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Reasonable trust : an analysis of sexual risk, trust, and intimacy among gay men Botnick, Michael R. 2002

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REASONABLE TRUST: A N ANALYSIS O F SEXUAL RISK, TRUST, AND INTIMACY A M O N G GAY M E N by MICHAEL R. BOTNICK BS in BA, Boston University, 1968 MA, University of British Columbia, 1995 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF T H E REQUIREMENTS FOR T H E D E G R E E OF  DOCTOR OF PHILOSOPHY  In T H E FACULTY OF GRADUATE STUDIES DEPARTMENT OF ANTHROPOLOGY AND SOCIOLOGY V^e accept thjs^ thesis as conforming to the recjuired stancjpri*  THE UNIVERSITY OF BRITISH COLUMBIA © Michael R. Botnick,;....  2002  In  presenting this  degree at the  thesis in  University of  partial  fulfilment  of  the  requirements  British Columbia, I agree that the  for  an advanced  Library shall make  it  freely available for reference and study. I further agree that permission for extensive copying  of  department  this thesis for scholarly purposes may be granted or  by  his  or  her  representatives.  It  is  by the  understood  that  head of copying  my or  publication of this thesis for financial gain shall not be allowed without my written permission.  Department of The University of British Columbia Vancouver, Canada  DE-6 (2/88)  ABSTRACT REASONABLE TRUST: A N ANALYSIS OF SEXUAL RISK, TRUST, AND INTIMACY AMONG GAY M E N  This thesis explores the psychosocial dynamics of sexual risk-taking in men who have sex with men, with particular focus on the dilemmas that gay men face in establishing trust in themselves and reasonable trust and intimacy with their sexual partners. As well, the practical function of this study is to analyze past and current social marketing efforts aimed at reducing the spread of HIV/AIDS, and to offer suggestions for how to approach a strategy to reduce HIV incidence in gay men and at the same time bolster efforts to assist men who have sex with men (MSM) in adhering to safer sex guidelines.  In part, this thesis uses a sample of participants of the Vanguard Project cohort (St. Paul's Hospital, Vancouver, British Columbia), in order to explore the social meanings attributed by MSM towards sex, risk, intimacy, and attitudes toward HIV/AIDS. Through the use of first-person narratives, this thesis examines the concordance or discordance of MSM beliefs and behaviour with long-standing theoretical models of harm reduction methods concerning sexual risk.  The study reveals that, in great measure, due to past life course events, many gay men suffer from a lack of trust in themselves, which results in a tendency to make irrational or unreasonable decisions concerning their long-term sexual ii  health, and a lack of trust in other gay men. As welL through the misguided and often untruthful health models that advocate fewer sexual partners and rely upon the false assumption that all potential sex partners are carriers of contagion, the sense of mistrust has been reinforced. The lack of confidence in self and others further translates into a suspicion of the motives and/or efficacy of social institutions entrusted with community health development and maintenance, rendering their efforts even less effective. Moreover, traditional harm reduction messages, especially 'fear campaigns', often act as a deterrent, rather than as an incentive, to harm reduction. O f more appeal are supportive harm reduction messages delivered by someone whom the recipient trusts, especially when the social meanings of sex, risk, trust and intimacy are, for many gay men, less fixed and more contingent than for the population at large. This means that attempts to modify risky behaviour must acknowledge and negotiate multiple meanings, shifting values and changing social climates, as well as routine epidemiological concerns.  The research identifies four key themes within a problematic of trust, risk and intimacy, and delineates the harm reduction social complexities experienced by gay men in the study group; these recurring themes deal with family and early sociahzation, internalized homophobia, contingency and instability of meanings of risk, trust and sex, and the toistworthiness of the messengers of harm reduction strategies.  Out of these recurring themes come a number of  iii  recommendations for remedial programs aimed at both mid- and long-term reductions in H I V incidence.  The recommendations are grounded in the  recognition that homophobic and/or dysfunctional social conditions are, to a great extent, implicated in sexual risk behaviour, and therefore must be eliminated or ameliorated before meaningful harm reduction gains can be realized. The discussions with the gay men in the study reveal their need for positive role models and communal social support in their efforts to combat HIV infection, suggesting a need to rethink the meanings of what it is to be gay, a need to redevelop and revitalize what was once a vibrant and cohesive corrimunity, and bearing in mind the lessons of the past, a need to re-approach the task of sternming the tide of HIV infection in ways that are sensitive to the factors that adduce high-risk sexual behaviour.  iv  T A B L E OF C O N T E N T S  ABSTRACT  ii  FIGURES  vii  TABLES  viii  ACKNOWLEDGMENTS  IX  PREFACE  1  CHAPTER 1 - THEORY  17  RISK, TRUST AND INTIMACY AS PROBLEMATICS RISK MACRO PERSPECTIVES ON TRUST MICRO PERSPECTIVES ON TRUST BRINGING TRUST AND RISK-TAKING TOGETHER  21 25 29 43 47  C H A P T E R 2 - G A Y M E N , S E X U A L F R E E D O M AND HIV  HIV/AIDS STATISTICS  52  53  FRAMING THE DEBATE HIV AND RISK BEHAVIOUR T H E SOCIAL PSYCHOLOGY OF RISK PERCEIVED INVULNERABILITY UNDERSTANDING SO-CALLED NON-RATIONALITY T H E SOCIAL SIGNIFICATION OF SEX WIDER SOCIAL CONTEXTS T H E THEORY OF COGNITIVE DISSONANCE ALTERNATIVES TO DISSONANCE THEORY OTHER THEORIES G A Y M E N AND RISK BEHAVIOUR G A Y COMMUNITY ATTACHMENT UNPROTECTED VERSUS UNSAFE A N A L INTERCOURSE ADOLESCENT SEXUAL BEHAVIOR CONCLUSION  58 65 73 77 81 86 93 105 109 112 115 118 126 128 131  C H A P T E R 3 - SOCIAL MARKETING: T H E O R Y AND PRACTICE NONSTAGE AND STAGE THEORIES - STATE OF CHANGE FEAR CAMPAIGNS INEFFECTIVE USE OF FEAR APPEALS T H E PERSUASIVE HEALTH MESSAGE (PHM) Do THESE (OR ANY) CAMPAIGNS WORK? CONCLUSION , C H A P T E R 4: E N A C T I N G R I S K A N D T R U S T  135 143 149 160 161 189 192 196  INTRODUCTION T H E STUDY GROUP METHODOLOGY RISK BEHAVIOUR, AND COMING OUT IN THE SAMPLE GROUP HEALTH BELIEFS AND RISK BEHAVIOUR  V  196 202 206 214  COMPARING KNOWLEDGE AND ATTITUDE PRACTICING TRUST How Do PEOPLE TRUST? CONCLUSION  220 228 232 236  ;  C H A P T E R 5 - ASSESSING S E X U A L R I S K A N D R A T I O N A L C H O I C E THE PURPOSE OF THE CASE STUDIES CASE STUDY-CHRISTIAN CASE STUDY - PATRICK CASE STUDY - MARTIN CASE STUDY - JOSH CASE STUDY - ALAN CONCLUSION  241 241 244 257 267 281 292 309  C H A P T E R 6 - PROBLEMATISING S E X U A L RISK AND T R U S T  324  THEME ONE - FAMILY AND EARLY SOCIALIZATION 330 THEME TWO - INTERNALIZED HOMOPHOBIA 337 THEME THREE -CONTINGENCY AND INSTABILITY IN A SEXUALLY VECTORED GAY WORLD .... 344 THEME FOUR - T H E MESSENGER 359 CONCLUSION 365 CHAPTER 7 - CONCLUSION  373  SUMMING UP HIV OPTIMISM SAFE SEX FATIGUE HIV PREVENTION INTERVENTION SOCIAL SUPPORT INTERNALIZED HOMOPHOBIA SOCIAL MEANINGS TRUSTING OTHERS SOCIAL POLICY CHANGES PERSONAL EMPOWERMENT SOCIAL MARKETING LIMITATIONS OF THE STUDY  373 383 384 385 388 394 400 404 409 414 421 427  APPENDIX 1  430  GLOSSARY  430  APPENDIX 2  433  SAMPLE CRITERIA CORRESPONDENCE  434 436  INFORMED CONSENT FORM  440  APPENDIX 3  442  VANGUARD QUESTIONNAIRE - BASELIINE  443  VANGUARD QUESTIONNAIRE - FOLLOW-UP FOURTH WAVE  456  APPENDIX 4  475  . INTERVIEW SCHEDULE  476  BIBLIOGRAPHY  480  vi  FIGURE  PAGE  1- 1:  From intention to risk management  26  2- 1:  A I D S , Males, 1977, Canada  56  2-2:  Year 2000: Median age o f first diagnosis  57  2-3:  Theory o f Planned Behaviour  73  2-4:  A dynamic model o f sexual interaction  97  2-5:  Attitudes to condoms by gay community attachment  119  2- 6:  Gay community attachment by age  123  3- 1:  A I D S : The Climax o f Death  152  3-2:  Winners A l w a y s Use Condoms  155  3-3:  Don't Die o f Embarrassment  158  3-4:  Safer Sex: Keep It U p !  164  3-5:  Your Sex Partner for Life  167  3-6:  Anytime you sleep with someone . . .  170  3-7:  Good Boys  174  3-8:  I Love Condoms  175  3-9:  Always  178  3-10:  Party  180  3-11:  Welcome to Condom Country  182  3-12:  Framework for developing culturally specific P H M  187  vii  TABLE  PAGE  2-1:  54  A I D S incidence over time, Males, A l l ages  2-2: Year 1994: Median age o f first diagnosis  56  2-3:  68  Risk M o d e l (McLure & Grubb)  2-4: Behaviour (Vanguard Project)  71  2-5: Reason for not using a condom  82  4-1:  Sex education by age, source and first impression  219  4-2:  Attitudes toward H I V therapies and potential infection  222  7-1:  Hierarchy o f sexual stigmatization  401  viii  ACKNOWLEDGMENTS  I want to thank the following people, without whose aid, guidance and patience, this dissertation would have taken twice as long, and contained half as much.  Bob Ratner — my supervisor for this and other projects. Bob has been my mentor, friend, advisor, taskmaster, and inspiration for the past 8 years, and will continue to be someone whom I highly respect for his patience, thoroughness and erudition. Bob has assiduously inspired me to work harder, think deeper and write better.  Bob Hogg — also a committee member, and my supervisor/mentor at The Vanguard Project. Bob keeps my numbers honest and teaches me new things. His patience with someone who is not well acquainted with the disciplines of Epidemiology, Demographics, or Statistical Analysis was both a relief and an impetus to learn and work.  Tom Kemple — another long-term survivor of my academic career, and one of the most talented theoreticians I have ever met. Tom sees connections that less wise people would never notice, and most of all, Tom understands me.  Hon. Senator Laurier L . LaPierre, O.C. without whose encouragement I would not have gone back to University, and would not have accomplished my dream. Vive le Canada!  Ann Douglas — whose transcription skills surpass human capability — how she ever understood what was being said in the group discussions is beyond me, but indeed, she made sense of the multiple voices, and provided me with superb transcripts.  ix  This project would never have started if it were not for Dr. Bill Coleman. His enquiring mind provoked me to explore this topic, and his absolutely invaluable work in leading the discussion groups made them both productive and fun.  I am deeply indebted to St. Paul's Hospital, Centre for Excellence in HIV/AIDS, The Vanguard Project, and especially Steve Martindale, without whose active assistance I would never have been able to recruit participants for this project. Also, many thanks to Keith Chan, who repeatedly 'crunched numbers' for me, but more importantiy, explained to me what was in the numbers, how to read them, and what not to assume about them.  Also, hugs and kisses to my mother, Anna Lee Botnick, for showing the patience of Job. She has supported me throughout this endeavor, and encouraged me when I thought it would never end.  My thanks go out to Donna Wilson, Executive Director of The Centre, where I did my interviews and group work. Without the faculties of a 'gay space', known to all and located in the heart of the gay village, I don't know how I would have accomplished the fieldwork for this study.  My friends (especially Jeff and Maggie, and Mirelle and Nick) and co-workers had to endure lengthy explanations of 'what I do', and put up with my frustrated days (and sometimes weeks) with grace and understanding. I am deeply indebted (and somewhat amazed) by their patience, love and understanding throughout this process.  Last, but in reality first, I want to thank the brave men who participated in the interviews and in the group sessions. Their candor, honesty and willingness to talk provided me with new insights into the attitudes and behaviours of a generation other than my own, adding up to a memorable learning experience. Although my respondents in this research are all identified by pseudonyms, x  they know who they are, and it is because of them I was able to include the crucial first-person accounts, extracting the richness of their experience and insight.  xi  PREFACE  When I began conducting interviews and developing the fieldwork aspects o f this dissertation in the fall of 1999, my standpoint was informed by my conviction that there appeared to be an obvious correlation between self-esteem and condom use, especially amongst gay men and men who have sex with men (MSM) regardless of how they self identify sexually. This belief was born out o f numerous studies (see Odets, 1994; Pajares, 2000; Gonsiorek & Weinrich, 1991; Gagnon, J . H , 1988; Strathdee S.A. et al; 1998) that indicate that gay men more frequendy suffer from low self-esteem than straight men, are more frequendy underemployed, and are almost always marginalized both as adolescents and as adults. Coupled with the general absence of an appreciable decrease in new H I V infections , the studies suggest that self-esteem and unprotected anal intercourse 1  (UAI) may somehow be linked.  After all, is it not logical to assume that the  preservation of life is one of the strongest human endeavors and that high-risk sexual behaviour is counterproductive to that enterprise?  I enlisted the cooperation of the Vanguard Project, a prospective open cohort study involving gay and bisexual men between 15 and 30 years old (at baseline),  1  In particular demographic sectors, significant real increases in infection rates have been observed, particularly in Black and Latino communities.  1  who have not previously tested positive for the H I V antibodies. Subjects are recruited through physicians' clinics and community outreach in Vancouver, B C . Participants are tested annually for H I V antibodies and asked to complete a selfaclministered questionnaire pertaining to sociodemographic characteristics, sexual behaviours and substance use.  For my purposes, potential participants in the  project were screened to meet the following criteria; 1) they had to have engaged in U A I in the 12 months prior to completing their last questionnaire and 2) they had to meet certain general conditions of self-esteem, and drug or alcohol use. (The complete list and relative weighting can be found in Appendix 2.)  The  eligible subjects were then sent an invitation to participate in this project, and the participants were randomly selected from the response cards that they sent back.  In the past three years, having interviewed a number o f these Vanguard participants, conducted 10 group discussion sessions with a sub-set of the Vanguardians who were also individually interviewed, and analyzed reams of quantitative data on self-esteem, sexual behaviour and demographic information, I no longer hold so tenaciously to the belief that self-esteem and the more comprehensive measure of self-efficacy are highly correlated with not using condoms for anal intercourse. In fact, the qualitative discourses and quantitative data suggest that self-esteem is, at best a minor consideration, and in fact men who have sex with men (MSM) (whether they self identify as gay or not) with  2  either consistently low self-esteem or consistently high self-esteem behave almost exactly alike with respect to sexual risk-taking (Vanguard data, unpublished). Additionally, only a minor fluctuation was observed in those people with nomadic self-esteem. Nomadic self-esteem is characterized by fluctuations depending on the time and circumstances. For example, in a cruising situation in a bar, having been rejected a number of times when approaching someone with whom to have safer sex, a man with situationally low self-esteem could accept the risk of U A I out of desperation and frustration. It is important to understand why the starting point for this analysis was initially grounded in empirical and epidemiological factors.  Simply put, this has been the modality for H I V  prevention strategy development for almost two decades and has been the prevailing paradigm.  I originally adopted a traditional health belief model, since it appeared to me that the most effective mechanism for slowing down or halting the spread of H I V in male homosexual and bisexual communities in North America would be the widespread adoption of new-style interventions to alter sexual behaviors that place people at risk of infection. Since the start of the epidemic more than 20 years ago, public understanding of H I V has expanded, and research has identified a number of relatively effective medical and social interventions for H I V and A I D S ( H A A R T - Highly Active Antiretroviral Therapy, prophylaxis, better nutrition, and stable housing to list a few). However prevention efforts have, in  3  the main, not begun the move from purely educational (or knowledge-based) messages to behavioral and psychosocial-based interventions that motivate and sustain behavior change (Cain, 1997).  Focusing on individuals, groups or  communities, such interventions attempt to change individual attitudes, beliefs, skills, and risk behaviors associated with H I V transmission as well as community and social conditions that encourage or at least do not discourage risk behavior. Agencies that deliver interventions have been slow to abandon, or at any rate modify their own traditional health behavior and harm-reduction beliefs, and consequently have neglected new forms o f intervention along the lines o f risk self-appraisal and harm-reduction skills.  With the release of the "men's survey" (Myers et aL 1993), it became apparent that the efforts of safe sex educators was meeting with only moderate success. This study indicated that only 68.9 percent of the 818 gay and bisexual men surveyed nationally reported using condoms all the time for insertive anal intercourse and 71.7 percent reported using them for receptive anal intercourse. Most alarming was that 12.2 percent and 11.5 percent of the men respectively indicated that they never use condoms for anal intercourse.  