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HIV negative gay men’s experiences of barebacking in casual sexual relationships Bayzand, Laurence John 2005

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H I V N E G A T I V E G A Y M E N ' S E X P E R I E N C E S O F B A R E B A C K T N G I N C A S U A L S E X U A L R E L A T I O N S H I P S by L A U R E N C E J O H N B A Y Z A N D B . A . , The University of Victoria, 1984 A THESIS S U B M I T T E D I N P A R T I A L F U L F I L L M E N T O F T H E R E Q U I R E M E N T S F O R T H E D E G R E E O F M A S T E R O F A R T S in T H E F A C U L T Y O F G R A D U A T E S T U D I E S Counselling Psychology T H E U N I V E R S I T Y O F B R I T I S H C O L U M B I A January 2005 © Laurence John Bayzand, 2005 Abstract The purpose of this study was to examine the phenomenon of unprotected anal intercourse, or barebacking, among H I V negative gay men. There currently exists scant literature, particularly that of a qualitative nature, relative to barebacking behaviour. A qualitative phenomenological methodology was chosen to explore the meaning and experience of gay men who bareback so that the voices of these men could come forth and be heard. The research consisted of interviews with 6 participants: four Caucasian men, and two Asian men. The men ranged in age between 24 and 55 years. A l l six of the men acknowledged that they barebacked in casual, non-primary, relationships. The main question the participants were asked to consider was: What is the meaning and experience for you, of barebacking in your casual sexual relationships? The participants were invited to discuss their experiences as i f they were telling a story, with a beginning, a middle, and an end. The interviews were transcribed and analyzed in accordance with an abbreviated version of Colaizzi ' s (1978) model of phenomenological data analysis. This model served as a guideline for the identification of the five themes that emerged through the analysis. In no particular order, the themes that were experienced were: (a) Sense of Increased Intimacy/Connection; (b) Burden of safer Sex; (c) Sense of Enhanced Sexual Pleasure, Excitement, and Empowerment; (d) Sense of Powerlessness; and (e) Awareness of Responsibility to Self. These themes are discussed in terms of their implications for future research and counselling. i i i Table of Contents Abstract i i Table of Contents i i i Acknowledgements • • • • v Chapter One - Introduction 1 Purpose of the Study 8 Chapter Two - Literature Review 12 Awareness and Prevalence of Barebacking among Gay M e n 12 Barebacking and Bug Chasing 19 The Meanings of Barebacking 23 Chapter Three - Methodology 33 Method Selection 33 Phenomenology 35 Personal Assumptions and Bracketing 37 Research Procedure 39 Data Analysis 45 Limitations of the Study 47 Chapter Four - Results 50 Participant Biographies —50 Common Themes 56 Chapter Five - Discussion 79 Comparison with the Literature 79 Implications for Future Research 91 iv Implications for Counselling 93 References 99 Appendix A - Advertisement for the Study 107 Appendix B - Participant Informed Consent Form ,...108 Appendix C - Orienting Statement 110 Appendix D - Interview Questions 111 Appendix E - Resources 113 V Acknowledgements A study of this nature could not have been undertaken without the assistance and support of a good many people. I would, therefore, like to acknowledge the following individuals, without whom the completion of this research would have proven exceedingly difficult: Pat MacDiarmid, Volunteer Coordinator at The Centre, who provided a safe and convenient location for the participant interviews; Peter Toppings, Education and Outreach Coordinator at The Centre, for assisting in the distribution of the recruitment poster; Eric Isbrucker, for his inquisitive mind and unfailing eagerness; Drs. Victoria Alfonso and Marv Westwood for their encouragement and assistance throughout the research process; Dr. Judith Daniluk, whose keen eye and ability to improve a turn of phrase I can only hope to emulate, and without whose enduring advocacy this work may have defied completion; M y friends and family who gave me confidence; Todd Benko, who loves and supports me in all that I do; and most certainly The men who came forward and shared their compelling stories with me. 1 Chapter One Introduction More than 20 years after the onset of the pandemic, H I V / A I D S continues to be a worldwide public health concern. Estimates from U N A I D S indicate that more than 60 mil l ion people have been infected with H I V worldwide, with one-third of these having already died (Hogg et al., 2002). It is further projected that within 20 years, another 68 mil l ion people w i l l die from H I V / A I D S globally (Hogg et al.). A t the extreme end of the spectrum, "[l]ife expectancy at birth in Botswana (which, at 38.8%, has the highest adult prevalence rate in the world) has dropped below 40 years—a level not seen in that country since before 1950" ( U N A I D S , 2002). The number of current and future projected H I V infections internationally is staggering, but may be partially attributable to factors such as lack of education, lack of access to condoms and medications, and differing cultural and religious norms that may serve to inhibit discourse on the subject of H I V / A I D S . The first cases of A I D S were diagnosed in the United States in 1981, although evidence suggests that earlier cases may have existed (AIDS Education Global Information System, 2001; Grmek, 1989/1990). Since that time, over 500,000 North American lives have been lost to the disease (Centers for Disease Control and Prevention, 2003; Health Canada, 2003a). The first reported Canadian A I D S diagnosis occurred in 1982, with close to 20,000 cases having been diagnosed to the end of June 2003 (Health Canada, 2003b). The group that was first and most profoundly impacted, and remains highly vulnerable to the syndrome, was gay men (Centers for Disease Control and Prevention; Health Canada, 2003a; Rotello, 1998; Shilts, 1987). Reporting data more 2 commonly refer to men who have sex with men ( M S M ) in order to capture data relevant to men who may not self-identify as gay. According to the Canadian Centre for Infectious Disease Prevention and Control (CIDPC): [P]rior to 1996, 77.1% of positive H I V test reports among adult men were attributed to M S M . This proportion decreased steadily to level off at around 48.5% during 1997-1999. It increased to 53.6% in 2000 and then decreased to 48.3% in 2001. In the first half of 2002, this percentage was 51.4% (Health Canada, 2003c, p. 42). These data indicate that an increase in positive H I V tests among Canadian M S M has occurred in both 2000 and 2002, and may suggest behavioural changes that are leading to increased rates of infection. While sceptics exist (Duesberg, 1996; Maggiore, 1999; Shenton, 1998), the majority of the scientific community and the public accept that H I V is the cause of A I D S (Grmek, 1989/1990; Health Canada, 2003a; Montagnier, 1994/2000; Rotello, 1998; Shilts, 1987). M u c h fear surrounded the onset of A I D S , as the causal agent was initially unknown. While researchers in North America and Europe struggled to identify its cause, A I D S quickly spread through the gay, intravenous drug user (IDU), and haemophiliac communities (Shilts). Due to the manner in which H I V is spread, largely via the exchange of body fluids such as semen or blood, gay men were particularly at risk of H I V infection because of their sexual practices (Shilts). Once the cause of A I D S , namely the H I V virus, and its transmission methods were determined, efforts were made by both health officials and the gay community to educate the public regarding safer sex 3 practices (Shilts). A J D S Vancouver (2003) describes the infectious nature of H I V and safer sex practices as follows: H I V is only infectious in blood, cum or pre-cum (semen), vaginal fluids and breast milk. Therefore, any activity that allows infected blood, cum or vaginal fluid (or breast milk) to enter the bloodstream of another person w i l l place that person at risk of getting the virus. Tiny painless cuts or abrasions can happen during sexual intercourse and allow infected blood, cum or vaginal fluid to come into contact with the bloodstream. These cuts are more likely to occur in the lining of the rectum and anus than the lining of the vagina. They are also l ikely to occur in the lining of the penis around the meatus (the hole at the tip of the penis). H I V is not infectious in any other body fluid, such as saliva, tears, sweat, urine or mucous (http://www.aidsvancouver.org/basics/prevention/safersex/index.html). The guidelines as stated above exist today in the same form as when they were first introduced in the 1980s. The medical and scientific communities have maintained an unfaltering position regarding H I V infection as leading to A I D S , and the methods by which such infection may be averted. Grmek (1989/1990) asserts that "there is absolutely no evidence that A I D S has ever been spread under normal l iving conditions... .It breaks through the barrier separating individuals only by sexual activity, the biology of maternity, the injection of drugs, or medical intervention" (p. 90). Gay men had been loathe to acknowledge that H I V may be transmitted sexually, and viewed the suggestion as an attempt by a homophobic society to regulate their behaviour (Rotello, 1998; Shilts, 1987). Sexual freedom was considered a cornerstone of 4 a new-found sense of liberty in the post-Stonewall era. Unfortunately, the very behaviours associated with this freedom, specifically unprotected anal intercourse (UAI) with multiple partners, provided the opportunity for A I D S to spread rapidly among gay men at the outset of the epidemic (Rotello). As Grmek (1989/1990) states: [C]ertain initial errors [were] committed as much by those responsible for public health as by the homosexual organizations. There was a hesistancy to place any limits on the free expression of the "right to sexuality"....The spokesmen of homosexual organizations had not pleaded for moderation of some customs, nor had they yielded to the "medicalization" of the group's sexuality (p. 19). Not only did gay men fear a reversal of sexual liberty, but a greater social backlash was feared, and to some extent experienced, as A I D S was almost exclusively associated with gay male sexual behaviour. Prior to the appellation of A I D S , the disease had first been referred to as the gay cancer, and then was renamed G R I D or gay-related immune deficiency (AIDS Education Global Information System, 2001). These designations had appeared appropriate as A I D S was originally detected in the gay male population, but as other social groups were shown to be impacted, they became less meaningful. In 1982, A I D S or acquired immune deficiency syndrome was coined (AIDS Education Global Information System). A s Grmek points out, this widely-accepted term is in fact incorrect, as " A I D S is a pathologic state emanating from infection with the H I V v i rus . . .AIDS thus becomes not so much a syndrome as a retroviral infectious disease" (p. 33). Ultimately, H I V is a retrovirus that gains access to its host via certain behaviours that are not exclusive to gay men (Montagnier, 1994/2000). 5 If ADDS is not, in fact, a gay disease, then what factors allowed the virus to enter the gay community in such a devastating fashion? According to Grmek (1989/1990): It is certainly true that the epidemic had broken out in American homosexuals not because they had "sinned against nature," but because as a group, they had been more prone to promiscuity than heterosexuals....American homosexuals created the conditions which, by exceeding a critical threshold, made the epidemic possible. They were a sort of "culture medium" that permitted virulent strains of H I V to emerge (p. 168). In other words, the behaviour of gay men, not being gay unto itself, provided the opportunity for H I V to enter the community. Shilts (1987) and Rotello (1998) documented the behaviours prevalent among some gay men that had arisen during the 1970s that eventually led to the spread of H I V . Gay men had experienced a period of unbridled sexual freedom, manifested by: Multiple concurrent partners, versatile anal sex, core group behavior centered in commercial sex establishments, widespread recreational drug abuse, repeated waves of STDs and constant intake of antibiotics, sexual tourism and travel....Multipartner anal sex was encouraged, celebrated, considered a central component of liberation. Core group behavior in baths and sex clubs was deemed by many the quintessence of freedom. Versatility was declared a political imperative. Analingus was pronounced the champagne of gay sex, a palpable gesture of revolution. STDs were to be worn like badges of honor, antibiotics to be taken with pride (Rotello, p. 89). 6 It would appear, therefore, that the very freedom gay men sought, and believed to be their right, ultimately led to the devastating loss of health and life wrought by A I D S . Nevertheless, once H I V was proven the cause of A I D S , many gay men, and others, altered their sexual behaviour in accordance with the safer sex guidelines, resulting in an eventual decline in H I V infections. Specifically, the introduction of the condom code, or the use of condoms during anal sex, appeared to slow the progress of H I V transmission, leading gay men to believe that H I V / A I D S may be on the wane (Rotello, 1998). The trend of decreased new H I V infections in North America became apparent in the mid-1990s and continued through to the late 1990s (Centers for Disease Control and Prevention, 1982-2001; Health Canada, 2003a). More recently that trend seems to be changing. Canadian data show specifically that there was an increase in H I V diagnoses in 2000 and 2002 among M S M , although the infection rate declined in 2001 (Health Canada, 2003b). B C Centre for Disease Control (2002) reported 105 new H I V infections among B C M S M in 1999, compared to 158 in 2002, representing a 52% increase. In Canada, and the majority of the industrialized world, information, condoms, and medications are readily available, yet the rate of H I V infections once again appears to be on the rise within the gay community. After many years of steady decline, it seems important to ask why H I V infection rates among gay men are climbing. While many factors may be at play, unlike the ethos of the 1980s, it appears that there is currently considerable complacency in the gay community regarding H I V / A I D S (Carballo-Dieguez, 2001; Gauthier & Forsyth, 1999; Suarez & Mil le r , 2001). Some gay men may no longer fear H I V infection as they once did, possibly due to the advent of new medications for managing the disease, such as 7 protease inhibitors (Dilley et al., 1997; Elford et al., 2000; Ke l ly et al., 1998; Ostrow et al., 2002; Remien et al., 1998). Some researchers (Gold et al., 1994; Bancroft et al., 2003) have also noted a connection between drug and/or alcohol consumption and unprotected sex. Furthermore, younger gay men in particular who were not witness to the devastating prevalence of illness and death in the gay community during the 1980s may be at risk due to their "lack of respect for this potentially fatal disease" (Suarez & Mil le r , p. 293). The most blatant example of this new complacency is found in the practice of barebacking. Suarez and Mi l l e r (2001) define barebacking as "the deliberate and conscious choice to engage in risky sexual behavior knowing that there are risks involved" (p. 288). Commonly, barebacking refers to "intentional anal sex without a condom with someone other than a primary partner" (Mansergh et al., 2002, p. 653) although it may also refer to "oral sex with swallowing of the semen, and gloveless fisting" (Suarez & Mil le r , p. 288). Furthermore, a number of researchers are beginning to report on the barebacking phenomenon (Carballo-Dieguez, 2001; Crossley, 2002; Gauthier & Forsyth, 1999; Halkitis et al., 2003; Mansergh et al., 2002). U N A I D S (2002) describes how: In most high-income countries, the almost-legendary successes achieved by, and among, men who have sex with men are clearly now a thing of the past. Prevention efforts appear not to be reaching the large numbers of men among whom increases in unsafe sex are being mirrored by higher rates of sexually transmitted infections—in Australia, Canada, the United States and countries of Western Europe (fU). 8 The data that have been presented to date suggest that barebacking is becoming somewhat of a craze among some gay men. According to Gendin (1997), an H I V positive man: "Wi th the risks so hazy and the benefits so brilliantly clear, no wonder riding bareback is all the rage" (111). The research has not, however, clearly identified what dynamics may influence H I V negative men to participate in a practice known to be the highest risk for seroconversion. Seroconversion is defined as "the development of detectable antibodies in the blood as a result of infection, or in other terms going from negative H I V status to positive H I V status" (Always Your Choice, n.d., %2). The potential for seroconversion is not the only risk associated with barebacking. Sexually transmitted infections (STI) such as syphilis and gonorrhoea may also be transmitted via U A I (Health Canada, 2003c). Consequently, the practice of barebacking may negatively impact the health of gay men on a variety of fronts. Factors that may contribute to an increase in barebacking include depression (Carter, 2003) and i l l ici t drug use or abuse (Seely, 2003). Among 1,854 B C M S M surveyed, Trussler et al. (2003) "found a 25% increase in U A I with multiple partners between 2000 and 2002....About 27% of the...sample reported U A I with one or more partner of 'unknown sero-status' within the previous year" (p. 30). Therefore, a better understanding of why an increase in this high risk-taking behaviour among gay men is occurring is both necessary and timely. Such information may enable improvements to be made to existing or future H I V and STI prevention programs. Purpose of the Study The purpose of the study is to develop a set of themes that describe the experience of gay men who engage in barebacking behaviour with casual sexual partners. Gay men 9 specifically w i l l be the focus of the study as men who have sex with men continue to represent over 75% of the A I D S cases among adult males in Canada (Health Canada, 2003b). Further, it is l ikely that an increase in U A I w i l l result in a proportionate rise in HrV infection rates among sero-negative gay men. While it appears that some gay men may have undergone a behavioural change resulting in decreased usage of condoms during anal sex, some gay men may have never practiced safer sex. The present study w i l l seek representation from both of these groups. B y documenting the stories of these men it is hoped that some insight may be gained into the barebacking phenomenon. The data may prove helpful in targetting men who are practicing U A I with appropriate educational messages, thereby preventing additional HrV and other sexually transmitted infections. The research question guiding this inquiry is: "What is the meaning and experience of barebacking in casual sexual relationships for gay men?" The goal of the study w i l l therefore be to gain an understanding of the meaning and experience of engaging in barebacking for gay men who may or may not have previously practiced safer sex. For the purpose of this study, barebacking w i l l be defined as receptive or insertive U A I ; as also employed by Gauthier and Forsyth (1999), Halkitis et al. (2003) and Ridge (2004). Furthermore, the barebacking must occur within the context of a casual or non-primary sexual relationship. Accordingly, condomless sex between primary, especially monogamous, partners w i l l not fit the inclusion criteria for this study. Whi le research into the practice of barebacking has begun to appear in the literature, the majority of studies have taken place in the United States, Great Britain, or Australia. The data collected from these studies have informed the health care community as to the phenomenon, but additional research is required to better understand 10 the scope of the behaviour and its implications for HIV/ADDS education and prevention. Some researchers (Adam et al., 2000; Carballo-Dieguez, 2001; Ridge, 2004; Suarez & Mil le r , 2001) have found that gay men are already well informed as to H I V transmission methods. They suggest that current prevention models that focus largely on condom use are proving ineffective and must also address the more complex nature of sexual behaviour. Crossley (2002) agrees with these findings and questions whether any efforts to change the behaviour of gay men that come from outside of the gay community itself w i l l prove efficacious. She suggests that perhaps public health officials should take no further action and that the gay community should increase its efforts to educate and promote health among its members. Therefore, the present study, coming from within the gay community, may provide information that encourages gay men to re-examine their sexual behaviour and its implications. Rationale With the rise of barebacking and the subsequent increase in H I V infections within the gay community, it would appear that there exists a need for increased discourse on sexual health issues among gay men. Crossley (2002), in fact, believes that "a 'taboo' of unsafe sex" (p. 64) has been created by the apparent lack of discussion around barebacking. In light of gay men's historical feelings regarding interference in their sexual practices (Rotello, 1998; Shilts, 1987), the onus for opening the discussion on barebacking may rest with gay men themselves. Illuminating the experience of, and motivations for, knowingly participating in a high risk and potentially fatal sexual activity may serve to advance this discussion and contribute to our knowledge and understanding. Accordingly, this study w i l l seek to inform both the health care and gay 11 men's communities regarding the practice of barebacking and its implications in terms of the health, education, and sexuality of gay men. Because the study w i l l engage participants from the Greater Vancouver area, it w i l l provide a Western Canadian perspective that may prove different from that of American, Australian, or British men, due to disparate cultural values or social mores. Furthermore, this research may serve to inform the counselling community of trends in gay male behaviour that could prove beneficial when working with this population. The study may also contribute information of value to future research on gay male conduct in general, and barebacking in specific, by providing a voice to some of the men who are participating in the behaviour. 