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Increasing intimacy and pleasure while reducing risk: Reasons for barebacking in a sample of Canadian and American gay and bisexual men



Recent advancements in HIV treatment and prevention call for a re-imagination of our definition and understanding of bareback sex. The present online study used content analysis to examine 256 gay and bisexual men (GBM)’s definitions, reasons, contexts and feelings about barebacking in Canada and the US. Themes were related to defining barebacking, psychosexual benefits and narratives of risk. Findings suggest that barebacking increases relational intimacy, and that GBM use harm reduction strategies (such as seropositioning and PrEP) to reduce risk of HIV transmission. Previous literature has pathologised the act without considering how GBM who bareback may enhance pleasure and intimacy while reducing HIV risk. HIV-prevention efforts should focus on increasing access to PrEP, adherence to ARVs and efficacy of harm reduction strategies for GBM who bareback.
Psychology of Sexualities Review, Vol. 8, No. 1, Summer 2017 5
Special Section
Increasing intimacy and pleasure while
reducing risk: Reasons for barebacking in
a sample of Canadian and American gay
and bisexual men
Natania Marcus & Joseph Roy Gillis
Recent advancements in HIV treatment and prevention call for a re-imagination of our denition and
understanding of bareback sex. The present online study used content analysis to examine 256 gay and
bisexual men (GBM)’s denitions, reasons, contexts and feelings about barebacking in Canada and the
US. Themes were related to dening barebacking, psychosexual benets and narratives of risk. Findings
suggest that barebacking increases relational intimacy, and that GBM use harm reduction strategies (such
as seropositioning and PrEP) to reduce risk of HIV transmission. Previous literature has pathologised the
act without considering how GBM who bareback may enhance pleasure and intimacy while reducing HIV
risk. HIV-prevention efforts should focus on increasing access to PrEP, adherence to ARVs and efcacy of
harm reduction strategies for GBM who bareback.
Keywords: HIV; gay and bisexual men; sexuality; bareback; sero-adaptation; risk.
BAREBACK SEX emerged as a term during
the latter half of the AIDS epidemic in
the 1990s (Frasca et al., 2012). However,
denitional variation exists within the litera-
ture. While some investigations focus on inten-
tional condomless anal intercourse (CLAI) as
the hallmark of barebacking behaviour (Grov
et al., 2007, 2010; Halkitis et al., 2005), others
operationalise the term as intentional CLAI in
the presence of risk of contracting HIV (Balán et
al., 2013; Carballo-Dieguez & Bauermeister,
2004; Frasca, Dowsett & Carballo-Dieguez,
2013). Additionally, there is evidence to
suggest that there is a disparity between how
researchers and gay and bisexual men dene
bareback sex. For example, a qualitative
study of 120 men who bareback found that
the majority of respondents dened ‘bare-
backing’ simply as condomless sex, while a
minority of respondents mentioned inten-
tionality and awareness of risk in their de-
nitions of bareback sex (Carballo-Dieguez
et al., 2009). Similarly, Halkitis, Wilton and
Galatowitsch (2005) found that of 195 men,
only 18.5 per cent believed that bareback sex
characterised ‘unsafe sex’ that was intended
and the majority of the sample believed that
unintended relapse in condom use could also
be considered ‘barebacking’. Denitional
disparity proves to be hazardous in academic
research. Firstly, barebacking broadly dened
as ‘condomless anal sex’ can vary from low to
high risk of HIV transmission, depending on
context. For example, a gay couple engaging
in condomless sex who are monogamous
and have recently received negative HIV tests
presents a very different level of risk than
two men who meet at a bar and engage in
condomless anal sex without discussion of
HIV status. Further, recent advancements in
HIV treatment and prevention suggest that
condomless anal sex is no longer unequivo-
cally ‘high risk’. Thus, an updated investi-
gation into how communities of GBM are
6 Psychology of Sexualities Review, Vol. 8, No. 1, Summer 2017
Natania Marcus & Joseph Roy Gillis
currently dening barebacking is needed in
order to further develop an understanding
of the phenomenon. The remainder of the
introduction will refer to ‘barebacking’ as
‘condomless anal sex in the presence of risk of
contracting HIV’, as the majority of research
summarised below qualies that barebacking
occurs in HIV-risk contexts.
Barebacking has caused controversy in
HIV-prevention research, as it is often framed
as a public health crisis that may be respon-
sible for recent increases in HIV infection
among GBM (Berg, 2009). Previous research
aiming to ‘prevent men from becoming bare-
backers’ (Parsons & Bimbi, 2007, p.283), has
described barebackers as those who ‘inten-
tionally engage in potentially harmful sexual
behaviours’ (Houston et al., 2012, p.2214),
and has described bareback behaviour as ‘less
than healthful’ (Berg, 2008, p.762). More-
over, research has connected barebacking to
misinformation, low self-esteem, and depres-
sion (Halkitis et al., 2008) or has examined
distortions, contradictions and self-justica-
tions in reasoning for barebacking (Frasca et
al., 2012). Additionally, one literature review
conates barebacking with the idea of ‘bug
chasing’ and ‘gift giving’, or intentional HIV
transmission (Breitfeller & Kanekar, 2012).
Much of this research risks pathologising the
act by framing it as misinformed, harmful,
and irrational.
A number of qualitative investigations
have aimed to provide a more nuanced
understanding of motivations for bare-
back sex by highlighting pleasure-seeking,
resistance, eroticising risk and free market
choice as motivators. Carballo-Dieguez et al.
(2011) interviewed 120 men who engage in
bareback sex and noted how barebacking
is often motivated by pleasure seeking and
can overpower knowledge about risk, health
concerns and intentions to have safe sex.
Additionally, critical health theorists have
identied how psychological factors interact
with sociocultural norms and attitudes
toward gay male sexuality to increase likeli-
hood of barebacking. For example, Crossley
(2002) argued that in certain contexts, bare-
back sex and barebacker identity can be
viewed as a form of unconscious resistance
from hegemonic societal narratives that seek
to regulate and sterilise the sexuality of gay
and bisexual men after the AIDS crisis of
the 1980s. Furthermore, safe sex ideology
appeals to morality and rationality, while
condomless sex connotes danger and irra-
tionality. Thus, Junge (2002) posited that
narratives of risk and danger deem bare-
backing as a forbidden act, transforming
bareback sex into an erotically charged
sexual fantasy. Moreover, Adam (2005)
argued that barebacking is a social symptom
of neoliberalism, which ‘constructs human
actors as rational, adult, contract-making
individuals in a free market of options’
(p.344). Thus, condomless intercourse,
particularly among HIV-positive men who do
not disclose their serostatus, is rationalised
through the individualistic moral position
wherein each person is responsible for his
own sexual health. While the above research
on bareback sex provides some insight into
how barebacking motives may be inuenced
by sociopolitical context, bareback sex is still
often framed as deant, reactive or sympto-
matic of sociocultural ailment, so to speak.
While barebacking may increase the risk
of STI and HIV transmission, the social iden-
tity that surrounds it may facilitate connection
between men who seek to have bareback sex
(Halkitis et al., 2005). Additionally, many gay
and bisexual men who engage in barebacking
believe that it increases connectedness, inti-
macy and romance (Carballo-Dieguez et
al., 2011; Halkitis, 2007; Halkitis & Parsons,
2003). Critical theory can help elucidate
these ndings. In Tim Dean’s (2009) book,
Unlimited Intimacy: Reections on the Subcul-
ture of Barebacking, he states ‘gay men have
discovered that one of the things they can
do with HIV is use it to create solidarity and
form communities… HIV transmission has
the potential to create social bonds that are
both symbolic and material; membership is
etched into the body like a tattoo’ (p.77).