The report itself, through its numerous tables and figures provided a tremendous amount of data with respect to 'what' was happening in the field o f H I V prevention, but did not delve to any great degree into 'why', after more than a  4  decade of concentrated H I V education, so many gay and bisexual men were continuing to take risks through their sexual behaviors. These findings were alarming not only because of the data presented, but also because they called into question the efficacy and methodologies that had been used, and were still being used, by A I D S service organizations (ASOs) to stem the tide of new infections.  Could it be that the messages were too harsh, too dogmatic, directed at the wrong populations? O r were they as effective as one could hope for, and the cold reality was that there would always be a certain percentage o f the population that would not heed the warnings? The latter supposition was too depressing to consider, since in a sexually vectored society, a mere 1% of new infections per year could amount to a more than a 50% population infection rate in less than a decade.  2  In Vancouver, new approaches were hastily tried — community forums on sex and A I D S were planned and executed, increased presence of safe-sex educator volunteers in the most likely environments for unprotected sex was initiated (the bathhouses, parks and Wreck Beach — a nude beach with a 'gay' sector), and pamphlet and condom distribution programs were developed for all of the gay bars in the city.  In short, almost all of A I D S Vancouver's resources were  redirected towards H I V education and condom distribution.  However, a few people felt that 'more of the same' was not the answer. There  5  had to be some underlying reasons that explained why M S M were continuing to have unprotected  anal intercourse, despite the massive public education  campaigns — social marketing interventions geared to behaviour change.  Some  people were o f the opinion that gay men (especially those whose lives had not been touched direcdy by infection, or indirecdy by the illness or loss o f friends) were 'naturally' promiscuous or intrinsically shy about discussing condom use 'in the heat o f the moment'.  Others believed that there was insufficient personal  motivation to adopt safe sex practices on a consistent basis — that either many gay men believed that H I V and A I D S were the inevitable outcome o f a sexually vectored lifestyle, or that a denial factor was at play - a belief that 'it won't happen to me'.  In fact, response categories provided in almost all survey questionnaires allowing participants to explain why they did not use condoms (for example, in the Myers et al. study) were all pragmatic and situational categories such as "He was my regular partner," "The sex was so exciting," "It makes me lose my hard-on," "I am H I V negative," "I pulled out before cumming," "I was using alcohol," "We did not have a condom." It appears that the researchers gave no consideration at that time to any deeper meanings o f sex, intimacy, trust, the significance o f fluid exchange and other psychosocial variables that might have an impact on the decision not to use condoms for anal sex. A n d why should there be such  2 The formula is: .01 + (.01+.01) + (.01+.01+.01) + (.01+.01+.01+.01)  6  ten iterations = .55  considerations? A t the time, it was believed that condom usage was a mechanical issue that required a mechanical response. It was assumed that using condoms should be viewed in the same light as wearing seatbelts in an automobile — an automatic response to a potential risk.  In July 2000, health officials in San Francisco made the shocking pronouncement that after an impressive decline and then a subsequent leveling-off of reported cases of H I V infection in the city, the number of men testing positive for the virus had significandy increased. Nine hundred new infections were recorded in 1999 - a rate almost double that of the previous year. Gay men accounted for 575 o f the new cases. (Barillas & Garbo, 2000; Coates, Katz, Goldstein et al, 2000)  While the absolute numbers for Canada are proportionately lower, it is known that reported cases rose more or less steadily from 1986 through 1992, remained stable from 1992 - 1995, and then experienced a dramatic decrease from 1995 (1165 cases) to 1997 (373 cases).  Preliminary data for 1999 (Health Canada,  1999) suggests that an estimated 4,190 Canadians (all categories) became newly infected with H I V in 1999, compared with almost the same estimate in 1996. However the distribution among exposure categories changed significandy. From 1996 to 1999 there was a 30% increase in new infections per year among  7  M S M (from 1240 to 1610), and a 27% decline in the number of new infections among injection drug users (IDUs).  3  The San Francisco data triggered alarm bells all over the continent. Could San Francisco's experience be indicative of new H I V infection rates elsewhere? O r was this merely an anomaly?  Coincidentally, that same month there were also  reports from the XIII International A I D S Conference (held in Durbin, South Africa) about the high rates of H I V infection among gay men in the United States.  Community workers, health professionals, and clinicians blamed the  increase of new H I V cases on a relaxation in many gay and M S M communities' adherences to safer sex guidelines.  However, that interpretation fails to consider other factors. For example, how many respondents dispense with the use of condoms within the confines of a monogamous relationship? A n d on a broader scale, might the new data represent a failure of the 'use a condom every time' prevention message to motivate gay men in an era of treatment advances and lower A I D S mortality?  Steven Goldstone, M . D . states:  Clearly, we would never tell an HIV-negative monogamous heterosexual couple to always use condoms. We need to adapt to safer sex teaching for gay men to accommodate the large numbers of monogamous gay men . . . that said we must also realize, as evidenced by a recent Australian 3  There has also been arisein heterosexual infection (from 700 in 1996 to 880 in 1999)  8  study, that a significant number of men who consider their relationships monogamous are still getting infected with H I V . That's why education efforts are so important. (Quoted in Barillas & Garbo, 2000) Dramatic improvements brought about by the new anti-retroviral drug 'cocktails' have simultaneously breathed new life and a concomitant easing of safe sex practices into the M S M community. The question becomes how are we to establish H I V prevention in an era when there is a palpable weariness with A I D S , and complacency that the epidemic is practically over?  Therefore, I begin this work with the hypothesis that the great majority of gay men who fail to maintain traditional safe sex behaviors likely do so despite knowing the potential risk.  Additionally, I hypothesize that those men who  deliberately choose to have sex in a manner which they know could be infectious may feel the need to justify their decisions to themselves at the same time they make them, through a process known as 'internal dialogue'. In this regard, the study also examines the belief held by cognitive therapists that internal dialogue contributes causally to symptomatic behaviors, and that it is therefore a useful locus of intervention for changing the behaviors. (Gold, 2000) These selfjustifications are a variant of what is referred to as individuals' 'internal dialogue' or 'self-talk'. This is not to suggest that the gay men, in the throes of sex, talk to themselves in sentences and paragraphs; but there may very well be a mental conceptualization of these dialogical processes, perhaps merely limited to a series of perceptual images.  9  If self-justification does indeed contribute causally to the occurrence of high-risk sex, we need to know if and how A I D S education might counter it. Almost always, A I D S education is delivered at a time and place other than during sexual contact. So the beliefs that are accessible at the time education is being received - the beliefs with which it comes into contact — are 'cold light o f day' beliefs (Gold, 2000). T o the degree that rationalizations arise out of reasoning that is rejected in the cold light of day, potential high-risk takers may be unaffected by any educational information. If gay men do not hold a resilient 'cold light of day' belief that they may become infected with H I V as a result of their behaviors, telling them that infection is possible will end up a rejected message, and ultimately prove of litde personal concern.  Effective communication and education therefore, must be understood in light of how sexual risk is perceived, internalized and operationalized by gay men. What pressures come to bear when education and information collide with intimacy and arousal? What has and has not worked in the past?  What has been the  relationship between life course events and personal or social change? What has been the role of trust as well as the role of stigma, agency, and peer or community pressure through social marketing programs?  Difficulties arise with this  approach, however, since it is highly likely that even with all o f this information, most gay men will not react uniformly given that they are not, in themselves a homogeneous group, nor do they ascribe the same meanings to sex, love,  10  intimacy, risk, trust, social pressure, or social marketing messages. In fact, one of the major premises of this examination is that there is no more homogeneity amongst gay men than there is amongst heterosexual men.  A t one point in the history of A I D S education, the prevailing paradigm was 'empowerment' — that is, teaching and sanctioning gay and bisexual men, through the use of purported community norms, to 'just say no' — 'no' to unprotected 4  sex, 'no' to multiple casual partners, 'no' to sexual encounters — without first negotiating the limits and boundaries that one would accept.  However, I  hypothesize that negotiation of sexual safety within relationships is not only a matter of individuals bargaining for their own preferences  (from perhaps  different positions of power); rather, these preferences may be at least partly formed in response to the qualities they perceive in their partners, and in their relationships with them.  I suspect that these exchanges may inform future  practices, and therefore result as much if not more so, from sexual and emotional experience, as they do from elements that are a consequence of 'cold light of day' knowledge.  Psychologists and sociologists have considered whether optimistic biases about risk reduce the adoption of precautions. Weinstein and Lyon (1999) argue that acknowledgment of personal susceptibility promotes a form of precaution  4  Similar to Nancy Regan's concept with respect to drug use in the United States.  11  implementation ("I'd better not do that").  O n the other hand, Taylor and  Gollwitzeer (1995) suggest that while people may engage in risk avoidance strategies  in the  abstract,  when  concrete  circumstances  requiring new  precautionary behavior present themselves, it is more usual that an optimistic risk assessment bias emerges ('It won't happen to me"). It will not happen to me' risk denial perceptions are a major finding emanating from epidemiological research (Vanguard, 2000). In this study, I examine the acceptability o f risk by considering how individuals weigh relative risks with their own health and their 'love relationships'.  Unprotected sex may be 'reasoned action' (Ajzen and Fishbein 1980, Ajzen 1988, Conner and Sparks 1996) in the context of certain relationships, and may be a concomitant acknowledgement of the place of emotions in sexual behavior, (Rhodes and Cusick, 2000); hence, the tide of the thesis - "Reasonable Trust". Reasonability, in the context o f this thesis refers to 'agreeable to reason or judgment', or in other words, it is based on some belief, action or thought, whether that belief is true or not. People may believe, for example, that they are an expert in a particular sport, while the reality may be that, compared to others, they are not. This unfounded belief may then lead them to take risks that are beyond their real capabilities. While in the purely technical sense, "reasonable" and "rational" have been linked with the notion of pure reason, or impartial, highly logical abstract thought, in current parlance it has taken on a more contingent property —  12  that of 'simple common sense, equitability and fairness'. (Webster, 1989: 1197) Also underscored is the notion that relationship quality is as likely to influence sexual behavior as sexual behavior is to influence relationship quality (Rhodes and Quirk, 1998; Rhodes and Cusick, 2000). Thus there is a symbiotic interaction between the significance of condom use and relationships. This is especially salient when one considers that emotions may be held to be a major feature of reasonable risk and relationship decision-making. If we recognize that sexual activity interacts with desire and perceptions of relationship quality, we can see that decision-making about sexual behavior may not simply be inherent in the individual as an expression of his or her self-interests. In this rationality of desire among couples, the mere pleasure of sex and the communication of relationship quality may be accorded greater common sense importance than potential health dangers. This, in turn, has important repercussions for the sense of balance that is struck between relationship quality and virological safety. In fact, non-condom sex is most prevalent within the context o f 'primary' or 'intimate' relationships. This has been found to be the case among sex workers, gay men, heterosexual men and women, and injection drug users (Day 1990, Stall et al. 1990, Davies et al. 1993, Wight 1993, Rhodes et al. 1994, Cusick 1998). The balance between relationship quality and viral safety is a particularly important aspect of explicit or implicit negotiation in primary relationships.  13  If health risks are perceived to be of subordinate concern to both sexual satisfaction and relationship quality, and appear to be incompatible with these cherished aspects of sexual behavior, then H I V prevention, which accentuates individual physical health over emotional relationships and gratification, may provoke 'resentment and resistance' in those whom they target (Lucey, 1998). As we shall see, safer sex and fears of transmission may be perceived as a barrier to emotional intimacy. Additionally while HIV-positive gay men appear to be more anxious to protect their partners, especially those who are H I V negative, this protectionism can, in turn, serve as a barrier to the development of emotional relationships.  Concurrendy, sex with casual partners (which thus avoids  emotional entanglements) is on the rise (Piaseczna et al, 2001). This in turn leads to another convindrum: what is the degree of responsibility of someone who is HIV-positive to inform and or protect this casual partner, when that partner has no emotional connection or exclusive attachment to him? We will discover that in the interviewed members of the Vanguard cohort, this is a major issue.  A  further working hypothesis is that sexual safety is inversely related to  relationship quality. This notion has been supported by Wellings et al. (1994) who also suggests that relationships which falter at the 'condom barrier' do so for a wide variety of reasons, not the least of which is an unfounded perception that the inevitabihty of infection is always present, and thus part of everyone's sexual  14  script — an acceptable or sometimes unacceptable risk, however disagreeable it may be.  Thus far, we have been referring to anal intercourse without a condom as "unprotected anal intercourse" or " U A I " . However, from this point forward, it becomes important to distinguish between sexual behaviours that are unplanned (condom-less sex because no condoms were available, or drug / alcohol induced laxness, for example) and those that are planned, whether articulated or not. In the former instance, U A I is an appropriate, value-neutral description of the event. In the latter case, it is not.  In the latter situation the notion of 'unprotected' becomes awkward.  One  naturally assumes latex (or polypropylene) condoms constitute 'protection', but are condoms the only form of protection worthy of consideration? As will be demonstrated, the idea of protection extends far beyond the perfunctory use of condoms, into the realms of the social and psychological (conscious and subconscious thought).  Therefore, from this point on, I intend to make a  purposeful distinction between " U A I " and "barebacking". " U A I " will represent condom-less anal intercourse that is neither planned nor generally acceptable in the 'cold light of day', while the term 'barebacking' will signify anal intercourse that is deliberately devoid of condoms.  The distinction is not merely  terminological, as I shall show. There are significantly different implications and  15  repercussions socially and personally, depending on what type of condom-less is at issue.  16  CHAPTER 1 - THEORIZING SAFE-SEX RESEARCH  The plan of this thesis is that I initially examine what constitutes risk for H I V infection, the notion of the sociology of decision-making and risk-taking in its individualistic and wider social contexts, and the various theories with respect to rationalization of risk and the relationship between beliefs and behavior. In that light, it is important to discuss briefly why theoretical considerations o f trust, risk and intimacy are salient in this thesis.  Theory has a number of purposes in assisting us to comprehend communication processes. In the behavioral sciences, one of the most fundamental roles is that of description. Theories expose the complex world in which we live, and in so doing, help it to become understandable.  John Dewey, an early 20th-century  philosopher, commented on the role of theory by posing the following question:  Does it end in conclusions which, when they are referred back to ordinary life experiences, render them more significant, more luminous to us, and make our dealings with them more fruitful? O r does it terminate in rendering the things of ordinary experience more opaque than they were before? (Dewey, 1929: 3) The second function of behavioral theory concerns the prediction o f outcomes. Predictive theories elaborate on descriptive theories to their subsequent logical point by stating: 'if X occurs, then Y is more (or less) likely to occur'. This is a higher level of theory in that the procedure of presupposing and distingxushing  17  relationships among antecedents and consequences accords an even greater degree of comprehensibility to the world around us.  