12 Chapter Two Literature Review This review of the literature w i l l examine the research relevant to the experience of M S M who engage in unprotected anal intercourse, or barebacking. The term barebacking was only recently coined (Signorile, 1997). For this reason few studies refer specifically to the behaviour and instead tend to concentrate on unprotected anal intercourse. This review places a greater emphasis on that research which names the behaviour as barebacking, in accordance with the purpose of the current study. Studies that appeared prior to the 1997 appellation and those that continue to employ U A I as their preferred terminology have also been reviewed and considered in terms of their impact on the existing body of knowledge. Awareness and Prevalence of Barebacking among Gay Men Mansergh et al. (2002) set out to measure awareness of barebacking and its prevalence among a sample of M S M in San Francisco. The researchers stated that "[i]n recent years, sexual risk behavior and sexually transmitted disease (STD) rates have been rising among men who have sex with men ( M S M ) , and increasing H I V incidence may follow" (p. 653). Furthermore, the researchers believed that barebacking had arisen as "a sociocultural phenomenon" (p. 653) in concert with the reported rise in sexual risk behaviour, and that "[b]areback behavior is a call for new health promotion paradigms for a subgroup of men" (p. 658). Because Mansergh et al. considered barebacking behaviour to be potentially related to increased H I V and sexually transmitted infections, they determined to explore why men were barebacking and the venues in which they met their sexual partners. 13 Participants were recruited at locations such as bars, dance clubs, and community service agencies in the San Francisco Bay Area. Snowball sampling was used in tandem with this convenience sampling method. The researchers over-sampled African-American and Latino M S M as well as HrV positive men "to increase their representativeness in the study" (p. 654). However, Mansergh et al. (2002) provided no explanation as to why this over-sampling was necessary. From a total of 2278 men approached, 554 men met the researchers' inclusion criteria, agreed to participate in the study, and completed the survey. Ethnicity of participants was: 28% African-American, 27% Latino, 31% white, and 14% another race or combination. Self-reported HrV status of participants was found to be 35% HrV positive, 61% HrV negative, and 4% unknown. Seventy-nine per cent of the men identified as gay, 19% as bisexual, and 2% as neither gay nor bisexual. The median age of participants was 35 years, with a range of 18 to 67 years. The authors noted that [t]his sample of M S M is more diverse in terms of ethnicity, income, sexual orientation identification and self-reported H I V serostatus compared with other recent studies on convenience and probability samples of M S M in San Francisco and other U S cities (p. 655). A quantitative survey methodology was employed by Mansergh et al. (2002). Participants were asked to complete a questionnaire that was administered by an interviewer. A question was first posed to assess the participants' awareness of barebacking without providing a definition of the term. This was done to permit inclusion of "every man for whom the sociocultural phenomenon of barebacking could possibly be pertinent" (p. 654). Once a participant had indicated awareness of the term, 14 the researchers' operational definition of barebacking was provided, which was "intentional anal sex without a condom with men who are not a primary partner" (p. 654). Mansergh et al. believed the intentionality of the behaviour to be important, as it differentiated from "poor planning or spontaneous decisions about condom use" (p. 654). Further questions assessed, for example, the frequency of the participants' barebacking behaviour, where sexual partners were met, whether alcohol or drugs were used, and history of sexually transmitted infections. The researchers found that over two-thirds of the men in their sample were aware of barebacking, with a greater awareness among white men than African-American or Latino men. A s well , more men who identified as gay, rather than bisexual, recognized the term. Barebacking behaviour within the previous 2 years was reported by 10% of the total sample. Fourteen per cent of the participants with an awareness of barebacking reported the behaviour: 22% of the H I V positive men versus 10% of the H I V negative men. Mansergh et al. (2002) found "no differences in the prevalence of barebacking by race/ethnicity, education, income or sexual orientation identification" (p. 655). However, differences emerged when receptive anal sex behaviours were analyzed. The authors found a strong preference among participants to sort partners by their serostatus. In other words, H I V positive men were more l ikely to practice receptive anal sex with other H I V positive men, while H I V negative men were more l ikely to practice receptive anal sex with other H I V negative men. A similar result was obtained by Suarez et al. (2001) in their study of 472 H I V negative men in Milwaukee, W I . The researchers asked men at a gay pride festival to complete a brief anonymous survey regarding A I D S and H I V infection. Amongst numerous findings, they found that their study participants were 15 more apt to perceive " U A I as less risky with a sex partner who stated that he was H I V negative than with a partner with unknown H I V status" (p. 474). Mansergh et al. (2002) reported the use of alcohol or drugs during sex among at least half of the men in their study, with greater frequency among H I V negative men. Bars and dance clubs, friends, and the Internet were the most frequently mentioned venues or methods for meeting sexual partners. The most common reasons for barebacking behaviour related to increased physical sensations and the desire to feel closer or more connected to one's partner, findings echoed by Tewksbury (2003). Qualitative research such as that proposed in my study may provide additional themes to explore or further support the authors' findings. Mansergh et al. (2002) acknowledged that their methodology did not allow for generalization to other populations of M S M within San Francisco or elsewhere. Nevertheless, the study represents a first attempt to quantify awareness of barebacking and prevalence of the behaviour among M S M and its impact on sexual health. The authors deemed barebacking a behaviour requiring address so that potential STI or H I V infections may be averted. The increase in sexual risk behaviour is cited to be partially attributable to "the availability of improved treatments and declining rates of A I D S diagnoses and deaths" (p. 658). Mansergh and his colleagues further recognized that existing H I V prevention models do not address subgroups of M S M , but instead provide a single overarching message. They suggest that appropriate messages be developed to reach men of differing serostatus while acknowledging the complex nature of U A I , a position also expressed by Davis (2002). Upon reviewing the existing lay and scientific literature on barebacking, Goodroad et al. (2000) stated that "[p]revious absolute 16 behavior change prevention messages, although effective in the short term, fail when expected to affect long-term behavior" (p. 35). Studies such as mine may assist in the development of such messages by expanding existing knowledge of the barebacking phenomenon and the possible meanings for those men who participate in the behaviour. In a study of gay and bisexual men in New York City, Halkitis et al. (2003) sought to investigate barebacking behaviour. The authors believed that "the practice of unprotected anal intercourse.. .has gained momentum in the last several years, in part because of relapse from safer sex.. .but also to the increasingly popular behavioral phenomenon of intentional unsafe anal sex, referred to as 'barebacking'" (p. 351). The authors further expressed a belief that U A I places gay men at significant risk for H I V transmission and for contracting other STIs. Accordingly, the purpose of the study, like Mansergh et al. (2002), was to measure awareness of the term barebacking, the frequency with which gay and bisexual men were engaging in the practice, and to seek possible explanations for the behaviour. Study participants were recruited using "[a] cross-sectional brief street-intercept survey method" (Halkitis et al., 2003, p. 352). This method involved approaching men at a variety of gay venues or on the street in gay neighbourhoods in Manhattan and requesting that they complete a questionnaire. The approximate time to complete the survey was eight minutes. The authors recruited 518 men of which 448 were aware of the term barebacking. The study sample was thus comprised of these 448 men who represented White, African American, Latino, and mixed race or other ethnicities. While 93.7% of the participants identified as gay, the remaining 6.3% identified as bisexual. The average age of the participants was 38.21 years, with 18.4% reporting an H I V 17 positive status, and 80.6% reporting an H I V negative status. The five boroughs of New York City were represented in the sample and the authors found "no significant differences in key variables (i.e., whether or not participant reported barebacking, number of barebacking partners, etc.) by venue of recruitment or by zip code or borough" (p. 352). Results of the study indicated that 45.5% of the participants "reported engaging in bareback sex with at least one sexual partner in the previous 3 months, whereas 54.5%...indicated they had not barebacked" (Halkitis et al., 2003, p. 354). Neither sexual orientation nor ethnicity was determined to be related to the decision to bareback. Serostatus was, however, related to barebacking. O f the HIV positive participants, 60.9% reported barebacking, while 41.8% of HIV negative participants reported engaging in this behaviour. Furthermore, "[c]ompared to HrV- men, HIV+ men reported a greater number of bareback sex partners" (p. 354). O f the participants reporting bareback sex, HTV positive men reported more partners of HIV positive status than HIV negative or unknown status. HrV negative men, in turn, reported fewer partners of HIV positive status than HrV negative or unknown status. Aside from assessing the frequency and demographics of barebacking in their sample, the researchers were also interested in determining the perceived benefits of barebacking. Using a "5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree)" (Halkitis et al., 2003, p. 353) participants were asked to respond to statements such as, "Barebacking increases intimacy between men" or "Barebacking is sexier than sex with condoms." Participants who reported barebacking during the previous 3 months perceived significantly greater benefits of the behaviour than did those 18 who had not barebacked. In addition, the authors cited the following participant perceptions for the emergence of barebacking: (a) boring safer sex campaigns, (b) advances in H I V treatments, (c) fatigue about the ADDS epidemic, (d) the perception of barebacking as a sexual and cultural phenomenon, and (e) consumption of recreational drugs. In fact, 70.2% of participants believed that gay men were more likely to be taking il l ici t drugs when having bareback sex. It w i l l be interesting to see i f these perceptions prove similar to themes identified by the men who elect to participate in my proposed research. The study authors acknowledged that their results "should be viewed in light of the fact that the data are both self-reported and cross-sectional. A s a result, causal implications should not be inferred" (Halkitis et al., 2003, p. 355). Moreover, the sample was a convenience sample "and may not be representative of the larger population of gay and bisexual men" (p. 355). Nonetheless, the data provide insight into the frequency of barebacking among gay and bisexual men in a large urban centre and some explanations as to why the behaviour may be occurring. The authors believe that a greater understanding of the barebacking phenomenon is needed. They specifically call for "future assessments of barebacking... to more clearly delineate the meanings that gay and bisexual men ascribe to barebacking" (p. 356). A s the quantitative methodology employed in this study does not address the possible "meanings" of barebacking, qualitative research of the type proposed in my study as well as that employed by researchers such as Carballo-Dieguez (2001), Crossley (2002), Davis (2002), and Ridge (2004) seems timely and warranted. 19 Barebacking and Bug Chasing Gauthier and Forsyth (1999) examined the practice of bug chasing, the purposeful seeking of HrV infection by HIV negative gay men via barebacking. To access information on this phenomenon, the researchers culled data from the existing literature on the topic as well as numerous Internet sources. The authors stated that, "Web sites, chat rooms, mailing lists, and personal ads devoted to the subject of barebacking have become part of the Internet landscape in the past few years" (p. 88). Accordingly, the research is anecdotal in nature, as the sample population was not able to be clearly defined, nor were the participants directly interviewed. Participant comments were appropriated by the researchers from various websites and employed as data. Because of the somewhat underground nature of barebacking and the dearth of published data on the subject, the authors made use of what they believed to be the most viable data available. A literature review was also conducted to contextualize the phenomenon within the existing structure of sexual deviance. Gauthier and Forsyth (1999) were interested in exploring the sociology of sexual deviance. Consequently, they approached their research from a sociological, rather than a psychological, perspective. The authors believe that barebacking, and particularly bug chasing, falls into the category of sexual deviance described as sociological. This category "consists of... those sorts of behavior that generate distinctive forms of social structures that serve to recruit participants, train them, gather people together to perform the act, and/or provide social support for the actor" (pp. 87-88). The purpose of the research was, therefore, to determine why an individual might knowingly engage in a sexual activity known to be at high risk for HrV transmission and to propose reasons for 20 the behaviour. Specifically, the researchers postulated that "the panicked controversy surrounding.. .bareback sex is a reflection of a larger cultural division over the complex meanings of sexual behaviour in the formation and maintenance of personal identities" (pp. 86-87). Regarding bug chasing, Gauthier and Forsyth (1999) found that the behaviour necessarily involved both HrV negative and H I V positive men. They reported that "[f]our lines of explanation have emerged from the literature and Internet data sources" (p. 93). Without providing further details as to how they determined or analyzed their themes, the authors categorized their findings as: Fear and Relief, Risk Taking as Eroticism, Loneliness and Group Solidarity, and Political Actions. Fear and Relief suggests that becoming H I V positive wi l l relieve the fears of becoming infected and allow for an increase in quality of life. Risk Taking as Eroticism proposes that safe sex guidelines detract from the potential for erotic sex. Loneliness and Group Solidarity theorizes that some H I V negative men feel lonely and isolated and seek H I V positive status to belong to a group. Individuals classified under Political Actions believe that anal sex is the right of gay men and represents a political statement aimed at a perceived homophobic society. Finally, the authors conclude that bug chasers may be attempting to manage the stigma they experience in their lives, first as gay men, and second, as H I V negative men. The formation of these categories was useful in describing the divergent rationales for bug chasing, and attempting to understand the motivation for such behaviour. Further, it may assist other researchers, such as myself, who wish to study bug chasing, or barebacking, by providing a more informed starting point from which to address the practice(s). 21 Gauthier and Forsyth (1999) acknowledged that they were unable to qualify the exact characteristics of the bug chasers they sought to study: "The anonymity provided by the Internet makes identification of these individuals for interviews particularly difficult, and consequently, demographic characteristics can only be surmised from user profiles, which are not always available" (p. 97). Not only is the trustworthiness of user profiles questionable, but so are the authors' sampling techniques. Due to an individual's ability to employ any number of screen names, Gauthier and Forsyth may have sampled the same individuals on more than one occasion. Such a sampling error could negatively impact the credibility of their findings. A s well , because not all individuals participating in barebacking or bug chasing have access to the Internet, there likely exists a larger population that requires study. In a study of Internet personal advertisements, Tewksbury (2003) wished "to identify a profile of barebackers and to determine whether barebackers are actively seeking FHV infection" (p. 467). He believed that the Internet provided a forum in which like-minded individuals were more readily able to meet and indulge their particular sexual tastes. The researcher wondered whether those men who were seeking bareback sex were actually bug chasing, or whether they were motivated by other factors. Tewksbury (2003) chose to investigate a particular website that is devoted to the barebacking community. He downloaded all new profiles posted to the website during a one-week period, constituting a total of 880 advertisements on a base of over 180,000 such ads. He noted that approximately one dozen men had posted more than one profile during this time period, therefore only the first posting was included. The profiles were examined and then coded for statistical analysis. The researcher found that his sample 22 was predominantly white (83.7%), was of average height (mean = 5' 10") and weight (mean = 180.6 pounds), and had a mean age of 34.5 years. Forty-four states were represented as home to the profiled men, with most of the ads coming from men in California (23%). Self-reports of HIV-status were: 70.6% H I V negative; 19.3% H I V positive; and 10.1% status unknown. Analysis of the stated preferences of the sample found no evidence that these men were seeking H I V infection. Tewksbury (2003) stated that "[l]ess than 1% of uninfected men say they are seeking an infected partner, and less than 2% of infected men are specifically seeking an uninfected partner" (p. 477). He did caution that 71.9% of HrV positive men and 17.4% of H I V negative men expressed no preference as to the H I V status of their partner. The author speculated that these results might suggest a willingness on the part of some H I V negative men "to 'risk' possible infection, although perhaps not actively and adamantly seeking infection" (p. 477). Furthermore, the researcher believed that his analysis demonstrated that "there does not appear to be a deviant or skewed profile for men who utilize Internet sources to search for bareback male sexual partners" (p. 479). A s noted earlier, Gauthier and Forsyth (1999) classified bareback sex as sociological sexual deviance. Tewksbury suggested that "based on the growth in numbers of persons involved in bareback sex this activity may be redesignated by theorists as normal sexual deviance in the near future" (p. 479). Results of the research done by Tewksbury (2003) indicated that bug chasing is not prevalent among gay men who engage in bareback sex. Instead, he hypothesized "that other motivations draw men to bareback sex, including the risk and eroticism of the event, seeking of group solidarity, excitement from the fear and relief from fears, and 23 possibly political activism" (p. 480). This author provided a number of possible motivations for barebacking behaviour that may or may not be espoused by the participants in my proposed research. W i l l his assertion that "[s]afer sex is not perceived by many men who have sex with men to be intimate and while barebackers recognize the presence of risk, it is defined as an acceptable risk in exchange for the rewards" (p. 481) be borne out by the experiences of the participants in my study? The Meanings of Barebacking Carballo-Dieguez (2001) sought to inform the psychotherapeutic and H I V prevention communities regarding the practice of barebacking among gay men. In addition, the author wished to pose questions that may elicit further discussion and/or research in the field. For example, he asked "Do we assume that our patients are using protection i f they do not spontaneously disclose otherwise?" (p. 233), and "From a public health perspective, what could or should be done to promote a healthy, disease-free sexuality among gay men?" (p. 233). To gain access to participants, Carballo-Dieguez (2001) relied upon referrals by friends and acquaintances. Three of the 4 participants were acquired in this manner, while the fourth was located via the Internet. A l l of the men lived in New York Ci ty and self-identified as barebackers. Three were H I V positive while the other participant's HrV status was unknown. Demographic data such as age, ethnic/racial background, religion, occupation, and preferred sexual position(s) were gathered by the researcher. This qualitative research took the form of face-to-face interviews with 3 of the participants, with the fourth interview being conducted over the telephone. N