Saeed Jones: OK, let's be real: We have to start with Truvada if we're going to have a candid discussion about gay men and sex in 2014. The drug has sparked a heated debate about the past and future of the HIV/AIDS crisis as well as necessary and complicated questions about everything from bareback sex in our bedrooms and in porn to disclosure, serosorting, and relationships between HIV-positive and HIV-negative gay men.
If HIV-negative gay men take Truvada once a day, they drastically reduce their chances of acquiring HIV. (Antiretrovirals can also be taken up to 72 hours after an unsafe sexual encounter — this is known post-exposure prophylaxis, or PEP — but people should be aware that the evidence for whether this kind of HIV "morning-after pill" works is much less solid.) Personally, I'm still learning and making up my mind about whether or not Truvada is an option I'd like to act upon. But it is great to know that I at least have a new option. Still, though, I was a bit taken aback when Larry Kramer told the New York Times: "There's something to me cowardly about taking Truvada instead of using a condom." Steven, what did you think about Kramer's comments?
Steven Thrasher: I was kind of stunned by Larry Kramer's comments initially, though not entirely surprised after thinking about them a bit. In Tim Murphy's outstanding New York Magazine article, you can see how it is easy to imagine a young Larry Kramer — the author of The Normal Heart and basis for its protagonist — as very at odds with the elderly Larry Kramer who made those comments. The second (and last) time I interacted with Larry Kramer, I found him to be almost entirely against a position he was haranguing me to be for the first time I'd met him. (Of course, like any of us, Kramer has certainly earned the right to change his mind over time.)
But I've certainly seen a big generational difference in how people respond to HIV, especially in reporting the story about Michael Johnson. (Johnson, a former college wrestler, is awaiting trial on one count of "recklessly infecting another with HIV" and four counts of "attempting to recklessly infect another with HIV," felonies in the state of Missouri.) Some young activists asked me after reading the story why I hadn't written about Truvada, or PrEP. However, the truth is that this is all very new to the public. The men I wrote about having bareback sex in St. Louis did not know about Truvada in early 2013. Most probably don't still. Safe sex to them was simply a matter of using condoms. I questioned the school in that story, Lindenwood University, about why it didn't have condoms available for free or for sale on campus. A year and a half later, Truvada is only barely starting to register as an option for people who are highly informed about HIV/AIDS in major metropolitan areas. I think this summer will be looked back upon as a turning point in using Truvada as a major tool for HIV prevention, especially considering the Centers for Disease Control and Prevention's recent endorsement for all sexually active gay men to take it and a study presented last week at the International AIDS Conference that showed how effective taking the drug can be. But we're not there yet. I mean, while working on the story, I met someone in St. Louis who said his doctor refused to prescribe Truvada because it was a "whore's drug."
David Tuller: I think the introduction of Truvada for HIV prevention has definitely been really challenging for guys of my generation, and Larry's — I'm 57, so I'm quite a bit younger than him. It's upended the basic assumptions we've lived with for 30-plus years. (Can it really be 30 years?) I had my first sexual experience with a guy when I was 21, in 1978. I didn't feel comfortable having sex at all at first, but by the time I was starting to, the epidemic was already getting underway. In those days — the early '80s — I pretty quickly became terrified to have sex at all. Could you kiss? What about blow jobs? Fucking felt too fraught to think about. What could you do? It really froze my budding sex life in place. I'd missed the wild days of the 1970s, or rather, I just caught the very end of it. And that terror stayed with me for years. And now, it's a completely different world. We were, basically, terrorized into using condoms. You were a bad community citizen if you didn't. And of course, those of us who adhered to the "condom code" did not get infected, thankfully. But the price we paid was that sex was always — always — accompanied by great fear and second-guessing. I think many men of my age cohort think, If we could use condoms faithfully, why can't you?
SJ: I'm 28 years old. When I started realizing I was attracted to men, one of the assumptions I made was that HIV/AIDS and being a gay man were inextricably linked. I did a lot of reading and learning (and mis-learning) on my own because I didn't feel comfortable asking questions about sex and, obviously, my high school sex education course didn't address LGBT sexuality, HIV/AIDS, etc. America is still "debating" whether or not we should teach middle school students about birth control; imagine how far we have to go toward teaching teens and pre-teens about LGBT-relevant sex. Kids are coming out (across the LGBT spectrum) at earlier and earlier ages, but sex education is playing catch-up.