While research has found that many of those
who bareback wish to avoid HIV transmis-
Psychology of Sexualities Review, Vol. 8, No. 1, Summer 2017 7
Reasons for barebacking in a sample of Canadian and American gay and bisexual men
sion (Adam, 2005; Balan et al., 2012), Dean’s
(2009) discussion of barebacking as forming
solidarity and community may still hold true,
especially for those who claim a barebacker
identity. Gay sex has historically been stig-
matised by the public, and during the onset
of the HIV/AIDS crisis, it became inextri-
cably linked to death and disease (Frasca et
al., 2012). Indeed, according to Robinson
(2014), ‘most gay men can probably not
even conceive of their sexuality and sexual
practices outside of a public sexual health
framework’ (p.235). Thus, fostering sexual
intimacy through bareback sex may articu-
late a form of kinship that acts as an impor-
tant remedy for the fear and shame that gay
sex so often connoted (Dean, 2009; Junge,
2002; Robinson, 2014).
Barebacking is understood to occur in
HIV-risk contexts, therefore the multiple
ways in which gay and bisexual men attempt
to reduce HIV transmission during CLAI
must be considered. Barebacking often
occurs in a context of planned risk or seroad-
aptation (Snowden et al., 2004). Seroadapta-
tion refers to a number of harm-reduction
strategies that use HIV status to inform
decision-making during sexual encounters
(Cassels & Katz, 2013). Examples of seroad-
aptation include serosorting (engaging in
anal intercourse only with partners of the
same serostatus) and seropositioning (inten-
tionally appointing the partner living with
HIV or of unknown serostatus to be the
receptive partner during unprotected sex)
(Snowden et al., 2004). There is evidence
to support the use of seroadaptive practices
to reduce risk of HIV transmission. For
example, condomless receptive anal inter-
course can pose up to a ten times greater risk
of infection than insertive anal intercourse
(Vittinghoff et al., 1999). Additionally, a
number of longitudinal cohort studies have
found that serosorting and seropositioning
can effectively reduce risk of HIV transmis-
sion (Philip et al., 2010; Vallabhaneni et al.,
2012). McConnell et al. (2010) estimated
that failure to consider seroadaptive tactics
among seropositive men could overestimate
risk of HIV transmission during condom-
less anal sex by more than 50-fold. Previous
research has posited that a number of GBM
are ‘scientically active’ (Race, 2003, p.375)
or ‘savvy consumers of sexual health infor-
mation’ (Grace et al., 2014, p.324). Thus, gay
communities frequently integrate medical
research into sexual risk-taking practices,
which can be motivated by increased sexual
intimacy and pleasure (Grace et al., 2014).
Bareback sex must also be considered
within the context of recent advancements
in biomedical HIV treatment and preven-
tion. Pre-exposure prophylaxis (PrEP) and
post-exposure prophylaxis (PEP) have prom-
ising implications for those who engage in
condomless anal sex. PrEP involves the use of
anti-retroviral therapies (ARTs) as a preven-
tative measure for those who are at high risk
of contracting HIV, while PEP refers to the
use of ARTs in order to prevent HIV infec-
tion after being exposed to HIV. In terms
of PrEP efcacy, recent studies suggest that
PrEP may reduce risk of HIV infection by 86
per cent (McCormack & Dunn, 2015) and
that of 657 MSM who were prescribed PrEP
in 2012, no new HIV infections were found
during a 7.2 month mean follow-up time
(Volk et al., 2015). While PrEP may be efca-
cious in reducing risk of HIV transmission,
research has suggested that PrEP use may
increase rates of CLAI due to the minimised
risk of HIV transmission (Volk et al., 2015)
and high rates of STI infection have been
found among PrEP users (Dolling et al.,
2016). Additionally, more research is needed
on the demographics and behavioural char-
acteristics of PrEP users. One survey by Liu
et al. (2008) of 1819 gay and bisexual men
found that only 16 per cent of the sample
was aware of PrEP, and awareness of PrEP
was associated with being white, older than
25, having an income greater than $10,000
per year and having seen a medical provider
in the past year. Updated research on how
access to and availability of PrEP inuences
sexual decision-making is needed.
Treatment as Prevention (TasP) relies
on the premise that treating people living
8 Psychology of Sexualities Review, Vol. 8, No. 1, Summer 2017
Natania Marcus & Joseph Roy Gillis
with HIV with ARTs signicantly reduces risk
of transmission to others, due to an unde-
tectable amount of viral load in the semen
(Rodger et al., 2014). In terms of TasP
efcacy, the PARTNER study found that
no linked HIV transmission has occurred
after 900 couple years of follow-up so far
in 586 heterosexual and 308 gay male sero-
discordant couples where the HIV positive
partner is on ARTs and has an undetectable
viral load (Rodger et al., 2014). Additionally,
one study of 177 HIV-positive GBM with an
undetectable viral load found that 57 per
cent considered their own undetectable viral
load in the decision to engage in CLAI with a
casual partner (Van Den Boom et al., 2013).
Thus, not all GBM living with HIV consider
TasP as a harm reduction strategy, however,
more research is needed on the ways in
which such advances in treatment impact
sexual decision-making and risk-taking in
this population.
As the risk level of condomless sex evolves,
so too does our denition and understanding
of bareback sex. No qualitative studies to
date have examined denition, justication,
meaning and feelings toward bareback sex
and CLAI while considering the use of harm
reduction strategies. Thus, an investigation
into how GBM maximise pleasure and inti-
macy while reducing risk of HIV during CLAI
in the context of advancements in biomedical
treatment and prevention is warranted.
The present study
The overarching research question of the
present study is: How do gay and bisexual
men maximise sexual pleasure and intimacy
while reducing risk of HIV transmission?
Specically, research questions include:
1. How do participants dene ‘bare-
2. What are the main reasons provided for
engaging in CLAI? And what do these
reasons tell us about the meaning of
3. What are the contexts in which partici-
pants describe having condomless
sex, and how do GBM psychologically
appraise instances of ‘higher risk’ sex?
What harm reduction strategies are
being used during CLAI and how does
this impact appraisal of the sexual expe-
rience? What are gay and bisexual men’s
feelings about having bareback sex?
The present study examined the qualita-
tive data from an online, cross-sectional
survey, which had qualitative and quantita-
tive components (Marcus, 2016). The study
reports ‘small q’ qualitative research (Kidder
& Fine, 1987), which uses qualitative data
collection and techniques independent from
a qualitative paradigm. The survey contained
a number of standardised questionnaires
assessing personality and behavioural corre-
lates of CLAI and sexual risk behaviour, as
well as questionnaires regarding seroadapta-
tion and harm reduction strategies created
by the researcher. Demographic information
was collected such as: age, sexual orienta-
tion, income, relationship status, etc. Finally,
three open-ended questions were included:
(1) ‘What does barebacking mean to you?’;
(2) ‘What are your top three reasons for
engaging in barebacking?’; (3) ‘If you have
engaged in CLAI with a partner of unknown
or positive HIV status in the past three
months, please describe the context in which
it occurred’, with prompts related to setting,
uniqueness of encounter, feelings afterward,
and risk reduction given; and (4) ‘How
would you describe your motivations for not
using a condom during that encounter?’ The
qualitative answers collected were typically
brief due to the inability to ask participants
to elaborate on their responses, however, for
question (3) and (4), numerous participants
provided paragraph-long answers. While this
methodology is limited in terms of obtaining
in-depth answers, it allows for an efcient
way of obtaining a wide breadth of answers
as a large number of diverse views are repre-
sented in participants’ own words (Jowett &
Peel, 2009).
Participants were recruited online
through a variety of community recruiters
Psychology of Sexualities Review, Vol. 8, No. 1, Summer 2017 9
Reasons for barebacking in a sample of Canadian and American gay and bisexual men
including gay and bisexual men who had
access to a network of other gay and bisexual
men, Canadian and American AIDS service
organisations, LGBT organisations, online
HIV publications and online news and
support groups for gay men and people
living with HIV. The survey was live from
26 September 2015 until 1 November 2015.
The study URL directed participants to the
consent form, which outlined the goal of the
research, the survey process and the right
to withdraw. Consistent with research ethics
principles, participants were assured of the
condentiality and anonymity of their data.
In order to qualify for the study, participants
had to be living in Canada or the US, iden-
tify as male and as gay, queer or bisexual,
be over the age of 18, and have been sexu-
ally active in the past three months. Upon
completion of the survey, participants were
given the opportunity to enter into a draw
for a $100 Canadian dollar VISA gift card
and to receive a summary of the results. The
HIV Ethical Review Board of the University
of Toronto approved the research project.