o further details as to the format of the interviews were provided. Verbatim accounts were included to provide the 24 reader with a clear sense of these men's experiences. However, the author noted "that these cases may be atypical and no generalizations to other gay men are made or are warranted" (p. 226). In addition, had the study included an H I V negative participant, a different perspective on the barebacking phenomenon may have emerged. Carballo-Dieguez (2001) identified a number of common themes among the participants regarding their sexuality and behaviour in 2001, although caution must be taken in interpreting and generalizing these findings as the author did not describe the methodology by which he derived or analyzed these themes. Themes identified by the author included: progressive relaxation of safer sex, epidemic and condom fatigue, meanings of sex, assumption that others have the same serostatus, and emotions related to unprotected sex. Carballo-Dieguez found that due to the lack of a vaccine or cure for H I V , safer sex measures that were initially construed as temporary are now perceived by these participants as permanent, resulting in condom fatigue. He suggests that barebacking has arisen partially from this sense of fatigue. Moreover, the participants described how condomless sex is linked to enhanced physical sensation, a sense of connection between partners, and for some, drug use. On a psychological level, sexuality for these men represented inner needs of belonging, desirability, personal freedom, and power. Particularly powerful were the participants' descriptions of the conditions under which barebacking may occur and the negotiation, or lack thereof, that may occur. For example, they reported that in their experiences an assumption of equivalent serostatus is often made between them and their sexual partners. The extensive use of verbatim comments by the 4 participants allowed Carballo-Dieguez (2001) to vividly portray the participants' real-life experiences and put a voice to 25 the barebacking phenomenon. In combination with his synthesis of life and sexual histories, a picture emerged as to the factors contributing to barebacking behaviour for these men. The author emphasized the importance of "the multiple meanings that having sex with someone had for these men" (p. 232). Carballo-Dieguez questions the assumptions that psychotherapists make about the sexual practices of their clients and whether it is the therapist's function to raise this issue. Based on his findings, he suggests that the opportunity may exist to gain access to the client's inner world, but that it must be done in a non-judgmental fashion, thereby maintaining the therapeutic alliance. He asks, "If we improve our understanding of the meanings and emotions attached to sex, could we guide our HIV-prevention efforts to generate additional ways of personal fulfillment for gay men?" (p. 233). According to the researcher, various harm-reduction strategies are needed as, "it is obvious that alternatives to condoms need to be developed" (p. 233). Representing one of the few attempts to understand the experiences and meanings of U A I for gay men, this study underscores the need for more bottom-up research which provides gay men with the opportunity to speak openly about their current sexual experiences and practices of condom usage and to reflect on the meanings of these experiences in their lives, in an open and unstructured context, without judgment. Wi th the apparent increase in the incidence of unprotected sex among gay men, as also noted by Tewksbury (2003), it seems critical that such information be gathered from the men who are l iving this experience i f counselling and education efforts with this group are to continue to be effective in promoting and protecting the health and well-being of gay men. 26 Crossley (2002) takes the position that current methods of promoting health and education among gay men may, in fact, be responsible for the so-called "barebacking backlash." She contends that "directive education may encourage a 'reactive' stance in which people, both consciously and unconsciously, act to defy prohibitions they feel are being imposed upon them" (p. 50). Davis (2002) also found that gay men are aware of the health risk posed by unprotected intercourse. Crossley believes that the safer sex guidelines, which have been in place since it was first determined how H I V is transmitted, have come to represent, for some people, an onerous burden that is no longer able to be supported. Wi th this stance framing her work, the purpose of the author's research was to demonstrate, via "case study of unsafe sexual practices among gay men" (p. 50), how barebacking may be perceived as an act of rebellion or "psychological independence and resistance" (p. 50). Data for the study were derived from a number of sources. The author had previously evaluated an H I V prevention and health promotion service which occasioned the interviewing, in a semi-structured format, of representatives from 38 agencies providing such services to the gay men's community. In addition, she conducted semi-structured interviews with 23 gay men and a focus group that included 7 gay men. A l l of the gay men who were interviewed or participated in the focus group were clients of the evaluated program, so were actively seeking support or health services of some nature. Crossley also drew extensively from the "literature produced by dominant gay activists in the debates surrounding health promotion and H I V prevention" (p. 51), as well as Internet sources to further her thesis that "a new 'discourse' has emerged" (p. 51) relative to barebacking behaviour. 27 Unfortunately, assessment of the significance and trustworthiness of the author's findings is hampered by the lack of an adequate description of her data analysis methods. Crossley (2002) refers alternatively to a case study methodology, narrative analysis, and an analysis of her interviews with gay men. Failure to provide further details also renders replication extremely difficult. Notwithstanding Crossley's lack of methodological clarity, the researcher found that the eroticization of U A I is occurring, the term barebacking itself being an indication of such eroticization. According to Crossley, Internet postings, chat rooms, and contemporary gay activists and writers all appear to support this view of barebacking as erotic, resulting in an implied shift in the perception of H I V infection. She believes a number of factors may be at play. For instance, Crossley suggests that younger gay men may be experiencing a lack of self-esteem and may also be inadequately targetted with safer sex messages. Ridge (2004) has also reported an increase in U A I among younger gay men. Based on her findings, Crossley also speculates that U A I may be perceived by some gay men as "symbolic.. .of rebellion and transgression" (p. 56); and even "an extension of the gay liberation movement" (p. 60). Her findings suggest that current H I V prevention models fail to consider such factors, thereby rendering them ineffective, similar to the position espoused by Ekstrand et al. (1999) that prevention activities fail to recognize the value of sexual expression for gay men. Crossley (2002) is also critical of the notion that the emerging bareback culture is "a vehicle for 'cultural rebirth'" (p. 62). A s per the following quote, the author's expressed belief is that H I V infection is undesirable under any conditions: 28 It is all very well feeling creative, autonomous and free while engaging in unsafe sexual practices, but i f the result is H I V infection, any sense of rebellion or subversion is surely severely circumscribed? Even i f H I V infection may not necessarily mean death any more, but 'just a chronic illness (at least for those who can afford protease inhibitors), who wants a chronic illness? (p. 62). Crossley cites a number of gay men and advertisements from barebacking websites whereby H I V infection was actively sought, a finding also reported by Gauthier and Forsyth (1999) and Tewksbury (2003). However, the apparently condescending tone of the passage cited above suggests little understanding of, or objectivity toward, the rationale employed by some gay men seeking HTV infection. The author fails to acknowledge the complex social and personal factors, such as a need for affiliation or low self-esteem, which could contribute to such behaviour. Crossley (2002) concludes that HTV prevention strategies are unsuccessful because they "fail to take account of the meanings of sexual practices" (p. 63). Consequently, she speculates that U A I has become a taboo subject, outside of mainstream discourse. She cites the need for increased discussion of safer sex practices, but also notes the resistance with which these messages are sometimes received when delivered by forces outside the gay community. The author reasons that this resistance may result in the elimination of efforts at increased health promotion among gay men. The author's conclusion provides further support for the present study. Data collection and analysis from within the gay community may prove more sensitive to the lived experience of gay men who currently engage in U A I in their casual sexual relationships. 29 Employing a qualitative research design, Ridge (2004) explored the barebacking behaviour of younger same-sex attracted men in Melbourne, Australia. His goal was to examine "the meaning and circumstances underpinning practices of 'barebacking'...in episodic sexual encounters" (p. 259). The author's purpose was to shed light on the perspectives of younger gay men in relation to their unsafe sexual practices and the implications for H I V prevention activities and public health discourses. Furthermore, he recognized that few studies had "taken an interpretive and 'grounded' approach to understanding gay male sexual interactions" (p. 261) and wished to enhance the existing literature in order "to understand and better predict where the H I V epidemic is going" (p. 261). To achieve his goal of a more interpretive approach, Ridge (2004) chose a modified grounded theory methodology. He explained the method as "inductively interpreting concepts and themes from socially specific phenomena in the data" (p. 264). The researcher believed his modification would allow for a focus not on the minutiae, but rather the larger issues impacting the participants' behaviour. The description of the sampling methodology is vague, whereby "[principles of theoretical sampling were used to locate informants and direct interview questions" (p. 263). Ridge does clarify that due to changes in his sampling model "the sampling framework turned out to be a hybrid of theoretical and quota sampling" (p. 263). Nevertheless, as no further information is provided, the reader is left with no true sense of how the 24 participants, aged 19 to 36, were recruited. N o further demographic data were supplied, except that most of the participants were in their 20s. A multi-stage interview process ensued, which included an informal interview or telephone conversation, a formal audio-taped interview, and 30 subsequent discussions and telephone calls. The author referred to "informal discussion[s] with a range of informants not interviewed" (p. 264) such as health professionals and gay men, as another stage of the interview process. A journal of fieldwork experiences was also maintained. Ridge (2004) described his findings in terms of the meanings the men ascribed to sex and barebacking, and the social dynamics of barebacking. He categorized the meanings as: masculinity, instrumentality, contracts and compulsion, and H I V risk. Ridge explained that "these meanings were contextual, and frequently had an emotional basis" (p. 264). Similar to Carballo-Dieguez (2001), the researcher found that certain sexual experiences may have multiple meanings as well as differing degrees of significance. For example, a first sexual encounter with an individual was often deemed significant, while "some sexual encounters were considered mundane" (p. 265). Even in the context of a casual encounter, meanings such as love, connection, and romance were often attributed to the experience by the study participants. The social dynamics of internal dialogue, communication, and power were identified by the author. He discovered that for his informants, sexual dynamics related to both the self and the sexual encounter. In terms of the self, thought, internal dialogues and fantasies emerged as important in the description of encounters. The key interactional dynamics mentioned were non-verbal communication and directing (manoeuvring) of sexual activities, and power (p. 270). Overall, Ridge (2004) determined that his study participants often found themselves in situations "where barebacking was a real possibility" (p. 274) and safer sex was not 31 necessarily the norm. The decisive factor in whether condoms were used was the w i l l of the participants themselves, as determined by their "own meanings and circumstances of sex" (p. 274). Additionally, safer sex practices were impacted by the sexual dynamics of the encounter. For instance, the author suggests that one's internal dialogue may focus on concerns other than condom usage, thereby rendering the individual susceptible to acts of unsafe sex. Mansergh et al. (2002) and Halkitis et al. (2003) established that men who have sex with men appear to be aware of barebacking and that some HrV negative and HrV positive men are participating in the activity. These researchers have further suggested that the behaviour is increasing, thereby placing M S M at an increased risk of contracting H I V or other sexually transmitted infections. Factors such as drug and/or alcohol consumption; advances in HTV medications; and a perception of barebacking as sexier have been suggested as possibly related to the rise of the barebacking phenomenon. Gauthier and Forsyth (1999) and Tewksbury (2003) investigated whether some HrV negative men were deliberately seeking HIV infection, a practice known as bug chasing. While Gauthier & Forsyth believed that they found evidence of the practice, Tewksbury concluded that bug chasing is not prevalent. Both Ridge (2004) and Carballo-Dieguez (2001) found that the meanings gay men attribute to barebacking are manifold. Furthermore, Crossley (2002) noted the need for more discussion of safer sex practices as well as the failure of existing HrV prevention efforts to recognize the meaning(s) ascribed to sexual activities. Halkitis et al. called for more qualitative research to focus on the meanings of gay men's sexual experiences. Perhaps the findings of my study w i l l 32 also address the meaning of barebacking to gay men and supplement the existing literature. 33 Chapter Three Methodology Method Selection This study employed a qualitative, phenomenological approach. Marshall and Rossman (1995) describe phenomenology as "the study of experiences and the ways in which we put them together to develop a worldview" (p. 82). A phenomenological research design was appropriate for use in this study as it sought to describe an experience rather than test an hypothesis, as in quantitative research (Colaizzi, 1978). Beck (1993) further asserts that "[qualitative research is needed to identify the characteristics of phenomena" (p. 263). Because, as previously demonstrated, little is known about the barebacking phenomenon, this approach allowed for a description of the participants' experiences in their own voices. A number of the studies previously published relative to barebacking have been quantitative in nature (Halkitis et al., 2003; Mansergh et al., 2002), tabulating responses to survey questions pre-determined by the researchers or have reviewed information found on websites devoted to barebacking (Gauthier & Forsyth, 1999; Tewksbury, 2003). While some studies (Carballo-Dieguez, 2001; Ridge, 2004) have taken a qualitative approach to examining this phenomenon, additional insight regarding the experiences of individuals who participate in this behaviour may further elucidate the existing literature on this topic. A s Patton (1990) proposes, a phenomenological enquiry attempts to answer the question, "What is the structure and essence of experience of this phenomenon for these people?" (p. 69). The study, therefore, did not seek to measure or explain behaviour, but rather to explore the experience of gay men who elect to engage in 34 unprotected anal intercourse. This approach served well to investigate the research question: "What is the meaning and experience of barebacking in casual sexual relationships for gay men?" A phenomenological methodology was also well-suited to my training as a counsellor. Osborne (1990) believes that "[u]nless rapport and trust are established the researcher is unlikely to get authentic descriptions of a co-researcher's experience" (p. 84). Counselling skills naturally promoted the establishment of rapport with the participants, ensured sensitivity to their feelings, and allowed their stories to be revealed. Osborne further states that: The relationship between researcher and co-researcher parallels the relationship between counsellor and client. The two parties co-constitute a relationship. The researcher is part of the co-researcher's experience just as the counsellor is part of the client's experience; there is a truth for the co-researcher and a truth for the client. There is considerable positive transfer between the context of counselling practice and counselling research (p. 88). Accordingly, the design allowed me to employ my counselling skills to achieve an active role in the research process and establish a relationship with the participants. In light of my lack of experience in counselling research it was reasonable that I would draw on established skills. These skills proved helpful in, for example, setting the tone for the research interview and assisting the participants to elaborate on their stories. I remained vigilant to ensure that the focus of the interview remained research and not counselling of the participants. I found that there were indeed moments when participants would divulge information or ask rhetorical questions that triggered a counselling response 35 within myself. A s well , on one occasion, a participant described a belief that he held that I suspected to be erroneous and potentially harmful to his health, but I did not correct him, although I struggled with my decision at the time, and even later. Phenomenology Phenomenology as a research methodology grew from the "philosophical perspectives of...Husserl.. .and philosophical discussions to follow by Heidegger, Sartre, and Merleau-Ponty" (Cresswell, 1998, pp. 51-52). Giorgi (1985) argues that a definition of phenomenology is difficult as Husserl's writings reveal an ongoing development of thought and that his followers were unable to agree on a definition or define a single valid methodology. Nonetheless, according to von Eckartsberg (1998) "Husserl articulated the central insight that consciousness is intentional, that is, that human consciousness is always and essentially oriented toward a world of emergent meaning" (p. 5). Phenomenology as a philosophy is therefore concerned with describing the human experience. Phenomenological research methods were developed to provide a means by which to access the consciousness of participants. Husserl's methodology began "with the 'phenomenological reduction,' or 'epoche,' which involved the attempt to put all of one's assumptions about the matter being studied into abeyance, to 'bracket' them" (von Eckartsberg, pp. 5-6). Giorgi (1985) aligns his understanding of phenomenological philosophy more closely with that espoused by Merleau-Ponty than Husserl. Giorgi points to four components of Merleau-Ponty's phenomenological methodology to illustrate the underlying philosophy: (a) the method is descriptive, with the analysis following description; (b) "reduction" of prejudices and pre-conceptions of our experiences, so 36 ".. .we describe them simply as they present themselves..." (p. 43); (c) the search for essences as, "a means of bringing to light all of the actual ' " l iv ing relationships of experience'" (p. 43); and (d) intentionality "which means that consciousness is always directed or oriented toward something that is not consciousness i t s e l f (p. 43). Although Giorgi believes that the philosophical description of phenomenology has been clearly stated, the corresponding psychological description is less clear. He questions how to translate the philosophy into psychology. For example, Giorgi wonders "What is a good description as opposed to a bad one?" (p. 45) and "Must essences always be ascertained first, before we go to the facts, or is the procedure reversible?" (p. 45). Whi le acknowledging that the task is difficult, Giorgi concludes by determining that a psychological perspective "must discover its own methods, procedures, rules of interpretation, and so on by a direct contact with its own phenomena of interest and working through whatever is necessary to achieve stable and significant psychological findings" (pp. 45-46). The role of the phenomenological researcher, according to Giorgi , is therefore to uncover the appropriate methodology through connection with the participants experiencing the phenomenon under study. Polkinghorne (1989) states that "[p]henomenological psychology is not a subfield of philosophy; it is a psychology that draws on the philosophical insights of phenomenology" (p. 43). He believes that phenomenology as a psychology stands alongside other methods within the psychological tradition: "It selects for study the phenomena relevant to psychology and investigates these phenomena in a methodical, systematic, and rigorous way" (p. 43). Not unlike Giorgi (1985), Polkinghorne acknowledges that the translation of phenomenological philosophy to psychological 37 methods "is unfinished" (p. 43). Nonetheless, he presents a strong argument for why phenomenological research methods are important to psychology: Natural scientific research aims to produce the kind of knowledge that allows one to predict and control the topic under investigation. Phenomenological research is quite different; it seeks understanding for its own sake and addresses the question what? not why? Productive phenomenological research supplies a deeper and