The third function of theory is explanation.  Although theories that predict  relationships among variables generate hypotheses and fuel much research, these theories do not necessarily explain why. i.e.: 'if X occurs, then Y is more (or less) likely to occur because . . .' Theories that are explanatory in nature create even greater understanding. They are often crucial in attaining the ability to prescribe effective interventions.  The final goal of theory involves prescription.  Prescriptive theories build on  prediction and explanation. Stated in the abstract: ' X may be made more (or less) likely to occur by doing A , B , and/or C, which in turn will make Y more (or less) likely to occur'. (Maibach et al (1995:2). This type of theoretical construction endows theory with its highest level of understanding.  It is the difference  between understanding that condoms are made from latex (or other material), that condoms prohibit the transmission of sexually transmitted diseases or unwanted pregnancies, and understanding that a condom, when properly used will preserve life, protect others from infection, and slow'the attrition rate o f gay men.  Behavioral decision-making (BDM) is largely concerned with the cognitive processes by which humans perceive, structure, and evaluate alternative courses of action. It goes far beyond the relatively simplistic cost-benefit  18  components included in the Health Belief Model, The Theory of Reasoned Action and Protection Motivation Theory. B D M research includes the study of risk perception, problem structuring, consequence (outcome) valuation, probability judgment, and heuristics and biases. (Holtgrave et al, 1995:24) In other' words, the B D M model more closely approximates the objectives o f analyzing trust, risk and intimacy as a complex series of cognitive and emotive issues that, while interlinked, have their own unique, and sometimes so-called irrational elements.  Second, I interrogate historical safer sex social marketing models, focusing on the most popular, K A B (knowledge, attitude, and behavior), through an analysis of a number of theory-driven strategies for behavior change, especially campaigns that rely on appeals to fear in order to promote better health practices. These campaigns will be examined using a number of examples of H I V prevention messages from around the world. Their shortcomings, as well as their strengths, will be scrutinized in light of Canadian and American data on infection rates over the past number of years.  Third, I investigate issues of life course and self-esteem, human agency and strategic adaptation, and how these relate to both individual statuses and identity perceptions, using case studies of some Vanguard participants. Stigmatization and its effects on life course will also figure prorninendy in my analysis o f sexual behavior, risk and safety, with a focus on the rules that couples (casual or regular) make regarding sexual behavior that differentiate amongst sexual activities,  19  partners and contexts.  In this analysis, three organizing principles emerge —  sexual behavior is a social construction; freedom of action is constrained by social material conditions; and social structure and organization influence risk behavior.  One of the most understandable impediments to modern-day harm reduction planning is the fact that many gay men in particular are fed up with H I V / A I D S education, being told what to do, and being told that there is still a crisis o f immense proportions plaguing the community. (Rofes in Barillas & Garbo, 2000) Again through the medium of case studies, I examine the psychosocial affects o f both creating and living in a culture of crisis, the difficulty of maintaining that crisis mentality over a prolonged period of time, and what happens when people do not acknowledge this crisis mentality. Significant in this analysis is the notion of trust and intimacy, as opposed to distrust and detachment. Also, the binarism of 'good fag, bad fag' is examined in light of community norms and standards, media portrayals of H I V / A I D S , and the values and meanings of gay sex.  Finally, there is a need to merge the discourses on trust, risk, and sex. I therefore examine the production of trust theoretically and practically, distinguishing between the different processes of granting and receiving trust, and examine how trust or distrust manifests itself in decision-making with respect to risk-taking. It is at this juncture that we are likely to find the manner in which life-course events and health-belief models have a particular bearing on trust levels, and in so doing,  20  on risk-taking. I then examine whether so-called 'wholesome health beliefs' are a sigtiificant motivation for behavioral change, given that behavioral change itself is frequendy thwarted by the allure of pleasure and personal gratification. Finally, I consider the degree to which risk-taking is a part of a lifestyle, how much risk is 'deprogrammable', and how much may be virtually entrenched or 'hard-wired' into our psyches.  In establishing the confluence of trust, risk and intimacy, my analysis will clarify why I believe the entire array of social marketing efforts to reduce H I V infection needs to be re-thought, and why I believe that risk taking is so complex an issue that no single model can have utility for anything more than narrow market segments. I locate this analysis not in the existing paradigm of rational choice and moral panic, but in a new problematic of reasonable trust and sexual risk. This paradigmatic shift will become more evident as the chapters unfold.  Risk, Trust and Intimacy as Problematics As defined, in this analysis it is apt to regard risk, trust and intimacy as problematics. Louis Althusser (1970), in For Marx explains the concept as one in which a "word or concept cannot be considered in isolation; it only exists in the theoretical or ideological framework in which it is used" (1970: 253). While the above 'problematics' are not of world-view proportion, that is, not essentialized from discourse or action, they rest on what Dorothy Smith suggests are a  21  "possible set of questions that have yet to be posed, or of puzzles that are not yet formulated as such, but are "latent" in the actuality of our experienced worlds." (Smith 1987:110)  The integration of these multiple problematics: social  marketing in general and in particular the K A B — knowledge, attitude, behaviour model; notions of trust and how trust evolves into risk analysis and decisionmaking; and intimacy (physical and emotional) as both a human 'necessity' and a 'common sense' social behaviour, forms the bulk of this dissertation.  As Smith proposes, and as this thesis investigates, "The term 'problematic' enters an actual aspect of the organization o f the everyday world (as it is ongoingly produced by actual individuals) into a systematic inquiry. It responds to our practical ignorance of the determinations of our local worlds so long as we look for them within their limits. In this sense the puzzle or puzzles are really there." (110)  Ultimately, the purpose of this study is to examine the dynamics of why numerous men who have sex with men continue to do so without the consistent use of condoms, contrary to all so-called accepted logic surrounding contagion and prevention. T o do this, we need to understand the meanings gay men and M S M ascribe to risk, particularly the risk of contracting H I V ; to examine the relationship between the pleasure of sex and the rationality of desire; the importance of relationship quality as it pertains to trust in oneself and one's  22  partner; the linkages between beliefs and behaviours; and what, if any, social marketing interventions may hold some promise with regard to changing the behaviour patterns and sexual scripts of people who choose to have unprotected anal intercourse.  It then makes sense to view these issues in the context of problematics, especially in light o f their interdependent nature, and to organize the everyday world of sex and sexual expression into 'systematic inquiries'. The general hypothesis that I am pursuing in this investigation is that the crucial dynamic in deciding to bareback is based in trust, which is born o f a multiplicity of factors. There is no unicausal source of 'deviance' or risk, and therefore there can be no metanarratives that will ameliorate risk, or cause trust to be withheld or granted.  The social marketing models that purport to inform, educate and  condition M S M to reduce sexual risk-taking fail to consider the diversity o f meanings surrounding a wide variety of social and personal constructs that impact safer sex decision-making, the motivations and cognitive rationales employed by M S M to either justify or excuse the use of condoms for anal intercourse, and the community and personal histories o f 'unprotected' sexual behaviour that has infiltrated the beliefs and actions of M S M .  Additionally, I  demonstrate  for safer  that the generally applied theoretical models  sex  interventions fail to take in to consideration the many anomalous situations and psychosocial variables surrounding people's decisions to engage in high-risk  23  sexual behaviours, with the result that such models are relevant for specified and limited populations, but ineffective or occasionally counter-productive for others. In order to unpack, or at least to evaluate the problematics' of risk, trust and intimacy as they apply to the everyday lives of sexually active gay men, I follow a number of methodological pathways: to be sure, considerable reliance is placed on theoretical models of risk behaviour, rationality, sexual behaviour, social marketing, trust and trust-making. However, a theoretical understanding alone of these problematics would leave us fairly much in the same quandary as we started — puzzles with no solutions, or, few clues towards solving those puzzles. In that respect, I also examine how these notions play out through the use of interviews and group discussions.  Using the words of the interviewees and group  participants I weave a (somewhat meandering) path through the intersection o f the  problematics', not so much as to provide, at that point,  concrete  operationalizable actions for the future, but more to demonstrate the confluence of these issues, the contingencies surrounding their individualized and collective meanings, and thus the potential for social change, given an appropriate alignment o f strategies, target markets, messages, community support and a host of other socially implicated structural and behavioural issues.  24  Risk "Risk" as we know it is a relatively new concept in the sociological lexicon. Before the modern era, risk was a neutral term, used frequendy in scientific and mathematical models to indicate probability, losses or gains.  A gamble or  undertaking that was related to high risk suggested that there was a strong likelihood of substantial loss or substantial reward. However, risk has been coopted as a term generally equated with negative or undesirable outcomes, much like "danger",  "jeopardy",  "peril", or  "hazard" (Word  2000  thesaurus).  Furthermore, the notion of risk begets a moral facet, such that perpetrators o f risk may be held to account in some way or another (Douglas, 1992:22-25).  Risk assessment is a technical procedure, which, like many other aspects o f modern life, submits to a rational calculation o f means and ends, costs and benefits. (Fox, 1991) The following figure (1-1) is based on an illustration of the process of risk assessment from the British Department o f the Environment:  25  F i g u r e 1-1: F r o m Intention to R i s k M a n a g e m e n t  Description of hazard  1 Identification of consequences  Estimation of probability of conseauences  Estimation of magnitude of conseauences  Risk Assessment  /  /  t  Risk Management  Figure 1-1 suggests the "simple, logical sequence of steps" (Department of the Environment, 1995:5) to be taken to identify and manage risk. This model has been widely adopted over the past 50 years (Carter, 1995). Within its parameters, all risks can be acknowledged, appraised and duly dealt with, such that all may be foreseen and offset, so that risks, accidents and insecurities are mmimized or prevented altogether.  However, such explanations fail to  problematize risk and its assessment. A more critical approach, addressing the socially constructed and historically specific character of the conceptualisation of risk and its assessment has been proffered by the social sciences.  The  work of anthropologist Mary  Douglas has  been  instrumental in  understanding the cultural end of the spectrum of social theories about risk  26  (Douglas, 1966).  In analysing fears over pollution, she observed that it was  baffling that people refused to purchase flood-plain or earthquake insurance, crossed dangerous  roads, drove non-worthy vehicles, purchased  accident  provoking gadgets and did not listen to educative messages on risk.  She  suggests that the reason such behaviour seems baffling is the failure to consider culture. Employing the typology of cultures she developed (Douglas, 1996), she illustrated how the risks one focused upon as an individual have less to do with psychology (which informs rational-choice theory and the health-belief model) and more to do with the social forms in which people construct their understanding of the world and of themselves.  Further, as Rayner (1992) puts it: If the cultural processes by which certain societies select certain kinds o f dangers for attention are based on institutional procedures for allocating responsibility, for self-justification, or for calling others to account, it follows that public moral judgments will advertise certain risks powerfully, while the well-advertised risk will turn out to be connected with legitimating moral principles, (p. 92) What is considered a risk, and the purported gravity of that risk, will be perceived differently depending on the organization or grouping to which an individual belongs (or with which s/he identifies). The free-market environment, for example, will see competition as the main risk, to be repulsed by teamwork and leadership.  The bureaucrat perceives radical change as threatening, requiring  group commitment as a risk reduction strategy.  27  Risk assessment must start with some previous information about the world, what is 'feasible' and what is 'improbable', what is 'significant' and what is 'inconsequential' or patendy 'ridiculous'. Such judgments may originate with 'scientific' sources, may depend on 'common-sense', or may be the product o f experiential learning; in any case, the perception of a hazard's existence and notions about the etiology of that hazard will depend on these judgments. H o w the judgment is constructed (i.e.: what evidence is included and what is excluded) is relative and culturally contingent.  Furthermore, psychologists generally acknowledge that to be a teenager is to be in a permanent state of crisis. Rickel and Hendren (1993: 141) indicate that the period of adolescence in the life-course is "perhaps one of the most complex periods of physical growth and development". As sex organs develop, grow and the body becomes enslaved to hormonal changes, the simultaneous acquisition of specific sex-role identities and gender scripts create a "challenging and difficult period" (Ibid.) for youth.  The mixed pressures for both abstinence and participation in sexual activity are a normal experience for adolescents; unfortunately, either choice produces a sense of guilt or of longing. One of the earliest theories to emphasize the direct influence of interpersonal and social factors was Davis' 1944 socialised anxiety perspective.  H e argued that each social class and each culture exercised its own  28  degree of social control in the form of instilled guilt over budding adolescent sexual urges. If there was too litde social control or anxiety, or too much, the adolescent would be led into dysfunctional sexual behaviours. However, a suitable degree of socialized anxiety (depending on each culture's values regarding sexuality), would lead an adolescent to meet external standards for sexual behaviour.  Hirschi  (1969) added that adolescent sexual behaviours increased when agents of socialization (family, school, church) failed to convey sociocultural expectations for sexual behaviour.  Given the lack of sociocultural expectations for sexual behaviour for adolescents who are gay (other than complete prohibition), it becomes obvious, according to Hirschi's postulation, that gay adolescents should seek out sexual experiences more frequendy and more aggressively than their heterosexual counterparts. Davis (1944) would concur, in that the social prohibitions against homosexuality, and in favour  of compulsory heterosexuality, leads one  into so-called  dysfunctional behaviours. As we can see from the above examples, being both adolescent and gay, whether or not one has the language to self-label, is to be quite alienated from oneself, one's peers, and society.  Macro Perspectives on Trust Since trust relationships are fundamental  to the stability of social and  psychosocial interactions, they deserve centrality in the analysis o f barebacking  29  and sexual risk taking. Although a clear consensus of the precise meanings o f 'trust' and of 'sex' amongst the interviewees is elusive, all appear to agree that trust (as they individually define it) plays a significant role in their day-to-day functioning. In the absence of trust, what are often complex systems of rules and standards must be constructed to shield the individual against exploitation and opportunism (in the heat of the moment), if the ultimate intent is to counter the characterization o f risk as 'fun' and 'adventuresome'.  Even these rules, as has  been demonstrated, are blunt instruments that do not effectively produce the kind of social support that comes from the existence of trusting relations.  