(French to English translation of SB. “Post-bareback: pour une prévention efficiente et sans moralisme comportemental”, Warning Association (Paris, Montreal, Brussels, Geneva), 2012, October 20th.)
If I had to give a queer and provocative definition of post-bareback, I would say “the rectum is not a grave anymore” (shaped nod to the work of Leo Bersani [1]). Warning is a think tank that builds concepts (“serochoice”, “seroadaptation”[2], “seropride”, “trad-prevention”). Not by intellectual snobbery, but to describe adequately the realness and the changes in LGBT socio-sexual lifestyles, by linking them with the notions of freedom, pleasure, desire and norms – so much political notions. Bareback period has produced – at least in France – sterile polarizations legitimized by the inquisitorial and guilt on sides of the moral community dear to trad-preventionists. Those trad-preventionist indictments refused to take seriously account of the impact of HAART on the lives of people living with HIV and the behaviors of gays. This causes a serious crisis in relation to prevention speeches which became inaudible for a growing share of poz or non-poz gays. They slowed the necessary renewal of prevention paradigm by integrating new tools such as seroadaptation, rapid testing, home testing, post-exposure prophylaxis (PEP), treatment as prevention (TasP) and pre-exposure prophylaxis (PrEP). On the political front, the bareback period has been the climax of dogmas of all-condom, all behavioral, all judicial. Sensationalism and media moral panic [4] around bareback has created, through the stigmatization of scapegoats [5] – indeed catastrophic for the self-esteem and the care of the self and others, so the empowerment – the political environment of criminalization of HIV/AIDS transmission and non-disclosure (in some countries). From a political point of view, post-bareback is the affirmation of a sexuality that is not hostage of the behavioral moralism on one side, and the biopower of doctors, pharmaceutical companies and public health systems on the other. Ideologically, post-bareback corresponds to rejection of any normative injunctions: whether the all-condom, the mandatory treatment [8] or the pozitivity confession.
First, a semantic concept
I had the post-bareback intuition from a comparative observation of LGBT sociability and sexualities between France, Quebec, on the one hand, and sociological/epidemiological readings on HIV from the other. I realized that terms as « bareback », « unprotected sex » or worse, « risky sex » were methodologically ineffective, socially stigmatizing, medically inaccurate and politically moralists because they included too many different situations in terms of context, actors involved and HIV risks [10]. The first aspect of post-bareback thought was to outlaw all words that distort reality. And then guide the perception to moral judgment, because the morality has no space in prevention, in public health and social sciences. Therefore Warning speaks of “condomless sex”, “sex without latex” or “looking for condomless sex” when it is an intentional act and even a claimed identity; of “seroadaptation” rather than “serosorting”; or “serodifference” rather than “serodivergence”. By intellectual rigor, we prefer a factual rather than connoted or oriented semantic.
Beyond words, refusing epidemiological and medical misinformation
Post-bareback suggests a conceptual field to deconstruct trad-preventionist amalgam between HIV and other sexually transmitted infections (STIs). Indeed, HIV is, detected in time and treated, a chronic disease which cannot be cured but from which do not die anymore. Most other STIs (syphilis, gonorrhea, chlamydia, LGV, shigellosis, human papillomavirus, and hepatitis B [11]) are treatable or vaccine-preventable and endemic: when they are not subject to health surveillance, they come back quickly (like other diseases such as measles). As gay men health approach allows us to grasp that the mental, emotional, sexual and social consequences and severity between HIV and other STIs are not the same. Consider the contrary is an intellectual and medical ideological bias, but also acts as a powerful weapon of social control through sexual behaviors, widely used by trad-preventionists. The post-bareback aims to restore the true epidemiological reality against HIV/STIs amalgam, but also against the irrational panic about the danger of super-infections that, whatever sexual morality contractors was saying, were not the massive mortal danger that has been theorized before the arrival of HAART. It has been known since the panic about bird flu in France how dangerous it is to shake public health risks that are not realized because people lose confidence in its speech.