clearer understanding of what it is like for someone to experience something (p. 58). Personal Assumptions and Bracketing O f the phenomenological approach, Colaizzi (1978) writes that a researcher "begins by asking not what is a convenient or merely interesting or scientifically approved topic of investigation, or how an experiment can be designed to investigate it, but instead he asks first, why am I involved with this phenomenon?" (p.55). In response to this question, I submit that I am myself a gay man who has lived with the knowledge and presence of H I V / A I D S my entire adult life. H I V permeates my existence. I have borne witness to the physical and mental decline, and eventual death, of close friends. H I V is omnipresent through my friends and past lovers who today live with the disease. I have known the fear of contracting H I V . Recently, anecdotal evidence and personal observation suggested to me that condom usage amongst some gay men may be on the decline. It is therefore in this context that I undertook this research. I recognize that I brought to the study certain assumptions and presuppositions that required acknowledgement to ensure its credibility and encourage a "v iv id and faithful... description of the phenomenon" (Beck, 1993, p. 264) to emerge. These 38 assumptions included, but were not limited to the following: (a) some gay men may be experiencing condom fatigue after many years of practicing safer sex; (b) younger gay men may not perceive H I V as a serious threat to their health, having never personally witnessed deterioration and death caused by the infection; (c) some gay men may believe that advances in H I V treatments have rendered the infection merely chronic, rather than fatal; (d) the use and/or abuse of i l l ici t drugs or alcohol may impair the judgement of some gay men leading to potentially reckless behaviour; (e) there exists a "code of silence" surrounding the practice of barebacking; and (f) some gay men who are well educated in H I V transmission methods are knowingly participating in high risk sexual acts. I expected to find that some or all of the above-stated assumptions might prove true for each of the participants. Being gay unto itself does not indicate homogeneity of individuals. Unlike other minorities, there is frequently no shared history among gay people. We come from all backgrounds and are uniquely united by our love for members of the same sex. Hence, as a cross-section of gay men was recruited for the study it was reasonable to expect that a variety of factors may contribute to the decision of participants to participate in U A I . Knowledge of these, and other presuppositions, guided and informed me during the data collection and analysis processes. I recognized that my values had been influenced by a review of the literature, my family of origin, current and past relationships, and the experiences of a lifetime. M y values were similar to some participants and dissimilar to others. I strived to remove my personal biases from the research process to ensure that participants felt comfortable to speak freely without fear 39 of judgement and that themes were permitted to emerge naturally, without manipulation (Osborne, 1994). I found that, at times, I recognized a conflict between my beliefs or values and those of some participants. While remaining aware of the conflict, I allowed the participants to relate their stories without interjection or comment, unless required for purposes of clarification or continuity of the interview. To further address this concern, I kept a journal of my thoughts and feelings regarding the subject matter, the process, and my reaction to the participants' stories, van Manen (1992) asserts that: Researchers.. .have found that keeping a journal, diary or log can be very helpful for keeping a record of insights gained, for discerning patterns of the work in progress, for reflecting on previous reflections, for making the activities of research themselves topics for study, and so forth (p. 73). Hence, I continued to journal for the duration of the study in order to maintain a self-reflective posture throughout the research process. M y journal provided me with the forum to reflect on both the research process and my experiences with the participants, thereby potentially influencing and assisting the interview process. A s suggested by Beck (1993) my journal allowed for the recording of my "actions, interactions, and subjective states during the investigation" (p. 265). Research Procedure Participant Criteria The study participants included six men who: (a) self-identified as gay; (b) were sero-negative or of unknown H I V status; (c) were at least 19 years of age; and (d) acknowledged that they regularly or on occasion practiced unprotected anal intercourse, or barebacking, with casual sexual partners. I was not contacted by any men younger 40 than 19 years of age, but had I been they would not have been accepted as they had not yet reached the age of majority in British Columbia. A l l participants were available to participate in a process interview lasting between 1 and 2 hours and a subsequent validation interview of 1 to 2 hours following preliminary data analysis. Articulation of the participant's experience is key to the phenomenological approach (Colaizzi, 1978), therefore fluency in the English language was required as I am no longer conversant in any other language. According to Baker et al. (1992): Phenomenological studies are designed to describe the essence of a given phenomenon and informants are chosen because they have lived the experience being investigated. Sampling is, therefore, purposive. In keeping with its aim of illuminating the richness of individual experience, the sample size is kept deliberately small (p. 1358). The final number of participants was determined through the data collection process itself. A s participants were interviewed I was in search of common themes. Once the emergent themes had been exhausted, no further participants were recruited. Participant Recruitment A recruitment poster created by the researcher was placed in the following locations: The Centre (a community centre supporting the gay, lesbian, bisexual, and transgender communities), F212 Steam (Vancouver and New Westminster locations), M 2 M Playspace, Spectrum Health clinic, Gayway (a resource exchange for gay men in Vancouver), and Little Sister's bookstore (see Appendix A ) . The poster identified the purpose of the study, approximate participant time requirements, the researcher, my 41 supervisor, and our affiliation, and provided a telephone number to call to inquire further about the study and/or to volunteer to be a participant in the study. A n abbreviated version of the recruitment poster was distributed widely on a distribution list maintained by the Education and Outreach Coordinator for The Centre. In addition, participants were sought in a chat room for Vancouver residents on the gay.com website. Individuals who contacted me and expressed interest in participating in the study were screened for suitability by determining whether they meet the inclusion criteria. Participants were provided with further details regarding the purpose and parameters of the study along with the estimated time commitment. Participants were also provided the opportunity to ask questions about the study and were informed of their right to withdraw at any time. Prospective participants who met the criteria were then asked several questions to establish the demographic profile of the study participants. Demographic data such as age, occupation, education, ethnic/racial background, and relationship status were gathered at this time. Finally, during this telephone conversation arrangements for the first interview were made. Details included the date, time, and location of the meeting. Participant interviews were held at The Centre in downtown Vancouver or on the University of British Columbia ( U B C ) campus. The first five men who met the selection criteria were accepted for inclusion in the study. Following the conclusion of the interviews with these participants and a preliminary analysis of the data, an additional participant was recruited. Data Collection I am a Master's Degree student in Counselling Psychology, and as the primary researcher collected the data using tape-recorded interviews. According to Osborne 42 (1994), "[t]he data sources for phenomenological research are usually spoken or written accounts of personal experience. The interview is the most commonly used means of data gathering" (p. 171). Two interviews were therefore conducted in this study to elicit detailed descriptions of the experience of barebacking in casual sexual relationships. The first interview was an in-depth, unstructured, audio-taped data collection interview that lasted between 1 and 2 hours. The second interview also lasted between 1 and 1-1/2 hours and served the purpose of validating the themes derived from the initial data analysis. Each interview was conducted by the researcher at The Centre or on the U B C campus. I recorded my reaction to each interview in my journal following its completion. This activity assisted me in improving my interviewing skills throughout the data collection process. M y goal was to schedule the first interview to occur within 2 weeks of the participant screening telephone conversation. This proved difficult to achieve, but all interviews were scheduled as quickly as was possible considering the availability of the researcher, the participant, and meeting space. To ensure the establishment of rapport with the research participant, I began the interview by reviewing the purpose, parameters, and conditions of the study. To reinforce the notion of informed consent, the participant was reminded of his right to withdraw from the study at any time and the confidential nature of the study process and results. To ensure his anonymity, the participant was invited to choose a pseudonym. For those who did not wish to choose a pseudonym, I chose one when reporting the results of the study. I explained to the participant that the audiotapes of the interview would be erased or destroyed upon completion of the study and that transcripts would be kept in a locked file cabinet for 5 years, after which they 43 would also be destroyed. The participant was asked to pose any questions that may have come to mind or to address any outstanding concerns. The participant was then asked to sign two copies of an informed consent form (see Appendix B) . One copy was provided to the participant for his records while I retained the other. The tape recorder was then turned on to begin audio-taping the interview. I read an orienting statement prior to commencing the initial interview (see Appendix C) . The function of this statement was to establish the context of the interview. While I had prepared a list of possible questions to pose to participants should it have proven necessary to prompt them during the interview or to aid in more in-depth exploration of topics or issues raised by the participants (see Appendix D) , the interview was largely unstructured and conversational in nature. The intent of this format was to allow the participants "to recount their experiences as they happened and not worry about what they think the researcher might want" (Osborne, 1994, p. 183). According to Patton (1990), "[t]he conversational interviewer wants to maintain maximum flexibility to be able to pursue information in whatever direction appears to be appropriate" (p. 281). For example, a sample interview question was, "Under what conditions do you bareback?" This type of open-ended question allowed for Patton's suggested maximum flexibility. Hence, I was prepared to follow each participant wherever he wished to go, without imposing restrictions. Nonetheless, as van Manen (1992) suggests, "one needs to be oriented to one's question or notion in such a strong manner that one does not get easily carried away with interviews that go everywhere and nowhere" (p. 67). I encouraged participants to tell their story until it reached its logical conclusion, prompting them only when they appeared stuck or when clarification was required to ensure understanding. A t 44 the end of the interview, I specified a tentative date by which I would contact the participant to arrange the validation interview. Because the interviews were audio-taped, neither I nor the participants were distracted by note-taking. I remained emotionally present with the participant throughout the process, relying on my skills as a trained counsellor to minimize possible interviewer effects, while maximizing responsiveness to the individual participant and the stories he chose to share (Patton, 1990). However, I was careful not to confuse my role as a researcher with that of counsellor. I endeavoured to remain clear that my purpose was to gather information relative to the barebacking phenomenon, not to address any counselling needs the participant may have had. It was anticipated that these interviews would last approximately 2 hours. In fact, all of the interviews lasted between 1 and 2 hours. In the unlikely event that a participant found the interview process disturbing or determined that he would like to discuss his feelings with a professional, a list of suitable counsellors and support organizations was available for referral (see Appendix E) . Following initial analysis of the participants' stories, a subsequent validation interview was conducted. This follow-up interview was not audio-taped, and lasted up to 1-1/2 hours. The interviews were again held at The Centre or on the U B C campus, as described above. In one case the interview was conducted via telephone as the participant was out-of-province for an extended period. The participants were asked to review and verify their personal demographic data that I had initially captured. In addition, the participants were presented with the clusters of themes derived from all participants' interviews. They were invited to examine the themes to ensure an accurate 45 reflection of their experiences of barebacking. Feedback was taken into consideration in the analysis and refinement of the data. Data Analysis In order to be analyzed, all participant interviews were transcribed verbatim and double-checked for accuracy. 1. To address the trustworthiness of these data, I met with my supervisor following partial transcription of my first participant interview and prior to any further interviews. She read the transcript and provided me with feedback regarding the questions I had asked during the interview process. Following this feedback, I modified my questioning technique during subsequent interviews to ensure I did not lead the participants in any particular direction. Osborne (1990) believes that: Phenomenological methodology accepts the difficulty of representing human experience through language. Although there are non-verbal ways of communicating, most data are in the form of language which. . .does not necessarily convey lived-experience unambiguously. The meaning of verbal descriptions has to be interpreted by the researcher (p. 83). Accordingly, great sensitivity was required in the interpretation of the participant data. I read and re-read the transcripts so as to immerse myself in the data and gain a sense of what each participant was communicating about the meaning and experience of engaging in barebacking. To achieve this end, interview transcripts were analyzed according to Colaizzi 's (1978) procedure. Briefly, this procedure involved: 1 During transcription of a participant's interview it was discovered that the 'B' side of the tape had been recorded at a speed too slow to be intelligible. Efforts were made to retrieve the data, but they were unsuccessful. Approximately ten minutes of data were lost. Clearly recalling the interview, I am confident that no new data potentially impacting the outcome of the study were presented. 46 1. Reading the participant interview transcripts to gain a sense of their meaning. 2. Later returning to the transcripts to search for particular statements that were directly related to the phenomenon under investigation. 3. Attempting to ascertain the meaning associated with the noteworthy statements that have been culled from the transcripts. This required that I employ a degree of creativity to differentiate between what was said and what was meant. 4. Organizing the derived meanings into thematic groups and validating these themes against the original transcript. 5. Combining the obtained results into an exhaustive description of the common themes whereby all of the components of each theme were described and then illustrated in the participants' own voices. Upon completion of these five steps another attempt was made to ensure the trustworthiness of the data. A s indicated earlier, during the second interview each participant was asked to review the emergent themes. Cola izz i (1978) states that during the final validation stage with participants "[a]ny relevant new data that emerges from these interviews must be worked into the final product of the research" (p. 62). While some questions were posed, no participants disputed any aspect of the presented themes. The sole data changes that occurred related to participant biographical details that were slightly altered in order to ensure anonymity. A copy of the findings was made available to each participant at the validation interview. Furthermore, should this study later be published in an academic journal, I agreed to notify all participants. 47 Limitations of the Study I recognize that the barebacking phenomenon encompasses a multitude of facets not addressed by the present study. Care has been given to the determination of its scope for a number of reasons including: (a) the time and resources required to undertake a study of a larger scale, (b) my lack of experience in research design and analysis, and (c) my personal interests. I propose that the study merely reflects the experiences and voices of the individual gay men who shared their stories with me. Osborne (1994) states that "[t]the focus of phenomenological research is the individual's experience of the phenomenon and generalization to others through empathic generalizability ("Does it fit for the reader?")" (p. 178). This research does not claim to represent all H I V negative gay men who bareback. Other gay men could read this study and determine whether the data did in fact fit for them. While an attempt was made to include a demographically diverse sample of participants, this study has been limited by its reach. Regardless of the method of recruitment, all of the participants had close ties to the gay community in Vancouver's West End neighbourhood. Furthermore, the sampling method was not randomized, and the sample size of six men was relatively small, although still appropriate for the phenomenological methodology utilized. According to Osborne (1990), "[t]he researcher needs as many participants as it takes to illuminate the phenomenon" (p. 80). The inclusion of four Caucasian and two Asian men does approach the ethnic mix found in Vancouver. A s well , an age range of 24 to 55 for the recruited participants allowed for inclusion of individuals for whom H I V / A I D S had been prominent throughout their lives, in addition to those who had become aware as sexually active adults. 