With Condoms, and
Without

Michael Shernoff should be a very angry man. An openly gay psychotherapist with a practice in Chelsea in New York City, Shernoff was infected with HIV during the darkest days of the epidemic and lost many of his close friends to AIDS. Yet even then, before protease inhibitors changed the face of HIV, Shernoff was being visited almost daily by gay male patients who refused to use condoms. Over the years that followed, Shernoff listened attentively as Internet chat rooms and drugs like crystal meth fueled massive rises in unsafe sex and prompted near-hysterical coverage in mainstream news outlets such as Rolling Stone and The New York Times. That said, one would think that Shernoff's book, which draws on a large number of case studies and over 1,500 responses to an Internet survey posted by the author, would be something on the order of a right-wing screed. Without Condoms is quite the opposite. Instead, Shernoff takes on the hornet's nest of psychological factors that propel a large number of gay men to take serious risks in the bedroom. Shernoff also takes aim at AIDS activists who believe that barebacking is an epidemic confined to a limited number of a pathologically self-destructive gay men. He spoke with me by phone from his office in Manhattan after a full day of meeting with patients.

In the preface to your book, Without Condoms, you explain that you're an HIV-positive man who has lived with the virus for more than 20 years. You've lost many of your friends to AIDS. As a therapist you treat gay men who engage in very risky sexual behavior, yet you advocate an approach that is free of judgment and what you call "sex-negativity." Is this a place you arrived at after writing the book? I would call it an evolution. I started discussing unsafe sexual behavior with patients in the earliest days of the epidemic. But as use of crystal increased in our community, many of the men I worked with who were partying on crystal, or "Tina," were also discussing engaging in unsafe sex. It's important for me to meet patients where they are at. Good therapy provides curative emotional experiences. I don't need to act like a nonapproving parent. With patients who have developed drug problems, I needed to advocate a harm-reduction approach if the patient in question wasn't ready to stop using. I decided to apply that same approach to men who engage in unsafe sexual behavior so that I wouldn't run the risk of alienating them or driving them away from my office. If I shake my finger at them and try to tell them what to do, the patient feels judged and infantilized. A harm-reduction approach doesn't eliminate harm all together, but it can help the individual make certain choices that reduce the risk to himself and to the broader community should he choose not to use condoms during sex.

Many people believe that barebacking is confined to young gay men who didn't witness the worst of the AIDS epidemic. Is this true? It's absolutely not true. This is happening across the board. All our current research says that the vast majority of gay men are not using a condom every time they have sex. This is not a single group of "bad gays." This is everybody, at least some of the time, regardless of ethnicity, educational background, and age. True, young men who never saw their friends covered with lesions are among those who engage in unsafe sex. But men of my generation who practiced safe sex for decades are now moving back into unsafe sex.

You write that a "sex-negative" approach is detrimental to any discussion of barebacking or risky sexual behavior. Can you define "sex-negative" and explain some of the problems posed by this approach? Basically, a sex negative approach is antipleasure. It preaches abstinence only, and it doesn't recognize that, for some men, sex without a condoms fulfills a variety of deep important needs, some of which are actually spiritual. Here in the United States, our AIDS organizations receive federal money, so they preach the equivalent of an abstinence-based approach, which is that every gay man must use a condom every time he has sex. There are a great many gay men out there who understand the risks of sex without condoms and have no desire to contract HIV, but they still find themselves with a deep desire to have unprotected sex. These men come to me tormented by these desires because they believe them to be pathological or wrong. The first thing I tell them is that these desires in of themselves are completely normal. No, we don't have the freedom to have risk-free sex without condoms, but if we want to grow strong and cohesive as a community, we have to be rid of this notion that desires by themselves can be bad things. Look, the reality is that there are different phenomena going on out there. There are men who want to bareback because they feel that it will give them a greater sense of intimacy and connection with their partners. Then there are men who have taken on the identity of the barebacker because it is their way of remaining a sexual outlaw. To encourage these men to increase their condom use, we need to meet them where they are and speak to them in a way that addresses their realities.