Condomless gay sex was not a fad, self-hatred, denial or suicidal unconsciousness, but a possibility without real danger in terms of HIV risks in certain configurations (between seroconcordants relations especially couples) and under certain biomedical conditions (for relations between serodifferent peoples). The gays have quickly realized, especially condomless subculture, whose members have established themselves empirical knowledge to reduce the risk of transmission. And they assumed their sexual health by practicing regular screening and peer to peer education on current epidemiological and biomedical researches. It is discrimination, prison, sero-ignorance, and community high HIV prevalence, which contaminate the overwhelming majority of gay/bisexual men and trans women, not sexual practices: the second wave of contaminations due to the dreaded relapse has never occurred [12]. Last CROI showed us that 1 on 6 gay does not use condom systematically on a long period. Thinking post-bareback, is to understand this and refuse any epidemiological and medical misinformation.
To think socially about prevention
From a historical perspective, post-bareback corresponds to the advent of embodied biomedical technologies (PEP, TasP, PrEP) and dissemination of combined prevention paradigm. Is this bio-medicalization of risk the final step in the medicalization of sexuality? The future will tell. In any case, as paradoxical normalization of AIDS (or post-AIDS crisis) [13] was linked to the arrival of HAART, post-bareback is a new stage of pharmaco-sexuality related to the preventive integration of these HAART [14]. Post-bareback is condomless sex that integrates combined prevention knowledge: a managed condomless sex which has buried the evil poz gift-giver myth. And that, thanks to biomedical prevention, social sciences and exclusion of political anathemas.
But more than historical analysis, it is necessary to clarify that “post” should also be understood beyond a step on a time axis as a critical reflexive startle. Thus, post-bareback prevention is not just a matter of effectiveness – the condom or TasP used properly are highly secure – but also of efficiency: are people going to be able (and how, and where, and for which epidemiological accountability?) to integrate and combine appropriate holistic prevention which is biomedical, behavioral, and structural [15]? They can, provided that the health institutions, the community organizations, the researchers and stakeholders think socially about this combined prevention. Susan Kippax focused on the issue in a recent article [16].
She says that “while many of these newer “biomedical” technologies […] are not directly tied to the act of sex, thus giving them an advantage over microbicides and condoms, the use of which may interrupt sexual activity, they also need to be assessed for their effectiveness overt time. It is not good enough to simply demonstrate efficacy.” Any innovation, any strategy or intervention has an intrinsic social nature. Its appropriation, to be efficient, must take into account the “specific social” of populations and individuals involved. To oppose it the categories of “behavioral” and “biomedical” would thus not serve to make sense for the prevention of a targeted population, but only for those who draw it. This requires to stop “the steadfast beliefs, held by many biomedically trained professionals in public health [and also some psycho/sociologists], that the patient is a neo-liberal rational actor or agent, an individual, who will act after being counselled and tested. Effective prevention entails developing community capacity and requires that public health addresses people not only as individuals but also as connected members of groups, networks and collectives who interact (talk, negotiate, have sex, use drugs, etc.). Researching HIV prevention demands that we all (biomedical and social/political sciences) avoid invoking a nature/culture distinction that supposedly separates prevention technologies from humans whose lives are affected by HIV.” And that by “engaging with HIV efforts to prevent it as they are encountered in life – as biological and material; as information and technological; as emotional and affective; as social; collective; and institutional.”
Effective prevention “need to enable people to act in ways that resonate with their sexual and drug injection lives” in constant mutations. That “enabling people to take up the technologies and sustain safe sex and safe injection practices depends on a number of social, cultural and political factors including political commitment, community mobilization, stigma reduction, se education and mass media.” This includes “education, law reform, gender equality, poverty reduction, community systems, employer practices and health systems/infra-structure. […]. In short, HIV prevention programmes involve all levels of society because a social transformation is necessary to achieve consistent and sustained reduction in HIV incidence. HIV prevention is most successful when governments and communities act together in partnership on the basis of the evidence provided by social and biomedical scientists.”
Notes:
[1] Bersani, Leo. (2010). Is the Rectum a Grave? and Other Essays, Chicago: Univ. Chicago Press.