48 The participants in this study were unusually well-educated. A number of the men admitted that they had volunteered to participate in the study due to their desire to assist in completion of a graduate thesis or due to their own interest in the subject matter. The selection of appropriate participants was limited by the somewhat small number of men who came forward via self-selection and who also met the inclusion criteria. Regarding qualitative research methods, Krefting (1991) wrote that: [T]he ability to generalize is not relevant in many qualitative research projects. A strength of the qualitative method is that it is conducted in naturalistic settings with few controlling variables. Each situation is defined as unique and thus is less amenable to generalization (p. 216). Hence, the results of the current research are not intended to be generalized to any other population. The experiences of the men who agreed to participate in the present study are not necessarily akin to those of other gay men who bareback in Vancouver, or anywhere else. Additional research that employs randomized sampling methods, as well as larger samples, could conceivably support the results of the present study while further expanding the body of knowledge on the barebacking behaviour of gay men. A further limitation relates to the roles of participant and researcher as persons. The research question requested each participant to reveal themselves to me in a fashion that was new and disturbing for some. For this reason, it is possible that some or all of the participants provided the information that they believed I wanted to know, even though I clarified that I sought no particular details. Perhaps, some participants found certain information too painful or embarrassing to divulge. Further inhibiting the procurement of data may have been the participants' inability to effectively express 49 themselves, although this was not apparent during the interviews. When a participant appeared to be struggling, I employed my counselling skills to assist h im in moving forward or providing clarification. It is nonetheless conceivable that some aspects of the participants' experience were deliberately withheld or simply not mentioned. A s the researcher, I too represent a limitation of the study. I recognized that the creation of a safe, non-judgmental environment was critical to the success of the research. While I believe that I was largely successful in this endeavour, based on both my own observations and participant feedback, I cannot assume complete success. Furthermore, the results of this study are based on my interpretation of the participants' experiences. B y categorizing these experiences into themes, I place myself within the data. Accordingly, the data is necessarily subjective. To reduce the effects of my subjectivity I have outlined my presuppositions, values, and beliefs. In this way, I tried to remain true to the spirit of the information that was so graciously shared with me. 50 Chapter Four Results This fourth chapter of the study begins with a brief biographical synopsis of the six participants. The intent of this section is to acquaint the reader with the individuals who volunteered to share their experiences of barebacking with me. For the purpose of maintaining confidentiality the participants have been assigned pseudonyms; chosen by them or by myself in those cases where no preference was indicated. Following the participant biographies is a discussion and analysis of the themes that emerged from the participant interviews. Wherever possible the voices of the participants themselves provide v iv id illustration of the themes and support their meaning in the lives of these men. Participant Biographies Dmitri Dmitri is a 36-year old Caucasian gay man who describes himself as coming from a " W A S P y " family background. His parents have not been made explicitly aware of his sexual orientation, but as he states, "they're not stupid people but we.. .1 mean we just don't talk about stuff or anything." Dmitri is out to his friends and co-workers and considers himself to have a strong support system. He is not currently in a relationship and does not have a history of relationships of long duration. Throughout the interview he spoke of his desire to bridge the "gap of sex versus intimacy," as he described it. He believes that his barebacking behaviour has been an attempt to bridge this gap. Dmitr i lives in both Vancouver and Winnipeg, having been raised and educated in Winnipeg. He has obtained a Master's Degree and now works in the f i lm industry. Due 51 to his profession, Dmitri spends long periods of time in Vancouver where he first encountered the barebacking phenomenon. He describes his experience of barebacking as occurring almost exclusively in the bathhouse setting and as having peaked approximately 2 years ago. He believes that his barebacking behaviour has declined due to his busy work schedule, a decreased sense of novelty, and an increased awareness of the potential health risks. Unlike all of the other participants, Dmitr i has never been tested for H I V and is, therefore, unsure of his serostatus. Vito A 55-year old single Caucasian gay man, Vi to holds a management position within an area of the government. He has completed some college-level education, but has not earned a diploma or a degree. Although he has lived in Vancouver for a number of years, he has also lived in Los Angeles, Ottawa, and Toronto for long periods of time. Vi to describes himself as a "barebacker." For Vi to , barebacking is not so much a behaviour as a "lifestyle choice." From his perspective, one is either a barebacker, or one is not. Vi to believes that the term barebacking, as well as the behaviour itself, has taken on a certain cultural status amongst gay men. He further believes that the re-labelling of sexual acts once commonly referred to as unsafe allows for a new discourse on the subject of gay male sexuality and relieves some of the pressure of safer sex espoused by the HrV/AIDS establishment. According to Vi to , in the past he would generally not have discussed his unsafe sexual practices, due to the shame involved, but he can readily discuss his barebacking activities. He perceives barebacking as alluring and sexy. Vi to stated his preference to socialize largely with other barebackers for the very reason that they form a club of like-minded individuals. 52 When the A I D S crisis began, Vi to was l iving in Los Angeles with his long-term partner. Whi le he and his partner were active in the gay community and the fight against A I D S , they never engaged in regular condom use. To this day Vi to eschews condoms, stating that he is "not particularly interested in having sex with condoms." Some years ago, when his partner died of a non-HTV related illness, Vi to was concerned for his sexual future as he was unprepared to begin using condoms. He is upfront with his sexual partners regarding his desire for bareback sex as well as his HIV-negative status. In this way, he feels the potential partner can choose to forego unprotected sex. Equally, should sero-conversion occur, Vi to states that he would be honest with potential partners regarding his serostatus. Perry Perry is a 33-year old Caucasian gay man. He has earned an undergraduate degree and is currently at work on a Master's degree. Perry grew up in rural Alberta and moved to Vancouver approximately 3 years ago. He describes his search for community in Vancouver as having been difficult, and he has struggled to "find his niche." Perry believes that the social difficulties he has experienced have negatively impacted his self-esteem, which in turn may have impacted his decision-making process regarding barebacking. In other words, he feels his need for affiliation may have led to sexual behaviour he knows to be at a higher risk for transmission of a variety of STIs, including H I V . Nonetheless, Perry acknowledges that he perceives bareback sex to be a greater "turn-on" than sex with condoms. When Perry became sexually active in his teens he never used condoms. His first 7 years of sexual experiences occurred primarily without condoms. He states that he did 53 not perceive condom usage to be particularly important at the time or that the thought had not occurred to him. His sexual encounters were described as fairly anonymous during this period, and he was not yet open regarding his sexual orientation. When he did become aware of the prevalence of H I V he determined that he must already have sero-converted. Not until he was 25-years old did he get tested for H I V and found that he was in fact HIV-negative. From that time forward he "pretty much religiously.. .used condoms with a few exceptions throughout the years." Approximately 2 years ago, Perry entered into a 6-month relationship with a man with whom condoms were neither used at the outset nor throughout the relationship. He considered this to be a low-risk activity as his partner had only had a single sexual contact prior to himself. From that time forward Perry has remained single and has vacillated between condom use and bareback sex, to a degree in response to his partner's desire. Breen Breen is a 49-year old Caucasian gay man. He was raised in Calgary in an environment that he characterizes as "redneck" and "homophobic." The eldest of four brothers, one of whom is also gay, he describes his parents as loving and supportive. He earned an undergraduate degree and worked for many years in a support function at a post-secondary institution in the Lower Mainland. Having recently become disabled, Breen is no longer working and walks with the aid of a cane. Although he has had three long-term relationships throughout his adult life, Breen is currently single. Two factors clearly impact Breen's decisions to bareback: (a) the physical sensations associated with barebacking and condom use, and (b) the difficulty in changing behaviour to regularly use condoms. Breen states that for him barebacking is 54 necessary due to the uncomfortable and often painful nature of receptive anal intercourse with condoms. His experience has been that anal intercourse is only pleasurable when condoms are not used and is therefore reluctant to both lessen his pleasure and increase the likelihood of physical pain. Furthermore, Breen became sexually active prior to the onset of HIV/ADDS when condom use was unusual. He has found it "difficult.. .to make the change to consistently use condoms" whether in the context of an ongoing relationship or with a casual partner. Twice in his life Breen has been raped. The first occasion occurred when he was a young man and involved a number of men who dominated and abused h im in a bathhouse. The second occasion took place in the context of a bondage and discipline scenario whereby his partner did not adhere to the agreed upon protocol and violated the safety of the situation. When asked i f these rapes had impacted his sexual behaviour in regard to barebacking, Breen stated that they had. He considers himself to have "gotten.. .very much in touch with [his] intuition and feelings." Accordingly, he now seeks respect in all sexual situations and declines sex with those men whom he feels disrespect him, whether the sex would have been bareback or not. Ernest Ernest is a 24-year old Chinese-Canadian gay man who was born in Northern B C but has lived most of his life in Vancouver. He describes himself as a student, although he has recently completed his undergraduate degree. Ernest is currently single and does not have a great deal of experience in relationships. In both of his two relationships, condoms were always used. His first barebacking encounter occurred 3 years ago. As a 55 person who actively seeks relationships, Ernest sees barebacking as a means of creating relationships and not just a physical act. Ernest perceives his first act of barebacking as having been a necessary rite of passage. He referred to the act as "kind of adding to my sexual C V or something." He depicted the event as being most important from an overall sexual perspective first; the barebacking component being secondary. Nonetheless, in the moment of insertion he was aware of the potential ramifications and determined to trust his partner. Ernest characterizes trust as a key component of his sexual relationships and thus trusts in his partner's health status to the degree that he has been informed. When deemed necessary, Ernest w i l l initiate discussion of H I V and STI status with potential sexual partners. In this way he is able to maintain the level of trust that he desires and not take on the role of "rejecter" that he wishes to avoid. Ernest desires relationship and is therefore wil l ing to potentially forego condom use in order to establish and maintain the bond with his partner. E.J. E.J . is a 39-year old gay man originally from Southeast Asia . He has completed a Master's Degree and is currently working on a Ph.D. E . J . has only been out as a gay man for 7 years and has had no relationships with men. He related how he had no sexual encounters with men whatsoever for the first 2 years after coming out. He was an observer, trying to understand the world of gay men and their sexual behaviour. His sexual experience has been confined mostly to encounters in bathhouses that he describes as "casual and fleeting." 56 E.J . describes his experiences of barebacking as largely having occurred accidentally. He did not seek out the barebacking encounters, but found himself in a position in which his partner was requesting unprotected sex. A s E.J . considers himself a morally responsible person he was initially disinclined to engage in unprotected sex. However, once he had experienced bareback sex, he found that "[i]t opened a different dimension of anal sex.. .1 began to realize how pleasurable it could be." A self-proclaimed uncompetitive person, E.J. 's lack of competitiveness extends to his sexual behaviour. He views himself as a giver who seeks to provide pleasure to his partner. In order to maintain his sense of personal responsibility, E . J . w i l l generally not ejaculate inside his partners. He believes he is doing his partners a favour by providing them with the unprotected sex they desire, yet it is a "relatively less irresponsible form of barebacking" due to his HIV-negative status and the lack of fluid exchange. Conversely, when he is the receptive partner during anal intercourse, E . J . "demand[s] that there should be a condom." Therefore, his barebacking experience is limited exclusively to the insertive role. Common Themes The analysis of the data culled from the in-depth interviews with the participants revealed five major areas of thematic content. These themes, in no particular order, are: (a) Sense of Increased Intimacy/Connection; (b) Burden of Safer Sex; (c) Sense of Enhanced Sexual Pleasure, Excitement, and Empowerment; (d) Sense of Powerlessness; and (e) Awareness of Responsibility to Self. Each of the themes w i l l be presented as a means of better understanding the participants' experience of barebacking in their casual relationships. 57 Sense of Increased Intimacy/Connection A theme that emerged as significant for all participants was the sense of increased intimacy or connection they felt with their sexual partners when barebacking. The participants spoke frequently of their quest for intimacy, or their belief that intimacy would be more likely obtained through barebacking. For some participants, the intimacy or connection they sought was not achieved as anticipated and they came to view their experiences of barebacking with sombreness. Generally, the participants expressed the opinion that barebacking represented a more personal and special experience than could be expected should a condom be used. According to one participant: Barebacking is much more personal. It creates almost, not a bond, but a link with myself and the other person which makes it a personal experience rather than just like raw sex or like using a dildo or something. The connection between himself and his sexual partners is greatly valued by this participant. His desire is for his sexual experiences to transcend the mere physical. He views barebacking as a means by which he can more effectively communicate with his partner on an emotional level. For this man, condoms are seen as a barrier to both intimacy and sexual pleasure. He described protected anal intercourse thusly: " A condom seems to be like a wall , which it is. It's a barrier between us. The sensation is different with a condom." Therefore, because he feels the condom is both a symbolic and a real barrier, the participant chooses not to use them so as to obtain the intimacy that he seeks. 58 A number of participants spoke of the association between barebacking and intimacy in similar terms. These men equated barebacking with an increased sense of connection as well as being an indication of trust between themselves and their partners, even i f the sexual contact was only casual in nature. For example, one participant stated: I have a feeling that it is more intimate not using a condom. It's hard to describe. I think there's a feeling of being more connected to the person...probably a feeling something like this person trusts me enough to do this. While no participant clarified exactly what this trust entailed, in all cases the underlying implication was that no infection would be passed between partners. In other words, by allowing the barebacking behaviour to occur, the participants and their partners were being trusted to not infect the other with an STI, in particular, H I V . One participant articulated this sentiment clearly when he said, "but for me I trust this person and it's the ultimate gift I can give them. It's basically my life." This recognition of the potential consequences of the trust they granted in exchange for intimacy was implicit in the words of each participant. The trust motif was expounded upon by another participant in this fashion: For me to trust someone in a sexual relationship is for me to allow myself to be more emotionally vulnerable in the situation—emotionally vulnerable not only in terms of whether they meet my emotional or mental needs but just in the fact that they even at some shallow level meet the physical needs or that I am okay enough to be in that situation. According to this man the trust he placed in his partners could potentially impact not only his physical health, but bis emotional health as well . B y allowing himself to be 59 vulnerable to his partner and by participating in barebacking, he exposed himself to risk: the risk of contracting H I V , or other STIs, but perhaps more significantly for him, also the risk of causing himself emotional damage as he seeks intimacy and validation through the sexual contact. The participant further explained that: In the situations where I've had sex without a condom.. .1 really just wanted the closeness so much that I 'm wil l ing to compromise more of what I—what's going through my head.. .closeness, intimacy, in this case I would use them almost synonymously. The desire for closeness, or intimacy, this man reported is so strong that he is wil l ing to disregard any concerns that he may have in order to feel closer to his partner. Although he acknowledged that he may be required to compromise himself, he rationalized his barebacking behaviour by focussing on those needs that are being met. Another participant described how he believes that his barebacking behaviour signifies a personal quest: I think I am looking for a connection. Not just physical necessarily, but in my mind I think it is more than just a physical connection. To have intercourse and then to not have a condom on is even more of a thing.. .to me the main thing isn't to have bareback sex, I think. It's to try to explore my boundaries and capacities for the sexual. I don't know, I mean intimacy or communication, type of thing. I mean that's, for me, I think that's definitely a consideration. In this instance, the participant referred to his search for connection and how barebacking is associated with this search. He indicated that barebacking is not an end unto itself, but rather a means to an end. For this man, barebacking relates to his desire for intimacy in 60 conjunction with a curiosity about his sexual limits and how these two concepts are interconnected. Sex without a condom is a method by which he is able to explore these desires and learn more about himself. Two of the participants raised questions about the relationship between intimacy and barebacking. While they both acknowledged that their barebacking behaviour had, at least initially, been an attempt to achieve intimacy with their partners, they ultimately came to believe that this is a faulty notion. For example, one participant recounted his burgeoning awareness as follows: The fact that this guy.. .wanted to engage in barebacking with me on the bottom...I realize that there's absolutely nothing intimate about that at all and like [it is] quite impersonal and non-intimate. So, I think that's what clued me in to the fact that barebacking isn't necessarily any.. .doesn't get you any closer to intimate relationship or intimacy of the moment.. .than using condoms. After having engaged in numerous episodes of unprotected sex, and reflecting upon his conduct, this participant realized that his need for intimacy would not be satisfied through barebacking. He indicated that the realization had been quite recent and that his curiosity about barebacking has been satisfied to a certain degree, although the allure continues. Another participant described his changed perception of intimacy and barebacking in this manner: I may have started barebacking to achieve that sort of intimacy and when I realized it wasn't providing me with that intimacy.. .1 just began to lose interest in sex for the sake of sex. 61 This participant reported that his interest in sexual activity has waned due to his recognition of the lack of intimacy involved in his barebacking encounters with casual partners. He revealed that as his desire for intimacy has increased, his overall number of sexual encounters has decreased, although his frequency of barebacking stayed the same. He explained his conduct as being due to his "search for greater intimacy." Even though both men reported gaining awareness regarding barebacking not necessarily leading to greater intimacy, neither of them has ceased all barebacking behaviour. Burden of Safer Sex A l l of the participants spoke of the difficulty that they had experienced in the past, or continued to experience, regarding the consistent practice of safer sex. These difficulties fell into a variety of categories that shall be explored further and which also sometimes reflected the age of the participant. For example, a difference was found in the manner in which safer sex was perceived and acted upon by men who were sexually active prior to the onset of A I D S and younger men who had grown up with knowledge of the syndrome. One reason cited by the participants for the inconsistent or negligent use of condoms during anal intercourse was the inability to maintain a satisfactory erection. A s might have been expected, older participants were more l ikely to state that they or their partner(s) found it difficult to maintain an erection throughout a sexual encounter when a condom was used. Younger participants tended not to mention the same difficulty. According to one participant: One of the things I find is that many men lose an erection, or cannot maintain it, when they have a condom on, especially middle-aged and older men. So, often 62 I ' l l start barebacking with them, and then as they're arousal heightens I ' l l sometimes stop and put a condom on them. But then again, not i f they lose their erections. This participant described a situation that he encounters with some of his sexual partners. The men are unable to achieve a sufficient erection with a condom and therefore the participant feels that he must bareback with them in order for the encounter to continue or to come to a mutually satisfying conclusion. Conversely, regarding the difficulty he sometimes encounters when wearing a condom, another participant stated: I would say there's another issue about barebacking and I 'm, I would say, a bit scared about it for myself. I lose erections i f I use a condom at some point, primarily because I 'm a bottom. But I have to perform so that's the reason why sometimes I should dip and then once I approach orgasm I pu l l . . .put a condom [on] and continue the fucking i f I need to, considering that he still wants to get fucked. In this case, the participant expressed his anxiety around his need to perform sexually and how he feels a condom can be an impediment to his performance. In both cases, the participants' descriptions illustrated how they feel condom usage can impact their ability to enjoy their sexual experiences. Amongst some participants it was clear that they had grown weary of hearing about H I V and the possible ramifications of infection. Again, this was particularly true with the older participants, although not exclusively so. For example, one participant expressed his frustration with the prevailing HIV/ADDS paradigm in the following words: 63 I just get concerned that we have bought into—queer people have bought into— the whole agenda that.. .and it obviously is changing among queer men, but that it's just become institutionalized, H I V / A I D S , to the point where you're, you know the institutions are telling me you're a really bad person, you know, for not using a rubber and you can't do this. W e l l , yes I can. A n d he can too i f he wants to. A n d we can i f we want to together. This participant reflected on feeling that his barebacking behaviour places him in a position whereby he w i l l be judged or negatively perceived by others, gay and straight alike. He believes that he has the right to self-determination, as do his partners, although he does not advocate a complete flouting of convention regarding the use of condoms. From a different perspective, a younger participant related his experience: I grew up with that HrV paranoia, the H I V paranoia like I think most people in my age group grew up—maybe not with a full paranoia but like with knowledge that that [HIV/AIDS] was one of the consequences....The messages that I had received were I—first of all the abstinence message, so therefore sex is just no longer safe. This participant described how he had come of age during a time when sex was presented as an inherently dangerous activity. From this participant's perspective the message is that no sexual activity is truly safe, compelling him to indulge in risky behaviour in order to participate in the sexual world. In this context, he sees barebacking as an extension of other sexual behaviours, each of which carries their own associated risk. Both of these participants deemed the mandate to "use a condom every time" to be unrealistic and even oppressive. 