Qualitative analysis
The present study employed a postpositivist
framework to data collection and analysis.
A postpositivist paradigm holds that an
objective reality is inaccessible and multiple
truths exist (Ponterotto, 2005), however,
that science still requires ‘precision, logical
reasoning and attention to evidence but [is]
not conned to that which could be directly
perceived’ (Clark, 1998, p.1245). The study’s
research aim is to determine denitions,
justications, meaning and feelings toward
bareback sex and CLAI while considering
the use of harm reduction strategies. Thus,
the postpositivist framework pairs well with
the study’s research aim as the study extracts
meaning directly from participants’ subjective
responses, however, themes are closely linked
to the data themselves and aim to answer
a specic and targeted research question.
Approximately 20 single-spaced pages of data
from 265 respondents’ answers were avail-
able for analysis. Summative content analysis
was used to analyse participants’ denitions
of ‘barebacking’ in order to determine the
frequency at which various denitions were
provided (Hsieh & Shannon, 2005). This
approach involves identifying and quantifying
words or content to determine frequency of
usage. The analytical methodology employed
for the remaining data (reasons and contexts
of CLAI and barebacking) is conventional
content analysis (Hsieh & Shannon, 2005).
Conventional content analysis aims to inform
concept development or model building
(Lindkvist, 1981), rather than theory develop-
ment or validation, which ts with the present
study’s research aim. A data-driven, induc-
tive approach to analysis was used, meaning
that the themes were strongly linked to the
data themselves, as opposed to a theoretical
approach (Braun & Clarke, 2006). However,
interpretation of the data was completed
after extensive overview of the barebacking
literature, therefore themes were necessarily
linked to previous literature. The data were
read twice thoroughly in order to obtain a
sense of the whole. Next, data were read
word by word to derive codes, and initial
codes were derived using exact words from
the text (in vivo coding). Notes were made
regarding the initial analysis, and labels
for the codes were rened and broadened.
Codes were then sorted into categories based
on common meaning. A tree diagram was
created to map the relationship between cate-
gories and subcategories, and categories were
collapsed, revised and redened. This process
was repeated three times until nal categories
were selected (Hsieh & Shannon, 2005).
The sample included 256 gay, bisexual and
queer people who identied as male from
both Canada and the US. Two-hundred-and
seventy-three people consented to participate
in the study, however 17 participants either
did not meet the inclusion criteria or exited
the survey before completing the study. In
terms of sexual orientation, participants were
asked to ‘select all’ sexual orientations that
applied to them. Thus, these percentages
10 Psychology of Sexualities Review, Vol. 8, No. 1, Summer 2017
Natania Marcus & Joseph Roy Gillis
represent overlapping categories and do not
add up to 100 per cent. Seventy-seven per
cent of respondents identied as gay, 17 per
cent were bisexual, 11 per cent identied as
queer, 9.3 per cent identied as a man who
has sex with men, 2.3 per cent identied as
polysexual, 0.8 per cent identied as trans-
sensual, 0.8 per cent identied as asexual,
0.8 per cent were two-spirit, 1.2 per cent were
questioning. Participant ages ranged from 18
to 68 (M = 29.1 SD = 9.64). Forty-four per
cent of participants lived in Canada, while 54
per cent of respondents lived in the US. In
terms of income, 20 per cent of participants
reported making $24,999 per year or less,
30.7 per cent made between $25,000–$54,999,
23.2 per cent made between $55,000–$84,999,
25.2 per cent made over $85,000 Canadian
dollars. An examination of race and ethnicity
indicated that the majority of the sample was
White (80.2 per cent). Of the remaining 7.3
per cent were Biracial or mixed race, 1.2 per
cent were Native American or Indigenous
Canadian, 0.8 per cent were South Asian, 0.4
per cent Filipino, 3.1 per cent Mexican/Latin
American, 1.2 per cent West Asian, 2.7 per
cent Chinese, 0.4 per cent Korean, 0.4 per
cent Japanese, 0.4 per cent African/Black,
and 2 per cent ‘Other’.
In terms of HIV prevalence, 8.9 per cent
of the sample was living with HIV (N=22),
67.3 per cent reported being HIV negative,
and 23.7 per cent had never been tested for
HIV. One-hundred per cent of participants
living with HIV were currently taking ARTs.
Further, 91 per cent of participants living
with HIV (N=20) reported having an unde-
tectable viral load, while the remaining two
participants reported that their viral loads
were 40 or less. Eight per cent of the sample
(N=20) reported taking PrEP to reduce
risk. Eighty per cent of the sample (N=207)
reported having a current romantic or sexual
partner or partners. Fourteen per cent of the
sample (N=35) had engaged in condomless
anal intercourse with a partner of unknown
serostatus in the past three months.
Six main themes were identied: Dening bare-
backing; Barebacking increases relational intimacy;
Barebacking increases sexual pleasure and enjoyment;
Planned risk: Reducing risk of HIV transmission;
Inferring safety and retroactive safety negotiation;
and Unplanned risk: Heat of the moment ‘slip ups’.
Dening barebacking
Participants were asked ‘what does bare-
backing mean to you?’ Seventy-two per
cent of participants (N=183) dened ‘bare-
backing’ as simply condomless anal sex with
anyone, regardless of HIV risk or partner
status. Answers such as ‘anal sex without a
condom’ (P60, age 44, status unknown),
and ‘condomless anal sex in general’ (P156,
age 22, status unknown) and ‘any form of
anal sex without a condom’ (P27, age 30,
HIV-) were common. Fourteen per cent of
participants (N=39) dened ‘barebacking’ as
either condomless anal or vaginal sex. Only
three per cent of participants (N=7) dened
‘barebacking’ as ‘condomless sex with a non-
primary partner’ (P50, age 23, HIV-). Finally,
one per cent (N=3) implied that barebacking
requires responsible decision-making and
calculated risk. For example, one participant
dened barebacking as ‘anal sex without
a barrier that reduces risk of transmission
of infectious agent by 95 per cent’. Other
denitions that came up very infrequently
included elements of fetishism, consent, sex
without lube, condomless sex with a primary
partner, ejaculation, duration, receptive anal
sex and the subculture of men who are mostly
HIV-positive. Evidently, most denitions do
not specify intent or HIV risk, which contrasts
how most researchers dene bareback sex.
The remainder of the paper will refer to bare-
backing using the participant-driven, broad
denition of ‘condomless anal sex’.
Barebacking increases relational intimacy
The most frequently cited reasons for
engaging in bareback sex were related to
intimacy, emotional involvement and trust.
Justications for engaging in barebacking
included ‘improved intimacy’ (P156, age
Psychology of Sexualities Review, Vol. 8, No. 1, Summer 2017 11
Reasons for barebacking in a sample of Canadian and American gay and bisexual men
22, status unknown), ‘it’s a small part of
what makes a relationship special’ (P47,
age 23, HIV-), ‘wanting to feel connected’
(P170, age 23, HIV-) and ‘I feel closer to
that person’ (P100, age 21, status unknown).
Many respondents described how skin-to-
skin contact facilitated a sense of closeness
and intimacy that is difcult to achieve when
using a condom, suggesting that condoms
may act not only as a physical barrier, but
also an emotional barrier. Intimacy was
reported as a reason for having bareback
sex both in and outside of intimate rela-
tionships, for example: ‘Physical intimacy,
emotional connections, feels great and is
lots of fun. Giving yourself to a good guy
or friend and sharing the passion as one is
totally cool’ (P67, age 68, HIV-).
Trust was also mentioned by a signi-
cant number of participants as a reason for
engaging in bareback sex. A mutual under-
standing between partners that neither had
engaged in higher risk sex with other partners
was frequently described, for example: ‘Having
a partner you bareback with is a sign of trust
– that they are monogamous with you, or do
not engage in risky (i.e. bareback) behavior
with other guys’ (P114, age 28, HIV-). Some
respondents living with HIV mentioned that
barebacking can increase trust and connec-
tion with other gay or bisexual men living
with HIV: ‘I think it’s a way for two or more
poz guys to share their life experience in a
way that is fully connected. I see it as a level
of ultimate trust’ (P258, age 29, self-identied
barebacker, HIV+).
