished pleasure in terms of arousal and physical sensations, from condom usage (Crosby et al., 2005; Sanders et al., 2012; Greene et al., 2014) to other risk reduction strategies such as abstinence which in turn sacrifices the possibility of sexual pleasure, serosorting which limits the potential pleasure to be found with other partners, and even seropositioning which can limit an individual’s range of sexual activities, thus limiting their sexual pleasure. Sexual pleasure in of itself is mitigated by many different factors, many of which lie in the individual. Yet as seen in the risk chapter, pleasure is a factor which is weighed against risk of HIV and other STD’s, more so among MSM. This in general has created a climate of concern among many MSM. Should sexual pleasure outweigh one’s risk taking behavior, and the moral obligation to the overall MSM community? Additionally, not only has the concept of pleasure become associated with risk, but those individuals who place the concept of

36 sexual pleasure above their own safety and safety of their potential partners are further stigmatized. This is seen in the stigma chapter where individuals report an increased level of pleasure from condomless sex, yet will face stigmatization from being identified as doing so. It is clear that the concept of pleasure is an integral component to MSM sexual behavior. This chapter will attempt to explore the meaning of pleasure. Its influence on sexual health behavior, and what that may hold for the future of PrEP.

Sexual Morality and Pleasure

During my time in the field I had the opportunity to speak with many MSM who practiced bareback sex. My dialogue with them included many of the already identified factors surrounding bareback sex motivation. Many of these factors discussed in the earlier chapters are reflective of the findings of previous research. Yet, foremost in my discussions are the themes of pleasure:

Fifth:“I like getting fucked bare, because it feels so much better.” Kevin:“How so?” Fifth:“Its like the ultimate form of pleasure…..you connect with the guy. In that one moment, you are one.” -Fifth, BullChat, 13-03-16

“I can’t use condoms because they just don’t feel good.” “I wanna feel good when I’m getting fucked” -Eight, Bullchat, 18-04-16

“Honestly It feels so damn good, I could never go back to condoms.” -Anonymous Sex Party Participant, Field Site E, Date retracted

The theme of pleasure often seemed straightforward response to my questions concerning the motivations to practice bareback sex. Yet, despite the perceptions and experiences of pleasure from condomless sex, bareback sexual practices are continuously regarded taboo. In response to this assumption I often asked my respondents their views on the acceptability of bareback sex in the overall MSM community. One of my respondents Mark, whom I had the pleasure of spending an afternoon debating the intricacies of MSM sexual behavior over a few cups of coffee had this to say:

“So our [MSM] expression of sexuality is sometimes defined by this expression of shame. I think it comes from the days of the AIDS crisis, with all the guys dying. Sex seemed wrong, we were spreading a disease, so we became dirty….or I should say the sex became dirty, and we [MSM] became dirty from it. So flash forward to now and we still have this result where certain sexual behaviors are seen negatively, that sex is not about pleasure any more. It’s about safety.” -Mark, 39, Key Informant, 25-03-16

This narrative with Mark reveals a common opinion among men who practice bareback sex. To go without a condom is indicated by a majority of respondents as

37 pleasurable and more intimate than without, yet it is not considered a morally acceptable sexual practice among MSM:

“I think people who bareback are being morally irresponsible! They are putting the rest of us in danger.” -Seventh BullChat 20-03-16

“Honestly I think its disgusting that some guys will only do bareback sex. I really don’t know what goes on through their head.” -Third, Grindr, 08-04-16

As reflective of the quotes above, bareback sex is often tinged with a negative moral view. Further evidence of this was found among my many afternoons spent in Field Site A sharing a drink with some of the regular patrons. Often crowded during the rush hour of afterwork patrons, Field Site A offered me the perfect opportunity to gather the views of various men in a social yet sexually charged environment. Most of the men acknowledged the practice of bareback sex in Field Site A itself, yet also made it clear that such practices where not openly acknowledged. When confronted about why such a thing was not discussed, many of my respondents indicated that there was a stigma tied to such behavior, even in places where it occurs frequently. As one such respondent indicated:

“Going bare may be hot, and may feel good, but its considered pretty bad. Maybe, thats what makes it so hot?” -Anonymous Respondent Field Site A, 10-03-16

This theme of Good versus Bad sexual behavior is prevalent among the concept of pleasure in sexual behavior. What is often considered morally ‘good’ is safer sex practices such as condom usage and drug-free sexual contact. On the other hand, morally ‘bad’ sexual behavior often associated with chemical sex (drug usage) and condomless sex are often reflections of attitudes in HIV preventative and safer sex messaging. These associations can be linked with stigmatizing attributes found in both sexual behavior as well as the most recent debates concerning PrEP usage among MSM. What society deems as morally unacceptable often influences the basis of what is considered good or bad sexual behavior. This in turn plays a role on how an individual may choose to partake in such a behavior. While being considered ‘bad’ by society and even one’s own community, bareback sex is still often practice, albeit without much discussion in places like Field Site A or other cruise type bars. I will posit that the overarching moral environment as created by HIV preventive programs and interventions has aided in creating a culture surrounding the practice of bareback sex. What is most important know if to understand how or why such a culture may play a role in the development and implementation of PrEP.