64 Not only was the physical reality of using a condom during each act of anal intercourse perceived as onerous by the men in this study, but initiating a discussion of sexual health with prospective partners was also viewed with trepidation by several of these men. Participants recounted how they had sometimes found it arduous to raise the subject of safer sex. A s one participant simply stated, "It's awkward to ask a person his H I V status or even his S T D status." The participants expressed how introducing the topic of safer sex often proved a psychological burden that could be difficult to overcome. A s aptly captured in the words of one participant in reference to an encounter with a casual partner at a bathhouse: This super-attractive guy, you know, expressed interest and he wanted to know i f I got into fucking. I said yes. A n d the condoms were right there but, of course, he didn't use them. I just didn't make an issue of it, but I was uncomfortable enough with it. . .he didn't work out. L ike , it didn't last very long as it is so he just sensed it was sort of uncomfortable and that kind of ended it. So rather than making an effort to discuss the condom issue, we just didn't talk about it. A n d so ended the interaction. According to this participant the sexual encounter ceased due to his perceptible discomfort with the fact that his partner did not even discuss the issue of safer sex. Interestingly, it was through his body language, not his verbal expression that he communicated his discomfort. Even though the participant was, by his own admission, uncomfortable, he chose not to speak up and rather, informed his partner with more subtle cues. 65 Another participant talked about his fear that discussing condom use would break the flow of the situation and affect his partners' impression of him. Rationally, nothing should really unimpress them about wanting to use a condom.. .mentally, intellectually it really shouldn't be anything. But I think, just in terms of the feelings involved in the moments, I think it's a bit of a sense of— kind of almost hesitation.. .1 also am sometimes second-guessing whether or not it could potentially be a symbol of intimacy for the other person. So therefore i f I 'm breaking that intimacy then, like, I wouldn't like they perceive me as being emotionally distant. Most of the participants sometimes struggled with how to broach issues of sexual health, even when they wanted to. A t a minimum, such a discussion was often perceived as anxiety-provoking, i f not outright frightening. Some reasons that were posited for this anxiety included social awkwardness, fear of rejection, and concern for the partner's feelings. Regardless of the reason, many of the participants found themselves in sexual situations whereby they were unable to adroitly and comfortably discuss condom usage. Consequently, they did not use condoms in these situations, whether or not they wished to. The following quote may best encapsulate the participants' overall attitude regarding the burden of safer sex, "I would be very surprised to find anybody, especially a gay man, who would consistently and unfalterably use condoms 100% of the time. I think that's, in my opinion, that's an unrealistic expectation of any human being." Sense of Enhanced Sexual Pleasure, Excitement, and Empowerment For all but one of the participants, the reason most often cited first as to why they engaged in barebacking behaviour related to the physical, mental, and emotional 66 sensations they experienced during condomless sex. For some participants, the focus was more on either the physical or the emotional component of the sex, while for others it was a combination of both factors. Except for the participant who did not believe that enhanced pleasure of either kind factored into his decision to bareback, the participants were unanimous in their position that bareback sex was markedly more enjoyable. Ranging from a complete abhorrence of condoms to an acknowledgement of increased stimulation, participants described their physical experience of bareback sex in various fashions. For one participant, pleasurable sex was not possible with condoms. He explained why bareback sex was the norm for him as follows: Certainly it's the physical pleasure aspect to it; the tactile thing, you know.. . .But yeah, I would say that it's—the reason is the tactile part of it, you know, definitely. It's not the same at all and no matter how many different condoms like, you know, they say it's a natural sensation. I mean, it's like fucking wrapping it up in shrink wrap man, you know, it's like not the same. This participant felt that a condom placed an unnatural barrier between himself and his partner which resulted in a sexual experience that he found dissatisfying. Accordingly, he chooses to almost never use condoms instead of introducing a "plastic by-product" into his sex life. Similarly, another participant related how condoms hinder his sexual enjoyment: "If the guy's wearing a condom I 'm not very happy chewing on a piece of rubber." For both of these men, condoms are seen as foreign objects, an impediment to a natural act, and a deterrent to satisfying sexual relations. Not all participants expressed such an adverse reaction to the notion of condom usage. Instead, some participants found that while they preferred sex without a condom, 67 they did not engage in bareback sex exclusively. One participant observed that, "Wel l , I guess I certainly have much more pleasure when the sex is unprotected as opposed to protected sex." Another participant expressed a comparable sentiment when he described his first act of bareback sex as follows: So I thought that hmm just a different experience. It opened a different dimension of anal sex to me. I could feel the difference between condoms and barebacking and I can.. .1 began to realize how pleasurable it could be. Sex without a condom had previously been unimaginable to this participant and he had not considered what physical sensations he might experience without a condom. However, once condomless sex had been savoured, his perspective changed: I realized that I cannot be satisfied sexually as a top i f I 'm not barebacking. I discovered that it is pleasurable to be a top but I can maintain erections only when I 'm. . .play without a condom. Hence the.. .it's a scary experience or scary thought that Oh Boy so i f I 'm a top then it should be bareback. It runs counter to my playing it fair and playing it responsible. It's the.. .that's the scary part of it. On the other hand, it's a discovery that, to be a top is pleasurable and it's nice and I could do it. The participant recognized that his sense of responsibility to his partner(s) and himself is at odds with his desire for fulfilling sexual experiences. Nonetheless he also acknowledged that his experience of sex is enriched by foregoing condoms during anal intercourse. L ike this participant, a number of the men in this study found that a dichotomy existed between what they knew to be appropriate and responsible behaviour and what they knew to be pleasurable behaviour. 68 In addition to the heightened physical pleasures that the participants largely acknowledged, there also existed an intensification of their mental or emotional state. In plain terms, most of the participants found bareback sex much more arousing than sex with condoms. For example, one participant described his perception of barebacking in the following manner: Emotionally, there's something hot about it, something that's a turn-on. I don't know exactly why....It 's hard to say, I 'm, like I 'm not exactly sure what it is about it that turns me on. It's certainly like, when I watch porn, I 'm much more turned on by watching bareback sex.. ..It's not something I know a conscious reason why. It's just, you know, I think we all find things that are a turn-on but we don't necessarily know why. While this participant was not able to articulate what aspect of barebacking triggered his sexual desire, he was nevertheless clear that his desire was in fact intensified. This sentiment was echoed by numerous participants, who described barebacking alternatively as "empowering," "alluring," and "a bigger thril l ." In particular, the allure of barebacking was mentioned by several men. For these participants, the so-called taboo nature of unprotected sex provided an additional level of excitement to their sexual activity. Because, according to the safer sex guidelines, all anal intercourse should include condom usage, the deliberate act of omitting condoms from the sexual act represented, for some participants, an act of defiance that they found titillating and ultimately sexually stimulating. One participant described how barebacking was a way for him to let his inhibitions down and engage " in something that was taboo and within the community of like-minded guys." This participant goes on to 69 compare barebacking to being at war, " . . .not the physical battle but just like being in war-time and everybody's sort of facing lots of challenges sort of as a community, like the gay community and just trying to seek comfort with each other." For this man, as well as another participant, unprotected sex additionally represented a connection with a particular segment of the gay community: the barebacking community. This connection provided for these men a sense of empowerment whereby they were free to make decisions relating to their sexual and emotional well-being, without the constraints that might be dictated by the medical community or even other members of the gay community. Sense of Powerlessness A theme that arose for all but one of the participants related to a sense of powerlessness that they occasionally felt, resulting in barebacking behaviour in which they may not otherwise have chosen to partake. The exception among the participants endeavoured to never use condoms and was frank with all of his sexual partners about his intent. For the remaining participants, there was largely a sense that condom usage could or might depend on the inclination of their partner. Whi le most participants acknowledged that they preferred anal intercourse without condoms, they also acknowledged that there were physical and emotional risks associated with this behaviour. Consequently, rather than make a decision that they recognized as potentially dangerous to themselves, some participants would defer to their partner. If the partner indicated a desire for bareback sex, then these men would acquiesce. In other situations, the participants reported that they participated in barebacking for fear of losing the intimacy of the sexual contact, in order to please their partner, or due to low self-esteem. 70 Some participants spoke of their concern that, once started, sexual encounters would not continue should they insist upon condom usage. Participants described how they perceived that because of their partners' desire for bareback sex, they had little choice but to comply as they too wished for the intercourse to endure. For example, one of the older participants depicted a scenario in which he might feel obliged to bareback: Say I 'm with a guy who's 45 and he says, "I gotta bareback you 'cause I can't keep an erection." So now I have to make a choice. If I want to enjoy sex with this man it has to be on those terms. If I don't, then I've lost that opportunity. So in a way, I look at that as being pressure put on me to make a decision. A s the participant explained it sex, although desirable, would not be possible for the partner in such a case i f a condom were to be used. His decision as to whether he should have unprotected sex with his partner would determine whether the sex occurred at all . Because the participant wanted the sex to occur, he felt pressure to bareback. Another participant described a similar scenario in which he questioned whether his partner would disengage from the encounter i f a condom were introduced. There's some possible insecurity involved in it . . . in that quite often, I guess. The sex has been pretty casual and there's probably a question of, you know, i f I stop what's going to happen? If I take the time out to put on a condom is he going to leave or something like that? This participant conceded his insecurity regarding discussing condom use or taking the initiative to employ the device. His insecurity would hence result in his agreeing to have unprotected sex, even though the participant may have preferred to use a condom. A s another participant phrased it: "I can remember situations where it's like i f you don't 71 kind of go with the flow of things, then things w i l l stop more abruptly than you'd want." A l l of these participants therefore experienced pressure to bareback in situations where they felt unable to insist upon condom usage i f they wanted the sexual encounter to continue. Some participants connected their search for intimacy with a perceived expectation of barebacking or lack of w i l l to resist the behaviour. For these men, barebacking was occasionally required in order for their desire for intimacy to be met. For example, one participant explained: I think the similarity in these occasions [of barebacking] have really been where I 'm in a position where I feel more pressure to please the other person probably. They're similar in that not desperate but I would probably be in a position where I would want some sort of closeness more. This man felt that by participating in barebacking he would be pleasing his partner while at the same time addressing his own intimacy requirements. Furthermore, the participant's description of his thoughts at the time indicated that he believes the closeness he seeks with his partners is sometimes contingent upon condomless sex. Another participant described his perception of his quest for intimacy through barebacking as follows: I've thought of it more as a show of weakness, not strength. I would think. Like , it's—but it's reaching out for, you know, some sort of intimate contact.. ..But I think it is rooted in weakness. The weakness in not using condoms and giving in to the temptation, not facing up, like, facing your—like the emptiness that you're 72 looking—you're trying to f i l l with that type of activity.. ..I think ultimately it 's more rooted in weakness, for sure. This participant recognized that, for him, barebacking was a tempting activity, particularly in the context of seeking intimacy, and that he was not always able to withstand the temptation. Moreover, this man expressed a generalized feeling of hollowness in his life that he attempted to address via barebacking. B y referring to his barebacking behaviour as a sign of weakness, he effectively illustrated the notion of powerlessness that most of the participants periodically experienced and expressed in relation to barebacking. A number of participants described a lack of self-esteem as being a possible factor contributing to their barebacking behaviour. For these men barebacking sometimes resulted when they perceived themselves unable to insist upon condom usage in situations where they may have wished to do so. One participant articulated why he might participate in barebacking as follows: I might suggest that since I've been l iving in Vancouver that my self-esteem has suffered somewhat....I find it a really superficial and unfriendly place in general, so that may have, I 'm sure it has affected my self-esteem to some degree and that may have been why I've been more wil l ing to risk myself in these situations. The participant believed that his lowered self-esteem impacted his ability to make prudent decisions regarding his sexual health. He believed his need for affiliation combined with an absence of a support network resulted in behaviours that he acknowledged as risky. The participant further explained, "I don't always have the self-73 esteem to really have that protective drive." Another participant described how his self-esteem and his need for acceptance could work together to result in unprotected sex. So then it's also about trusting my own—my self-esteem issues but because I don't want to be perceived as the one to be the more intense one—to be the more, the one with more issues about it. This man was concerned that his partner would perceive him as too intense and too concerned about whether barebacking occurred or not. He was, in fact, less concerned about whether sex included barebacking but was concerned about whether the sex bespoke intimacy and furthered the possibility of a relationship between himself and his partner. Again, for this participant, self-esteem played a part in the decision-making leading to barebacking. While not explicitly stated as such, perception of self was clearly implied as a motive for barebacking by yet another participant. I don't want to do barebacking but because these partners want to then I deliver. In some sense I 'm maybe a bit grateful from them because they agreed to play with me. The little white.. .the few God-like men who [are] wil l ing to play with me. So I feel a bit, I would say, affirmed as a person. On the other hand, and hence maybe I 'm showing a sense of debt of gratitude that, Okay you're wil l ing to play with me. I could expose myself to risk. Although he maintained his lack of comfort with barebacking, the participant indicated that he did so in order to please his partners. Furthermore, he stated that his sense of gratitude to his sexual partners influenced his decision as to whether to bareback. The participant suggested that when he perceives himself to be unworthy of the sexual contact 74 with a particular partner he compensates by knowingly risking his health through barebacking. Awareness of Responsibility to Self Regardless of their age or the length of time they had been barebacking, all of the participants demonstrated an awareness of their personal responsibility to themselves. This awareness took a variety of forms ranging from an acknowledgment that unprotected sex could result in physical harm, to specific actions taken to minimize potential risk. The majority of participants indicated that they had developed methods that they believed served to protect them from the physical and psychological risks associated with barebacking. In this way, the men who participated in this study recognized that barebacking did indeed pose a risk, that they were ultimately responsible for their own health, and that they should take action to guard against potential harm to themselves and to their partners. Perhaps the most basic method used by some participants to ensure their physical and emotional well-being involved simply talking to their partners. These men related how they engage their potential partners in a discussion of sexual health as a means of determining how to proceed sexually. For example, one participant described how he approaches the subject of personal healthcare. I always ask a person's H I V status. I know a lot of people lie about it. But, I don't so much listen to their words; I watch their body language and their facial expressions. A n d i f there's any twinge of doubt or concern, I try and use a condom. On the other hand, i f I feel very comfortable with someone then I w i l l let them bareback me. 75 In this case, the participant opens a conversation about H I V , but is not necessarily guided by his potential partner's verbal response. Instead, he takes notice of all available cues, whether verbal or otherwise. Ultimately, he seeks confirmation that barebacking with this individual w i l l not be a decision he later regrets or that puts him at risk. His willingness to bareback is based on his level of comfort with his partner, and this comfort, or discomfort, can be conveyed with or without words. Another participant explained how he introduces health discussions into his sexual encounters as follows: I've actually been in situations where I've actually paused and been like, okay, it's time to have a little talk and then you know divulge information that way.. .I've never had a problem with people freaking out about my asking that but what ends up happening is that, like, in every situation I've always been the one to bring it up . . . . I ' l l pause and be like...are you safe? Have you been tested? A n d I don't even just do H I V . . .And then it's about believing the other person. Similar to the previous participant, this man takes the onus to initiate a dialogue regarding safer sex and his partner's H I V and STI status. While he finds that his partners are open to such a discussion, he too struggles with whether to believe his partners' replies as the risks to his own health are considerable. Yet another participant explained under what circumstances he discusses H I V status with his partners thusly: "I don't think it's part of the discussion i f it 's a trick, and it's anonymous.. .but i f I wanted to see that person again then the second time that we're together I just make it a personal rule to ask." A l l of these men declared their comfort with taking the lead in questioning their partners regarding their sexual health. They take 76 this step in acknowledgement of their need for self-protection and with the knowledge that barebacking could prove hazardous to their health. A number of participants also reported engaging in certain behaviours to stave off sexually transmitted infections, H I V in particular. These men have developed strategies that they perceive as effective inasmuch as they have not yet sero-converted. For example, one participant described the following method by which he can enjoy the pleasure of condomless sex without the associated anxiety: I learned as well during my [HIV] testing that there's this thing called "dippy-do" or "dipping" where you just put your dick inside the anus for anal sex but just dip it and then just to give the sense of or the pleasure of having it there and then pull it out for the condom and then do the—finish the intercourse. In lieu of intercourse without a condom, this man w i l l partially insert his penis into his partner to simulate the sensation of barebacking. His understanding is that this activity is safer and less likely to result in an infection. Another participant detailed his plan for infection avoidance: The other thing I do, and I haven't really got a definite opinion whether it's right or wrong—if I 'm barebacking with someone I tell them I don't want them ejaculating inside of me, and when they're ready to come I want them to withdraw. Most guys do, some guys don't... .If they do ejaculate in me I have— it's a bottle, basically it's a plastic squeeze bottle that's used to give yourself an enema. And , i f it happens I immediately douche, I guess, for the lack of a better word with just plain tap water to try and get everything out that might be in there. 