For many participants, the act of bareback
sex was infused with meaning. This nding
conrms what has been found in previous
research; that barebacking can increase rela-
tional intimacy and has benets above and
beyond physical sensation (Carballo-Dieguez
et al., 2011; Halkitis & Parsons, 2003).
Barebacking increases sexual pleasure and
A common thread throughout the data was
that barebacking increases pleasure and erot-
icism. As has been previously reported, many
respondents reported that sexual pleasure
was a strong motivator for engaging in bare-
back sex. Statements such as ‘better sensa-
tions during sex’ (P115, age 25, HIV-), ‘more
pleasurable’ (P166, age 28, status unknown),
and ‘it makes topping feel better and more
intense’ (P5, age 24, HIV-) were common.
Further, while some participants framed
their justication for barebacking around
an increase in pleasure, others framed their
responses around how condoms decrease
pleasure: ‘Condoms aren’t sexy in general.
Sex is much less pleasurable for me person-
ally with a condom, however, I leave the
choice up to my partner’ (P73, age 40, HIV-).
Similarly, a number of respondents
described a ‘rhythm’ of sexual energy that is
often interrupted by putting on a condom,
for example:
It makes sex more convenient. Instead
of having to sh for a condom, even if it
is on hand, you simply lube with spit or
otherwise and insert. This makes sex less
interrupted in terms of ow, and more
natural. (P244, age 27, self-identied
barebacker, HIV+)
Likewise, another respondent commented
that: ‘It is more “organic” than interrupting
sex to put on a condom’ (P7, age 44, HIV-).
Furthermore, while some responses framed
condom use as a nuisance, others reported
that condoms cause pain, discomfort and
physical difculties during sex. For example:
‘There’s nothing natural about latex. It also
simply hurts my rectum, and sex with latex
always leaves me feeling raw and chaffed in
my interior’ (P4, age 34, HIV-).
It was also common for participants to
mention difculties maintaining an erection
when using a condom during active anal
sex. For instance, one participant stated:
‘Occasional bouts of erectile difculties have
rendered barebacking more conducive to
successful sex’ (P78, age 26, HIV-), while
another commented that: ‘I lose sensation
with a condom to the degree that I lose my
erection’ (P7, age 44, HIV-).
12 Psychology of Sexualities Review, Vol. 8, No. 1, Summer 2017
Natania Marcus & Joseph Roy Gillis
These varying responses reveal different
attitudinal biases toward condoms, as some
simply attend to the pleasure of condom-
less sex, others report that condoms act as
a barrier to their pleasure, and still others
experience such discomfort using condoms
that barebacking may occur more out of
necessity than pleasure-seeking. In addition
to increased pleasure and absence of phys-
ical difculties, many participants’ responses
contained a psychological appraisal of
arousal or eroticism in relation to bareback
sex. For example, bareback sex was described
as ‘psychologically arousing’ (P33, age 34,
HIV-), ‘hotter and more sensual’ (P148,
age 24, HIV-), and ‘sexier conceptually/
mentally (P140, age 31, status unknown)’.
Certain participants described barebacking
as fullling a particular sexual fantasy or
desire: ‘I think we are animals, and sex is
more afrming of that part of ourselves than
perhaps anything else besides eating. Bare-
backing for me afrms my natural/animal
self’ (P4, age 34, HIV-).
A few respondents mentioned that the
risk of engaging in condomless sex can
increase excitement and eroticism. For
instance, one participant wrote: ‘It just
makes me feel sexier, taking that risk’ (P55,
age 27, HIV-), while another commented:
‘Now, thinking about it, it does engage some
greater sense of trust/distrust (maybe that
is something about risking: a sense of non-
mediated closeness, gambling without disclo-
sure)’ (P35, age 28, HIV-).
Finally, a signicant number of respond-
ents described semen exchange as being an
important aspect of sex. Semen exchange,
in particular, was often described not only
in terms of fullling a sexual desire, fantasy
or fetish and also as increasing intimacy with
the other partner, for example: ‘It’s mostly
about the psychological benets, emptying
yourself in somebody else is exciting and
intimate’ (P125, age 19, status unknown).
Thus, while sexual pleasure is a common
motivator for bareback sex, it is often coupled
with a psychological, fetishistic aspect of
sexual arousal. Similar to how multiple partic-
ipants described bareback sex as symbolic
of emotional intimacy, many respondents
described the act as fullling a relational
fantasy. The desire to ‘take the risk’ with a
partner, the intimacy of semen exchange and
the desire to engage in an organic and uid
sexual process with another person sheds
light on the interaction between pleasure-
seeking and interpersonal connection
through a shared erotic experience.
Planned risk: Reducing risk of HIV transmission
A large number of participants described
using harm reduction strategies to reduce
the risk of HIV transmission when describing
justications and contexts of barebacking.
The use of such harm reduction strategies
imply that for many gay and bisexual men,
barebacking occurs in the context of planned
risk. A number of respondents described
using relational strategies to reduce the risk
of HIV transmission such as monogamy,
negotiated safety, sero-sorting and sero-
positioning. While many respondents simply
cited monogamy as reason enough for bare-
backing, multiple respondents described a
process of transitioning from condom use
to CLAI that involved HIV and STI testing.
For example:
I won’t be cheating, I feel more comfort-
able dating someone who is committed to
me and is willing to have no barriers. Early
on I feel it’s important to talk about being
monogamous, telling my partner not to
keep secrets and be out in the open. I also
made sure we both went to the doctors
and got tested. (P80, age 31, HIV-)
Many respondents who reported having a
non-monogamous primary partner also
described negotiated safety, or the strategy
of dispensing with condoms within HIV-
seronegative concordant regular sexual part-
ners and using condoms with casual partners
(Kippax et al, 1997), as a reason for bare-
backing. For example: ‘I “bareback” with
my primary partner but use condoms with
others no matter of their HIV status: whether
Psychology of Sexualities Review, Vol. 8, No. 1, Summer 2017 13
Reasons for barebacking in a sample of Canadian and American gay and bisexual men
I know they’re neg, HIV + and undetectable,
or unknown’ (P15, age 25, HIV-). Another
commented: ‘Only with my husband,
condoms for everyone else. It is because we
share intimacy and trust each other with our
sexual health’ (P118, age 32, HIV-).
Again, barebacking with only one partner
and using condoms with others is discussed
in relation to reinforcing trust and intimacy
in the context of non-monogamous rela-
tionships. In relation to more casual sexual
encounters, a number of participants reported
having a discussion about barebacking or
condom use as well as disclosure of HIV status
before the sexual encounter. Many respond-
ents reported discussing and assessing level of
risk of HIV transmission before going forth
with barebacking, suggesting a calculated or
planned risk. For example:
We had communicated via for
at least two to three years before we nally
got to meet. We had lots of conversations
about what we wanted to do, our prefer-
ences (for barebacking with each other),
our HIV status. (P245, age 45, HIV-)
Consent and discussion were often mentioned
as prerequisites for the use of risk reduction
strategies, which is essential for the efcacy of
such strategies in reducing HIV transmission.
For example, using frequent HIV testing
and negotiated safety to reduce HIV risk
requires honesty and open lines of commu-
nication between partners about test results
and precautions taken with other sexual
partners, respectively. A minority of partici-
pants also described interpersonal means of
reducing risk in relation to their partners’
serostatus. The use of seroadaptive strate-
gies such as serosorting and seropositioning
were mentioned frequently. Seropositioning
and serosorting was described both by sero-
positive and seronegative participants. One
seropositive respondent who self-identied
as a barebacker describes serosorting below:
In practicality, I only bareback (gener-
ally) with persons living with HIV
(so-called ‘sero-sorting’). Furthermore,
for me, bareback sex only occurs when all
parties are aware of each others’ statuses,
for HIV or other STIs, and consenting.