Trust is, after all, the product of two determinants — the nature of the uncertainty of the situation and the degree of the actor's perceived vulnerability. If the social actors feel that their degrees of vulnerability are reduced by either chance, informed choice of partners, or by any other means, the level of uncertainty diminishes. O n the other hand, if the level of uncertainty is considered to be high, then trust is correspondingly lessened; in this scenario, rule-making comes into play, and the individual chooses to participate in a game of chance, often betting 'against the house', but occasionally winning. The prize, in this instance is gratification, be it sexual or cerebral. But, unlike purported safe sex experts and health promotion activists, one should make no judgments about the value o f the game — to some participants assuming risk for the sake of pleasurable outcomes is extremely important, and to others, it is relatively unimportant.  30  Current research on trust has focused on the functional properties of the notion. Guido Mollering (2001) suggests that:  Trust can be defined, first of alL as a state o f favourable expectation regarding other people's actions and intentions. As such, it is seen as the basis for individual risk-taking behaviour (Coleman 1979), order (Misztal 1996), and social capital (Coleman 1988, Putnam 1995). However there are a number of typologies of trust, as can be seen by the various interviewees' comments and definitions presented in this study.  Trust can be  produced through a process-base, as in the case of finding a lover who is new to the gay scene, or the (often false) assumption that H I V / A I D S is a 1}ig city' occurrence; a character-base, such as barebacking parties among close friends; or through an institutional-base such as having faith in the published information about the purported relative safety of unprotected oral sex.  Regardless of the  manner by which one comes to trust, however, all share what Simmel (1989:179 quoted in Mollering 2001), describes as 'idiomatic trust':  To 'believe in someone' without adding or even conceiving what it is that one believes about him, is to employ a very subde and profound idiom. It expresses the feeling that there exists between our idea o f a being and the being itself a definite connection and unity, a certain consistency in our conception of it, an assurance and lack of resistance in the surrender of the Ego to this conception, which may rest upon particular reasons, but is not explained by them. Simmel makes a strong case for the importance of trust when he opines that "without the general trust that people have in each other, society itself would disintegrate" (1989:178). It provides agents meanings that serve as their bases for  31  realistic and functional behavior. For Simmel, trust represents a force that acts for and through people as well as human associations in general; it "manifests itself at all levels of society" (Mollering, 2001:405)  Niklas Luhmann (1979) embraces this notion of trust, but adds that there is an additional element — indifference — expkining that the "trick of trust" (p. 26) is that it condenses social complexities by generalizing within systems, thus exchanging inner certainty for external certainty, or in other words, shifting the onus of proof of trustworthiness from the self and one's own processes o f trust building to more easily recognizable external, and concrete clues. In other words, the onus is placed on functional, structural or interpersonal social relations, rather than on reflexivity and self-examination. As he states:  Although the one who trusts is never at a loss for reasons and is quite capable of giving an account of why he shows trust in this or that case, the point of such reasons is really to uphold his self-respect and justify him socially. (Luhmann 1979:23 as quoted in Mollering, 2001:409) "Despite its apparent fragility and our many attempts to do without it, it is clear that, in many societies where it is well established, trust is remarkably robust." (Good, 2000) As infants, we generally learn to trust caregivers, and then to trust significant others. During early socialization in the family, it is the comfortable, warm and affectionate fiduciary trust coming from the parents — caring, helping, and sympathizing - that instigates the development of the trusting impulse. (Sztompka 1999:98) There is an asymmetrical reciprocity at this point, as the  32  child does not yet fully recognize, or have command over external values and social systems. As the child matures, new forms of trust manifest themselves in peer groups: play circles, team games and sports, and school-mates — the natural primary social groups that surround the growing child. The development o f trust manifests itself in the axiological notions of fair play, loyalty, and the sharing and keeping of secrets.  When the child learns the meanings of trust in a tangible way through the practices of trusting someone with a valuable toy, piece of sports equipment, or information, more symmetrical expectations of reciprocity slowly crystallize (Ibid.). The slowest to surface are instrumental expectations about proficiency, effectiveness, and rationality, which begin to manifest themselves only in the occupational sphere for adults.  In each of these stages, the evolving range of trust may be met or violated, fulfilled or dishonored. If they are met, the trusting impulse begins to entrench itself in the individual. If, on the other hand, trust is frequently breached, the impulse may never materialize, or it may become censored, apprehensive or paralyzed. "The most devastating effects for the impulse to trust are brought about by the decay of the family . . . The trusting impulse becomes replaced with inherent  suspiciousness,  obsessive  distrust,  developments in the social realm . . . " (Ibid: 98-99)  33  and  alternative pathological  Sztompka suggests that, on an ontological level, there has been a swing from viewing action or behaviour as purely rational — "homo economicus" — toward a "richer  picture  including also  emotional, traditional, normative, cultural  components: value orientations, social bonds, attachments, loyalties, solidarities, identities" (Sztompka, 1999:2).  This development evokes two streams o f  understanding: psychological meanings and cultural meanings. The former involves motivations, reasons,  intentions  and  attitudes,  while the  latter  emphasizes more culturalist aspects of rules, values, norms and symbols. Sztompka draws his support from Giddens' (1990:223) conception that "rational choice theory needs to be complemented with an analysis of social norms; and that norms provide sources of motivation that are irreductible to rationality". What this ultimately implies is that this duality tolerates a variety of "qualitative, interpretative, hermeneutical procedures" (Ibid: 3) useful in understanding the cultural characteristics of behaviour. Additionally, it reverses the standpoint of viewing behaviour as the dependent variable explainable by a rational evaluation of situations, by dealing with behaviour as an independent creative variable implicated in constructing, shaping and modifying other social objects.  Sztompka defends his use of these 'soft' variables by noting, pace Luhmann and Dahrendorf, the degree to which our own behaviour, in spite of various social dependencies (charismatic leaders, parliaments, innovators, social movements,  34  political parties, etc.) has migrated from societies based on fate (or the actions of others) to human agency; underscoring the need to employ trust in others who are involved in our lives and our own social realities. Just as Durkheim wrote about 'organic solidarity' in society, we are at a point in history where we are dependent on the cooperation of others, and therefore, dependent on both receiving and granting trust as "an essential condition for cooperation" (Misztal 1996: 269).  Frequently, however, the notion of agency is lost when sexual  behaviour and condoms enter the equation; in fact, there appears to be a return to an element of fate, or trusting others to make decisions, and an abdication of personal agency for sexual (and other) wellbeing.  Another reason for the burgeoning of both academic interest in trust, and the deployment of trust in society, is that social life has become more marked by threats and hazards of our own making: "The more technology is applied to nature and society, the more life becomes unpredictable.  The complex  interactions of technology as they bear upon nature and society create an ever larger number of unintended consequences" (Stivers 1994:91 in Sztompka 1999: 12). Coping with the increases in vulnerability in what has been coined the 'risk society' (Beck 1992) requires an enlarged pool of trust. Additionally, as people's options for action increase along with opportunities created by the proliferation of new technologies, the less predictable are the decisions they (and their partners) might take. For example, in a macro environment, to choose among a  35  variety of actions (e.g., to support a particular political party, to purchase a particular brand of product, to consult a particular doctor or naturopath), we often have to resort to trust.  Likewise, the uncertainty about how others will  behave, when faced with their own collection of options (which policies the party will pursue, what effect the product will have, what the doctor or naturopath will prescribe) makes trust an essential component of our actions. O n a micro level, the same holds true (e.g., choosing to ask a particular person for a date versus the fear of rejection, deciding whether or not to have sex on the first date versus possibly being perceived as promiscuous, deciding whether or not to negotiate sexual safety versus possibly being rejected, infected, or supported in the decision). A l l involve profound levels of trust.  Hence we routinely find ourselves in a condition of uncertainty about, and uncontrollability of, future actions. We usually cannot know and cannot control what other people will do independendy of our own actions, and even more we cannot be sure and cannot completely safeguard how they will react to our actions. Thus to repeat: What weighs on all social systems and what all social action must deal with is the unavoidability of an unknown [and, let us add - uncontrollable] future" (Barbalet 1996: 84). "Uncertainty and risk are integral to the human condition" (Short 1990: 181)." (Sztompka 1999: 24) <c  In circumstances when one has to act in spite of uncertainty and risk, trusting becomes the fundamental tactic for dealing with future outcomes. Generally, trusting others evokes positive actions towards those others. Trust is liberating, trust mobilizes human agency; it releases creative, uninhibited, innovative, entrepreneurial activism toward other people (Luhmann, 1979:228). Social actors  36  become more open towards others, more poised to initiate interactions, to enter into lasting relationships. Uncertainty and risk framing their actions are lessened, and hence "possibilities o f action increase proportionately to the increase in trust" (ibid: 40). Additionally and perhaps most importantiy, interactions with those whom we endow with trust are without anxiety, suspicion, and watchfulness permitting more spontaneity and openness. There may also be an additional bonus: our own trust may be reciprocated, and then we enjoy all the benefits of being trusted.  It stands to reason then, that diametrically opposed consequences are brought about by distrust. We may be reluctant to initiate interactions (and therefore may pass up opportunity), carefully scrutinize all our moves (remaining constantly vigilant) and follow safe routines (avoiding innovation and spontaneity). In some cases, we may also expect mutual distrust, with all of the harmful effects that it may bring.  As confidence declines, people develop a sense of defensive pessimism to protect themselves against further risk and vulnerability . . . they are likely to have relatively closed minds and to react as i f they have concluded that their partner is not truly concerned about them or the relationship. Positive behavior by the other will be viewed with suspicion. (Holmes and Remple, 1989:241) O n the other hand, being trusted evokes at the very least, a temporary suspension of normal social constraints and ambitions: such persons, roles, organizations, and institutions obtain a "credit of trust", a temporary release from immediate  37  social monitoring and social control. The result of this 'release' is a wide margin for nonconformity, innovation, originality, in short — freedom of action. Additionally, being trusted by someone may be an argument for others to grant trust as well. The need of trust and the importance of trust grow as networks become more complex: "without trust only very simple forms o f human cooperation which can be transacted on the spot are possible . . . trust is indispensable in order to increase a social system's potential for action beyond these elementary forms" (Luhmann, 1979:88). This is not to suggest, however, that unconditional trust is necessarily imperative or even desirable, especially in relation to macro social systems — unconditional trust may be inclined to license behaviour that ought to invite reactions of distrust.  Systems of trust may be schematized into four categories (although more frequendy more than one category is present at any given time). Reciprocal trust develops most smoothly and acquires a self-enhancing capacity. Quite simply, trust breeds trust. It precedes and reinforces a culture o f trust, Ixirning trust into a normative rule for both the trusters and the trustees. However, i f the nature of the trust is blind and naive, it may produce a temporary culture of trust, but that trust will not ultimately be reciprocal. It binds the trusters, but not the trustees; therefore, it is subject to collapse as it accumulates substantiation of breaches o f trust.  38  If the predominant situation is justified distrust, then a culture o f distrust will inevitably emerge, and a self-enhancing vicious spiral of deepening cynicism and suspicion will commence. As with the case above, distrust breeds distrust. "This trust has an inherent tendency to endorse and reinforce itself in social interaction" (ibid: 74). In the most extreme case, obsessive distrust may provisionally attain normative sanction as the rule of suspiciousness. It too may also set off a vicious spiral: "once distrust has sent in, soon it becomes impossible to know if it was ever in fact justified, for it has the capacity to be self-fulfilling, to generate a reality consistent with itself (Gambetta, 1988: 234). As we have seen previously, it is far easier to turn trust into distrust than the other way around. G o o d (1988) makes the point by stating that:  If presented with a clear breach of trust by someone, our faith in that person will be fatally undermined. However, i f an untrustworthy person behaves well on one occasion, it is not nearly so likely that the converse inference will be made. (p. 43) When trust becomes fixed as part of the cultural or normative system, it attains a measure of autonomy, acquiring functions and dysfunctions o f its own. However, it is functional only i f the rules are two sided, that is, it has been prescribed and therefore releases trust, but lapses must also be strongly condemned, therefore preventing breaches of trust.  In other words, the  functional culture of trust must comprise strong norms with positive sanctions and strong taboos with negative sanctions.  39  When that culture is mono-  dimensional, prescribing trust but ignoring or condoning breaches o f trust, it is more akin to a culture of naivety, and has dysfunctional (Sztompka, 1999:111-112)  consequences.  When it is manifest as a blind trust, prohibiting  criticism and skepticism, it is even more dysfunctional. This is frequendy the case with "group-think", described by Irving Janis (1982) - a condition when the extreme cohesiveness of the group leads to complete conformity and prohibits any dissent.  Sztompka (1999) describes five macro-societal circumstances as being conducive to the materialization of a trust culture. First is normative coherence, and its opposite is normative chaos, much like Durkheim's anomie.  In the normative coherence  scenario, social life is unproblematic, orderly and predictable with fixed scenarios indicating what people should and will do. Feelings of security and certainty encourage anticipation of predictive trust. As well, there are enforceable norms more immediately relevant for trust, requiring honesty, loyalty, and reciprocity. In the anomic condition, the social rules regulating human conduct, as well as o f the agencies enforcing obedience, are in chaos. Nothing is predictable except for the most egoistic, self-interested conduct.  Insecurity and uncertainty lead to the  withholding o f predictive trust, and honesty, loyalty, and reciprocity are suspended.  40  The second structural condition relevant for the probability of rewarded trust is the stability of the social order, and its opposite, radical change. If the social order is long lasting, persistent, and continuous, it furnishes reference points for a social life featuring routine and habitual responses. It is easy to offer trust since one can expect trust to be returned. Social change is compatible with trust, providing that change proceeds gradually and in a constant direction. In times o f rapid and radical social change, as in a crisis, instability undermines the existential fabric of social life.  Faced with reshaped groups, new associations, and indeed new  identities, feelings of estrangement, insecurity, and uneasiness arise. The odds that our expectations about the actions of others will not be confirmed, and that our predictive trust will be violated, are high. This cultivates suspicion and a tendency to withhold trust.  The third contextual, macro-societal factor is the transparency o f the social organization, and its opposite, the organization's pervasive secrecy. The availabihty of information about efficacy and levels of achievement, as well as failures and pathologies, provide a feeling of security and predictability.  Even failure to  succeed is more reassuring than not knowing what is going on. O n the other hand, i f the principles of operation are veiled in secrecy, the expectation that there is something to hide engenders rumor, gossip, and conspiracy theories. In this case, people fail to grant trust.  41  The fourth factor is the familiarity or the strangeness of the environment in which people undertake their actions.  This factor is similar to the previous case of  stability, as it also has to do with accustomed routine; however in this instance we refer to situations where people find themselves physically displaced, in a new environment rather than in a changing, but nonetheless familiar locale. feeling of familiarity breeds trust.  