77 Recognizing the potential danger of contracting H I V or other STIs, this participant protects himself by means that he considers helpful even though he concedes that he is unsure of the true safety of this technique. Although he reported being uncertain as to whether douching under these circumstances can avert an infection, the participant is nonetheless taking steps he believes w i l l protect his health. Another method employed by one participant relates to partner selection: About 2 years ago I met my boyfriend at the time and I guess the first time we got together I didn't use a condom and I knew he had only been with one other guy before and only one occasion, so I figured the chances were it was pretty safe... .In the last 3 or 4 months I've been seeing someone. It's pretty much just a sexual relationship. It's not anything committed or anything but I knew that he was a virgin when I met him and so I wasn't concerned about it [HIV], from my perspective anyway. For this man, one way to ensure that he does not become HrV infected is to choose partners that are unlikely to have come in contact with the virus. B y barebacking with partners whose sexual histories are limited and known to him, the participant feels he is able to guard against exposure to infection. The common link between all of these strategies is the participants' conviction that their chosen method has thus far proven effective in avoiding H I V infection; and therefore should continue to prove equally effective in the future. Overall, participants expressed a high level of awareness of the possible ramifications of their barebacking behaviour. In that regard, they seek strategies that they believe w i l l protect them from harm while still allowing for the seeming pleasure and 78 intimacy of condomless sex. A s well , some of these strategies also serve to protect their partners, as some participants reported a sense of responsibility not only to themselves, but to others. Ultimately, the following statement from one of the participants expresses a common view among the men in the study: "I feel it 's totally my responsibility. I am educated in the pros and cons of barebacking, so I 'm not stupid about this, or going in blind....1 know the consequences, or what they could be." 79 Chapter Five Discussion The purpose of this study was to document the subjective experience and meaning for gay men of unprotected anal intercourse, or barebacking, in their casual sexual relationships. A phenomenological methodology was employed as "its focus is on the subject's experienced meaning instead of on descriptions of their overt actions or behavior" (Polkinghorne, 1989, p. 44). The research question posed to the participants was: What is the meaning and experience for you, of barebacking in your casual sexual relationships? Five themes arose from this research that give expression to the experience of the 6 gay male participants. This chapter includes a comparison of these findings with those from the available literature, as well as a discussion of the study's implications for both future research and counselling practice. Comparison with the Literature In the context of HrV/AIDS education and prevention, a great deal has been written about the sexual behaviour of gay men. The majority of the existing literature has focussed on so-called risky behaviours, primarily unprotected anal intercourse, and the factors contributing to the decision to participate in condomless sex. For example, are some men influenced by optimism regarding H I V treatments or a lack of knowledge about how H I V is transmitted? Very little research has taken a qualitative approach or considered the meanings of the experience of barebacking for those who engage in the behaviour. A comparison between the barebacking literature and the results of this study demonstrates a number of similarities and differences. The following analysis therefore 80 concentrates on these similarities and differences and also includes a discussion of results from the more general research on U A I where germane. Based on the findings of their study of 554 men in the San Francisco Bay Area, Mansergh et al. (2002) argued that barebacking is a public health concern more so than unprotected anal sex in general due to its intentional nature. These researchers reported, based on their sample, that: Bareback behavior is transgressive in that it is not in the context of 'negotiated safety'; (i.e. a long-term, monogamous relationship; repeated testing to verify HlV-concordance; a verbal agreement in the context of a trustworthy, communicative relationship) (p. 657). Crossley (2002), in her study of U K gay men, similarly advanced the position that barebacking equates to transgression. Mansergh and his colleagues believe that because barebacking falls outside of the rubric of negotiated safety, the gay community is at even greater danger for transmission of HrV or other sexually transmitted infections. This perception appears to be based on the definition of barebacking employed by the researchers, whereby intentional U A I with a non-primary partner is separated from acts of "poor planning or spontaneous decisions about condom use" (p. 654). Such a stringent definition was not used in the present study. Participants responded to a variety of recruiting notices that requested the involvement of gay men who barebacked in casual sexual relationships. If clarification was requested, barebacking was defined simply as unprotected anal intercourse. Nonetheless, all participants ultimately acknowledged that they perceived their behaviour as barebacking, and that they had responded to a notice based on this fact. 81 While a number of participants in the current research discussed the taboo nature of barebacking, a term also found in the survey administered by Mansergh et al. (2002), only one of the six participants considered his behaviour to be transgressive. However, in this man's case, these acts of transgression were aimed more at the existing HIV/ADDS institutions and paradigm rather than the gay community itself. He felt that, in effect, "the whole thing has become a business." This participant was aware of the possible health risks associated with barebacking and took precautions, largely in the form of sero-sorting, to protect both himself and his partners. Mansergh et al. found that the H I V negative men in their study tended to bareback with partners who reported the same serostatus. This finding was replicated by the present study. In fact, each of the 6 participants displayed knowledge of H I V and STI transmission methods and employed a variety of techniques to avoid infection, as evidenced by the theme of "Awareness of Responsibility to Self." Studies by Davis (2002) and Ridge (2004) also concluded that gay men are aware of the danger associated with unprotected sex and H I V infection. In the end, there is no evidence to suggest that the 6 participants in this study pose a greater risk to the public health than individuals who would define their condomless sexual acts as something other than barebacking. Intentionality was a component of the barebacking behaviour for only 2 of the participants in the present study. The application of the barebacking label would not, therefore, appear to automatically denote inherently more risky behaviour. It is possible that the behaviour of men in the San Francisco Bay Area, who have long been severely impacted by H I V / A I D S , may be more politically motivated than that of the Vancouver sample. Perhaps these men were indeed seeking to flout conventional 82 wisdom regarding safer sex. However, the data presented by Mansergh et al.(2002) showed that only 10% of H I V positive men, and 17% of H I V negative men reported barebacking in order to do something taboo or racy. Furthermore, 80% of H I V positive men and 65% of H I V negative men indicated that greater physical stimulation was the main reason for barebacking, followed by the desire to feel emotionally closer or connect more for 40% of HrV positive men and 39% of H I V negative men. These findings were echoed by the results of the present study in which 5 of 6 participants were motivated to bareback due to the increased physical pleasure involved, while all six men cited a desire for greater intimacy or connection as a motivation. In a similar vein, Halkitis et al. (2003) suggested that their sample of 448 gay and bisexual men in New York Ci ty familiar with the term barebacking "perceived numerous psychological and emotional benefits associated with barebacking, including but not limited to feelings of connectedness, intimacy, and masculinity" (p. 355). This suggestion is supported by the data from the present study through the themes of "Sense of Increased Intimacy/Connection" and "Sense of Enhanced Sexual Pleasure, Excitement, and Empowerment." In a review of research on the sexual behaviour of M S M throughout the 1990s Stall et al. (2000) observed that "[m]en often report enjoying unprotected anal intercourse more than wearing condoms and this preference is not surprisingly reflected in behavior" (p. S104). Moreover, Tewksbury (2003) also noted that barebacking reportedly provided a sense of connection for his study participants. L ike Mansergh et al. (2002), Halkitis et al. (2003) employed a quantitative survey methodology, which in this case included three measures: Barebacking Behavior, Benefits of Barebacking, and Barebacking and the Internet. Using a Likert scale, 83 participants responded to statements such as: Barebacking increases intimacy between men or Barebackers can find others like them to communicate with on Internet. Whi le the findings of the current research are analogous to those of both Halkitis et al. and Mansergh et al., a significant difference lies in the method by which the results were obtained. The themes that arose from the present study did so naturally and without excessive prompting. Participants were not asked to respond to prepared questions or statements which could be the result of researcher bias. Instead, the interviews were informal and unstructured, consisting of a number of open-ended questions that were posed only as necessary; participants were encouraged to tell the story of their barebacking experiences with little intervention. Nonetheless, it would appear that the barebacking phenomenon among gay men is beginning to emerge in the literature, regardless of the methods employed by the researchers. Halkitis et al. (2003) further postulated that the emergence of barebacking as a phenomenon may also be linked to sociological factors. For instance, they cited "the prevailing use of 'club drugs'" (p. 355) as a likely contributor to the phenomenon. Mansergh et al. (2002) also made reference to half of their sample of HrV negative men having been "drunk on alcohol or high on drugs during their last bareback encounter" (pi 656). However, only one of the participants in the present study acknowledged that consumption of drugs and/or alcohol had been complicit in his decision-making process regarding barebacking. This man indicated that this behaviour was in the past and that neither drugs nor alcohol currently influenced his sexual behaviour. Five of the participants did not consume intoxicants in combination with sexual activity. It is unclear why these differing results should be obtained.. In the case of the present study, it may 84 relate to the self-selecting nature of the recruitment process. Each participant was required to contact the researcher directly, at which time he learned that he would be interviewed face-to-face i f he agreed to participate in the study. Individuals whose behaviour is heavily influenced by either drugs or alcohol were perhaps less likely to express interest in such a self-reflective process. The research by both Halkitis et al. (2003) and Mansergh et al. (2002) referred to issues such as fatigue about the ADDS epidemic, advances in the treatment of H I V disease, and ineffective H I V education and prevention campaigns as possible reasons for the increase in barebacking behaviour among men who have sex with men. These conclusions are not necessarily borne out by the current research. None of the 6 participants spoke of fatigue that they were experiencing relative to HTV" and ADDS, except in the context of the institutions that have been created to manage the epidemic, as mentioned earlier. Two of the participants were sexually active prior to the onset of ADDS, yet the behaviour of neither of these men appeared to be impacted specifically by ADDS fatigue. Nonetheless, the prevailing prevention message of "Wear a condom every time" was perceived as ineffective and unrealistic by a number of the participants, a position echoed by Goodroad et al. (2000) in their review of the lay and scientific literature on barebacking. Only the research by Bancroft et al. (2003), which included a sample of 589 men who have sex with men recruited in Indianapolis or Bloomington, IN , recognized a relationship between sexual risk-taking and erectile dysfunction (ED). Two participants in the current study mentioned that either they or their partners suffered from E D on occasion, whereupon barebacking was thus necessary to complete the sexual act. 85 There was no suggestion on the part of any participant in the present study that they understood available medications to be a remedy for H I V infection, or that such medications rendered the infection inconsequential. One participant spoke eloquently on this issue: A lot of them [young gay men] too have the attitude now that we've got the magic cocktails and i f they get it [HIV], so what, which I don't think is the right attitude to take. I've thought about that quite seriously. I've even evaluated it for myself that i f I get infected I ' l l just take the drugs and I ' l l be okay. But then I have some Poz friends and they're not okay, even though they take the drugs. It's tough on the body. There's a lot of baggage that goes with the infection and taking the drug treatment. This position is in contrast to the findings of Mansergh et al. (2002) who cited 19% of their barebacking participants as agreeing that improved HTV treatments had caused them to have more condomless sex, while 15% of these men acknowledged that they engaged in more unprotected sex because fewer people were developing A I D S . A connection between the Internet as a communication tool and barebacking behaviour was specified by Halkitis et al. (2003). These researchers found that their participants "believed that use of the Internet facilitated the barebacking phenomenon among gay and bisexual men" (p. 354). Two of the participants in the present study were recruited via the Internet. Only one of these participants, and none of the others recruited via different methods, mentioned the Internet as a source of sexual partners. Although this man acknowledged that he did meet potential partners on-line, he was cautious as to who he would meet in person. 86 I have a tendency to meet guys on-line a lot and it's astounding how many guys on-line want bareback sex. I find I generally stay away from those that explicitly advertise their desire for it because I feel it's a greater risk. The position espoused by Halkitis et al., would therefore appear to be true for this participant as well , yet he was uncomfortable with the notion of bareback sex being sought exclusively. Accordingly, he reported that he would avoid contact with those men who specified their desire for unprotected sex, ostensibly due to the risk of exposure to H I V . Gauthier and Forsyth (1999) and Tewksbury (2003) investigated bug chasing, or the deliberate pursuit of H I V infection. The primary sources of data in both studies were personal advertisements posted on the Internet. These advertisements were analyzed for content that explicitly stated that H I V infection was sought or in which it was implied. Whi le Gauthier and Forsyth quoted a number of advertisements from individuals seeking infection, as well as those wil l ing to provide the virus, there was no quantification of the prevalence of the practice. Methodological problems may also have led to over-sampling of the population thereby increasing the likelihood of including multiple advertisements from the same individual. Tewksbury concluded that "no more than 1% of men seeking bareback sex partners are also actively seeking opportunities to either become infected or infect others with H I V " (p. 479). Consistent with this statement, each of the participants in the current research expressed concern for their health and the desire to remain H I V negative, i f their serostatus was known. The theme of "Awareness of Responsibility to S e l f demonstrated the efforts undertaken by the 6 participants to safeguard their health in the face of potential exposure to HTV or other STIs. A s one participant succinctly 87 explained about barebacking, "[t]here is the big danger, though, of H I V infection." In reference to bug chasing in particular, another participant stated that: Everyone's talking about it and I can't understand the concept of "The Gift ." Something like i f I have it then I don't have to worry about it anymore. Because maybe that's selfish of them. I don't want to be the judge. Whereas Gauthier and Forsyth considered bug chasing to be a phenomenon of note, neither the results of the present study nor those of Tewksbury confirmed this belief. The research approach taken by Carballo-Dieguez (2001) was qualitative in nature, comparable to the current study. He interviewed four self-identified gay men from New York City, three of whom were H I V positive, while one was of unknown serostatus. His results indicated that his participants, for instance: (a) had progressively relaxed their standards of safer sex conduct, (b) had grown fatigued by both the A I D S epidemic and condom usage, (c) frequently assumed that sexual partners had the same serostatus, (d) ascribed various meanings to sexuality, and (e) were aware of the risks inherent in unprotected sex. Similarly, for half of the participants in the present study barebacking had occurred due to a relaxation of safer sex practices. Conversely, the other half had either never used condoms or had begun to use condoms only once HTV was understood as a threat to their health. A s mentioned previously, no participants identified A I D S fatigue as a factor leading to barebacking, nor was condom fatigue cited. Nevertheless, while neither A I D S or condom fatigue, nor sero-sorting, may have been mentioned, the theme of "Burden of Safer Sex" clearly outlined the difficulty that participants experienced in maintaining safer sex practices. Carballo-Dieguez's informants spoke of their emotional needs that were met through sexual activity. 88 Participants in the current research likewise identified how sex in general, and barebacking in specific, satisfied certain needs. One participant described his feelings about sex and relationship in this way: " . . .and so for me part of the validation is whether or not sex w i l l or could occur—validation of the relationship is what I l ike." This participant indicated that barebacking would sometimes occur simply because he did not want to interrupt the rhythm of the encounter, thereby negatively impacting the relationship potential with his partner. Informants in Carballo-Dieguez's study expressed similar sentiments, akin to those comprising the theme of "Sense of Increased Intimacy/Connection." Risk awareness was prominent for the participants in the present study as well as those of Carballo-Dieguez. The theme of "Awareness of Responsibility to S e l f outlined both the level of awareness present in addition to the methods by which minimal risk to health was believed to have been ensured. A distinction of note is the HTV status of the participants in the two studies. Carballo-Dieguez largely interviewed men who were H I V positive. Their perception of risk management may have been understandably different than the men in the current research who were primarily HTV negative. Employing both interviews and focus groups, Crossley (2002) studied barebacking behaviour among gay men in the Liverpool and Sefton areas of the U K . Her concern was why gay men were having unsafe sex. In response to this concern, she proposed several possible explanations including the previously mentioned notion of barebacking as transgression. Crossley reported that her participants perceived ' "a lot of complacency' among younger gay men" (p. 55) regarding HTV and safer sex practices. One older man in the current study agreed with this opinion. 