(P244, age 27, HIV+)
Encouraging people living with HIV to have
sex solely with other seropositive individ-
uals has been criticised as a sort of ‘viral
apartheid’, as it discourages sero-negative
men from having sex with men living with
HIV (Dean, 2009, p.14). However, one sero-
negative participant mentioned that he
serosorts in relation to detectability of viral
load, rather than serostatus. He stated that
he does not bareback with partners who are
‘poz and NOT undetectable’ (P10, age 30,
HIV-). Indeed, articulations of interpersonal
risk reduction strategies were often coupled
with discussions of biomedical treatment
and prevention techniques.
A number of respondents used biomed-
ical risk reduction strategies such as anti-
retroviral therapies (ARTs) and pre-exposure
prophylaxis (PrEP). Responses related to
these strategies were either reported directly
by the user, or by partners of those who take
PrEP or ARTs. The majority of respondents
living with HIV reported having an unde-
tectable viral load or using treatment as
prevention (TasP). At times, TasP or PrEP
were mentioned as the only risk reduc-
tion technique, however some participants
compounded TasP with sero-adaptive strate-
gies, PrEP use or HIV testing. For example:
I am also living with HIV, on medica-
tion, and with an undetectable viral load.
I also almost exclusively play with other
persons living with HIV and who are
undetectable in their viral load, and on
medication. (P244, age 27, self-identied
barebacker, HIV+)
The majority of participants living with HIV
described barebacking either with other
HIV-positive individuals or with partners
who were taking PrEP. Further, respondents
living with HIV frequently mentioned the
14 Psychology of Sexualities Review, Vol. 8, No. 1, Summer 2017
Natania Marcus & Joseph Roy Gillis
undetectability of their own or their part-
ners’ viral loads:
I did not feel at risk for any STIs since we
are both HIV-positive, undetectable, and
on medication. I do not have any regrets
from making the above decisions, and
I feel condent in that assertion. (P244,
age 27, HIV+, self-identied barebacker).
As evidenced above, participants who were
using biomedical HIV treatment or preven-
tion often denied experiencing any negative
emotional reaction in relation to engaging in
bareback sex. Another example comes from
a PrEP user: ‘He is positive and undetectable.
I am negative and on PrEP. Neither of us is
concerned about the risk of HIV…No regrets.
No fear. Just ridiculously hot sex with an incred-
ibly sweet, sexy man.’ (P245, age 45, HIV-).
Interestingly, participants who mentioned
using PrEP as a reason for barebacking often
mentioned how HIV health literacy, educa-
tion and privilege have served to inform
their decision to bareback. For example:
While still exploring my life as sexually
active with multiple partners, I consider
myself fortunate to be able to have health
benets that cover PrEP and the luxury of
a routine that allows me to take my medi-
cation daily without major concern…
I can educate about barebacking respon-
sibly and turn down offers from those
who are ill-informed; this does NOT
mean turning down offers from HIV-
positive men. (P48, age 34, HIV-)
For this respondent, health literacy and
education trumps HIV status when deciding
with whom to bareback. However, access
to PrEP and ARVs as well as information
about HIV is bound up with socioeconomic
privilege. Thus, promotion of biomedical
treatment and prevention must prioritise
equity-based approaches in order to avoid
increasing socioeconomic health gaps. This
will be discussed further in the subsequent
section of the paper.
Inferring safety and retroactive safety negotiation
While many respondents described a risk
reduction process based on scientic
evidence, risk was not always planned using
objective strategies. A few participants
reported that level of risk was assessed based
on somewhat arbitrary characteristics, such
as ‘knowing the person well’ (P48, age 34,
HIV-) or having sex with a partner who
‘has his life together’ (P55, age 27, HIV-).
One participant expressed concern after a
sexual encounter when his sexual partner
stated that he only barebacks with ‘people
I have a good connection with’ (P3, age
26, HIV-). Additionally, a couple of partic-
ipants expressed difculty with ascertaining
a partner’s serostatus, for example: ‘We
always talk status. They always say negative.
You assume that some probably don’t really
know’ (P175, age 32, self-identied bare-
backer, HIV-).
A number of respondents also described
discussing HIV status and risk of transmis-
sion after bareback sex. In some cases,
respondents described agreeing on condom
use or abstaining from anal intercourse with
a partner pre-emptively, but then having
bareback sex in the heat of the moment. In
other cases, sex preceded discussions about
status and risk. For example, one respondent
commented: ‘I asked for a condom, and the
request was sort of acknowledged but not
responded to…afterwards I was concerned
that I had ejaculated in his ass so we discussed
sexual health’ (P3, age 26, HIV-). Similarly,
another wrote: ‘We talked, laughed, made
out and I ended up inside him condomless.
He stopped the situation and disclosed his
[positive] status’ (P35, age 28, HIV-).
While discussing barebacking and HIV
status disclosure was common, these discus-
sions varied in efcacy as a risk reduction
strategy depending on which characteristics
were used to infer safety, whether or not all
parties agreed on the safety strategy, and
the time at which the disclosure occurred.
Unplanned risk that occurs in the heat of
Psychology of Sexualities Review, Vol. 8, No. 1, Summer 2017 15
Reasons for barebacking in a sample of Canadian and American gay and bisexual men
the moment can occur due to a multiplicity
of factors (Adam et al., 2005), and such
encounters will be discussed further in the
following section.
Unplanned risk: Heat of the moment ‘slip ups’
In contrast to the participants who reported
the active use of risk reduction strategies
as impetus for engaging in bareback sex, a
number of respondents described forgoing
condoms due to the heat of the moment
of the sexual encounter. A small minority
of those who described barebacking in the
‘heat of the moment’ reported consciously
choosing to take the risk of engaging in
condomless anal sex. One participant articu-
lated this phenomenon explicitly:
It was very hot sex and so I avoided using
one because of the heat of the moment
and because when I am aroused I usually
have a strong desire to avoid using a
condom. I simply choose to take the risk.
(P265, age 28, HIV-)
Thus, for some, engaging in barebacking
is simply a personal choice that does not
require justication. However, the majority
of respondents who engaged in bareback
sex in the heat of the moment indicated that
risk of HIV transmission was ignored in the
moment. Such responses often revealed nega-
tive self-evaluations such as self-judgement.
For example, one respondent stated: ‘The few
times that I have barebacked in my life were
because I was caught up in the moment and
let my guard down with respect to making
safe sex a priority’ (33, age 34, HIV-). Another
commented: ‘Not interrupting the moment: a
personally consciously ignorant excuse. Heat
of the moment, surely’ (P35, age 28, HIV-).
Additionally, a distinct connection
between unplanned risk and narratives of
regret after engaging in barebacking was
noted in the data. HIV-negative respondents
not using PrEP often cited feeling regret
after bareback sex, especially when drugs
and alcohol were involved, for example:
In this case I was extremely drunk, and
was taken into a washroom cubicle in a
nightclub. I denitely regret it occurring,
and wish I had taken PEP, but I didn’t
think of it in time. This was obviously very
risky (and atypical) behaviour. (P114,
age 28, unknown HIV status)
While a number of HIV-negative or status
unknown respondents reported regret after
the sexual encounter, a few described their
sense of remorse or anxiety as impetus for
accessing PEP afterwards, for example:
I regretted fucking him without a
condom and cumming in his ass…we
had exchanged numbers, so I texted ‘the
bottom’ and asked him to get the rapid
HIV test. He did and was positive. The
next morning I went to the ER and started
a course of PEP. (P3, age 26, HIV-)
I was drunk, met a guy who was HIV+ on
Grindr. We agreed no sex. Things heated
up quick and after 30 minutes of intense
foreplay I ended up fucking him without
a condom. I freaked out over the next 24
hours, two days later went to the ER and
got PEP. (P206, age 26, HIV-)
Interestingly, the respondents above focused
on regret after the sexual encounter rather
than reporting on reduced risk related to
seropositioning, despite the fact that they
were both the insertive partner. Previous
qualitative research on condomless sex and
harm reduction strategies has noted that
some gay and bisexual men often who are
cautious about the efcacy of risk reduction
strategies will ‘act on their tentative beliefs,
often with feelings of regret and concern
afterward’ (Prestage et al., 2013, p.1359).