The  In its absence, feelings of uncertainty and  anxiety run deep. This is frequendy found in communities of immigrants as they try to relate to the majority culture.  Often, and especially after one or two  generations of integration, there appears to be a loss of cultural identity and the disruption of communities.  The last condition is the accountability of other people and institutions. opposite is arbitrariness and irresponsibility.  This is a crucial factor in the  development of trust or distrust, in that a stable, accessible, and properly functioning set of institutions will set standards and provide checks and balances with respect to conduct.  People feel confident that societal norms will be  observed, and that i f abuse occurs, correction will be made in some manner. However, in the absence of accountability, no one can be certain whether or not others will choose to harm their interests, and i f that should happen, whether there would be avenues of redress.  Suspicion and distrust become natural  responses.  42  Its  Micro Perspectives on Trust While Sztompka tends to focus on macro-social issues, he does not discount the micro processes that interlace social conditions. For example, when he discusses trust in relation to politics, he notes that ultimately, we have to trust people, not objects or events:  Intuitively we feel that trust must be vested in people, rather than natural objects or events. Even if we seemingly confer trust on objects, such as saying, "I trust Japanese cars," or "I trust Swiss watches", or "I trust French rapid transit", we in fact refer to humanly created systems and indirecdy we trust the designers, producers and operators whose ingenuity and labor are somehow encrypted in the objects. (Sztompka 1999: 19-20) Since Sztompka acknowledges that his macro-analysis is germane to the level of the individual, I will restate his five conditions of trust in a form more conducive to the purposes of this study — a micro analysis of trust.  In terms of normative coherence and normative chaos, rather than limiting the analysis to suggest that that only societies and social life can be orderly and predictable, or the reverse, Sztompka's model could apply to people's lives, in that they can be secure, and in the main, predictable, or they can be full o f uncertainty and danger. For the former, repetition and predictability serve to engender a culture of trust (at least in the familiar); however, for the latter, social rules regarding the conduct of other people (and often themselves) are either unclear, unknown or unknowable, and life may be, as Hobbes states "solitary, poore, nasty, brutish and  43  short" (Hobbes 1651: 186), and fraught with mistrust, as is the case for many gays.  Sztompka's second structural condition, stability of the social order and its corollary, radical change, is perhaps the easiest of the five conditions to reduce to a micro social understanding. In a macro setting, the assumption is that the social order is long lasting, persistent and continuous. However, we already have acknowledged that to be gay involves a process of coming to the realization that one is different, stigmatized and considered an outsider, which in turn breeds a form of social mistrust, whether it is internalized or overt within the family, at school, at work or in general society. As Sztompka suggests, gradual social change is compatible with trust; conversely, the process of coming out is a radical personal change and should, in that case, engender mistrust. There is no reason to expect reciprocal trust, predictive trust is difficult to assess, and suspicion and a tendency to withhold trust results.  This becomes clear when one examines the sexual  behaviour of gay men who have recently come out - in general, they fear the possibility of infection and, having absorbed 'safe sex' messages, usually insist on condom use, at least until they become more acclimatized to their new life as a gay man. It is only at this point that Sztompka's notion of a social order (albeit a new social order) is brought back into harmony with a more routinized and orderly life.  44  The third macro-societal factor, the transparency of the social organization can be seen in the 'fish-bowl' existence of gay communities. In most major centres, the visibility of gay-identified people and venues, as well as publications and social/recreational agencies act to insure that information respecting community strengths and weaknesses becomes widespread.  This sense of openness is  consistent with Sztompka's forecast of security and predictability, which allows the individual to relate positively (in most cases) with community. As we shall see, (Kippax, et al. 1992), gay community involvement has a significant bearing on health behaviours, and on issues concerning rational choice when it comes to condom use, especially with casual partners. O f course, this visibility is a doubleedged sword — the hitch is that once one is identified as gay, social stigmatization generally will follow, at least from some elements of the social order.  The  question of whether to remain closeted or to be out, to a great extent, depends on the cost/benefit ratio of being a part of the gay community or a part of the mainstream community. For some people, it is difficult to immerse themselves in both.  Fourth, the familiarity or strangeness of the environment can straightforwardly be brought to a micro level.  In Sztompka's analysis, he uses the example o f a  stranger in a strange land. In a micro environment, one of the most compelling reasons for gay community development is the sense of comfort and safety these communities produce. In fact, wherever a gay man travels, if he is able to locate  45  the gay commuriity (whether it is large or consists of only one bar) he would feel comfortable 'being among his own'. Being around other gay men, this feeling o f familiarity, is a comforting factor; one that would facilitate the granting of trust. O n the other hand, the problem of familiarity, especially within one's own community may foster a climate of mistrust, especially for those men who are sexually promiscuous, and have 'had' many people who circulate in their milieu. Knowing too much about someone's sexual behaviour may be as socially problematic as knowing too litde.  Finally, the accountability of other people and institutions, versus arbitrariness and irresponsibility is Sztompka's fifth condition of trust.  He refers to properly  functioning sets of institutions that set standards and provide checks and balances with respect to conduct. This element is perhaps the most difficult to reduce to a micro level, since it is dependent on the observation of societal norms. However, a case can be made for a micro analysis of this concept, in that individuals are ultimately responsible for the development and maintenance of the norms - each person has the ability to choose whether or not to accept normative behaviour and its attendant rules and taboos.  In an ideal situation, where one's H I V -  positive serostatus is not stigmatized, sexual conduct could be negotiated and, if necessary, sexual scripts could be modified to accommodate reasonable levels o f intimacy, trust and safety. Therefore, the accountability of other people, even in a  46  one-to-one situation, can be likened to Sztompka's accountability o f other people and institutions.  These micro conditions will be further illustrated in the following section, where the correlation between trust and risk-taking will be examined in light of the theoretical understanding of the nature of trust.  Bringing Trust and Risk-Taking Together Nicholas Luhmann (1979:78) suggests that self-confidence makes one more prone to take risks involved in trusting others. Anthony Giddens (1991:79) agrees, adding that self-concept is the mediating link between resources and trust, arguing that as self-concept increases by the possession of resources (knowledge, self-knowledge,  sense  of  identity), one  has  a  more  open,  optimistic  compassionate, relaxed attitude that translates into more trust toward others.  However there is another mediating factor to consider.  Our instincts and  expectation levels also serve as forms of insurance for our trust, because they may act to lower our relative vulnerability in case that trust is breached. People devoid of these resources tend to be distrustful, mainly because backup support is frequently absent, and vulnerabiUty is higher. It is in this light, bearing in mind Sztompka's classifications that we will be able to examine issues of risk taking, and the psychological well-being of the sample subjects discussed earlier. There are of course, other factors that in combination may increase or decrease  47  purported trust - job stability, the plurality of social roles that individuals play, the robustness of other held beliefs, power, formal education, social networks, and the family (either biological or of choice).  In sum, when one considers issues of trust in conjunction with high risk sexual behaviour, especially in the case of potential infection and untimely death, that trust must be unshakable, or if it is not, there must be some other factors that permit something less than a 100% faith in someone else to mediate that trust. Several writers have acknowledged that there are mediating factors that do permit trust to be qualified.  In Sex, Gay Men and AIDS (Davies et al., 1993) the authors examined social perspectives on anal intercourse.  Not surprisingly, they found an immense  symbolic significance in anal intercourse as it relates to its pivotal role in the transmission of H I V , but they also found that there were different meanings men ascribe to anal intercourse. Central to this analysis, is an understanding that anal intercourse is not something men must do (and cannot help themselves from doing), but something they actively choose to do in some circumstances and not in others.  48  During wave four of project Sigma , men were asked " H o w important is fucking 5  to you?"  The parameters employed in analyzing this question included the  centrality of anal intercourse in their lives, how anal intercourse informs their social and sexual identities, the meaning of orgasm, the relativity o f physical pain, closeness, love, intimacy, bonding, trust, relaxation and power.  Many men  mentioned trust. While trust took a number of forms, it was mostiy related to receptive anal intercourse. Being able to trust the partner to stop i f asked was common. Although trusting casual partners was an issue in general, prior experience of force was given as a concrete reason not to trust (almost 1/3 o f the respondents, n=33). Trusting the insertive partner to use condoms properly and to check the condom frequendy was also underscored.  Responses to the statement concerning trust were significandy associated with being fucked by a casual partner. Among those who agreed with the statement "I need to trust someone before I let them fuck me," only 19.3% had been fucked by a casual partner compared with 56.2% of those who disagreed (TI =41.94, df=2, p=<0.001). Response to this statement was also associated with insertive fucking with casual partners in the previous year: 28.6% who agreed had fucked a casual [partner] compared to 53.4% who disagreed (lT=16.81. gd=2, p<0.001). This is attributed to the fact that fucking casual partners in the last year was much more common among those who had been fucked by a casual [partner] also (67.8% versus 21.5%, rf-82.71, df=l, p<0.001) (Davies et al, 1993:135) 2  O n a qualitative level, respondents in the Sigma study had a number of points to make about trust and anal intercourse:  5  Project Sigma is an open cohort, formally titled Sexual Investigation of Gay Men and AIDS, operational in Great  49  A bit of trust is necessary and in one night stands you're not sure how much you trust them, to stop whenyou want them to.  It's to do with a level of trust and I need to know more than if I'djust met them minutes ago. The reason is I had a couple of bad experiences in my early 20's. It's important to trust the partner. My ex-partner gave me trust, it could have done safely and enjoyably, I knew he'd be careful with condoms.  In this relationship I prefer to be passive, partly because it's him, I trust him and relax.  It's a question of trusting them for being fucked; I find it uncomfortable, need to relaxed. (Ibid.) These individuals, as well as the study group as a whole, had to learn trust and distrust. In most cases, prior experience was the main conduit to knowledge, confinriing the distinction between casual and regular partners: trust is greater with regular partners than it is with casual partners. In Sztompka's terms, this phenomenon can be linked with his second point — the stability of the social order - regular partners provide reference points of routine and habitual responses.  In sum, the adoption or rejection of trust modalities is significantly influenced by earlier life course events and direct experience. In turn, those modalities inform adult behavior, as well as beliefs, attitudes, and interpersonal relations  Ultimately, I demonstrate that notwithstanding over 20 years of safer sex education directed towards both the general and the M S M populations, the  Britain.  50  shifting dynamics of risk, trust and intimacy have confounded attempts to create and support metanarratives promoting positive health beliefs, given that decisionmaking with respect to one's own health and welfare is not based merely on cognition and social or institutional aspects of life, but also on a complex welter of emotional, historical and psychological factors.  51  CHAPTER 2 - G A Y M E N , SEXUAL FREEDOM A N D HIV  If proof is needed that social marketing metanarratives as they have been constructed, are fundamentally incorrect and sometimes even insulting, one need only look at A I D S infections data to see the lack of permanent results of these campaigns.  In 1994, Walt Odets wrote:  T o date, more San Franciscans (90% of them gay men) have died o f A I D S than died in the four wars of the 20th century, combined and quadrupled. Thirty percent of 20 -year-olds will be infected or dead of A I D S by age 30 and the majority will become HIV-infected at some time during their lifetimes. The mean life expectancy o f a San Francisco gay man between the age of 16 and 24 is somewhere around 45. (p. 1) Fortunately, Odets' prognostication is now somewhat off the mark. With the advent of protease inhibitors, life expectancy even with H I V is significandy greater than it was in 1994.  However, in terms of percentages of men engaging in anal sex, current and past data do not appear to have changed since even before the onslaught o f the epidemic (50% to 60% of all gay men have anal sex). If there has been no change in the percentage of gay men who participate in anal intercourse, and subsequent to the tremendous upsurge in infections in the 1980's and early 1990's, new infection rates remained relatively stable for several years, it could be a safe  52  assumption that the social marketing messages have had, since then, less than the desired impact — that impact being a reduction in infection rates and an increase in condom use.  H I V / A I D S Statistics Data on H I V prevalence (based on testing statistics) always lags behind the times. Due to inconsistent reporting (some jurisdictions require full reports, while others do not), and the fact that most participating clinics represent a convenience sample rather than a probability sample, data needs to be interpreted with caution, because persons who attend participating clinics and hospitals are not representative of all persons being tested, not to mention those people who do not seek testing at all. In an ideal world, from a statistical perspective, there would be one source of information that would provide H I V data on a consistent basis. Such a reporting system does not exist.  In Canada, data is maintained on reportable diseases, such as A I D S .  The  following tables illustrate the rise and fall of 'full-blown A I D S ' cases from 19861997:  53  Table 2-1: AIDS Incidence Over Time. AIDS, Males, All Ages (Health Canada, L C D C , 1999)  Rate per 100,000 8  R  /  /  /  ,  \  ••  5  2 > g  |  |  j1  §  $  &  a  l  i  i  Year 1986 198711988 1989 19d0[l991 1992 1993 1994 1995 1996 1997  Rate/100,000 3.10 4.50 [5.60 [7.70  7.30 [6.80 j 8.80 T M \7M [7Jff S M 2.50 j  A t first glance, table 2-1 suggests that infecdon rates have dramatically dropped. A n d indeed, in Canada, the reported incidences of A I D S have declined since 1995. However, there is a world of difference between being infected by H I V and having reportable A I D S . What table 2-1 does illustrate is the magnitude of the impact of triple drug therapy on A I D S cases, since the data reflects only 6  6  NRTls (Nucleoside Reverse Transcriptase Inhibitors): zidovudine (AZT), didanosine (ddl), zalcitabinc (ddC), stavudine (d4'l), lamivudine (3'1'C), Combivir™ (AZT + 3TC), and abacavir (ZiagenTM). Pis (Protease Inhibitors): saquinavir (Invirase'lM & I-'ortovaseTM), ritonavir (NorvirTM ), indinavir (Crixivan®), and nelfinavir (Viracept ®). NNRTIs (Non-nucleoside Reverse Transcriptase Inhibitors): (Rescriptor®), and efavirenz (Sustiva'lM®).  54  nevirapine (V'iramune®), delavirdine  full-blown A I D S cases, not HIV infection. The dramatic drop in reported A I D S 7  cases, from 1995 to the present, is primarily reflective of this new therapy.  However, it bears repeating that one must be cautious in that this data is only reflective o f reported A I D S cases, not H I V infection. Until the advent of the use o f triple drug therapy on a large-scale, in the mid-1990s, the average time from infection to symptomatic A I D S was approximately ten years. Therefore these data must be viewed with that time constraint in mind, coupled with data previously presented on new H I V infections.  The following figure (2-1) illustrates the age of the Canadian A I D S population. Again taking into consideration the limitations outlined above, the high incidence o f 30 to 59 -year-olds with A I D S may be misleading with respect to the time at which they seroconverted, and could reasonably be set back by at least five to 10 years.  