Sexual Health Behavior and Condom Fatigue

The World Health Organization (WHO) defines sexual health as a state of physical, mental, and social well-being in relation to sexuality. In addition to my research, I operationalize sexual health as the practice of safer sex and HIV preventive behaviors in

38 accordance to sexual contact, such as condom usage. It is important to conceptualize the framework of what sexual health is in order to understand the role it plays in sexual behavior and decision making. During the course of my research and overall fieldwork, I had the privilege of speaking to many outreach workers in the field of HIV prevention and sexual health. Many of which had various opinions on the subject of bareback sex and PrEP. Yet, what I found most informative about my discussions with these individuals was the overall opinion that sexual health messaging lacks considerations into the pleasure driven aspect of sex, despite it being one of the key components to the definition of ‘sexual health’.

“I am the first to state how important it is to use condoms, especially for gay men, but if you are going to be realistic, we both know that condoms can interfere in pleasure. I don’t know many men who would prefer condoms to bare sex.”-Will, 33, Key informant, 02-04-16

This statement from Will, a HIV prevention worker sums up the role of pleasure in sexual health behavior and HIV prevention strategies, that to date the most supported methods for prevent HIV and STD’s come with a penalty to pleasure. It is clear that pleasure plays a pivotal role in human sexual contact (Abramson & Pinkerton, 2002). Thus, it should be concluded that anything which interfere with such pleasure would be more likely to become avoided or used reluctantly. The usage of barrier methods such as condoms have shown a decreased physical report of pleasure (Greene et al., 2014). Many of my key informants reported having the opposite behaviors from what they viewed professionally, one such informant Sam, who worked as a sexual health nurse had this to say:

Sam: “I feel like a damn hypocrite, but I don’t practice what I preach. I love the feel of cumming in a guy.” Kevin: “Do you tell others that you practice bareback?” Sam: “Only guys who have bare sex, my sexual partners know, but not my friends, or these guys, I don't want to face discrimination. I don’t want to face judgment from these guys.” Kevin: “Guys?” Sam: “My Co-workers, I would be judged so harshly, there is a lot of shaming.”

Informants like Sam and others who work in HIV prevention are well versed in knowledge about HIV risks, and the ways to prevent them. For him and the others whom I’ve spoken with, to knowingly practice bareback sex reveals a unique perspective on the behavior. It seems that pleasure, at least from my interaction with Sam, is a key component in the motivational force allowing men like Sam to continue to practice condomless sex despite their well-informed background. Throughout the course of my fieldwork it has become clear that the perception of pleasure is key to understanding the motivational forces surrounding HIV risk practices such as barebacking, as well as the forces which may influence preventive strategies such as condom usage and PrEP. The role of condom fatigue is also of interest when examining the individual motivations surrounding bareback sex. Condom fatigue also known as prevention fatigue is a term often used by sexual health educators and HIV prevention professionals to indicate a situation where there is decreased condom usage, as well as an indication of depressed

39 effectiveness in safer sex messaging and interventions (Stockman et al., 2004; Cohen, 2005; Brennan et al., 2010). This term has been particularly associated with research on MSM populations as an indication of men having grown disillusioned and exhausted by constant safer sex messaging. During my time meeting and discussing sexual behavior with men, I came across various instances where some respondents indicated a ‘fed-up’ attitude towards condoms and overall safer sex messaging. In response to my questions surrounding condom usage or feelings towards condoms:

“I’m sick of the know it all attitude from doctors and nurses, I feel like they keep shoving it down my throat [laughter]. Condoms this, condoms that, get tested here, don’t stick your dick there! I’m just tired of it. I simply nod my head say yes yes, and continue to go raw [laughter].” -Kel, 31, Field Site C, 23-04-16

“I use to be really afraid of getting fucked without a condom…..You always hear how dangerous it can be…never go bare or you’ll get AIDS. I just got tired of it, until one day I met a guy who only went raw, I finally…just went with it…and it was insanely hot [laughter].” -DJ, 22, Field Site A 27-04-16

