Attitudes towards men who ‘bareback’ are a barrier to wider use of PrEP

Two new qualitative studies from Toronto shed light on how stigma affects the uptake of pre-exposure prophylaxis (PrEP) and the experience of taking it. In the first, young gay men acknowledged that they did not always use condoms but did not see themselves as the kind of ‘barebacker’ for whom they thought PrEP was intended.

“PrEP embodies the notion of bareback sex, which traditionally has been associated with negative elements, and it is quite clear that the young gay men in this research do not want to be associated as a barebacking subject,” writes Julien Brisson in Anthropology & Medicine. “This is one reason why they did not want to use PrEP.”

In the second study, early adopters described concealing their PrEP use because of what it might suggest to others about their sexual behaviour. Nonetheless, most had an overwhelmingly positive experience of taking PrEP.

“Paradoxically, some men said that PrEP use both led them to experience stigmatizing reactions within their social and sexual networks, while also helping to remove stigma, shame, and fear related to HIV, sexuality, and sex with gay men living with HIV,” comments Daniel Grace in AIDS Patient Care and STDs.

Young gay men’s feelings about barebacking and PrEP

Julien Brisson of the University of Montreal conducted ethnographic fieldwork with young gay men in a gay neighbourhood of Toronto. As well as in-depth interviews with ten men, he reports on informal interactions at gyms, social events, an LGBT film festival and meetings about HIV prevention. Most of his informants were in their twenties and well-educated, although his interview sample was ethnically diverse.

The research was conducted in 2014, before PrEP was approved by Canadian regulators in February 2016. This was also before PrEP was added to Ontario’s provincial drug programme in September 2017, a move that has facilitated access to PrEP in Toronto, especially for people on low incomes.

The men taking part in the research were generally well-informed about HIV prevention. Having had their first sexual relations in the 2000s, they were highly aware of HIV prevention messages about condoms. They were also knowledgeable about the biomedical science relating to HIV prevention, often using pragmatic techniques such as ‘serosorting’ and ‘strategic positioning’ to diminish the risk of HIV transmission when they did not use condoms.  

Of note, on the first occasions that the researcher met his respondents, they all reported that they did not have bareback sex. They tended to express the idea that it was a bad and reckless practice. In line with the way in which medical and psychological researchers have represented men who bareback, the young gay men often described barebackers as people who had problems with depression, self-esteem or drug use.

For example, Brisson describes meeting a 25 year old at a party and explaining that his research was on bareback sex. The young man said with a tone of pride that he was a responsible person who always used condoms, while other men attending the party nodded in approval or said that they did the same.

Nonetheless, a few weeks later, the same man took part in an in-depth interview. This revealed both the man’s accurate knowledge of biomedical information about HIV transmission and his engagement in condomless sex. He said:

“I do get tested regularly, and I’m aware of the transmission risks of HIV. I’m not aware of the exact numbers, but I know, even if the person is HIV-positive and on ART and I’m the top [insertive partner], which I generally am, the risk is very low for me.”

Another man expressed pride in his knowledge of HIV prevention and his apparently consistent use of condoms when he first met the researcher. During the course of the fieldwork, the researcher was often present when the man shared detailed and entertaining stories about his sexual adventures with friends. Eventually, the man began to talk with the researcher about sexual practices that did not always involve condoms.

However, like the first man described, he was not interested in using PrEP. As he felt that he was ‘responsible’ when he did not use condoms, he did not think that PrEP would be right for him, as this interview transcript shows:

- No, I think that I am a little bit smarter about the disease, and I don’t think that I’m subjected to the disease as much as I am aware of it, so I don’t think it’s necessary for me to take a pill a day.

- No? Even though you like bareback sex?

- No, I love it! But I think that I am smart enough to know who to have it with.

- OK, so you would not take [PrEP] even though it prevents HIV?

- No, even though it sounds amazing, I don’t think I’m a high-risk individual, I don’t consider myself a high-risk individual, even though I’m gay and I enjoy partaking in bareback sex. I would not consider myself a high-risk individual, not today, not tomorrow.

- So is it because it is meant for high-risk groups that you would not take [PrEP]?

- I don’t think that I am. I don’t think that’s something for me – maybe for somebody else, but not for me.

None of the young gay male informants were interested in using PrEP at the time of the research. They supported other people using PrEP and rejected the stigmatisation of PrEP users as ‘Truvada whores’. But they tended to see themselves as different from potential PrEP users.