So, though I didn't live through the AIDS plague years, that terror you mention was definitely a part of my sexual coming-of-age. I remember going to the public library in my hometown and looking for nonfiction books about gay people. The only books available were either about HIV/AIDS or "coping with" your gay child. My sophomore year of high school, I stole a copy of The New Joy of Gay Sex from a Barnes & Noble! Though I didn't fully understand the politics of why I wasn't being educated in a useful way about gay sex, I knew I wanted and needed to understand my body and how I felt about guys. I shoved that book into the front of my jeans and walked, quite awkwardly, out of the bookstore — nervous but incredibly proud. It was like, Fuck you! I'm going to figure this out one way or another. At summer camp that year, the boy I was hooking up with would page through the book with me and then we'd try things out. (We even snuck away from the camp to buy condoms and lube at Walmart.) Having someone just as audacious, horny, and determined as I was helped me feel sane. It was the only time I had sex before my twenties that I wasn't terrified that the world wasn't going to collapse in on itself immediately after my orgasm.
ST: I'm 36, and I'm right between both of you. And I have honestly lived in terror of HIV for my entire life, long before I knew I was gay and before I was even consciously sexual at all. When I was growing up in the mid-'80s, kids would run around on the playground tagging each other, yelling, "You've got AIDS!" This fear of sex long preceded the joy of sex. All of my sex-ed classes in school were embedded with a strong message: "Pregnancy will shame you, but AIDS will kill you!" Ryan White was as influential a character, real or fictional, in my formative years as Ronald Reagan, Christa McAullife, or Luke Skywalker. When I arrived in New York City in 1995 and started going to a gay-affirming church, it was coming off years of nearly weekly funerals. (When I mentioned this to Mark Schoofs, who edited the Johnson story with Saeed, he wrote that the dates made sense, because 1996 was a "Rubicon in the history of AIDS and gay life. That's when antiretroviral drugs become widely available in the United States and other wealthy countries, slashing the death rate. So any American who's 30 or younger came of age sexually in an era when AIDS was no longer a certain death sentence. But there is still huge shame in having HIV — and the fear of that remains.")
DT: So we've all had some of that experience of fear, I guess. But the point is, I don't want 20-year-old or 25-year-old young gay men to have to have that terror. Life and sex are scary enough without that overlay on top of them. I want young gay men to have great sex lives, to be able to experiment and find out what they like. It doesn't seem reasonable to me to expect them to have the same attitude toward sex and condoms that I was forced to have when I was in my twenties and thirties, when people I knew were dying all over the place. Saeed, how did that terror that you felt impact your own process of coming out?
SJ: It impacted the way I felt about the sex I was having before and for several years after I came out. I started having sex with men when I was 15 years old. (I don't think that's especially unique, but correct me if I'm wrong.) The experience of sex was always a tug-of-war between my desire and my fear, which sounds similar to what Steven has said. I wanted to have sex because I thought sex was what it meant to be gay. There weren't a lot of images of out gay men that didn't portray them as purely sexual beings so I figured, OK, I guess that's who I am now. So I had sex and often it was pretty great. I always used a condom. I tried to be as careful as one can be when hooking up. But afterward, I'd get overwhelmed with feelings of shame and guilt. By the time I was a college student, I started wondering if I had a sex addiction. It wasn't until I had more gay friends who were sex-positive and able to talk intelligently and candidly about sex did I realize 1) I wasn't a sex-crazed maniac, and 2) the shame had much more to do with American culture than it did with me. The only thing that turns Americans on more than sex itself is shaming people who enjoy sex. When straight men talk about enjoying sex, America pats them on the back and says, "Boys will be boys." When gay men talk about enjoying sex, we're sex-hungry animals and perverts. And I should say, this attitude is perpetuated by gay men as well as straight people.
DT: That's interesting because no one ever really thought about "sex addiction" when I was coming out. In the '70s, it felt like you were supposed to be having sex constantly. I wasn't personally, but it was considered the norm and a "fuck you" to everyone who'd made us feel ashamed or bad for being the way we were. I remember when I first went to a bathhouse in New York, Man's Country on 15th Street, between Fifth and Sixth. It was incredible — nine floors, with an elevator! And all sorts of venues on different floors — a jail setup, a big meatpacking truck replica that was refrigerated and got colder as you went into it, rooms with slings, and whatever. Nine floors! Astonishing. I sort of imprinted on it as my image of what a bathhouse should be, and was always disappointed when I'd go to a sauna in other cities or countries that they weren't nine floors of naked men, with an elevator! But again, by the early '80s, when I would have been more ready to take full advantage of the opportunities for sex, things had already changed. No one really questioned the need for using condoms; you didn't have to have a discussion about them because they were simply accepted as necessary.