That would suggest that many men were becoming  infected with H I V between 1987 and 1992. Interestingly, this was the time when major AIDS-based education programs were taking place in urban centres. Again, this may suggest that the interventions were having httle effect on H I V prevention.  7  HIV infection is statistically converted to AIDS when one's viral load drops to a certain level (which varies  55  Table 2-2: Year 1994: Median Age Of First Diagnosis (Health A n d Welfare Canada, 1994)  YEAR  MEDIAN AGE  pre 1982  32 years  1983 - 1984  27 years  1985 - 1990  23 years  from time to time depending on government, health insurance and medical input)  56  As can be observed, prior to 1990, the age of first diagnosis was dropping rapidly. This is primarily due to the increase in anonymous testing facilities, people being tested, and overall confidence and interest in the test itself. There is new evidence to suggest that the age of seroconversion has risen in the past decade, as follows:  Figure 2-2: Year 2000: Median Age of First Diagnosis (Health Canada, 2000)  15-19  20-29  30-39  40-49  50+  Age Group (Years)  One o f the reasons for this shift to an older median age o f diagnosis may be the disappointment in the gay community that what was once a temporary measure to control the spread of H I V (condoms) has become a more-or-less permanent way of life. Early on in the epidemic, young men were unknowingly taking the majority of sexual risks.  When testing became available, the  statistics  demonstrated the magnitude of the epidemic. However, now, men between the ages of 30 and 49 are the highest seroconverting group. This must be explained  57  in ways other than lack of knowledge about viral transmission.  The logical  explanation is that these men (like many others not diagnosed) have anal intercourse without condoms, knowing that risk is part of the sexual script. If this is so, then the undertaking of risk must be a calculated decision, for it is inconceivable that such a large number of men are having U A I 'in the heat of passion', or influenced by drugs and/or alcohol.  In  any event, regardless  of the  age  at which one  seroconverts, H I V  seroconversion rates, which were relatively stable until now, are now on the upswing (Craib et al, 2000). There is no doubt that the knowledge issues have been addressed by the media and the social marketing messages. What is at issue is the lack o f gay men's response. Eric Rofes puts it thus:  Gay men may have been inculcated in safe sex behavior but inculcation has fallen short of ensuring protected sexual activity. The reduction of acts coded with meaning and historical context into consumer goods, underlies the gradual erosion of gay men's trust in community prevention efforts over the past decade. (Rofes, 1996:133) (italics added)  Framing the Debate In January 2000, a letter to the editor appeared in Xtra West, Vancouver's gay and lesbian biweekly newspaper, referring to a previously run article critical o f the practice of barebacking. Apart from sporadic articles and letters found in fringe publications and web pages, this was the first time gay Vancouverites were  58  confronted in a widely circulated publication by a sex-positive gay man who wrote unconditionally in favour of barebacking, and personal sexual choice:  Whatever my sexual practices are, they are about the adult choices that I make fo me in my adult life. I live without the needfor explanation, as I am without partner  My sexual adventures, may they be in the park, at the baths, with someone from bar or with that special someone after a Bad Boy's connection, are the kind of adul choices that I make for myself. Why should they be of anyone's concern if the on one I am responsible to is myself?  Most recently, I have found further liberation in the simple act of barebacking. I have found comfort in knowing that I am not alone. For the last two months, not one adventure has left me disappointed. Barebacking is the name for the times. A name that shouts rebellion, freedom and chance. Barebacking is truly a kickback to the decade(s) when life was lived with a sense of sexual and personal freedom. Thank God the Victorian Age has once again passed on.  Barebacking may be only a romanticised version of "gettingfucked without condom but what are my risks? People are not dying anymore. Not dropping off like flies, anyway. The quilt has gathered moss. The photos of loved ones no longer grace o community pages. We have obviouslyfound an ointmentfor the scratch.  I live my adult life with the belief that if1 want it, all I have to do is go there and ge it. That attitude has served me well I am a professional and a success. And truly, who loves me more than me? Rob Hamilton, Vancouver, BC (Letter to the Editor. Xtra West, No. 168, January 27, 2000, p. 4) The letter provoked a heated and vituperative response two issues later, and in turn, triggered a reply from the original author. The initial letter (above) provides us with some interesting insights into how (at least) one gay man assesses risk: the second sentence exclaims that explanations are unnecessary "as I am without partner". This suggests that Hamilton's position is contingent on his relationship status, which is further reinforced in the second paragraph, where he states that "the only one I am responsible to is myself. A second theme emerges in the third paragraph - one of defiance and rebellion: "I have found further liberation  59  in the simple act of bare-backing [sic]" and " A name that shouts rebellion, freedom and chance".  The act of defying supposed community norms  ("freedom" from what, one might ask) is heightened rather than tempered by the acknowledged risk ("chance"). Additionally, Hamilton notes that he has "found comfort in knowing I am not alone", implying that there was some initial sense o f discomfort with either his previous sexual scripts, or perhaps something more broadly based — his sense of community.  While professing independence and freedom of choice, Hamilton questions the veracity of the putative risk ". . . but what are my risks? People are not dying anymore. Not dropping off like flies, anyway." Presumably, Hamilton's decision to have bareback sex is also contingent on medical advances that slow the progression of the virus, and perhaps unintentionally, given the fact that so many men have already died, an unwillingness to believe that there could be yet another epidemiological holocaust in the gay community.  In the last paragraph, Hamilton touches on two additional themes — both o f which appear rather out-of-place, or non sequiturs: "I am a professional and a success." and " A n d truly, who loves me more than me?" In the first instance, Hamilton's socioeconomic status appears to have no relevance to his decision to bareback, and yet one must wonder i f he is obliquely referring to people o f lesser  60  means who may (in his mind) lack the capacity to call upon ambition, drive and persistence, suggesting that they may somehow be stereotypically unqualified to make independent health related decisions. Or, he may be referring to injection drug users (IDUs) who, like barebackers, are also at significant risk for H I V , in this case through needle sharing.  Second, and perhaps more telling, is his  concluding proclamation of self-love.  Here he exhibits a number of qualities  endemic to many gay men (and supported by responses from the interviews): narcissism, loneliness, a need for validation and the necessity of self-reliance.  Does Hamilton truly believe what he writes, or is hyperbole at play? O n the face of it, one must assume that Hamilton is genuine in his acceptance of risk, and his proclamation of sexual freedom. However, his response to his critics suggests something else. First let us examine Jon Levitt's response to Hamilton's letter in the February 24, 2000 edition of Xtra West:  Afterfirstreading the letter about barebacking by Rob Hamilton (Issue 168, Jan 27), my initial reaction was anger and sadnessfor the warped views ofthe writer, bu then I got increasingly angry at Xtra Westfor the placement ofthe letter at the top the page with, the edited headline: Barebacking Pleasures.  Why not? If the letter wasfrom a street IV drug user, an appropriate headline cou be, 'The pleasures of sharing needles," or how about a handgun enthusiast headlin with, 'The pleasures of Russian Roulette," or a letterfroma youth in a small isolated town entitled, 'The pleasures of glue sniffing."  Where is Xtra West's responsibility in journalism, let alone responsibility to our community? Where is your good common sense? Where is your conscience?  61  This letter was written by someone whose head is obviously buried in quicksan Extolling the virtues of barebacking because it shouts "rebellion, freedom and chance". Rebellion against two decades of trying to educate ourselves to rejoice in and sex without succumbing to genocide/extinction? Freedom to say, "fuckyou " t countless thousands of our loved ones who have died or continue to suffer from HIV/AIDS? Freedom to deny everything we've learned as factual about the transmission of one of the worst diseases ever known to humankind? Freedom t spread the dangerous view that barebacking is okay to impressionable horny you who already think they're immortal and immune to the oldergenerations'problems? But Rob, how about the chanceyou are encouraging others to take? Don 'tyou feel any moral responsibility toyourfellow giy beings? Jon Levitt Vancouver, BC It is interesting that Levitt first chooses to condemn the publication for allocating such prominence to Hamilton's letter (it was the lead letter). His initial anger is also directed at the headline "Barebacking Pleasures" positioned "at the top of the page", but quickly turns to the very fact that Xtra West chose to publish the letter at all. Levitt feels that it is irresponsible of the publication to give voice to such dangerous comments.  Levitt questions Xtra West's  "responsibility in journalism, let alone responsibility to our community."  The  irony is that both Levitt and Hamilton refer to community — Levitt in terms of silencing discourse concerning certain forms of sexual behaviour that should not be explicitiy discussed, and Hamilton in terms of opening discourse and finding like-minded individuals in the community.  Levitt then turns his anger to the letter writer himself.  Instead of addressing  issues raised by Hamilton, and perhaps providing a rational counter-point, Levitt  62  attacks the content with an emotional plea to remember our history during the epidemic, and an insinuation that informing "impressionable horny youth" that barebacking "is okay" is "dangerous". Levitt seems to make the assumption that these youth have not heard of, considered, or engaged in barebacking prior to Hamilton's disclosure, and have just been provided an alluring alternative sexual script.  In that same issue, Rob Hamilton qualifies his first letter with the following:  / make no apologyfor my letter on barebacking (Issue 168, Jan 27), as Ifelt it mas an issue that needed another voice at a time when the safe sex messag has all b disappearedfrom our baths, bars and community newspaper.  The intent ofmy letter was not to make light ofa serious issue, but to draw attent to the responsibility that we have to ourselves, our well bang and in keeping the sex message alive. Twentyyears later, a new generation of young men are coming into our I their community and we, as educators, are failing them.  Our gayyouth are not being met with the same bold awareness that greeted us in o not-so-distant past. If we are to learn anythingfrom history, is it that history teach us nothing? Why have we let ourguard down?  The bottom line on barebacking is that people are going to do what people are goi to do. Awareness providesfor the more informed choice.  If my letter and the response to it has served as a reminder on the importance o condom use and safe sex practice, then our dialogue has not been without purpo Let us notforget: SILENCE-DEATH. Our gay youth are counting on it. Rob Hamilton, Vancouver, BC The overall tone of Hamilton's second letter is inconsistent with his first one. In this latter missive, he extols the virtues of "keeping the safe sex message alive" — seemingly a reversal from his original statement that "Barebacking is the name for the times. A name that shouts rebellion, freedom and chance" [Ital. added]  63  added] He indicates (without saying so) that his first letter was intended to be a "reminder on the importance of condom use and safe sex practices".  If one  accepts this position, it stands to reason that the first letter should be considered satirical in nature, much like Jonathan Swift's enjoinder to solve the "Irish Crisis" by eating their babies. Yet Hamilton reinforces his original intent by stating that "people are going to do what people are going to do", a curious tautology implying that contrary to his previous statement that "a new generation o f young men are corning out into our/their community and we, as educators, are failing them", there is little hope of stemming the tide of barebacking, which he seems to have welcomed in the first letter. He concludes that thought with "awareness provides for the more informed choice," yet does not suggest what we should be aware of. Is he suggesting that we should be aware that some people choose not to use condoms for anal intercourse?  O r is he suggesting something more  profound — that as a community (or communities) we should be aware that sweeping controversial issues under the proverbial rug does little to inform gay men of their options, and perhaps makes the 'forbidden' seem that much sweeter.  Oddly, and perhaps inadvertentiy, he concludes his letter with the A C T - U P slogan " S I L E N C E = D E A T H " . Originally, this catchphrase was used to rally adherents and conscience constituents in the battle to move the F D A (United States Food and Drug Administration) and the pharmaceutical companies away  64  from their highly conservative drug trial protocols, and urge them to release promising A I D S drugs (on compassionate grounds) prior to fully testing them. The use o f the phrase is ironic in that while Hamilton initially suggests that his risks are minimal, since people aren't dying in the numbers they were before (or in other words, A I D S is a manageable disease), he invokes the mantra o f A I D S activists who were dying.  In all, this public discourse points to a number of important themes that need to be expanded and examined more fully.  First and foremost, as Hamilton and  Levitt point out, it is important to qualify what constitutes a risk for H I V infection; and coincidentally, is risk, in this case, absolute or relative? Second, it is clear from the three letters that the problematic goes beyond risk taking and risk avoidance, into the realms of community and the politics of sex and H I V . Third, they draw attention to the fact that there may be links between knowledge, beliefs and everyday behaviour. These associations need some elaboration as well.  H I V and Risk Behaviour In the early years of the A I D S epidemic, epidemiologists established the primary routes of transmission of a possible AIDS-associated pathogen, later identified as human immunodeficiency virus (HIV), and were confident that they were also able to identify the social groups, or networks that were associated with the  65  disease — gay men. They were so confident of this finding that the disease itself was initially christened 'GRID''—gay-related  immunodeficiency.  Thus, for the first time  in recent.history, a disease was classified by the identity of a social group rather than either the discoverer (such as Tay-Sachs or Chrone's disease), site-of-origin (Ebola Fever, Legionnaire's disease) or symptomology (Yellow Fever, Chicken Pox, and Retinitus). Although fraught with methodological issues and subject to erroneous assumptions, the popular notion of A I D S as a 'gay plague' took hold, both witMn and outside the gay populations of North America and Europe.  With the introduction of H I V antibody testing, a more precise understanding o f transmission was realized, as the presence of infection in individuals could now be ascertained.  Furthermore, the rate of infection could be measured in  categories of people with shared characteristics and behaviours, and the relative risk o f particular behaviours vis-a-vis potential transmission could also be 8  measured, refining even fiirther the quantitative assessment of risk o f infection. (Hart, 1995:55)  What this meant for gay men was that receptive anal intercourse without the use of condoms became hyper-stigmatized as the primary risk behaviour for potential infection, and other sexual behaviours (insertive anal and oro-genital sex) as secondary, but yet clearly identifiable, risk activities. Consequentiy, the medical  8  Non-penetrative sex, oral, vaginal and anal sex, injection drug use with shared needles.  66  model of risk reduction strongly advised gay men to abstain from all anal intercourse . 9  Before long, A I D S Service Organizations  (ASOs)  developed  guidelines under the rubric of 'safe sex' (USA) or 'safer sex' (Canada, U K , Scandinavia) to embrace sexual activities with varying degrees of risk.  In the  United States, the 'safe sex' message proscribed any fluid exchange (particularly semen and blood) and embraced a '100% safe, 100% of the time' epistemology. Elsewhere, the notion of relative risk was promoted, and sexual behaviour was categorized as ranging from high risk to no risk, depending on the activity.  9  Condoms, generally acknowledged to be effective barriers to HIV transmission are not 100% effective as they are subject to breakage, leaks, and mis- or non-use.  67  Table 2-3: "Risk M o d e l " -- Mclure & Grubb (CAS ) 10  BEHAVIOUR  COMMENTS  High Risk  Insertive or receptive penile-anal or penile-vaginal intercourse without condom, sharing needles or syringes, receptive insertion of shared sex toys.  All of the practices listed in this category present a potential for HIV transmission because they involve an exchange of body fluids such as semen, vaginal fluid, and blood or breast milk. In addition, a significant number of scientific studies have repeatedly associated the sex activities with HIV infection. Even when the exact mechanism of transmission is not completely clear, the results of such studies conclude that activities in this category are high risk.  