Despite its FDA approval and CDC support starting in mid-2012, PrEP – Pre-Exposure Prophylaxis to prevent HIV transmission – has remained under the radar as a viable method of HIV prevention. There are many factors affecting the slow uptake of this HIV prevention method (Young & McDaid, 2014). Environmental factors, such as the financial and physical accessibility of PrEP, as highlighted in Alanna’s February post on SexLab findings with surveyed young men who have sex with men (MSM), likely play a role. There are also concerns about the amount of adherence needed for the drug to work, possible side effects, and unknown long-term health effects (Golub et al., 2013). While these are valid concerns surrounding widespread use of PrEP, and must be addressed within the research and prevention communities, there is another topic that is often used as an argument against PrEP: the fear that PrEP will encourage MSM to stop using condoms. This fear reflects the persistent stigmatization of sex between men. Public health dialogue has reflected this for years by promoting condoms as the only way to reduce risk if you are a sexually active MSM. While acknowledged, HIV risk reduction methods like pulling out or topping instead of bottoming are highly discouraged and invalidated, despite this sometimes being the best protection for men who cannot or do not use condoms (Hart & Elford, 2010). This stigmatization has fueled fear around the use of PrEP.
But, if someone is aware of these risks and precautions while taking PrEP, why can’t they have the freedom to make that choice for themselves without being reprimanded by society, public health, and their community? When we consider the most recent statistics for HIV incidence rates in MSM that show a 12% increase in new cases between 2008 and 2010 (CDC, 2013), we also have to speculate about the extent to which condom-only sex education works. While condoms, clearly, are proven beneficial, the condom-only approach that has been historically available to MSM through hundreds, probably thousands of HIV prevention interventions targeting these communities, has actually threatened their safety by failing to address alternatives to condom use. But, where does this stigmatization of condomless sex come from? One thing is for sure, it would be neglectful to not consider this issue as resulting from systematic heterosexism and homophobia – manifesting itself in the constant reminder that sex among MSM is a form of deviance.
For some MSM, a fulfilling sexual experience, whether it be with a monogamous partner or not, includes not using condoms. We rarely hear the backlash directed toward heterosexual condomless sex, as it is considered normative and aligns well with a procreation agenda. Queer men’s sexuality and sexual behaviors have historically been deemed as disgusting and dirty, both for reasons of dominant “moral” beliefs around same gender intimacy as well as the nature of anal sex. Being penetrated or penetrating anally is often portrayed as a messy, nasty act (literally and figuratively). The shame and stigma attached to what is otherwise an erotic, intimate, and/or loving act for many men, is then internalized and perpetuated in queer communities. “Anal sex is dirty” and that’s what we’re told to worry about. It’s in the media, and it’s in our conversations about sex as queer men. “Douche it out, and never have sex without a condom, and if you do, do not talk about it or else prepare to be shamed. Use a condom, and protect yourself from the dirtiness of it all.” These internal community messages are compounded by the fact that for years, MSM have received health messages that stress that by merely having sex, their actions may have negative implications on their own lives and the lives of others. Anal cancer, HIV, and other STIs are at the forefront of how MSM are expected to see their sexuality, rather than for the deeply intimate, enjoyable, and satisfying experience that it can be. Heterosexism continues to impact MSM’s sexuality through framing anal sex in this stigmatizing way, such that condoms are the only approach to having “clean”, “safe” anal sex. In what ways can we resist these oppressive notions and instead honor the lived sexual experiences of MSM, moving beyond the myopic “one-size-fits-all” messaging that positions condoms as the only way?
There are certainly a slew of critiques that can be made in resistance to biomedical HIV prevention efforts, including potential side effects, perceived cost effectiveness, and politics around HIV and the medical industrial complex (Gee, 2014; Lauristen, 1993; Wilson, 2014). However, to say that some of these critiques are not confounded by the stigmatization of MSM’s sexuality only perpetuates the stigmatization and desensitizes us to the shame-ridden social control of MSM. The most important point to take from all of it is that PrEP is certainly a crucial piece of the puzzle that many MSM in this day and age can use to allow for them to express their sexuality freely. Preventing HIV prevention, especially for populations who are most affected by the epidemic, is simply unethical and only contributes to the health inequities faced by MSM.