Health educators should work with the inner contradictions that 'barebackers' express

When asked by researchers to talk about their practice of having ‘bareback’ sex (unprotected anal intercourse), HIV-negative gay and bisexual men express a contradiction between their concern to remain uninfected and their simultaneous awareness that their behaviour may expose them to infection, according to a study published in the July issue of Qualitative Health Research.

The research suggests that, rather than giving factual information about risks, health promoters should create spaces in which men who bareback can talk about their behaviour and its justification, in order to explore inner contradictions and reframe their behaviour.

This isn’t the first study to show that many HIV-negative gay men who bareback remain concerned about the prospect of acquiring HIV and want to avoid infection. However, previous studies have given little attention to how men understand and deal with this tension.

Researchers at Columbia University therefore recruited men who self-identified as a ‘barebacker’ or someone who ‘practices barebacking’ to take part in a two-hour, face-to-face, in-depth interview about their sexual behaviour. Men were recruited from dating web sites associated with bareback sex in New York. Interviews were conducted in 2005 and 2006.

Although HIV-positive men were also interviewed, this analysis covers the 89 HIV-negative men who took part. Their average age was 32, four-fifths were employed and they were broadly representative of the ethnic diversity of New York City.

Findings

Timothy Frasca and colleagues say that they “observed contradictions in some men’s narratives between their wishes to avoid HIV infection and their simultaneous acknowledgment of the risks involved in their barebacking practices”. The researchers identified a number of ways in which their respondents dealt with these contradictions during the interviews.

Some men said that, on occasion, intense sexual sensations could overwhelm their calculations about risk:

“Something happens. You know, you get to a point, it’s as if being sexually turned on – you know, they talk about how your judgment is impaired when you’re on drugs. I don’t need drugs. All I need is to be with a hot guy, and a good deal of my judgment gets put on hold.”

Men who said that they were powerless in the face of sexual desire did not try to explain such incidents away as not really being risky. Instead they admitted that they were unable to carry out their prior intentions.

However, the authors note that, like a number of others, this respondent used the present tense to describe this scenario. His language suggests a recurrent or habitual situation, rather than a specific and unusual incident.

Other men described sexual practices – such as withdrawing before ejaculation or not barebacking on a first meeting – which they thought could reduce the risk of infection. But at the same time, they often expressed doubt about the reliability of what they were doing.

“I know that precum has HIV in it too. So you really don’t protect somebody by pulling out. But it’s kind of a pretence toward that.”

“You know, if you do an enema, then that kind of washes everything around, so, um, [a doctor] said that’s not, not always, you know, a sure way to make sure that even if someone does come inside you, to get that out, so, you know [inaudible] risk is still high.”

Given interviewees’ lack of confidence in strategies such as these, the researchers suggest that the beliefs about sexual risk did not determine the limits of the men’s behaviour, but helped to reassure the men about the behaviour they were engaging in anyway.

A number of respondents employ a strategy that the researchers describe as ‘compartmentalisation’ – contradictory thoughts and ideas were separated out and dealt with at different times. Typically, men pushed their thoughts about HIV and risk aside for the duration of a sexual encounter.

“Sometimes I just try to push it out [of my mind] so I can enjoy the sex, because that’s what I’m there for. I’m not there to freak out about my status.”

 “If someone doesn’t put [the condom] on, then I actually get a little more excited, that, oh my god, he’s actually going to fuck me without a condom. And at that time, it doesn’t really come in my mind that, oh, I should talk to him first if he’s negative, or ... like, the risks involved, or does he do this often? Like, any of that stuff. I’ll say, like, no, no, no, it will just kill the moment. Let’s just do all that later.”

Some interviewees struggled to resolve the contradictions in their reasoning:

“Now granted, if, you know, a guy comes, and he fucks me, and I don’t have any other previous experience with him, nor do I know whether or not he’s taken loads, then I don’t know. So I know I’m at equally high risk, but I don’t know that I’m at that risk. Does that make sense?”

Others acknowledged the existence of contradictions, while expressing discomfort in doing so:

“You know what? I usually assume everyone is positive. Which makes it seem even more stupid of me to fuck without a condom, but I do it.” Researcher: Does it trouble you? “Eh, I tend not to over-process that sort of part.”

“Life is filled with contradictions… I suppose I’m contradicting myself by saying that I’m super concerned. I am. Granted, I am very concerned. But then, if I’m so concerned, why do I have unprotected sex? I honestly don’t know.”

Finally, some men expressed confidence in their ability to remain uninfected based on their success in doing so until now. Some men felt ‘invincible’ or suggested that they had an approach that had worked for them so far:

“I mean, I always, always tended to go with the gut feeling. With the gut feeling. And in the twenty-five years I’ve been on this earth, it has never led me wrong.”

Interpretation

Timothy Frasca and colleagues believe that the theory of cognitive dissonance, developed by the social psychologist Leon Festinger in the 1950s, can be helpful in understanding these men’s accounts.

Festinger argued that conflicting cognitions about beliefs and behaviours (e.g., “I want to remain HIV negative” vs “I am engaging in risk that could result in HIV infection”) produce discomfort and motivate individuals to resolve the tension by bringing the two cognitions into agreement – especially when the contradiction threatens the individual’s understanding of himself as being a decent or rational person.

The tension often leads people to change their beliefs to fit their actual behaviour, rather than to change their behaviour (which may be more difficult). They may deny or distort certain understandings, or incorporate new beliefs to make their overall beliefs more consistent.

The researchers comment: “When questioned about barebacking in the research interview, many men who practice it offered a perception of their own risk that fit the behavior engaged in. That is, the barebacking behavior of men in our sample appears to have influenced their construction of risk-avoidance postures that are consistent with continuing the practice. This is quite different from the assumptions of behavior change models that address perceptions of risk as a precursor to risk modification.”

Other researchers have used cognitive dissonance theory to design interventions to reduce behaviours such as smoking and excessive online gaming. The interventions typically ask participants to describe and advocate behaviours they themselves do not practice, with the intention that this will help them re-examine their own behaviour and beliefs.

For example, in one study adolescent girls with body-image concerns (for example dissatisfaction with their own body, believing themselves to be too fat) were asked to write a letter to a hypothetical younger girl that discussed the costs of pursuing of the 'thin-ideal'. In another session, they described incidents when they felt a pressure to be thin - and were then asked to think up verbal responses and challenges that could have been used.

The authors suggest that a similar approach with gay and bisexual men who bareback could be more helpful than giving men information about the dangers associated with their behaviour.

Indeed, many interviewees commented that taking part in the study had provided a rare and welcome opportunity to consider and reflect on their sexual behaviours, attitudes, and needs. The authors note that gay and bisexual men currently lack social spaces in which collective discussion of sexual choices can take place.

“As opportunities for the shared processing of decisions about sexual risk and satisfaction decline, individuals relying on their own emotional and intellectual resources naturally will seek plausible explanations for their individual behaviour,” they say.