ST: I was pretty late in coming to terms with my own sexuality and wasn't having much sex at all until my mid-twenties. I do wonder how much my anxiety about HIV played a role in this, as I grew up in a time (as a friend of mine put it) after the AIDS crisis started but before Will and Grace made the word "gay" acceptable for broadcast on NBC. When I finally got around to sex, I was talking to my partners about safe sex and sexual histories, and I was also engaging in a lot of exceedingly, excruciatingly safe sex. Your story, David, and Tim's in New York made me think about how much HIV and the pharmaceutical industry have played a role in the sex lives of gay men (who are both HIV positive and negative). Tim's story also points out that, in addition to possibly improving public health, Truvada could potentially transform gay men's sex lives emotionally and psychologically. I am a very nervous person by nature, including sexually. I worry not only about condoms breaking, but about risks I know are scientifically unfounded. Something like Truvada might help nervous people like me.
But I haven't decided to go on it, and it (like most things!) makes me nervous too. I worry about the side effects. All medications have side effects, and sexual medications (like birth control pills) have medical, political, and emotional side effects that will play out for generations. (I mean, who'd have predicted that 50 years after the Pill came out, a craft store would use it as a tool to limit health care access? Is Gay Inc. ready to defend "Truvada Whores" when Hobby Lobby undoubtedly uses them as fodder to further dismantle Obamacare?) Perhaps the side effects will be worth the overall benefit. One thing that fascinated me in the Michael Johnson story is that no one seemed to be having sex with fear. Michael didn't seem to be. The young gay men I interviewed who had lots of bareback sex with lots of people just after asking them if they were "clean" didn't seem to be afraid. The young straight men seemed to think, remarkably for 2014, that AIDS was still only a "gay disease." Like you said earlier, David, I don't want these young people to be afraid, but I recognize that they're quite different from me. Not better or worse, they're just different. They don't have my fears. And I don't want them to! But I do want them to be safe. If Truvada can help make them more safe, I think it should be considered.
DT: I asked my doctor about Truvada six months ago. I told him I was considering it. He has a large practice of gay and HIV-infected men, and he wasn't too excited about the idea. He asked if I was in danger of not being safe, and I said, well, in terms of getting fucked without a condom, no. So he asked why, then, I'd want to take it. And I said that, well, I want to be able to have sex again and not have that fear lurking around. Sex and fear have been yoked together in my life since the epidemic began. At this point, the fear is more a function of habit and a mind-set that I had to adopt at an impressionable age. Before I get too old to have sex at all — and I hope I never get to that point! — I'd like to experience what it's like not to have that linkage in my mind. Anyway, I didn't push it at that point, but told him I'd want to revisit the question next time I see him, which should be this fall. I'm still not 100% sure I want to do it, because I don't particularly want to take an antiviral open-endedly. But I'll be curious to see if his attitude toward it has changed, if he's more comfortable about it.
SJ: Among friends, and guys I've spoken to personally, I've yet to meet someone who didn't encounter some kind of challenge from their health care provider regarding Truvada — either [it] hasn't been covered by insurance companies or doctors themselves have argued against it. None of this helps my uncertainty. Also, it's not like I'm excited about the prospect of taking a prescription pill every day, but as I said before: It's about having the option. The similarities between this discussion and reproductive justice aren't lost on me. I do wonder if Hobby Lobby would cover Truvada for its employees…
ST: I'm curious, too, because I just don't think there is much awareness about it. I've been in Europe the past few weeks and I've met gay men who are pretty knowledgeable about HIV who've never heard of it. I only heard of PEP — that's post-exposure prophylaxis, or taking antiretroviral drugs after an unsafe encounter to help prevent the virus from taking hold — because my doctor, who is gay and sees many gay patients, gave me his home phone number and told me to call him any hour of the day or night if I ever needed it. (But, and I'll always remember this, he said not to worry if I was a top and the condom broke, but to take PEP if I was a bottom and the condom broke.)
Something I thought about reading your piece, David, is that so much of our lives as gay men — particularly our sex lives, but for so many, their entire existence — becomes in debt to the pharmaceutical industry. Big Pharma owns many populations across the globe, but HIV-positive people particularly so. And as much as there are gay men who want to have sex without being yoked to fear, which Truvada could help achieve, there are also gay men who want to have sex without being indebted, yet again, to Big Pharma. HIV/AIDS creates one kind of existential crisis, but needing another drug for living creates yet another crisis, at least economically. And consider, as David's and Tim's pieces both point out, that the marginalized groups who are most at risk for HIV — poor youth of color — are less likely to be enrolled in health care plans in the first place and are unlikely to easily qualify for HIV medication. The ones most at risk are the least able to get medication.