For some of those respondents, regret may
be a motivator to take prophylactic precau-
tionary measures and take post-exposure
prophylaxis (PEP). However, this is not
easily accessed as not all doctors prescribe
PEP and cost may be extremely high without
insurance coverage for medication.
16 Psychology of Sexualities Review, Vol. 8, No. 1, Summer 2017
Natania Marcus & Joseph Roy Gillis
The present study revealed a discrepancy
between how researchers and respondents
dened barebacking. Many respondents used
the term ‘bareback sex’ to describe CLAI
with a monogamous or primary partner,
while researchers often include risk and/or
intentionality in their operationalisation of
the term. As the most frequently cited reason
for barebacking was increased intimacy, gay
and bisexual men may use the term more
broadly in order to reify a sexual experience
that increases intimacy with sexual partners.
Furthermore, as HIV-risk contexts evolve due
to advancements in treatment and preven-
tion, research must explicitly redene terms
used for ‘high-risk’ sex between GBM.
Intimacy motivations for engaging in
bareback sex were reported by GBM with
primary partners, in monogamous relation-
ships, and in casual sexual partnerships.
Some GBM living with HIV reported that
engaging in CLAI with other people living
with HIV was a way of achieving ‘ultimate
connection’ with others who share similar
social (and biomedical) locations. Fostering
intimacy through CLAI may be an important
antidote to the stigmatisation of gay sex and
thus the fear and shame that often accom-
panied sex for GBM. Future research should
acknowledge both intimacy motivations for
CLAI and the protective effects of increased
intimacy for the wellbeing of GBM, rather
than solely framing barebacking as impulsive
or irrational. Additionally, increasing inti-
macy may also be a motivator for using risk
reduction practices. For example, a recent
study found that intimacy motivations for
engaging in CLAI was associated with PrEP
adoption intentions (Gamarel & Golub,
2015). Thus, HIV prevention interventions
should consider the role that intimacy plays
in sexual decision-making. Finally, many gay
and bisexual men reported having nega-
tive attitudes toward and experiences using
condoms, suggesting that health promotion
efforts should move toward increasing ef-
cacy of risk reduction strategies.
Many respondents described risk reduc-
tion practices in their answers regarding
context and justications for barebacking.
The notion of planned risk indicates
that engaging in CLAI is often a scientif-
ically-informed, calculated decision, again
debunking the notion that bareback
sex occurs due to misinformation or self-
destructive tendencies. However, a select
number of participants reported engaging
in unplanned risk, and these descriptions
often revealed negative self-evaluations and
were coloured with emotions such as fear
and regret. Regret and fear after CLAI are
justied reactions for HIV-negative gay and
bisexual men, as risk of contracting HIV may
be high in the absence of using seroadap-
tive strategies. However, some respondents
revealed shame and self-judgement that may
be magnied by the stigma of condomless
sex between gay and bisexual men. Much of
the literature ignores the complex cognitive,
personalised process that can occur after
engaging in risk-taking. Future research
should investigate the emotional appraisal
of higher risk sexual encounters in order to
determine if or how this may inform future
sexual decision-making and behaviour.
A select number of respondents in the
study reported using biomedical treatment
and prevention strategies. Increased acces-
sibility to TasP and PrEP as prevention strat-
egies not only have implications for sexual
pleasure and intimacy for gay and bisexual
men, but also for the eradication of HIV
stigma and the stigmatization of condom-
less anal sex. For example, on 23 January
2014, ofcials at the Center for Disease
Control (CDC) in the US responded to an
open letter headed by the Chicago-based
HIV Prevention Justice Alliance by agreeing
to stop using the term ‘unprotected sex’
to refer to sex without condoms, vowing
to replace the term with ‘condomless sex’
(Colbert, 2014). This linguistic shift both
signies a public acknowledgement by the
CDC of the efcacy of alternative strategies
like PrEP and TasP and that condom use
is no longer the sole method for protec-
tion from HIV transmission. Additionally,
Psychology of Sexualities Review, Vol. 8, No. 1, Summer 2017 17
Reasons for barebacking in a sample of Canadian and American gay and bisexual men
data from two prospective cohort studies
examining efcacy of condom use among
3490 serodiscordant men who have sex with
men (MSM) found that consistent condom
use was found to be 70 per cent effectivein
reducing HIV infection compared to never
condom use which is lower than that of PrEP
and TasP. Also, only 16 per cent of MSM
reported consistent condom use during anal
sex with partners of any HIV status during
the observation period (Smith et al., 2015).
Such ndings may promote ideological
shifts that could have profound implications
for subsequent research about HIV risk,
condom use and barebacking in gay and
bisexual men. As biomedical treatment and
prevention advancements are compounded
with seroadaptive strategies to signicantly
reduce risk, a radical transformation may
begin to occur in how gay and bisexual men,
academic research and society at large view
HIV and sexuality in this population. Thus,
increasing access to such treatment and
prevention options is paramount. Respond-
ents in the present study using TasP and
PrEP revealed how privilege of access to
education about HIV is linked to the privi-
lege of accessing biomedical HIV-prevention.
PrEP protocols require frequent HIV testing,
and those living with HIV and adhering to an
ARV protocols have frequent check-ups with
doctors to monitor health indicators such
as viral load and CD4 count, indicating that
it is those who already have access to such
health services who are often educated about
risk reduction strategies. Finally, despite
reducing risk of HIV transmission, seroadap-
tive practices and biomedical treatment and
prevention do not protect MSM from STIs,
and may in fact increase STI transmission
(McCormack & Dunn, 2015). Research and
intervention related to biomedical treatment
and prevention must focus on behavioural
STI reduction strategies such as frequent
and accessible STI testing.
There are two main limitations to the
present study. Firstly, methodological
constraints did not allow for the researchers
to engage in a deductive questioning process
with each participant, and some respondents
provided more detail than others. Thus, the
depth of the data was somewhat limited. The
second limitation is that respondents in the
present study were only asked to provide
details regarding episodes of condom-
less sex. Thus, the data does not capture
narratives related to the successful use of
condoms among GBM. In fact, quantitative
data from the present study suggest that
GBM who do not engage in barebacking
report that condoms increase sexual enjoy-
ment (Marcus, 2016). Thus, attitudes toward
condoms must be assessed and interven-
tions should be tailored accordingly. Alto-
gether, when used consistently and correctly,
condoms are highly effective in reducing
HIV transmission (CATIE, 2016), however
observational research suggests that a high
level of condom use efcacy may be dif-
cult for some people to achieve (Smith et
al., 2015). Thus, for those who engage in
barebacking or use condoms inconsistently,
promoting the consistent and correct use of
ARVs or PrEP may be more efcacious than
promoting condom use.
Natania L. Marcus MA, is a PhD student
in Clinical and Counselling Psychology in
the Department of Applied Psychology and
Human Development at the Ontario Insti-
tute for Studies in Education at the Univer-
sity of Toronto, Toronto, Ontario, Canada.
J. Roy Gillis PhD, is an Associate Professor in
the Department of Applied Psychology and
Human Development at the Ontario Insti-
tute for Studies in Education at the Univer-
sity of Toronto, Toronto, Ontario, Canada.
18 Psychology of Sexualities Review, Vol. 8, No. 1, Summer 2017
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... For example, participants who reported that they frequently used condoms or were sexually conservative did not access HIV testing because they did not believe they engaged in enough HIV risk. These issues relating to not testing for HIV, not using condoms, and not accessing PrEP have been reported by broader populations of GBM regardless of country of origin (Gianacas et al., 2015;Marcus & Gillis, 2017;Philpot et al., 2020;Prestage et al., 2012). They are unlikely to exclusively apply to migrant GBM, but they nonetheless indicate that individuals can have personal interpretations of the need to access HIV testing and PrEP and use condoms based on their perceptions of their sexual behaviour and beliefs about medications. ...