[2] Le Talec, Jean-Yves. Jablonski, Olivier. Seroadaptation instead of serosorting: a broader concept and more precise process model, Warning, September 7th, 2008.
[3] Barraud, Sébastien. Sérofier-e-s ?, Warning, June 7th, 2008 (French).
[4] Rubin, Gayle. « Thinking Sex: Notes for a Radical Theory of the Politics of Sexuality”, in Vance, Carole (ed.). (1984). Pleasure and Danger, New York: Routledge & Paul Kegan.
AIDS has been the moral panic of the 80/90’s, reaching its climax with debates around bareback, and even though we have entered in the “post-AIDS” era and that the institutions had made their streamlining. Paradoxically, the moral panic around bareback has been created, scoped and distributed by some of those who fought earlier moral panic about AIDS, rooted in the denunciation of homosexual promiscuity.
[5] See previous note.
[6] Barraud, Sébastien. « Pute » et « barebacker » : analyse comparative de 2 stigmates, 4 February 4th, 2009 (French).
[7] Barraud, Sébastien. De l’inefficace injonction à la norme préventive vers des standards basés sur les expériences intimes…, May 17th, 2007 (French).
[8] Sidéris, Georges. Ethics and health: eradicating the HIV epidemic by treating all HIV positive individuals, including those recently diagnosed, raises some important questions. Sean Strub Poz Blogs, August 25th, 2010.
[9] Charpentier, Nicolas. Menace éthique sur la santé : les relations de pouvoir entre l’Administration fédérale suisse et l’action de lutte contre le sida, VIH.org, Octobre 10th, 2012 (French).
[10] Barraud, Sébastien. Quand les mots mettent à mal un concept coupé du réel : le nécessaire passage à l’ère post-bareback, Warning, September 1st, 2009 (French).
[11] Note that shigellosis is rare, but has made an unusual comeback in Ontario and Quebec. So, here we have deliberately excluded hepatitis C from the analysis because:
1) It is a blood-borne infection, whose sexual transmission is extremely rare and controversy, difficult to prove, and occurs endogenously in a very specific population group (cluster): the gays HIV positive of the leather and condomless sex subculture of large Western cities.
2) This particular sexual transmission of hepatitis C has not presented a problem of public health at a global population or even [gay] community levels, unlike HIV and STIs. In Amsterdam, where precise searches were conducted and repeated, the supposed sexual transmission of hepatitis C among HIV-positive MSM has declined: Researchers have “suggested this trend might be explained by reduced risk behavior, earlier testing, more hepatitis C treatment, and « saturation » within the population at highest risk. Urbanus also explained that STI clinic staff and HIV specialists had increased educational efforts about HCV transmission”: http://www.hivandhepatitis.com/hiv-hep-coinfection/hiv-hcv-coinfection/3716-aids-2012-is-sexually-transmitted-hepatitis-c-among-hiv-gay-men-leveling-off-in-amsterdam.
[12] Barraud, Sébastien. Jablonski, Olivier. Interview with Michael Scarce: Struggle against HIV or domination of the community?, Warning, February 12th, 2010: http://www.thewarning.info/spip.php?article304.
[13] Setbon, Michel. (2000). « La normalisation paradoxale du sida », Revue française de sociologie, 41-1, p. 61-78 (French).
[14] Just think about the contraceptive pill, the morning after pill, the trans hormonal therapies, or erection pills …
[15] Structural prevention refers to the struggle against the socio-cultural aspects that can contribute to the epidemic: poverty, care and support health system, discrimination, legal penalty.
[16] Kippax, Susan. “Effective HIV prevention: the indispensable role of social science.” Journal of the International AIDS Society, 15:17357, April 26th, 2012.
[17] San Francisco: -36% from 2006 to 2008 (http://www.thewarning.info/spip.php?article325). Switzerland: -13% in 2008-2009 ; -4% in 2009-2010 ; -7% in 2010-2011 (http://www.bag.admin.ch/hiv_aids/05464/12908/12909/12913/index.html?lang=fr). Germany: -7% in 2010-2011 (http://www.ondamaris.de/?p=32725).
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