But can't you argue that a man who is determined to be a sexual outlaw isn't interested in having a conversation about condom use? How do we address the real public health issues presented by men who aren't interested in participating in the conversations therapists like you want to engage them in? Great question. But first off, let me state that in my entire career I have never met or worked with a truly sociopathic individual who is consciously trying to infect others with HIV. Nothing could impact such an individual. But it's important to distinguish between such a personality and someone who refuses to wear condoms out of a desire to connect to the rich sexual outlaw tradition among gay men. The man for whom barebacking has become an identity may very well be committed to disease prevention--it's condoms he won't talk about. A "rational barebacker" is what researchers call individuals who refuse to use condoms because their emotional need for unsafe sex outweighs the risks. But these men are not seeking to spread the virus or become infected themselves, and they can be open to exploring a harm-reduction approach when it comes to their sexual behavior. But that approach needs to be addressed to them without judgment.

What are some of these "emotional needs" that you see driving men to have sex without condoms? Connection. Intimacy. Desire. Pleasure. As a therapist, the most sophisticated approach is for me to help a patient understand what it was about a specific situation that lead them to be unsafe. The primary questions would be, Were they acting out of a need for approval, or were they after a sense of greater intimacy? For some people, sex without condoms is an expression of love and trust. For others, it's the belief that nasty sex is better sex. One of the greatest joys of sexuality is abandon, and AIDS throws a bucket of cold water on that. The fact is some people may prioritize pleasure and intensity over their own longevity. The point is these reasons are not all pathological. But they are difficult for gay men to discuss because many of us have vestiges of an internalized homophobia which turns into a kind of internalized erotophobia, a fear of sex and pleasure, which is a part and parcel of the Puritan streak in this country, where sex is used to sell everything except sex education. It's possible to have public health approaches to preventing both unwanted pregnancies and sexually transmitted diseases that are sex-positive.

When many of us hear the word "abandon" in terms of gay male sexuality, we imagine a return to the worst days of the AIDS epidemic, a dark period that followed years of intense sexual abandon. Are we Puritans for thinking this, or is it possible this is a valid interpretation of history? No one wants to see large numbers of new infections and people dying. But the desire for sexual freedom and abandon is normal and natural. Contemporary AIDS prevention efforts need to speak to all categories of gay men without demonizing those who don't use condoms as "bad gays who are pathological." And historically it's important to differentiate between the so-called sexual Camelot the 1970s, when no one knew there was a life-threatening virus being passed around, and the days after the onset of the epidemic, when large numbers of men were gravely ill or dying. During the darkest days of the epidemic, I heard a lot of gay men become sexual revisionists; they tried to disavow the fact that the sexual celebration of the 1970s had many wonderful bonding and community building aspects to it.

Throughout the book, you give high marks to the HIV prevention methods used by other countries. What do you think they're doing right? Which techniques should we borrow? Countries like England and Australia have come up with prevention methods that don't rely solely on campaigns that tell all gay men to wear condoms all of the time. In London, GMFA [Gay Men Fighting AIDS] spells out harm-reduction techniques for men who refuse to wear condoms [through a link to its Web site]. Another London Web site offers what's called a "negotiated safety agreement" for committed couples who want to work towards not using condoms but need to make certain agreements regarding monogamy and acceptable behavior with outside partners. The English, Australian, and Dutch governments are all funding research into the area of "negotiated safety agreements" and other nonabstinence-based approaches to HIV prevention. These countries all acknowledge that consistent use of condoms is the best way to reduce the spread of HIV. They also acknowledge that refusing to address the sex lives gay men are actually having is in fact counterproductive to limiting the spread of HIV. But here in the United States, this kind of sex research has been seriously hampered by the election of George W. Bush and the ascendancy of the religious right in Congress.