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Introduction Stigma is a significant contributor to the HIV diagnosis disparities experienced among migrants who are gay and bisexual men (GBM) living in high-income countries. Methods We conducted interviews with 24 migrant GBM in Australia diagnosed with HIV from 2017 onwards, who since their diagnosis had become well-connected to sexual health services and participation in research. Interviews were conducted between October 2018 and December 2019. We aimed to identify how HIV and sexual identity stigmas were barriers to accessing HIV testing and prevention. Results These stigmas were deeply embedded into social, cultural, and institutional settings in participants’ countries of origin, resulting in poor HIV literacy, reluctance to access HIV-related services, including HIV testing, and fears of being identified as gay/bisexual publicly. Underpinned by internalised stigma, these fears and poor outcomes often persisted after moving to Australia. Other barriers to accessing HIV-related services in Australia included apprehension about a potential HIV-positive result and the possibility of visa cancellation, concerns about confidentiality, and a lack of confidence and support in navigating the healthcare system, including how to access pre-exposure prophylaxis. Conclusion Addressing these multifaceted HIV testing and prevention barriers requires policies, systems, and interventions that increase health literacy about HIV testing, prevention, and treatment; build trust and confidence when navigating Australian health services; and reduce the impacts of HIV and sexual identity stigmas in migrants’ countries of origin on their experiences in Australia.
... Although not the focus of this review, HIV and PrEP stigma were referenced in many of the studies, notably in the qualitative responses of MSM (Collins et al., 2017;Philpot et al., 2020;. Openly promoting PrEP as enhancing sexual pleasure and positively depicting sex among MSM could chip away at the social norms that sanction only heterosexual sex or sex with condoms, which negatively stereotypes casual sex, club sex, and barebacking (Dubov et al., 2018;Knight et al., 2016;Marcus & Gillis, 2017;Schnarrs et al., 2018). In short, shifting the language surrounding PrEP from risk to pleasure has the potential to erase the line between "acceptable" and "unacceptable" consensual sex, reduce the negativity surrounding promiscuity, and stamp all sex -whether casual or committed -as equally safe (Auerbach & Hoppe, 2015; J. L. Marcus & Snowden, 2020). ...
Pre-exposure prophylaxis (PrEP) is an effective form of Human Immunodeficiency Virus (HIV) prevention for people at potential risk for exposure. Despite its demonstrated efficacy, PrEP uptake and adherence have been discouraging, especially among groups most vulnerable to HIV transmission. A primary message to persons who are at elevated risk for HIV has been to focus on risk reduction, sexual risk behaviors, and continued condom use, rarely capitalizing on the positive impact on sexuality, intimacy, and relationships that PrEP affords. This systematic review synthesizes the findings and themes from 16 quantitative, qualitative, and mixed methods studies examining PrEP motivations and outcomes focused on sexual satisfaction, sexual pleasure, sexual quality, and sexual intimacy. Significant themes emerged around PrEP as increasing emotional intimacy, closeness, and connectedness; PrEP as increasing sexual options and opportunities; PrEP as removing barriers to physical closeness and physical pleasure; and PrEP as reducing sexual anxiety and fears. It is argued that positive sexual pleasure motivations should be integrated into messaging to encourage PrEP uptake and adherence, as well as to destigmatize sexual pleasure and sexual activities of MSM.
... Guided by feminist perspectives on sexuality, which emphasize intersectionality and address the ways in which women's sexual experiences are tied to societal structures and inequities [16][17][18], researchers have advocated for assessing the sexual health outcomes that are desired by people with HIV and then studying the factors that enable those outcomes, rather than exclusively focusing on HIV prevention goals and other deficit-based analyses [15,[19][20][21][22][23]. Though a few studies have addressed these issues in MWH who have sex with men [24][25][26], there is a notable dearth of information on intimacy and pleasure among MWH who have sex with women, particularly around conception. ...
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Many men with HIV (MWH) in Uganda desire children, yet seldom receive reproductive counseling related to HIV care. Because men are under engaged in safer conception programming, they miss opportunities to reap the benefits of these programs. The objective of this sub-analysis was to explore the relationship and intimacy benefits of integrating safer conception counseling and strategies into HIV care, an emergent theme from exit interviews with men who participated in a pilot safer conception program and their partners. Twenty interviews were conducted with MWH who desired a child in the next year with an HIV-uninfected/status unknown female partner, and separate interviews were conducted with female partners (n = 20); of the 40 interviews, 28 were completed by both members of a couple. Interviews explored experiences participating in The Healthy Families program, which offered MWH safer conception counseling and access to specific strategies. Data were analyzed using thematic analysis. Three major subthemes or “pathways” to the relationship and intimacy benefits associated with participation in the program emerged: (1) improved dyadic communication; (2) joint decision-making and power equity in the context of reproduction; and (3) increased sexual and relational intimacy, driven by reduced fear of HIV transmission and relationship dissolution. These data suggest that the intervention not only helped couples realize their reproductive goals; it also improved relationship dynamics and facilitated intimacy, strengthening partnerships and reducing fears of separation. Directly addressing these benefits with MWH and their partners may increase engagement with HIV prevention strategies for conception.
... Both the lack of inhibition produced by the use of alcohol and drugs (Dir et al., 2018) and the spontaneity of an encounter appear to be represented as contexts inherently linked to risk (Camargo & Bousfield, 2009;Ellis et al., 2018). In the representations constructed in the social dialogue of young people and based on their everyday experiences, the lack of inhibition is assumed to encourage loss of rational control over one's behaviour whilst the spontaneity of an encounter involves not thinking conservatively about prevention, and only about the overall result or pleasure of the sexual encounter (Marcus & Gillis, 2017). Consistent with these ideas, risk also seems to be linked to sexual practice in public rather than private spaces. ...
In this study we investigate the social representations of risky sexual practices. Specifically, we analyse the circumstances in which young Spanish people consider a sexual practice as risky, and how such ‘representations’ of risk have implications for decisions about using condoms. We use the Grid Elaboration Method to gather the naturalistic thoughts and feelings of 175 young people regarding risky sexual practices and performed a lexical analysis of the content of the responses using Iramuteq software. Our analyses suggested two main textual universes regarding risky sexual practices. The first of these, at a theoretical-informative level, is clearly linked to the discourse of experts, where condom use is a key factor and risk is distanced from the self. The second, at a practical-applied level, represents risky sexual practices in a context that is linked to the unknown and a lack of control due to the use of substances or the spontaneity of the sexual encounter. We conclude that understandings of risk emerge from various sources of information, values, or social conventions that articulate everyday understandings and are likely to guide sexual practices, some of which are far removed from expert risk knowledge. We therefore understand representations of risk in sexual relations as situated within a social context. We conclude by discussing the substantive, theoretical, and practical consequences of this social construction of risk.
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Background: Pre-exposure prophylaxis (PrEP) has proven biological efficacy to reduce the sexual acquisition of the human immunodeficiency virus (HIV). The PROUD study found that PrEP conferred higher protection than in placebo-controlled trials, reducing HIV incidence by 86 % in a population with seven-fold higher HIV incidence than expected. We present the baseline characteristics of the PROUD study population and place the findings in the context of national sexual health clinic data. Methods: The PROUD study was designed to explore the real-world effectiveness of PrEP (tenofovir-emtricitabine) by randomising HIV-negative gay and other men who have sex with men (GMSM) to receive open-label PrEP immediately or after a deferral period of 12 months. At enrolment, participants self-completed two baseline questionnaires collecting information on demographics, sexual behaviour and lifestyle in the last 30 and 90 days. These data were compared to data from HIV-negative GMSM attending sexual health clinics in 2013, collated by Public Health England using the genitourinary medicine clinic activity database (GUMCAD). Results: The median age of participants was 35 (IQR: 29-43). Typically participants were white (81 %), educated at a university level (61 %) and in full-time employment (72 %). Of all participants, 217 (40 %) were born outside the UK. A sexually transmitted infection (STI) was reported to have been diagnosed in the previous 12 months in 330/515 (64 %) and 473/544 (87 %) participants reported ever having being diagnosed with an STI. At enrolment, 47/280 (17 %) participants were diagnosed with an STI. Participants reported a median (IQR) of 10 (5-20) partners in the last 90 days, a median (IQR) of 2 (1-5) were condomless sex acts where the participant was receptive and 2 (1-6) were condomless where the participant was insertive. Post-exposure prophylaxis had been prescribed to 184 (34 %) participants in the past 12 months. The number of STI diagnoses was high compared to those reported in GUMCAD attendees. Conclusions: The PROUD study population are at substantially higher risk of acquiring HIV infection sexually than the overall population of GMSM attending sexual health clinics in England. These findings contribute to explaining the extraordinary HIV incidence rate during follow-up and demonstrate that, despite broad eligibility criteria, the population interested in PrEP was highly selective. Trial registration: Current Controlled Trials ISRCTN94465371 . Date of registration: 28 February 2013.