Low Risk  Receptive fellatio without barrier (sucking cock), insertive cunnilingus (putting mouth and/or tongue inside vagina) without barrier, insertive or receptive penile-anal or penile-vaginal intercourse with barrier, injection of a substance using a needle and syringe which has been cleaned.  All of the practices listed in this category present a potential for HIV transmission because they involve exchange of body fluids such as semen, vaginal fluid, and blood or breast milk. There are also a few reports of infection attributed to these activities (usually through individual case studies or anecdotal reports, and usually under certain identifiable conditions).  Negligible Risk  Insertive or receptive fellatio /cunnilingus with barrier, anilingus, digital-anal intercourse.  All of the practices listed in this category present a potential for HIV transmission because they involve exchange of body fluids such as semen, vaginal fluid, and blood or breast milk. However, the amounts, conditions and media of exchange are such that the efficacy of HIV transmission appears to be greatly climinished. There are no confirmed reports of infection from these activities.  No risk  Kissing, solo masturbation, being masturbated by partner (without using semen/ vaginal fluid as lubricant), using unshared sex toys, urination, ejaculation or defecation on unbroken skin, massage, touch, caressing, dirty-talk, body rubbing, injection of a substance using a new needle and syringe.  None of the practices in this group have ever been demonstrated to lead to HIV infection. There is no potential for transmission since none of the basic conditions for viral transmission are present.  RISK  10 Canadian AIDS Society, 1999:20-21  68  This 'relative risk' notion (Table 2 - 3 ) conforms to the Canadian (as established by C A S — The Canadian A I D S Society) and Northern European model o f 'safer' sex. This is a significant departure from the American model of 'safe' sex whose prescriptive has been, and remains to this day, "100 percent safe, 100 percent o f the time."  Therefore, in the American paradigm, upon which much of  H I V / A I D S prevention work is modeled, the categories from high risk through negligible risk are collapsed into the 100% safe sex message.  Faced with an  almost certain inability to live up to the 100% dictum, especially with regard to negligible risk (and to some extent low risk), sexually active American gays and M S M came to realize that they had failed to uphold the supposed community standards surrounding safe sex, and many accepted this failure as proof that they were incapable of 'safe sex', and therefore engaged in high risk behaviour on the assumption that their failure is absolute, rather than relative. This notion of risk and failure has seeped into the Canadian psyche as well, primarily through the infiltration of American media, and on an academic level, the proliferation o f papers and books on the 'crisis' in the gay community, a crisis of noncompliance. Unfortunately, what began as a benign strategy to curb an epidemic has been perpetuated as normative, authoritarian one that castigates the deviants and exalts the conformists.  H I V is only transmittable in certain circumstances (primarily the exchange o f infected semen or blood.) and with varying degrees of efficacy. Clearly, in the  69  absence of viral infection, transmission is impossible — one cannot share that which one does not have. In that case, and in the cold light of day, one might assume that that which is known not to be a risk would be a guide to inform attitudes toward marginally risky sexual behaviour. A n d ultimately, the adoption o f safe sexual behaviours should then be promulgated with respect to high-risk activities. However, this does not appear to be the case. As early as 1991, when the data for the 'men's survey' (Myers et al, 1993) was collected, over 94% of gay men surveyed knew that anal sex without a condom was 'very high risk' , yet almost 30% o f the 11  same respondents who practiced receptive anal intercourse did not consistentiy use a condom.  More recent statistics (January, 1997) from the Vanguard Data Base indicate the following:  12  11  Myers et al (1993) Table 15, page 32  12  In this study, regular partners arc defined as "Guys you have sex with, at least once a month", and casual partners are "Any guys you have sex with less than once per month, including one-night stands".  70  T a b l e 2-4: Behaviour (Vanguard Project - W e b Site)  Regular Partners Casual Partners  <%)  (%)  N = 378  N = 410  anal insertive sex without condom with ejaculation  21  9  anal insertive sex without condoms without ejaculation  28  14  anal receptive sex without condoms with ejaculation  24  6  anal receptive sex without condoms without ejaculation  34  14  Behaviour  The difficulty in perceiving why, despite overwhelming evidence that certain sexual behaviours are associated with high risk o f H I V infection, many gay men continue to have anal intercourse without condoms, goes beyond the boundaries of so-called normative rationality.  Understanding it requires  adopting a  standpoint that does not characterize the individual as an autonomous entity, but as someone that considers risk conjoined with the person's direct and diffused social site and context.  This is not to negate human discretion or agency, but  rather to maintain that risk is informed by engagements with other people, social organizations and institutional issues.  71  The letters discussed earlier in this chapter are illustrative of this dynamic. In Hamilton's first letter he suggests that he is an autonomous individual — "adult choices that I make for myself.  However, his words are fraught with  contradiction, in that while ckiming that "the only one I am responsible to is myself, he also makes note of the fact that he is "without partner", thus acknowledging the possibility that he could have other responsibilities; his sexual "adventures" always involve other people; and most telling, he asks "who loves me more than me?" again leaving open the possibility that there could be someone else involved in this relationship of one. Perhaps without direcdy articulating it, Hamilton acknowledges the potential impact of other people and social institutions on his decision-making.  Clearly, Hamilton and others are making use of a variety of risk assessment strategies, both on conscious and sub-conscious levels. Both in deed and in thought, gay men, M S M and others operationalize some learned community social norms, adapt other norms or restrictions to suit their own needs, and disregard those that appear to be unattainable or undesirable. In order to better understand the combination of factors involved in how these decisions are reached, and how what appears to be irrational can in fact or in appearance be rational (especially with regard to risk assessment and risk taking behaviour), we need to examine some theoretical considerations.  72  The Social Psychology o f Risk Fishbein and Azjen's Theory of Reasoned Action (1975), and its successor, Azjen's Theory ofPlanned Behaviour (1988) propose that "behavioural intentions are the best predictors o f subsequent behaviour. In turn, intentions can be predicted by the beliefs and knowledge regarding the behaviour in question, together with the subjective norms. These relate to the extent to which individuals believe that important others would wish them to engage, or not, as the case may be, in the particular behaviour(s).  The relative influence of beliefs and subjective norms  varies with different domains of behaviour." (Ingham et aL (1992) p. 163) The theory can be illustrated as follows:  Figure 2-3: Theory of Planned Behaviour  73  This  model is useful  in understanding  why H I V / A I D S  organizations,  government health departments, and other social institutions have adopted the KAB  (Knowledge, Attitude, Behaviour) health prevention model in their  campaign against infection. The functionality of the model suggests that if one can establish the target population's feelings with respect to their current sexual behaviour (shame, guilt, pride, disinterest), relate this to how they perceive others feel (the subjective norm), and somehow determine what methodologies may influence behaviour change (media campaigns, posters, handing out condoms in bars, counseling in the bathhouses, public forums and so on), then one might be able to develop situation specific and appropriate intervention programmes designed to increase the individual's intent to use condoms. If such an intention can be sustained, according to the theory, the likelihood of a real behaviour change is concutrendy more probable.  This, as well as similar models  13  are referenced regularly in the H I V / A I D S  prevention discourses in attempts to refine the predictabiUty of behavioural outcomes for H I V intervention programs. They have been used as 'truths' in the effort to develop publicity campaigns in the field of H I V education. intended outcome -  The  after the population has been informed of the facts  surrounding H I V infection; the seriousness of the disease; the routes of  13  See Emmons et al., 1986; McKusick et al, 1995; Ruttet, 1989 for examples.  74  transmission; and the potential consequences of deviating from proscribed safe sex guidelines -  is an alteration of the individual's belief structures.  The  knowledge, attitude, behaviour (KAB) model has been used throughout the Western world for over 20 years.  However, judging by the condom usage  statistics presented previously, K A B may be at best outdated, and at worst counterproductive.  The condemnation of the K A B model stems from two points of reference. First, its initial hypothesis is that altering sexual behaviour is no less complicated than selling cars, or holiday vacations. The presumption that deeply ingrained social systems, such as sex and sexuality can be 'socially marketed' is fallacious. One need only point to the relative failures of other social marketing / public health programmes: unwanted pregnancies, heterosexually transmitted STDs, and cigarette smoking to name but a few (Odets, 1994).  The mere fact that  H I V / A I D S education must speak to a stigmatized, and possibly persecuted social minority whose core identity is intimately tied to the 'target behaviour' - sex in a sexually vectored epidemic — strongly suggests that catchy one-liners and 'prettyboy' graphics are insufficient to effect behaviour change dynamics, even minimally.  Second, the K A B models themselves are often homophobic misrepresentations and moralizations that disregard the social realities of the epidemic, and do not  75  pay attention to the specific social and psychological issues that arise. (Botnick, 1995) I shall deal with these issues in detail further on when I examine some social marketing advertisements.  The assumption that traditional rationality is directiy and inextricably connected to the understanding of sexual behaviour is not supported by the evidence. There are a number of impediments that prompt one to challenge the perception that there is an uninterrupted connection between knowledge, attitudes and behaviour (especially behaviour change).  The 'mens' survey' (Myers, 1993) reported that:  The probability of reporting a strong intention to use a condom for insertive anal sex varied between 12.0% and 96.0% according to the 3 predictors of The Theory of Planned Behavior. Men who are most likely to say they'll use a condom for insertive anal intercourse think the decision to use a condom would be completely their own; they trunk that using a condom would be extremely enjoyable and they believe most gay and bisexual men in their community think using a condom for insertive anal intercourse would be a very good thing to do. Men who don't like the idea of using condoms are unlikely to say they'll use a condom for insertive anal intercourse. Perceived behavioral control emerged as the most important factor. For example, consider the men who believe it would not be enjoyable to use a condom but who think the gay community feels it would be a "very good" thing for them to do. Among these men, there is a 77.0% probability of expressing a strong intention to use a condom for insertive anal intercourse if they perceive they have complete control over the decisioa If they perceive they have little control over the decision, the probability of expressing a strong intention to use a condom for insertive anal intercourse will be 27.0%. Attitude was the second most important variable, and perceived social norms, although significant, was the least important, (p. 58)  76  It is important to note that Myers' study, as is common with most (if not all) studies that involve self-reporting, may not be wholly indicative of the situation. What people report they do, or tbink, is not always what they actually do or think. This may seem self-evident, but it is an important factor in motivational education and the statistical reporting of beliefs and behaviour, especially when employing techniques that involve anything other than face-to-face training. In general, experience has shown that attitudinal studies have found that positive attributes are overstated, and negative attributes are understated.  These data,  and the data yet to come, must be read with that limitation in mind.  Perceived Invulnerability As a matter of record, gay men are generally cognizant of the seriousness of H I V , the routes of transmission and prevention strategies. (Abrams et al., 1990; Botnick, 1995, 2000; Myers, 1993; Kippax et aL 1993; Aggleton et aL 1995) Paradoxically, however, they frequently tend to rate their own personal risk as very low. Some simply deny the risk, perceiving that the issue is blown out of proportion. People who hold this view tend to have few, i f any close friends who are HIV-positive, or have had litde community contact with people whom they know are HIV-positive.  Others relate to a more optimistic outlook for  themselves - 'it's not going to happen to me', a variant of the notion that life is  77  full of so many risks that H I V risk in particular should not be privileged over other risks.  An  additional notion relates to  characteristics of sex partners.  the  alleged trustworthiness  and moral  This attitude regarding partners that suggests  safety include: their not being seen as promiscuous; that they have had only 'serious' relationships in the past; and that they created an impression through their appearance, general personality, family, job, place of residence and so on that they would not be the 'type' to infect someone else.  A further category of perceived invulnerability captures the mirror image o f the above — a personal sense of invulnerability based on one's own infrequency of sexual contact; the selective use of condoms when a partner is observed (righdy or wrongly) as a potential disease carrier; and the geography of the prospective partner (e.g.: the belief that H I V is less prevalent in smaller towns and cities outside of the perceived plague ridden cities o f New York, San Francisco, London, Amsterdam, Vancouver and so on).  Many gays and M S M feel that risk reduction is too difficult to navigate, and is ultimately beyond their control. In the first instance, as previously indicated, the American public response to the threat of H I V was (and generally remains) "100% safe, 100% of the time".  This includes all fluid exchange behaviour,  including oral-penile sex. Since virtually every study done in the past 15 years  78  (Adam, Schellenberg & Sears, 1998; Barillas & Garbo, 2000; Bloor, 1995; Dowie, 1999, Ekstrand & Coates, 1990; Gagnon, 1988; Gold, Skinner & Ross, 1994; Gold, 1989; Hart & Boulton, 1995) demonstrates that this American strategy for harm reduction (condom use for oral-penile sex) was all but ignored by sexually active gay men, by implication every gay man had already transgressed community norms and 'official' sociomedical advice.  Having both failed to  maintain putative community standards of sexual behaviour, and having admitted such failure, many men simply abandoned the doctrine entirely, believing that they were incapable of living up to such high standards.  Second, misconceptions (or self-delusions) give rise to a number of alternative meanings of safe(r) sex. One of the major doctrines of the 'official' advice is the use of a condom ' i f you do not know your partner' (Ingham, et al., p. 166). However, what constitutes 'knowing' one's partner is not delineated, leaving its interpretation vague and subject to (mis) interpretation. The matter o f knowing one's partner can take on a range of meanings, spanning casual acquaintance types o f 'knowing', (perhaps limited to such matters as name, place o f residence, sexual tastes, availabihty, and possibly age) to very deep senses of 'knowing' that come from years of cohabitation or 'dating'. Even then, as will be demonstrated in subsequent  chapters, knowledge of one's partner, not-withstanding the  presumed depth of knowledge, does not in all cases link with trust in one's partner — for example, the trust that they will not infect you. However, despite  79  the ambiguous nature o f this admonition, it does seem to imply that i f one does 'know' one's partner, condoms are thus rendered less necessary.  This situation is best exemplified by the highly prevalent practice of 'serial monogamy'. If, having been in a relationship for a few weeks or months, even if both partners re-test for the H I V antibody and test seronegative, it has been shown and will be re-emphasized in subsequent chapters, that the frequency of condom use drops off significandy as one gets to 'know' one's partner (Godin, 2000). Unfortunately, and most important however, given human frailties and a propensity to avoid confrontational issues, is the reality that neither partner can be absolutely certain that the other is not having unprotected sex with other people as well. Both anecdotal information and empirical data reflect the high prevalence of 'extra-relationship' sex — when one considers that it is even necessary for the Vanguard study, for example, to differentiate between casual and regular partners, one can see the degree to which monogamous relationships, at least in the gay sexual sphere, are not necessarily the norm.  Earlier, the notion of sex for sex's sake was introduced (Foucault 1982/83, Myers 1993, Gagnon 1988, Dowie 1999, Godin 2000).  