Kevin: “Are there instances you have used condoms?” Seventh:“I only do bareback, I don’t want people telling me how to live my life or what to do with my body.” Kevin: “What people do you mean?” Seventh: “People like you, doctors or the guys who give out condoms at parties, or the ones who talk about drugs and stuff. I feel like the government has too much say in how I want to have sex.” -Seventh, BullChat, 18-04-16

As indicated in the quotes above, these particular men indicate instances where they felt messaging about condoms and HIV prevention where exhausting them or taking away control of their own decisions to use them. It is possible that condom fatigue in this instance is connected to an individual’s motivation to seek sexual pleasure, and that the fatigue not only stems from an assumed, over saturation of condom usage and HIV prevention messages but from an exhaustion over fears and anxiety of HIV infection (see Risk). It becomes increasingly clear that (the concept) sexual pleasure, holds a considerable effect surrounding motivations of bareback sexual behavior. Yet, it is also important to note that pleasure can have a role on effectiveness of preventive measures themselves, in particular PrEP.

PrEP and Pleasure

With new preventive strategies and interventions being developed in the fight against HIV and other STD’s we have begun to see a shift in the role of sexual pleasure as an integral component to well-being (Fortenberry, 2013). With the advent of PrEP researchers and advocates have the ability to promote pleasure as a goal in HIV prevention, something not

40 often heard of in the MSM sexual scene. Previous prevention methods have focused on the role of condoms to help curb the spread of HIV infection, yet very few have attempted to promote pleasure in the form of condom usage. As stated earlier, prevention strategies such as barrier methods through condoms have been reported to interfere with the experience of pleasure in terms of physical sensation and intimacy (Greene et al., 2014). Yet, with the introduction of PrEP, we now have a non-barrier method which offers no risk to the role of pleasure in sexual contact. Recent research has found that MSM who believe that condoms will interfere with intimacy and pleasure, are more inclined to the usage of PrEP (Gamarel & Golub, 2015), thus indicating that potential users of PrEP may value it as a method to reduce risk without the loss of pleasure. This view is reflective of individuals whom I met both online as well as in cruise bars and sex clubs, when questioned about their views on PrEP:

“I can never stay hard when using a condom, So yeah, I’m really for PrEP.” -Anonymous, Field Site B, 10-03-16

“I can’t wait to get on PrEP! I hate the feel of condoms, it will be so much better once I can go without.” -Mac, 41, Field Site A, 27-04-16

“The nice thing I hear about PrEP is that you can fuck bare. I think this is good because condoms don't feel good. But I am afraid of not using them, because of AIDS.” -Tenth, BullChat, 18-04-16

I: Do you think PrEP is a good thing? R: I do, I do, I think Its a fantastic idea. We have moved past the time where condoms are really necessary. A lot of guys are having bareback sex because a lot more guys have gotten tested and are being treated if the have HIV. So guys don’t really jump onto using condoms. I: Oh? R: Yeah, like in the darkrooms and stuff they never asked me to put on a condom. Its either expected or not. But no guy has stopped me from fucking him without a condom, and I know that they can tell. So yeah I think PrEP is a good thing. I: Ok, so aside from that, are there any other potential benefits…… R: Well…honestly its good that it can protect you from HIV so guys can enjoy sex without condoms. Condoms do block the feeling…you know? -Scott, Bar Manager Key Informant

It can be seen from the above quotes that PrEP offers somewhat of a relief to men hoping to attain more sexual pleasure. While offering a layer of protection against HIV it also enables a chance to remove anxiety and fears over HIV transmission, thus enabling an individual to fully enjoy sex without the aforementioned anxieties. This in turn could be a potential psychological benefit to PrEP usage particularly in HIV high risk populations such as MSM. Additionally one PrEP user I met during my time in the field have indicated a decrease in anxiety over sexual contact with serodiscordant (HIV Positive) partners:

Kevin: “What are some things you experienced using PrEP?”