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Referrals for and initiation of preexposure prophylaxis (PrEP) for human immunodeficiency virus (HIV) infection increased dramatically in a large clinical practice setting since 2012. Despite high rates of sexually transmitted infections among PrEP users and reported decreases in condom use in a subset, there were no new HIV infections in this population.
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Background: In the USA, men who have sex with men (MSM) in primary partnerships are at elevated risk for human immunodeficiency virus (HIV) infection. Pre-exposure prophylaxis (PrEP), a new biomedical prevention strategy, has potential to reduce HIV transmission. This study examined predictors of PrEP adoption intentions among HIV-negative MSM in primary partnerships. Methods: The sample included HIV-negative MSM (n = 164) who participated in an ongoing cross-sectional study with an in-person interview examining PrEP adoption intentions. Results: Higher HIV risk perception, intimacy motivations for condomless sex, recent condomless anal sex with outside partners, education, and age were each independently associated with PrEP adoption intentions. In a multivariate model, only age, education, and intimacy motivations for condomless sex were significantly associated with PrEP adoption intentions. Conclusions: Intimacy motivations may play a central role in PrEP adoption for MSM couples. Incorporating relationship dynamics into biomedical strategies is a promising avenue for research and intervention.
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Intentional condomless anal sex in HIV-risk contexts (“barebacking”) has been heatedly debated in gay circles, the gay media, and, to a lesser degree, the mainstream media. Yet it has received little attention in the scientific literature. In order to better understand the reasons behind this behavior, we conducted a content analysis of messages posted on an Internet message board following's decision to close a company-sponsored bareback chat room. Individuals posting messages self-identified in their online profiles as being mostly White/ European gay men residing in the US, with an average age of 35 years. Out of 130 messages, 62 (48%) were pro-barebacking, 55 (42%) were against barebacking, and 13 (10%) referred to other topics. The content analysis of the messages showed that both those in favor of and against barebacking felt well-informed about HIV/AIDS and the risks of HIV transmission. Those in favor considered condomless sex more enjoyable than sex with condoms (both in actual experience and in erotic imagery), felt that condomless sex conferred a sense of freedom, minimized the risks involved in barebacking (assuming that practitioners were already HIV infected and that the risk of superinfection was small), and ultimately believed that barebacking was a personal decision and responsibility. Those against barebacking believed the behavior was dangerous, advocated for condom use and personal and social responsibility, and felt barebackers needed to be sensitized to the burdens of HIV disease. Implications of these results are discussed, pointing out the need for further scientific inquiry in this area.
SUMMARY This study examines conceptual understandings, definitions, and practices of barebacking in a sample of 227 gay and bisexual men recruited from four gay venues in the New York Metropolitan area. Findings demonstrated that 21% of the participants identified as HIV-negative (HIV−) and 61.7% as HIV-positive (HIV+). While 90% of the sample was familiar with the term “barebacking,” differences were noted in conceptual understandings and practices of bare-backing between HIV+ and HIV− men. In particular, the findings suggest that these men were more likely to socialize and have sex with seroconcordant partners and that these patterns of socialization may shape attitudes and practices about barebacking.
This article seeks to explore the idea that contemporary health promotion and education may actually be instrumental in creating the very conditions that encourage and perpetuate people's 'risky' health practices. Using the example of gay men, unsafe sexual practices and the contemporary 'barebacking craze', it argues that 'health promotion' is increasingly being oriented to by gay men as something to 'resist' or 'transgress'. The implications of this for future health promotion interventions are discussed.
We derived an estimate of male condom effectiveness during anal sex among men who have sex with men (MSM) because the most widely used estimate of condom effectiveness (80%) was based on studies of persons during heterosexual sex with an HIV-positive partner. Assessed male condom effectiveness during anal sex between MSM in two prospective cohort studies of HIV incidence by self-reported consistency of use. Analyzed data combined from US participants in the EXPLORE trial (1999-2001) public use dataset and in the VAX 004 trial (1998-1999) dataset. Initially HIV-uninfected MSM enrolled in these trials completed baseline and semiannual interviews about their sexual behaviors with male partners and underwent HIV testing. Using a time-to-event model, effectiveness of consistent condom use in preventing HIV infection was estimated among men reporting receptive and/or insertive anal sex with an HIV-positive partner, and consistency of condom use. Among MSM reporting any anal sex with an HIV-positive male partner, we found 70% effectiveness with reported consistent condom use (compared to never use) and no significant protection when comparing sometimes use to never use. This point estimate for MSM was less than the 80% effectiveness estimate reported for heterosexuals in HIV discordant couples reporting consistent condom use. However, the point estimates in the two populations are not statistically different. Only 16% of MSM reported consistent condom use during anal sex with male partners of any HIV status over the entire observation period. These estimates are useful for counseling efforts, and for modeling the impact and comparative effectiveness of condoms and other prevention methods used by MSM.
Sexual health discourses have become a defining part of many gay men’s sex lives. These discourses have effectively linked gay identity to HIV/AIDS discourses through telling most gay men how to rationally have sex and how to routinely get tested. However, some gay men who bareback – the choice often made not to use a condom – engage in condomless sex despite these larger discourses. Through using Weber’s theories on rationalization, I explicate how sexual health and HIV/AIDS discourses are calculable, efficient systems that are about protecting the public good. I show how this rationalized sexual health system disciplines pleasure and intimacy. Through this disciplining, I illuminate how sexual public health has disenchanted sex, specifically for some gay men, where some of these men who bareback may be attempting to find re-enchantment in this disenchanted sexual world. Through this Weberian framework, barebacking may be seen as an act that can allow for the re-exploration of personability, intimacy, eroticism and love.
Recent compelling evidence that HIV medication may decrease the chances of HIV transmission and acquisition bring to light once again the issue of ethical responsibilities of those infected and uninfected when engaging in sexual intercourse. Using data collected in New York City from 120 gay men who engaged in barebacking (operationalized as intentional unprotected anal intercourse in an HIV-risk context), we analyzed participants' attributions of responsibility to self and/or others and how these attributions varied by HIV status. Nearly all participants concurred that ethical judgments were involved and frequently offered a two-tiered response based on the right to individual decision-making and recognition of one's responsibility not to harm others. However, respondents merged the imperative for ethical action with an implicit requirement for communication, and their descriptions of sexual negotiations suggested ambiguities and conflicting assumptions. The result was a frequent tendency to shift the ethical burden to the partner rather than oneself in the context of diminished community dialogue about HIV. New scientific knowledge about HIV transmission offers opportunities for community discussions of sexual fulfillment, rights and responsibilities.
Seroadaptation describes a diverse set of potentially harm-reducing behaviors that use HIV status to inform sexual decision making. Men who have sex with men (MSM) in many settings adopt these practices, but their effectiveness at preventing HIV transmission is debated. Past modeling studies have demonstrated that serosorting is only effective at preventing HIV transmission when most men accurately know their HIV status, but additional modeling is needed to address the effectiveness of broader seroadaptive behaviors. The types of information with which MSM make seroadaptive decisions is expanding to include viral load, treatment status, and HIV status based on home-use tests, and recent research has begun to examine the entire seroadaptive process, from an individual's intentions to seroadapt to their behaviors to their risk of acquiring or transmitting HIV and other STIs. More research is needed to craft clear public health messages about the risks and benefits of seroadaptive practices.