DT: Well, let's also not forget the power of insurance companies to impact our lives as well. In the piece I wrote about insurers placing HIV meds in their most expensive "tiers" requiring patients to pay exorbitant amounts, it can be hard to figure out who is most responsible for the dilemma: the insurers, or the drug companies for charging huge amounts for the medications in the first place, or both? And as you point out, Steven, whichever it is, the ax falls hardest on African-American and other gay men of color. Middle-class white guys might have problems accessing drugs but often have more opportunities or social connections to help them access what they need.
One aspect that seems important to discuss is the great divide between poz and negative guys. Ten or fifteen years ago, the phrase "viral apartheid" was being tossed around a lot. Since the advent of protease inhibitors in 1996, I think that phrase has fallen by the wayside, but the divide still remains. As an HIV-negative guy, I've often been turned down by poz guys who don't want the hassle and anxiety of messing around with someone who could potentially get infected, even if everything we did fell within safe sex bounds — i.e., no fucking without condoms. And I totally get that, even though it means I've missed out on some opportunities for great, hot sex (or so I fantasize). And poz guys long ago seem to have decided to forego condoms to a large degree when fucking each other. So I understand their reluctance. If I've always retained some anxiety about infection, even if I haven't done anything that would get me infected, it makes sense that they would experience a parallel anxiety. And why should they put up with that, if they don't have to?
ST: I'm glad you brought that up, David. I didn't really understand until I wrote this last story that the stress is can be as bad or worse for positive guys as it is for negative guys when the two hook up together. What the Johnson story also taught me is that the onus is, legally speaking, 100% on the positive guy in such interactions to keep the negative guy negative. Aaron Laxton told me some HIV-positive guys he knows will make sex partners sign a form or record on video acknowledging their status.
And positive guys are encouraged to live with this burden almost entirely, lest they be shamed (or worse, prosecuted) for transmitting the virus.
A common attitude I found with guys who barebacked thinking they were negative in Missouri was that it was their partner's job to be "clean" and to not infect them, that they didn't need protection other than that. But one of my favorite responses to the article was written by drag queen Lady Bunny: "You are responsible for protecting your own @ss and what goes into it. Men can often be pigs and men are liars--especially when horny. If you protect yourself, there's no need to blame anyone else."
SJ: The word "clean" is used so often on Grindr profiles and during the hookups themselves that it is all but lost its meaning. If we say "I'm clean," aren't we also saying that HIV-positive people are "dirty"? It's a mind-set that's not all that different from how gay men were treated in general during the initial years of the AIDS epidemic. (I'm reminded of the scene in The Normal Heart when an airplane pilot refuses to fly the plane because one of the passengers has AIDS.)
DT: Yes, I've always wondered why the onus should be just on the positive guy to "confess" his status and not on the negative one to ask. That makes no sense — it's the responsibility of both. In fact, for many years I never bothered to ask because I assumed people were positive even if they said they were negative, or at least I had sex with them as if they were. In other words, if you used a condom, someone's status was really immaterial. The only reason you would have to know is if you intended to get into other stuff — which is what's going on a lot these days with younger guys.
ST: Also, neither the law nor public assumption give much credence to the medical reality that, if an HIV-positive person is properly medicated, the odds are almost nil that he will transmit the virus.
DT: That's certainly true, although people can have blips when their viral loads go up temporarily for whatever reason, so the protection isn't absolute. A much bigger risk, of course, is when people assume they're negative but are actually infected and have a high viral load. That's why the CDC has been making a push for people to get tested and find out their HIV status.
ST: In reporting our Michael Johnson story, it was fascinating for me to see in new ways how gay people of different races experience sexuality (and how sex intersects with medicine and law) so differently in America. And also, how differently HIV-positive and HIV-negative men experience sex and society. And what a powder keg it is when race and differing serostatus intersect! Obviously, the Johnson story got so much attention when it broke because he was an HIV-positive black guy using the nickname "Tiger Mandingo" who was accused of having sex with a lot of white college students. But interracial sex isn't at all unusual among gay men. In fact, when I met with Dr. Colleen Hoff last summer, who runs the Center for Research and Education Gender and Sexuality at San Francisco State University, she told me that in the Gay Couples Study (the largest ever such study, which has followed over 500 gay male couples for about six years now), some 50% of the couples were interracial. Which is a lot more than heterosexual couples. Still, even though we might be more prone to be in relationship with each other, gay American men of different races experience the world very differently. In the Johnson story, the black guy who had bareback sex was considered a perpetrator, while the white guys who had bareback sex were considered victims. We reported on research that shows that black men are more likely to be convicted of HIV-related crimes, and to be sentenced longer when they are. (And by the way, I found no shortage of white guys looking for raw black dick online as I researched that story in St. Louis.) As the Times reported last winter, "when only men under 25 infected through gay sex are counted, 80 percent are black or Hispanic — even though they engage in less high-risk behavior than their white peers" (emphasis added).