41 Hank: “Well, I have not been afraid to sleep with poz [HIV Positive] guys anymore.” Kevin: “Oh?” Hank: “Mmhm….I have slept with poz guys before, and after I would be so anxious about getting it. But since I’m on PrEP now I really don’t worry, I feel safe.”-Hank, PrEP User

Hank’s indications of reduced anxiety mirror those found in other research that has examined the role PrEP has played on sexual behavior, and how PrEP has shown an increase in serodiscordant partnering among PrPE users in San Francisco (Hojilla et al., 2015). However, HIV negative individuals are not the only ones to benefit from the introduction of PrEP. Men living with HIV have also shown favor towards the concept of PrEP, as one of my informants John indicated:

“There have been times when I have felt a bit of anxiety over sleeping with a guy who is negative…I guess I have always been afraid of giving it [HIV] to anyone, but with PrEP, I think its fantastic. I wouldn't have to worry about a guy I’m sleeping with, if they use PrEP” - John, Key Informant

The potential anxiety a HIV infected individual may feel during sex with a serodiscordant partner can easily effect their ability to derive pleasure from that sexual contact. While little has been done to study such anxiety and its effects on pleasure, it can be well reasoned that PrEP could be a tool used to relieve similar psychological barriers such as anxiety and fear from people living with and without HIV. It is also worthy to note the potential benefit of PrEP on pleasure and intimacy of MSM in serodiscordant relationships, allowing couples to experience sexual pleasure without concerns or barriers to their sexual experience.

Conclusion: Pleasure

The pursuit of pleasure, and in particular sexual pleasure can be seen as a driving force among humans. Among MSM it is important to understand how such a force can shape not only the individual’s motivations for certain behaviors, but shape the culture and society surrounding that individual. In the case of the MSM in Amsterdam, I have observed how the pursuit of sexual gratification/pleasure can often create pockets of cultures in which sexual pleasure is emphasized in various medias. My time in the gay cruise bars and sex clubs of Amsterdam, provided me the perfect platform for such observations, the sight of man after man, entering the bars and clubs not only for social interaction but just straight forward sexual contact has given me the concept of how pleasure can be a driving psychological if not social force for MSM. The sense of camaraderie often found in such places can reveal how pleasure and sex, can create and bind a community together. Conversely, the pursuit of pleasure also can become a driving force in such aspects of life such as risk taking and stigmatization. Overall, i would posit that sexual pleasure is a strong motivation for PrEP usage, and it should be openly acknowledged as such by various campaign and outreach activities. Doing so may not only create a beneficial demand for PrEP, but may also help in creating awareness of sexual health related behaviors as well as helping to create adherence

42 to PrEP medication, the key to successful usage and implementation. This in turn could help create a greater influence on HIV rates within a given community, and perhaps even country.

Chapter Six Concluding Thoughts

Conclusion- Final Thoughts and Discussion

As I come to this final chapter, I find myself reflecting on my choice of title. Risk, Stigma, and Pleasure: The role of PrEP and Bareback sexual behavior among the MSM of Amsterdam. Despite being quite the mouthful, the title holds the key to my concluding thoughts. Throughout my time in the field I came across many different avenues of issues to explore: The social issues surrounding men who practice bareback sex, their motivations and attitudes towards those who practice bareback and those who do not. There was also the possibility to explore those very same issues surrounding the implementation of PrEP here in Amsterdam, for there continue to be fierce debates over the release of PrEP to the population. Emotions run particularly high among healthcare professionals closely tied to HIV prevention and sexual health. While the debate seem to be split down the middle, the growing concern for the long term repercussions of PrEP usage lies on the minds of many key stakeholders. Despite these potential avenues, I wanted to focus on risk, stigma, and pleasure. A large part due to my own background in HIV prevention as well as psychosocial research. The topic of risk plays largely in both domains of my previous work, as well as remains a key influence in both the practice of bareback sex and PrEP. Arguments against PrEP often intersect with those against the practice of barebacking, the risk to one’s physical and in some cases social health lie heavily on the minds of parties involved. The risk undertaken by men who practice bareback sex is considered highly concerning by members of the public health community. A lack of care for one’s own self is often met with concern, or in some cases even stigma. The same can be said for the role PrEP plays now in the western world, have we open a Pandora’s box upon an already at risk population? Are we capable of remaining responsible in the usage of Truvada to protect against HIV? Concerns over a super-strain of HIV remain a concern among some of the infectious disease doctors I’ve spoken with. Others in the health care professions express concern over growing rates of other STD’s, in particular bacterial based,

