The Prejudice of PrEP: You’re Fucked if You Don’t Bareback

Bareback Privilege and the Demise of Risk-Aversion

There’s a new kind of gay male sexual privilege, one that’s entering dangerous areas of health, disease control, and prejudice: gay men who are on PrEP and only have bareback sex.

There Is Risk in Everything We Do

“As renowned PrEP educator and marriage and family therapist, Damon Jacobs, thoughtfully pointed out in a piece for The Advocate titled, “Sex With PrEP, Like Life, Is Never Without Risk,” 133 pedestrians are killed in New York City each year by cars. Just walking out on the street is dangerous. There’s risk in everything we do.” — Source

This period in history — the use of PrEP — reminds me of HIV shaming that happened in the 80s and 90s. Gay men who were negative (or thought they were) would shame HIV+ men by shunning them, which was most visible in online dating profile. You could read ads that said, “HIV- only”, or “Only safe and clean”, etc.. The truth is that anyone could lie and say they were HIV- or simply not disclose if not asked.

I remember having sex with a guy I met sometime early 2000s. I was fucking him with a condom and I noticed he had a tattoo of an AIDS ribbon. It was in an innocuous place that I only saw because of the position of his legs in sex. It took me out of the moment and confronted me with my own prejudice, but we keep playing and the sex ended well. It was a reminder to me that if I was protecting myself, I could relax. I hadn’t asked him prior to meeting about his status, probably because HIV had been around for over 20 years and the routine of asking, or being freaked out about someone having HIV had diminished — but clearly my fears and prejudice had not.

Human Behaviour and Unconscious Choices

We often make choices that are not in alignment with our best judgement, let alone our values, when we are denied something we want. In this case, the denial of affection and sex based on prejudice can lead to unhealthy choices and behaviours. In the late 90’s I witnessed the rise of so-called “bug-chasers”; individuals who actively sought HIV+ partners to agree to fuck them raw in the hope of seroconversion. Their desire was to have what they felt was denied them, the freedom to have sex “the way nature intended”.

Basic Human Needs

These choices — that of the bug-chaser to seek seroconversion — were psychological, based in human need and self-worth. Add onto these choices the social fabric of exclusion, being “othered”, not feeling accepted for who you are as a gay or trans man, and so on. Many of us took a self-righteous approach, assuming a higher moral ground, when in fact, there were many of us who secretly longed to ditch condoms and just “get it over with.” This is part of what lead to the term, “condom fatigue”, which sadly misses the real and deeper human truth entirely. As an already oppressed and marginalized group, now you’ve taken away our freedom to have sex however, and with whomever we want. The golden age of free, uninhibited gay sex was over. We had lost, what felt like, our only privilege.

What is this universe we live in now?

For the longest time you were taught to ask about your partner’s status, and many HIV- men had to face rejection on an all-too-regular basis. Then dating apps allowed users to select HIV status, sexual preferences, last testing date, and options like “negative on PrEP”, etc.

While those options are useful for making choices — having too many choices is problematic. Psychologically, when we are faced with too many choices, we have a hard time making a decision. We see this in supermarket research on consumers buying behaviours. If you have a shelf for jams and you have 10 flavours, with five companies offering the same 10 flavours, how do you choose? What if three of the brands are all on sale? Now make the comparison to the list of labels on a profile on Grindr or Scruff. Sometimes there are so many variables, not including the personal description that may be seeking or excluding other variables, you wonder if you will even be considered. What do you have to compromise on to get what you want?

Dorothy, I don’t think we’re in Kansas anymore

What scares me about these conversational interactions about PrEP since it’s become so popular and normalized — and since cheaper generics were introduced in Canada — is the laissez-fair attitude towards bareback sex. A couple of years ago I couldn’t figure out how guys in their early 20s could afford PrEP when it was $1,200 Canadian per month or more. “They get it off the black market”, a friend told me. “What? And they trust this pill with their life?” That’s like going out to a rave and buying drugs, not knowing if the pill contains fentanyl or something else that might send you to emergency or an early grave.

Many men on PrEP wear this choice as a badge of honour, like an over-zealous, flag-waving patriot. I’m on PrEP and I’m invincible! But are they really and what about the long-term side effects and compliance?

What about Long-Term Side Effects?

We are only a few years into this “PrEP experiment”. What happens in 10, 20, or 30 years of people being on this medication?

“The main adverse effects observed with PrEP are gastrointestinal related; basically mild to moderate nausea, vomiting and diarrhea. Other adverse drug effects worth monitoring are liver enzymes, renal function and bone mineral density. PrEP as an intervention to reduce HIV transmission appears to have a safe benefit-risk profile in clinical trials. It is recommended for widespread use but adherence monitoring and real-world safety surveillance are critical in the post-marketing phase to ensure that the benefits observed in clinical trials are maintained in real-world use.” (Emphasis mine) — Source

What about starting PrEP in your early 20's?

What are the psychological and physiological factors or taking PrEP earlier in life when your body is still developing, like taking steroids or testosterone in your teens or early 20's? The younger we are, the more risk averse we are, thinking we will live forever, or that our choices won’t have consequences.

“PrEP can also reduce bone density by 1–2%, causing slight thinning of the bones. This loss reverses after PrEP is stopped.

This side effect might be more important if you already have low bone density related to other factors.

It might also be important if you are younger than 30 as your bones are still developing.” — Source

Personal responsibility, self-care, and inclusion

The choices that we believe we are making for ourselves may sometimes have a butterfly-like affect. My concern is that the sexual politics of PrEP exclusivity (taking PrEP = only bareback sex), not only reinforces a form or privilege but may lead to yet another health crisis, be that viral or further psychological “gay shame”.

PrEP, PEP, and Safer Sex Resources

• Canadian guidelines for PrEP and PEP to help prevent HIV infection
• ACT Toronto
• Frequently asked questions about PrEP
• What’s the difference between PrEP and PEP? Find out more about these two HIV prevention methods with this infographic.
• Weighing Risks of TDF/FTC PrEP Side Effects in People Without HIV
• Pre-Exposure Prophylaxis for HIV Prevention: Safety Concerns
• HIV in the Modern Era
• PrEP and side effects
• Do the side effects outweigh the benefits of PrEP?