SJ: For many, many reasons, I'm obsessed with the intersection of race, racism, and sex in large part because it so often goes undiscussed, often with queer people of color bearing the brunt of the consequences. Just yesterday I was looking at the Secret app, which allows people to post anonymous "confessions," and one of the posts I saw said, "I want a black boyfriend!" The post, at the time, had two comments, almost anonymous: "I volunteer!" And "I want a black boyfriend too!" It all had a "How Much Is That Puppy in the Window" vibe to it, which was both absurdly funny and horrifying.
More broadly, though, I've found that a lot of LGBT people, gay men in particular, are terrible at talking about race and racism. This isn't unique to our community, of course, but so often I'll see queer people of color try to raise the question and white gay men bristle at the mere mention of racism as a reality in the way we are engaging each other. And I'm certainly not the first person to notice that whitewashing has certainly been present in the marriage equality movement.
ST: I think this is troubling, but fascinating. There have been a lot of critics, me among them, writing that the dominant narrative of gay progress this year portrayed in HBO's The Normal Heart, the HBO documentary The Case Against Eight, and Jo Becker's book Forcing the Spring have all perpetuated a meme that the advance for gay rights has been solely because of white (and sometimes even straight) men. And I think a lot of the frustration around this is because, even though we may fuck each other and love each other and even be in relationships or marriages with each other, our economic, medical, and legal experiences are so different as white gay men and black gay men in America. Peter Staley of ACT-UP, who was featured in the 2013 documentary How to Survive a Plague, opened the debate up about why so many gay white men are seen as heroes in AIDS narratives pretty interestingly here, but a lot of gay white men see no issue to critique here. And that's what happens, I think, after the LGBT movement has pulled so far from sex itself. Marriage and wedding registries are much easier to talk about than fucking, or diseases related to fucking, or life disparities between people who fuck each other.
DT: The marriage thing is interesting, too, because of the presumption that married couples will be monogamous. I've heard straight people say that they've come to support same-sex marriage because they know loving, monogamous gay couples. And I thought, Whoa, how do you know they're monogamous? It seemed like a pretty big assumption, although maybe that's what they told him, and maybe it was true. But I think that's a widespread assumption among heterosexual people — that men in same-sex marriages will adopt monogamy as a lifestyle value. And I think that's probably a very questionable assumption. I'm curious if young gay men coming of age these days have adopted that perspective or not, and if they have, how long they will adhere to it.
ST: One of the most explosive findings from the Gay Couples Study I mentioned earlier has been that half of all gay couples are openly non-monogamous. I wrote about that last year, and I got a fair number of negative reactions from gay activists I know for focusing "too much" on the sex lives of gay male couples. I don't think there's anything wrong with a couple choosing to be non-monogamous, but I do think it's dangerous to assume they are. In fact, a lot of sexualitiy academics I know find this to be a leading area of HIV prevention research. Because we've been taught that couplehood equals monogamy in heterosexual marriages (even when that's not true), a lot of gay men in partnerships have bareback sex more with their partners than single guys do with other single guys. Two single dudes are more likely to use condoms than two partnered dudes. And if half of all gay couples are not monogamous, this makes them more susceptible to STIs than single guys. A lot of people, marriage equality activists among them, have falsely advanced the idea that couples are more safe and more deserving because they are monogamous. Levels of monogamy could change over the coming generation, as legal recognition of gay union happens. Truvada could alter how susceptible couples are to HIV. But as of today, gay couples shouldn't be assumed to be monogamous, and their risks for HIV transmission ought to be considered seriously.
SJ: I can't speak for young gay men everywhere, but I think a committed open relationship is both practical and ideal. This shouldn't be (and hopefully isn't) regarded to my investment in marriage equality. It's just — like, isn't the entire point of being LGBT people that we don't have to live the way straight people choose to live? In a way, it goes back to the idea of the "joy" of gay sex, which I really believe in. I want equal rights, but that's not the same thing as wanting someone else's way of life. But hey, that's just me.
Obviously, this discussion could keep going — and it should! Which is why, on Aug. 5, BuzzFeed will be hosting a live panel with myself, Steven Thrasher, and Dave Tuller! A recording of our conversation will be available soon after and posted on the site.