In many relationships, rule-  making involves the negotiation of what types of sex can be had outside the primary relationship — whether it is location based (not in the same city as one lives), time based (when one partner is away for more than X days), whether it  80  must be done together (threesomes or more), and so on. Often, these decisions are reached as a compromise solution to the alternative of clandestine 'cheating' or the confines of strict monogamy.  Understanding So-Called Non-Rationality In many instances, reputational issues figure prominently in decision-making with regard to risk. For example, I was an active participant at a spontaneous (and clearly unauthorized) sex party involving about 8-10 registrants attending an American conference on H I V / A I D S Education, at which time the participants did not use condoms. While the relation of this incident is not intended, in any way, to diminish the importance of such information-sharing and learning forums, in a post-conference 'debriefing', it was frequently noted that the use o f condoms on this occasion was not even discussed — it was simply assumed that since the participants were all A I D S prevention workers, one's sex partner for the night was either H I V negative or i f not, would inform their sex partners that they were positive. The crucial point is that a number of people, extremely well versed in 'negotiated safety', and allegedly familiar with 'sex talk' demurred to 'negotiate' in the heat of the moment.  If this could be the case amongst some A I D S  educators, how then is it possible for people who are less skilled at communication, more inhibited with regard to 'sex talk', less aware of potential risks, and less able to assert their wants, to practice safe(r) sex?  81  The following table from the 'mens' survey' lists some of the reasons study participants gave for not using condoms. It is interesting to note that the items marked with an asterisk (*) are reputational in nature - they point toward nonfunctional issues — issues that relate to the individual's or partner's personal history.  Table 2-5: Reason For Not Using A Condom  (Myers et al. 1993:37)  Insertive Anal Intercourse  REASON  <%)  Receptive Anal Intercourse  (%)  * H e was my regular partner  49.4  61.9  The sex was so exciting It makes me lose my hard-on  25.9  28.4  24.3  -  * I am H I V negative I pulled out before camming  23.9  20.1  21.5 17.9  -  14  We did not have a condom  15.5 14.7  16.5 13.4  * H e said he was H I V negative I was using drugs  11.6 9.2  22.7 6.2  I was using alcohol * H e did not want to use one  13.4  I never use condoms  8.0  6.7  *I am already H I V positive  4.0  8.8  Respondents who had anal intercourse without a condom in the past year were subsequendy asked to identify separately the reason(s) that applied to their last condom-less episode, also chstingxushing between reasons for receptive and insertive anal intercourse. (Two reasons applied only to insertive anal intercourse: "I pulled out before curnming" and "I lost my hard on".) In general, the reasons  14  While this statement can be construed as instrumental, it has been more appropriately classified as reputational because its meaning is taken to be one involving trust - "He did not want to use one and I voluntarily acquiesced".  82  given for not using a condom for receptive anal intercourse fell into an expected order (this same order has been found in numerous other studies). The primary reason was "He was my regular partner" (61.9%) followed by exciting sex (28.4%). The significant difference in this study was the third most popular reason for not using condoms for receptive anal intercourse — the partner's selfreported HIV-negative antibody status.  This reason was given by twice the  proportion of men as those who gave the same reason for unprotected insertive anal sex.  A number of issues emerge from these data. Referring back to table 2-4, the definition o f a regular partner is someone with whom one has sex at least once per month - i t must be no less than that. Yet, there is nothing to suggest that this definition encompasses anything close to the concept o f monogamy. In fact, the probability is that in many of the cases, monogamy is not a factor.  What  accounts for the high (almost 1/3) proportion of men who have receptive anal intercourse without condoms?  If some people in this sample are in a monogamous relationship, then the others, who are not, must be assuming some degree of risk. The rationales for assuming these risks are complex, ranging from total detachment (indifference) to total commitment (trust). What is common though, is that people did have reasons for what they did. There was no category for "I didn't know what I was doing"  83  (despite the opportunity for write-in responses), since it appears that people knew, possibly excluding alcohol (13.4%) and drugs (6.2%) precisely why they did not use condoms. This clearly demonstrates that some form of thought process was employed in decision-making. In other words, these episodes do not fall under the category of mistake or misadventure - in most instances they are examples of barebacking, rather than U A I (unprotected anal intercourse).  It is also important to note from these brief examples that the justifications offered are reasonable from within the location of the respondents' own standpoints.  These diverse rationalities are at odds with, and frustrate, the  'received rationality' of official biomedical knowledge. One cannot even argue that what is observed is a situational aberrance — statistically there are too many incidences of non-condom use to suggest that this type of behaviour, and its corresponding rationality, he outside of what should be a bell-shaped curve.  One could put forward the argument that there is nothing rational or reasonable about putting oneself direcdy in the path of contracting H I V , given the realization that H I V is, for the most part, preventable.  However, there are  numerous rational (if one accepts the notion of 'rational' to mean having or exercising reason, sane, or lucid — Webster's: 1989)  motivations that have been  documented in favour of relaxing safer sex rules, or ignoring them altogether. In Meanings  of Sex Between Men,  Bartos et al. examined condom use in Melbourne,  84  Australia (N=97). Many men reported that it was hard to maintain an erection with a condom or that condoms were physically painful.  For them it meant  either refraining from insertive anal sex, or not using a condom. The more common reaction was a general dislike of condoms both in terms of an active dislike of condoms themselves, and a preference for unprotected contact.  I enjoy getting fucked. I don't like condoms. I know the man fucking me doesn't enjoy it as much if he's wearing one. They smell funny, the smell also turns me off. In the last month I've had ten different men. Six out of these ten fucked me up the arse and only one used a condom. Look, I've read about A I D S . I've even got information, but it's no good me saying to you that I won't fuck without them because I know I will. (VT, 57 years old, Retired Farmer) from Bartos et al (1994: 46)  One of the most common motives for rejecting condoms is that the negotiation of condom use will be a distraction to the sexual encounter.  For many men,  condoms are seen as mechanical intrusions to the natural flow o f sex. They introduce a technological factor into an encounter that was intended to be unconstrained. Additionally, the negotiation of condom use presumes a level o f communication that may not form a part of one's sexual repertoire.  Condoms, obviously, are emotionally associated with the risk of H I V . T o introduce a discourse on condom use at any point in the sexual encounter is to also introduce a discourse on disease and contagion and along with it an element of distrust, which may be perceived as a disruptive influence to the sexual  85  encounter.  Bartos et. al. report that there is further proof of this hypothesis,  proof which emerged through their interviews.  While for some of their  respondents there was a clear intent to have safe sex, initially permitting then to negotiate condom use, during the course of the sexual encounter the condom came off, was removed, or broke.  A t this point, the safe sexual act became  unsafe; however, once anal intercourse had commenced, it was difficult (and i n many cases impossible) to interrupt the process in order to replace the condom. (Ibid, p. 47)  This suggests that, contrary to the theories o f 'reasoned action' and 'planned behaviour', the formation of the intention to use a condom is not necessarily associated with carrying out or maintaining this intention throughout the course of a sexual act. It does suggest however, that there is a difference between the type of rationality employed during intention formation and that which is operationalized during sexual activity (Gold, 1994)  The Social Signification of Sex Decision-making models of the types previously discussed presuppose a certain measure o f autonomy and free choice, especially after one has been exposed to a reasonable amount of knowledge (the " K " of K A B ) . However, the models rarely incorporate the weight of various other pressures.  86  As illustrated by Table 2-3,  there is clear evidence of formidable coercions to abandon condoms and engage in bareback sex.  O f those engaging in the highest risk behaviour - receptive anal intercourse more than 28% responded that "the sex was so exciting". This response would indicate that if the encounter was with someone who is either 'hot', sexually adept, or both, there may be desire to maximize the sensations involved in sex, which could be a stronger motivation than the desire for protection, since latex barriers are perceived to inhibit the maximization of pleasure.  For many men, to be sexually active is equated in one's mind with being 'in demand' by peer groups. Perhaps historically fueled by a liberationist ideology, a rejection o f what is seen to be repressive heterosexist codes of morality, and the highly sexualized laar culture' of most urban gay communities, the notion of being sexually attractive to one or more people signifies an external validation of self-worth as a sexual object — a status to which many gay men aspire.  As Jeffrey Weeks (1985:80) points out, the significance o f sex to the individual has been viewed as the root of "our personal sense of self and potentially of our social identity". Havelock Ellis (1933:3) suggests that sex is "all pervading, deep rooted, permanent" and the last resort of our individuahty and humanity. While sex is the most enigmatic fact about us, it is also the component that has the deepest social signification. Sexual meanings are mediated through the traditions  87  and mores central to the use of different internal and external body parts, and the complicated symbolic labyrinths in which all eroticized activity is entangled. Some of the most important meanings are reserved for penetrative sexual practices. For many gays and M S M , only anal intercourse represents 'real sex'.  Standpoints have been put forth in 'common folklore' that heterosex and intercourse are the ultimate expression of one's love for one's partner, and the socalled 'natural' outcome of that intercourse is procreation. Historically, especially in the Judeo-Christian cultures, sex as pleasure has been looked upon as immoral, smful and wasteful . Homosex, in this context, has been especially vilified not 15  only as the embodiment of non-procreative sex, but also as the symbolic abrogation of traditional masculinity (to be anally penetrated is equivalent to performing the functions of a woman). However, the cultural significance of homosex goes far beyond the rebelliousness of gender deconstruction and religious disobedience.  The formation and maintenance of a gay culture cannot rely on social bonds informed by 'race', religion, ethnicity, language, socioeconomic status, geography, educational attainment, or most other social constructions that customarily bring people together into 'community'. A t best, what is common (to greater or lesser  15  Leviticus contains many verses referring to sex - including "Thou shall not spend thy seed upon the ground", which has been taken to be a reference to masturbation, but could also be read as a reference to coitus intcrruptus.  88  degrees) is a sense of 'otherness' — possibly aggravated by oppression, and one's sexuality. When critics of the so-called gay lifestyle hone in on sex as the focal point of gay culture, they are not altogether wrong in their assessment. T o be sure, there is more to being gay than sexuality — common stereotypes revolving around fashion sense, hedonism, the arts and so on all contain grains o f truth. However, I assert that the single most significant common thread is sexual. For many gay men, meeting and getting to know other gays often includes sexual activity (or at least some forms of physical intimacy) prior to emotional attachment. As proof of this hypothesis, one need only consider the proliferation of sexually oriented sites for finding sex — bathhouses, massage parlours, personal and professional (hustler or rent-boy) ads in gay papers, chat lines dedicated to seeking sexual partners, and a host of bars and after-hours clubs that cater to 'cruising' men. Sex is the cultural glue that binds many gay men to each other.  In particular, to those who define sex as penetrative (oral or anal), and involving semen, anything else is considered foreplay, or 'non-sex'.  This sense o f sexual  meaning, and the one previous, will be more fully explored in the interview chapters — at this point, suffice it to state that these propositions were articulated most clearly by some study participants. There are two distinct explanations for this conception of sexual activity: the dominance of penetrative sex as the paradigm of heterosexual sex, and the symbolic cultural meaning of anal intercourse and fluid exchange.  89  This former concept can be more clearly understood when one considers homoerotic behaviour between boys or men, without penetration.  The  proverbial group masturbation events that most young, heterosexual boys engage in, at some point in their sexual maturation, are not considered 'sex', or 'homosexual behaviour', at least not in their eyes. N o r does participation in one of these events suggest that the participants are (latendy if not overtiy) gay. The same holds true for M S M who engage in quick, anonymous sex in public washrooms, truck stops and porno parlours. Their sexual expression, generally devoid of anal penetration, does not speak to the same emotions as gay sex. A third example (if one is needed) is the presence of seemingly overt acts o f homosexual sex (often with penetration) in our prisons.  While the outward  behaviour mimics the homosexual notions o f 'real sex', it is generally acknowledged that once released, ex-prisoners who were not gay before entering prison immediately revert back to heterosexual sex, and rarely, if ever, have sex with men again . 16  The importance of anal intercourse between men is not just derivative of heterosexual penetrative sex. The symbolic meaning o f anal intercourse and fluid exchange is more complex and more substantive. In its own fashion, but equal to heterosexual penetrative sex, it has substance as the most intimate o f contacts with another person. As well, it has significance all of its own, as a particular type  1 6  Situational Homosexuality; also found in the military, boarding schools, and other all-male institutions.  90  of contact between men. Anal intercourse is a way of signifying that the sex is special, that the relationship or encounter is out of the ordinary.  While  heterosexual sex has always been 'normative', and accepted by society, gay sex, especially anal penetration, has historically been demonized. The transgressive nature of anal intercourse, for gay men (perhaps residing in an historical subconsciousness) makes the act all that more important physically, politically and emotionally.  In addition, the social significance of fluid exchange cannot be overlooked. First, and most obvious, is the intimacy that accompanies such an exchange.  For  example, most children can recall sharing their gum (already masticated) with close friends — a certain form of social bonding. Sharing food from the same fork is something that lovers often do, generally with more emotional significance than merely tasting. Deep kissing, as opposed to dry kissing, is generally reserved for intimate partners. So too, the sharing of semen can be seen as the ultimate form of intimacy, and not coincidentally, the ultimate expression of trust (since it is the most risky sexual behaviour vis-a-vis HIV).  Because anal intercourse is a mode of becoming nearer to another man, there is an inherent disinclination to use condoms, which are strongly perceived as barriers to the intimacy that is being sought. One particular way of intensifying the intimacy of intercourse is by ejaculating in another person, or even more fully,  91  receiving the ejaculate. For the receptive partner in anal intercourse, therefore, sex with a condom  may be perceived as anticlimactic, and for the insertive  partner, the physical and emotional sensations that a condom nullifies may make him feel 'cheated'.  Fucking is about being consumed and inside someone and they inside you. Condoms are a barrier to this. (CA, 54 years old, Teacher) Fucking as a consummation is easy to understand: to the extent that penetrative sex represents real sex, it can readily amount to the highest point of a sexual relationship. When penetrative sex is unsafe it has added to it the elements of exchange of bodily fluids as a further expression of intimacy, and the implications of trust and mutuality represented by unsafe sex. (Bartos et al, 1995: 51)  There is rationale to barebacking.  The sex itself is rooted in individualistic  requisites — that is, sex is consummated with a special person in a special rektionship (notwithstanding the fact that for some men, every night can be special!). The encounter is not necessarily related to or located in the context o f wider behaviour; the sexual act exists on its own terms, with its own rules. Rules about such behaviour do not necessarily carry over from or to other social events.  The act of sex itself is also something that is often considered inspiring and outside real time ('losing oneself in the moment'). A n d if sex is 'time out of time', then the computation of future risk rektive to immediate H I V concerns cannot operate. This is a di