89 I see a lot of people barebacking in the park. I often w i l l give them condoms. Some guys take them, most of the young guys don't. I don't know what the demographics are, rates of infection for a certain age group, young people or whatever, but I 'm concerned about it that a lot of them are undereducated in H I V infection and how to avoid it. However, this perception was not shared by the sole under 30-year old participant in the present study. In fact, to the contrary, this man referred to himself as having grown up with " H I V paranoia." Crossley further suggested that low self-esteem might account for the complacency among younger gay men. While the theme of "Sense of Powerlessness" in the current research does reveal a lack of self-esteem as a contributing factor to barebacking behaviour for some men, it was not limited to only the younger participants. Interestingly, the notion of low self-esteem among some gay men who bareback does not seem to be reflected in most of the available literature. Given that improved self-esteem could potentially impact an individual's ability to make sound decisions regarding sexual health, and otherwise, it would appear that this would be an appropriate area for future research and counsellor intervention. The determination by Ridge (2004) that the 24 participants in his study of gay men in Melbourne frequently found themselves in situations where barebacking was a possibility was strongly supported by the current research. In particular, the theme of "Sense of Powerlessness" revealed how the Vancouver participants sometimes engaged in barebacking simply because they were unable to extricate themselves from sexual situations in a fashion that they found socially or personally acceptable. Not only did these men occasionally struggle to raise the issue of safer sex with their partners, but at 90 times they would ignore their inclination to use condoms so as not to lose the sexual opportunity or risk driving their partner away. For example, one participant related that, "I can remember situations where it's like i f you don't kind of go with the flow of things, then things w i l l stop more abruptly than you'd want." The meanings of barebacking were addressed by Ridge (2004) in his discussion of his informants' sexual behaviour. He stated that: Importantly, while cognition and social relations trigger and mediate feelings, meanings in sex have an emotional content that plays a role in whether or not men prioritize the use of condoms in barebacking, regardless of levels of knowledge about safe sex. For instance, barebacking could be a means of expressing anger, expressing an emotional closeness or instrumentally dealing with feelings (p. 275). The themes of "Sense of Increased Intimacy/Connection" and "Sense of Enhanced Sexual Pleasure, Excitement, and Empowerment" from the present study also illustrated a comparable sensibility. For example, one participant explained how he had come to have bareback sex without the intention of doing so. I could see in his eyes that he was really wanting me to put it in and he nudged and nudged and nudged and said "Put it in. Put in. Put it in. Put it in . " So, then I decided not to just really put it in, but it slipped and it went in. It was pleasurable. In this instance, the participant recognized that unprotected sex presented a danger, yet he fulfilled on his partner's desire in order to provide pleasure and to afford a deeper connection. Another participant described his desire for unprotected sex as follows: 91 The penis inside me without a condom is far more comfortable and far more enjoyable than it is with one with a condom on it....It's more stimulating when it's bareback. It's much more arousing for me, and I guess more personal is the way to put it. For both of these men barebacking carried with it meanings that fulfilled on important and highly individual needs, just as Ridge described for his informants. The men who participated in the current research demonstrated that unprotected anal intercourse is occurring among some HrV negative men, even those who are wel l -educated in the methods by which the infection is spread. Each of the participants further demonstrated a desire to remain H I V negative and also to protect the health of their partners: bug chasing was not a relevant concept for any of the participants. The abuse of i l l ici t drugs and/or alcohol was not complicit in the decision-making of the study participants; instead a longing for increased connection between partners and the enjoyment of heightened physical pleasure were often cited as a rationale for barebacking. Erectile dysfunction did sometimes play a role in the decision to bareback for the older participants and their partners. For some participants barebacking occurred simply due to a relaxation of safer sex practices and without direct intent. Furthermore, a lack of self-esteem was mentioned by some men, and implied by others, as resulting in barebacking behaviour when they would not otherwise have done so. Implications for Future Research Findings from this study suggest a number of areas for future research. The gay male participants frequently spoke of the improved physical sensation associated with barebacking. Mansergh et al. (2002) indicated that their data "suggest[ed] that most men 92 who bareback are likely to use a future rectal microbicide, even i f such a product were protective only 50% of the time that it was used" (p. 658). Even with a failure rate of 50%, the participants in this study were wil l ing to forego condoms to experience the sensation of condomless sex. A s it would appear that barebacking is on the rise, perhaps more research should be directed towards development of such a product that provides men with the means to protect themselves to some extent while still affording the level of pleasure and connection that they crave. N o matter how thin or sensitive they become, it is unlikely that improved condoms would ever satisfy the physical desires of gay men, or anyone, due to the psychological barrier they may impose. A desire for increased intimacy was expressed by all of the participants in this study. Future research exploring what gay men are lacking in their intimate relationships could perhaps help to identify ways in which gay men might improve their relations with others while at the same time protecting their health. When asked directly i f they felt that their barebacking behaviour was impacted by past or existing H I V education activities, all responding participants indicated that this had not been a factor. In other words, they did not believe that existing H I V prevention campaigns were necessarily ineffective, although they did not perceive them as being especially successful either. Additional research among gay men as to what messages they would perceive as effective, could assist them in making health positive choices. Numerous studies (Ekstrand et al., 1999; Tewksbury, 2003; Van de Ven , 2002) have reported methods by which men who have sex with men attempt to reduce the risks associated with condomless sex. The present study, through the theme of "Awareness of Responsibility to Self," similarly reflected how the participants sought to protect their 93 health and that of their partners. More research to identify effective risk reduction strategies and to educate the public could affect the barebacking behaviour of some gay men. This research is liable to prove more meaningful should it take into account the different meanings of condomless sex for gay men. Multiple messages are required to address the economic, social, and psychological variations of gay men today. The theme of "Sense of Powerlessness" in the current research addressed the inability of most of the participants to sometimes resist the barebacking overtures of their sexual partners. Only Ridge (2004) referred to the tacit contracts that may exist between sexual partners rendering it difficult to avoid certain activities without causing offense or hurt feelings. The participants in the present study expressed feelings of this nature on many occasions. Future research that specifically inquires into the motivations of gay men who comply with requests for bareback sex against their better judgment might provide insight into an under-studied component of the gay male psyche. A n understanding of such behaviour might prove beneficial in the creation of H r V education materials. Finally, as the present study included only participants of HrV negative or unknown serostatus, future research might seek to replicate or expand upon these findings with an HrV positive population. Furthermore, a similar study with a sample of heterosexual men could prove equally interesting and informative. Implications for Counselling The five themes that emerged from this study have a number of implications for the practice of counselling. Most importantly, counsellors would benefit from the knowledge that, according to these participants, some gay men are not using condoms 94 with each act of anal intercourse (Al ) . In fact, otherwise responsible, well-educated men appear to be having bareback sex. Due to the consistent message from H I V education agencies and materials that a condom must be worn during all acts of A l , it is possible that counsellors may have been lulled into the belief that condom usage was the norm for the majority of gay men. The experiences of the men in the current research do not, nor are they intended to, characterize all gay men. Nevertheless, these men do represent a sample of the gay population that demonstrates that bareback sex has become relatively common in certain corners of the gay community. A n awareness of this apparent trend is necessary for counsellors working with gay men. Counsellor awareness of barebacking is merely the first step. Carballo-Dieguez (2001) asked of therapists working with gay men: [H]ow frequently do we probe into their sexual lives to uncover exactly the kind of sexual activity they have? Do we assume that our patients are using protection i f they do not spontaneously disclose otherwise? If they do not talk about condom use in the course of the sessions, is it our function to bring it up—or can we simply assume that this is not an issue that causes problems to the patient? (p. 232). These and other questions regarding client sexuality are potentially troubling to counsellors. What is our responsibility to our clients regarding their sexual health? Is their psychological health not also impacted by their sexuality? Obviously, it is not the counsellor's role to monitor their clients' sexual activities, but it is appropriate to assist clients in understanding the impact of their behaviour on all aspects of their health. According to Kauth et al. (2000), "physical health and the effect of risk behaviors are 95 interactive elements of global functioning and should not be ignored" (p. 435). Based on the level of shame exhibited by some of the participants in this study relative to their barebacking behaviour, it would appear that counsellor intervention on this subject may prove helpful. While some counsellors may themselves struggle to speak openly about matters of sex and sexuality, it is our responsibility to overcome such feelings in order to provide the highest level of service to our clients. When the dangers associated with unprotected sex are such that client lives may be at stake, counsellors ought to take the onus to raise the issue of condom use with their gay male clients, as suggested by Carballo-Dieguez. Davies (1996) further suggests that counsellors working with gay clients need to expand upon Rogers' (1951) core condition of unconditional positive regard "because the experience of l iving with a stigmatized identity makes lesbian, gay and bisexual experience different from heterosexual experience" (p. 39). Careful avoidance of judgment regarding behaviour w i l l be especially required, but providing an opportunity for an open discussion of sexuality would likely benefit clients. Ridge (2004) found that "[a] key insight from this study is that men became more aware of their experiences and feelings in sex in retrospect, (and sometimes through being interviewed!)" (p. 276). This finding was replicated by the present study. One participant became visibly disturbed by feelings of shame during the data-gathering interview as he spoke of his barebacking behaviour for the first time. During the validation interview, another participant revealed that he had significantly decreased his barebacking behaviour since the data-gathering interview. For both of these men, the process of discussing their behaviour with another caused them to reflect on the sexual decisions that they made. Counsellors could play this role for their clients as well . B y 96 opening a discussion on sexuality, clients would be afforded an opportunity to further explore their feelings. Some participants in the present study cited erectile dysfunction as a rationale for barebacking. Medications such as sildenafil citrate (Viagra), tadalafil (Cialis), and vardenafil H C L (Levitra) have been designed to assist men in obtaining and maintaining erections (eMedicine, 2005). Perhaps a referral to their general practitioner for assessment of the viability of one such medication would be in order for clients presenting with E D concerns, especially in the context of barebacking. The theme of "Burden of Safer Sex" illustrated how, for some participants, discussing safer sex practices with their potential partners proved too onerous and therefore did not occur. Counsellors could provide their gay male clients with opportunities to role play such discussions, or they could model the behaviour themselves. Davies (1996) believes that therapists have a role to play as educators. In regard to HTV awareness, he states that clients require .. .the skills necessary to effect behavioural change. These skills include an ability to negotiate with sexual partners, which involves having good enough self-esteem to feel their life is worth protecting, and the skills required in condom usage (p. 36). B y providing a safe environment in which clients can learn effective tools for communicating their needs and desires to their sexual partners, counsellors may be assisting in the development of improved sexual relations while also potentially safeguarding client health. 97 Based on the experiences of the men in this study, it appears that barebacking behaviour may be on the rise among some H I V negative gay men. The participants spoke of their desire for increased connection with their partners and the heightened sense of physical and emotional pleasure associated with skin-on-skin contact as key motivators to bareback. Furthermore, a number of themes illustrated a range of meanings that the participants ascribed to their sexual behaviour. A l l of the men were wel l -educated regarding the circumstances under which HTV or other STIs would be transmitted. Consequently, they had developed a variety of coping mechanisms that they believed would minimize the risks to their health. Unfortunately, these strategies were not always based on sound medical knowledge, but rather assumptions. It would be helpful for counsellors working with gay male clients to themselves be well-versed in matters pertaining to HTV/ADDS or be aware of appropriate resources to which their clients could be referred as necessary. This study represented for some participants a first opportunity to discuss their behaviour without fear of judgment or repercussion. The six men all expressed the belief that the process had been beneficial to them and they were pleased to have been involved. A number of the participants expressed the hope that the results of this study would be shared with the larger gay and HTV prevention communities as they believed the results to be significant. This result would suggest that gay men are not only open to discussing their sexuality, but that they would benefit from such a discussion. Counsellors might therefore wish to take the initiative to discuss issues of sexuality with their gay male clients. 98 A t the outset of the research process, I approached the subject matter with a defined impression of barebacking, its participants, and why I believed the behaviour was occurring. The interviews with the study participants alone, regardless of the subsequent analysis, moved my thinking in another direction. The experiences of these men, and their similarity or dissimilarity to my own, afforded me an opportunity to reflect on a number of my values and beliefs. While I would not contend that I am markedly changed as a person due to my involvement with these men, I would allow that my perception of barebackers and the practice itself has evolved significantly. A s a counsellor, I expect that my ability to work with gay male clients and issues of sexuality in particular has been ameliorated. 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Val le (Ed.), Phenomenological inquiry in psychology: Existential and transpersonal dimensions (pp. 3-20). 109 Study Procedure: The researcher w i l l meet with you for two separate interviews for a total time of approximately three hours to hear and document your experience of barebacking in casual sexual relationships. The first two-hour interview w i l l be audio-taped and transcribed. During the second one-hour interview you w i l l be given the opportunity to read my summary of the significant themes of your experience to verify that it accurately describes your experience as a gay men participating in barebacking in casual sexual relationships. I w i l l make every effort to ensure that the description reflects your experience as accurately as possible. Confidentiality: Your identity w i l l be kept strictly confidential. A pseudonym w i l l be used in the transcripts and in the communications of findings to ensure complete anonymity. Only myself and my supervisor, Dr. Judith Daniluk, w i l l have access to the audiotapes and transcripts. Audiotapes w i l l be erased following completion of the study and the transcripts w i l l be kept in a locked filing cabinet and destroyed after five years. Contacts: If you have any questions or concerns with respect to this study, you may contact Dr. Judith Daniluk or Laurence Bayzand at the numbers listed above. If you have any concerns about your treatment or rights as a research participant, you may contact the Research Subject Information Line in the U B C Office of Research Services at the University of British Columbia at 604-822-8598. Consent: Your signature below indicates that you have received a copy of this consent form for your own records. Your signature indicates that you consent to participate in this study. Participant Signature Date Printed Name of the Participant signing above V3: 2004-03-04 Page 2 of 2 110 Appendix C Orienting Statement The following statement w i l l be read to each participant at the beginning of the first interview: I am interested in learning about your experience of barebacking in casual sexual relationships. There is currently not a great deal of research available describing the experiences of gay men who bareback. A s well , some of the existing research on barebacking, most of which was conducted in the U.S . or the U . K , was not based on talking directly to individuals who were participating in U A I . The main question I w i l l be asking you is: "What is the meaning and experience for you, of barebacking in your casual sexual relationships?" Please feel free to take all the time you need to reflect on and answer this question. Y o u may wish to talk about your experience like a story with a beginning, middle, and an end. Or you might like to tell me about specific experiences or situations that we can explore further. For instance, you may wish to talk about the first time that you had bareback sex after a period of regular condom use. Or you may always have elected to engage in casual anal sex without condoms. I w i l l leave that up to you. I am not going to ask you a series of questions. Instead, I hope to encourage your own story-telling. This is a place for you to speak about your life and your experiences. During the interview I may ask you for more information or clarification about something you have said. I want to be sure that I fully understand your experience. Y o u are not obligated to answer any questions or discuss anything that you do not feel comfortable with. Do you have any questions before we begin? I l l Appendix D Interview Questions General Research Question What is the meaning and experience of unsafe sexual practices in casual sexual relationships for gay men? Probing Questions 1. How did it happen that... ? 2. How did you feel about...? 3. Could you please tell me more about... ? 4. Y o u mentioned . Could you please say more about that? 5. What do you mean by ? 6. Is there anything more you would like to add about that? Backup Questions 1. Are there specific conditions/circumstances under which you bareback, and i f so, can you tell me about them? 2. Was there a time in your life when you did not bareback, and i f so what changes have occurred in your life or your attitudes to make barebacking an acceptable choice/option/sexual alternative for you now? 3. What does it mean to you to engage in barebacking? 4. In what ways has your experience of sex and intimacy changed since you began barebacking? 5. In what ways do you think/feel barebacking has affected/changed your sexuality/self-esteem/identity/pleasure? 112 6. If you could use a metaphor to describe your experience of barebacking, what would it be? 7. Is there anything else that you feel you would like to add that we have not yet addressed? 113 Appendix E Resources Vancouver Crisis Line 604-872-3311 • Crisis intervention The Centre 604-684-5307 • Referral, peer support, networking, counselling A I D S Vancouver 604-681 -2122 • Information, referral, social support Greater Vancouver Mental Health 604-874-7626 • Counselling Family Services of Greater Vancouver 604-874-2938 • Counselling Family Services of the North Shore 604-988-5281 • Counselling 

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