43 which some have already begun to show antibiotic resistance in. From these concerns over risk, humans tend to ostracize groups, creating labels and branding those whom they may deem morally deficient, thus from risk (in this case) is stigma born. That is not to say that risk is the source of all stigma thrown at the MSM community over these particular issues, no, risk is simply one puzzle piece among many. Stigma stems from the need to separate ourselves from each other, to label and to classify one another. In my research and fieldwork, stigma is something of an awareness among the men I spoke too. Already stigmatized for their sexual attraction and behavior, MSM are keenly aware the weight it holds on social standing, as well as their individual well-being. Yet as we see throughout history, the stigmatized can sometimes be the harshest of stigmatizers. Stigma related to bareback sex is often held in contempt by the peers of the very men who practice it. Often associated with a rampant disregard for safety or the safety of others, MSM who practice bareback sex are often met with stigma from their own community. Tied closely to the history of the initial HIV/AIDS epidemic, stigma related to sexual risk in any form is often attributed to that traumatic past, which continues to lie heavily on the older generation of MSM. However, I among other researchers, have begun to notice a shift in stigma surrounding HIV, as generations get older, and younger ones are born into societies where HIV is no longer considered a death sentence. While a promising outlook, this particular shift in generational views also holds some concern, as the youngest of MSM do not hold to the strict view of risky sex as their older peers do, this creates opportunities for the continuation of HIV infection. Though this is mostly a gross overstatement, the nuances surrounding the issue are infinitely more complex than just generational differences and trauma related to HIV. The role stigma plays, is often a self-reminder for our own idiosyncrasies, to what we value and how we perceive the world around us. The stigmatization of bareback sex is influenced by many outer layers such as cultural/societal to even historical, and is often propagated or reflected back by the individuals own self. Stigma related to PrEP is similarly influenced, as it is mirrored by concerns of bareback or condomless sex. Though there lies a difference in what is so stigmatizing about it. The possible liberation from condoms often comes attached to slut shaming, as those who use or want to use PrEP are seen as whores. The term Truvada whore was first seen among the MSM of San Francisco during the initial run of PrEP there. This vilifying label often seen as negative by those who used it was quickly adapted as a label of status among some PrEP users, “Here I am, a Truvada whore!” This moved to be an empowering message to PrEP users everywhere, “I am now in control of my own sexual behavior and protection.” “I now hold the risks in my hand.” This is the message that lies at the root of many PrEP campaigns. That the role of this biomedical technology is not to enable a ‘free from condom’ lifestyle (though it can), but to allow an individual to take responsibility for their protection into their own hands. The giving, or taking back of this self-control is often seen as the primary goal of PrEP. It unlocks the potential for so much more in-terms of sexual health, and behavior. In taking back control of your sexual destiny you are thus taking control of your safety and awareness, as well as your passions and pleasures. Finally we come to the role of pleasure. As stated in the chapter before, in my eyes pleasure holds the key behind both motivations for risk as well as stigma. Sexual pleasure is often not openly discussed, yet during my time spent in gay saunas, dark, porn playing bars,

44 to labyrinths of darkrooms, pleasure is the one thing on everyone’s mind. Humans seek pleasure, for whatever the reason. It is a powerful force which influences are many decisions. When it comes to sexual pleasure we are faced with an intense drive to have intercourse or contact with another being. whether this need is driven by our evolutionary past, or a well- conditioned response to the environment around us, sexual pleasure is a keystone that drives sexual behavior in all humans. Thus my attempts to study it seemed mostly logical. The role of pleasure is often at odds in the world of HIV prevention, that is to say, many men feel that they have to compromise on sexual pleasure through the usage of barrier methods such as condoms. While this is not to be over generalized in any sense, it has be well established in previous research that condoms interfere with self-reported pleasure and intimacy. That being said, it is possible to assume that pleasure is a force of consideration for men who practice bareback sex. As shown in the previous chapters, many men have indicated their own pleasure or increased feelings over the ability to have sex without a condom, thus it should be reasoned that the same arguments for pleasure and bareback sex should and are mirrored in the arguments for PrEP. PrEP itself has the large ability to provide protection against HIV without sacrificing sexual pleasure. This in of itself has been unheard of in previous preventive methods. Thus, it has been recommended by many researchers and advocates that outreach messaging should be tailored to include this benefit. However, the role of pleasure also holds a moral overtone when concerning PrEP, and overall bareback sexual behavior. Is it morally right for someone to eschew on protecting themselves and others from STD’s just for the right to sexual pleasure? Is this gratification of the flesh worth the potential risk to not only our bodies but our moral values? Such questions are asked in the debates over PrEP usage, as they were asked during the roll-out of hormonal contraceptives, or the HPV vaccine. Are we making sex too safe for it to be good for us? Such questions are best left to philosophers, what can be said is that the times are changing. New biomedical advances will continue to test our moral compasses, and perhaps even begin to rebuild them. The advent of PrEP is bound to shake the world of sexual health. Its current long term effects on both the body and society are unknown. Yet what is known is the human tenacity to debate things into endless cycles. The role of PrEP is bound to change the lives of MSM, who are among some of the population to be heavily effected by HIV. The role of barebacking sexual practices is about to evolve in light of this. What can be said is that only time will tell where such changes will lead.

45

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