“If you wanna take the Truvada in order to have bareback sex, fine… If you believe that’s the right thing to do, I’m not the one to tell you you are wrong or to criticise… If you are doing it, I just hope you really understand the risks and what you are doing to yourself, and if it’s safe, good, amazing, good for you. Good too that you can have something in order to enjoy sex more if you need to have bareback sex.”

Julien Brisson argues that the contradictory meanings associated with PrEP made it harder for his respondents to imagine themselves using it. “PrEP embodies the idea of ‘HIV prevention’, which is attached to virtuous qualities, and PrEP simultaneously represents the idea of bareback sex, which has traditionally been saturated with problematic elements,” he says.

PrEP users’ experiences of stigma

The second study was also conducted in Toronto, but a year or two later, and with a different group of participants – gay men of a range of ages who had taken part in a PrEP demonstration project in the city. As such, they can be considered ‘early adopters’ of PrEP, who are likely to be enthusiastic about its potential.

Daniel Grace of the University of Toronto and colleagues conducted focus groups and individual interviews with a total of 16 gay men. Most were white and almost all were university educated. Four respondents were in their twenties, seven in their thirties, two in their forties, and three in their fifties.

The men reported that they had to manage other people’s assumptions about why they were using PrEP. Generally, people in the men’s social and sexual networks equated PrEP use with having condomless sex. Some participants described how PrEP-related stigma, or stigma related to having multiple sexual partners, had led them not to tell family or friends about taking PrEP, creating a kind of ‘PrEP closet’.

This man said that he did not discuss using PrEP as it would invite other people to make judgements about the non-monogamous relationship he has with his husband.

“I don't disclose that I am on PrEP to most family and most friends. That's maybe because I am married and I have kids, so for his [husband's] sake, I am not really, we are not open—fully open that we're open if you know what I mean. So I mean I should be able to be, but I don't think we're there yet. So I wouldn't say that I feel ashamed for it but I definitely have to hide it.”

Stigmatising responses could also come from sexual partners.

“There were several instances in which I had to calm people down once I told them that I was on PrEP because they assumed that my whole lifestyle is changed… One of the regulars that I had previous to going on PrEP decided to stop doing me because he assumed that I would instantly become like a receptacle for every gay plague known to man. So I mean that was kind of an uncomfortable conversation, but I was not ashamed about it.”

Some men described judgemental attitudes from doctors during their initial attempts to get PrEP. More generally, they felt that PrEP’s association with gay sexuality was a structural barrier to broader awareness and access to PrEP.

“If somebody invented an anti-cancer drug, people would say that it is a miracle, regardless of it costing $1000 a month. Because it's an HIV treatment, there's still a stigma. Gay men just get it [HIV] because they're fooling around. That's not true at all. I think that hurts too.”

Nonetheless, Grace emphasises that his respondents did not present themselves as being overly burdened by stigma or shame. They did not assume a victim narrative and explained that they could manage these negative experiences.

In discussing PrEP, they took pride in being responsible, sexually active gay men who were helping to prevent the spread of HIV. They also celebrated the impact it was having on their sex lives, allowing a ‘return to normality’.

“Frankly, it's been one of the greatest things of my life. I have absolutely loved it. I have a lot of sex, and I go to the bathhouses a lot, despite my advanced age. I can tell you, sex has never been better. For the first time in my lifetime, it's taken away the fear from having sex. Sex isn't meant to be something you're ashamed of or fearful of. It's meant to be enjoyable and PrEP has made sex enjoyable for me, which is fantastic… Now that I can have bareback sex again, it's just fantastic. Sex has been liberating again thanks to PrEP.”

More specifically, PrEP had allowed some participants to challenge stigma or taboos they had in relation to sex with people living with HIV. A man whose primary partner was HIV positive explained that PrEP had empowered him to have better sex with his partner. He explained that although his partner had an undetectable viral load, it was up to his partner to maintain this and he felt more comfortable with a prevention method that he was in control of himself.

Other men said that the use of PrEP could reduce stigma towards men with HIV in the wider community.

“It kind of made me feel good I don't have to ask guys what their status is and so poz guys don't have to worry about disclosure or rejection and you know all that stigma stuff, and I like the idea that they have a different experience now that there are so many guys on PrEP because some guys would just — like I don't ask.”

“These accounts of PrEP use help to shed light on broader stigmas and moral panics around sex and sexuality,” concludes Daniel Grace. “Successfully advocating for broader PrEP access requires that societal and structural stigma surrounding gay sexuality be addressed head on.”