Truvada, the gay community, and fear: Considering the meanings of condoms and pills.

Why Are Some Gay Men Hesitant About Preventing HIV With a Pill? A Few Thoughts.

Why Are Some Gay Men Hesitant About Preventing HIV With a Pill? A Few Thoughts.

Outward
Expanding the LGBTQ Conversation
Dec. 5 2014 7:00 AM

Twenty-One Attempts at Swallowing Truvada

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What does a pill mean?

Photo Illustration by Justin Sullivan/Getty Images

1

Here’s a relevant scene (and one that’s not uncommon in this, the Year of the Pill):

A group of youngish gay men—urban, professional, culturally and politically savvy—stand together on a roof deck. Glowing office towers provide most of the light (cloud-moistened white mixed with electric blues and greens), in which the men struggle to balance plates, cups, napkins, and wit with some semblance of grace. It is the point of a summer night at which cocktail recipes necessarily become more inventive, and friendly intimacy more readily assumed.

J. Bryan Lowder J. Bryan Lowder

J. Bryan Lowder is a Slate associate editor and the editor of Outward. He covers life, culture, and LGBTQ issues.

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At one corner of the platform, the conversation has turned—how could it not?—to Truvada, a drug originally designed for HIV treatment, which, since its FDA approval for the use in 2012, is increasingly being prescribed as “pre-exposure prophylaxis (PrEP).” Research suggests that taking the pill daily affords almost total protection against contracting the virus.

Did you read that piece? Was it hard for your friend to get a prescription? [Insert ironic #TruvadaWhore quip.] Does he really think everyone should be on it? Aren’t there side-effects? Well, that other piece said …

And then the scene becomes a bit more unusual.

As one man wonders aloud about Big Pharma and American pill culture, another man, as yet unintroduced, approaches and demands to know if we are “against” Truvada. No one gathered is against anything, we assure him, but some of us have concerns, most of which lie in the realm of marketing rather than medicine. But the interloper, suddenly irate, is not much interested in nuance: We are prudes, we are told, suffering from some kind of anti-sex indoctrination. We want to invade gay men’s bedrooms to forcibly prohibit them from bare-backing, which is how liberated people have sex. We are internally homophobic, serophobic collaborators who want to curtail pleasure and encourage shame. Because we have reservations about Truvada’s possible impact on the gay community, we are reactionary cretins, Anita Bryant-like in our refusal to embrace real gay intimacy. Oh, and drug-resistant gonorrhea isn’t real.

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Thoughts in the cab home: People are rude. Gonorrhea trutherism is apparently happening. This Truvada thing is way bigger than a pill.

2

When I came out to my mother, the first thing she said (after indicating that my effeminacy had already tipped her off) was that she feared my getting AIDS. To her credit, this fear came from a place of benign stereotype rather than bigotry, but still, not the ideal way to react to someone’s coming out. And yet, I do not recall being upset by this focus on disease then, nor am I particularly bothered by it all these years later. After all, my mother was not wrong that, the world being what it is, my orientation toward men brought the threat into my life in a statistically significant way. In that, her fear was based in fact.

Gay sex and HIV/AIDS have been grim dance partners since 1981. When I began waltzing men to bed in 2006, my moves conformed, with the instruction of my first real boyfriend, to the choreography, marked out in fear, by the generation of gay men before me. This never struck me as an imposition—there’s plenty of freedom within form.

I want to think more about the utility of fear.

3
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Did you ever see that movie Elysium? The one where health and safety were concepts that only existed within the confines of a gated community in the sky? It was terrible, but not because it was implausible.

4

I have been trying to swallow Truvada all year.

Well, not actually swallow it. (This is not that kind of personal essay.) It’s the idea of the thing that I can’t seem to get past my throat, down into my stomach where I might digest it and incorporate it as a normalized part of my queer blood and bones, seamlessly into my gay DNA. The call for that kind of total absorption—“There Is a Daily Pill That Prevents HIV. Gay Men Should Take It”—seems to be the growing chorus from much of the HIV/LGBTQ advocate class. And, at least from a public health point-of-view, I understand why: The science is sound, and the potential for preventing future infections is extremely promising.

But then, the cultural close-reader in me gets all nauseated: Do we really want to be implying that being gay requires a lifelong prescription?

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That’s a provocative way of putting the Truvada argument, I know, and certainly more intense than any current mainstream medical articulation. But I’ve noticed a larval version of the same impulse taking root around the edges of all the features and op-eds and freshly annotated sex-app profiles, a sense that soon, being a “good gay” in certain circles will require a daily alteration of one’s biochemistry.

In my darker moments, I can’t help but cringe at how this rush to embrace a drug to protect our bodies from ourselves gives new meaning to the term “internalized homophobia.”

5

What does it mean that the emerging “bridge” across the poz/neg canyon—truly one of the gay community’s most toxic, painful divisions—is for everyone to take up a medical ritual (indeed, the same powerful medicine) once reserved for those living with the virus? To get, as it has been phrased, “a taste of the HIV experience,” a chronic amuse-bouche?

I’m honestly asking. I can’t tell if it’s radically egalitarian or unanimity run amok.

6
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I am not anti-PrEP or anti-Truvada. In fact, I do not think it’s really tenable to be anti- a treatment concept or drug, especially when both are, to the best of our knowledge, medically sound.

But can I be anti- the way Truvada, like, feels? Or maybe anti- the way that no one seems to be acknowledging that medical technologies, once they leave the lab and enter the social field, acquire a connotative texture and emotional mass—a feel—properties that have little to do with efficacy statistics?

(On this point, the screaming man at the party and I seem to agree.)

I cannot tell you, definitively, why there is so much hesitance among many gay men to, as Rich Juzwiak concluded, “just take the fucking pill.” There are surely many reasons, some more compelling than others. But ignoring how a pill feels, and how that affective, cultural dimension is different (or worse or better) than that of the technologies that came before it, seems self-defeating. I guess I am anti- that.

7
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Rafi, my online source for a certain brand of Southern no-nonsense queer cultural commentary, recently asked his readers a question: “Am I allowed to be afraid of HIV still?

The post that followed was both frustrating and refreshing. The former, because Rafi eschewed much of the PC tiptoeing you’d usually see around such a question and, as a result, clumsily stumbled over issues of unequal access to healthcare and education. And the latter, because Rafi eschewed much of the PC tiptoeing you’d usually see around such a question and, as a result, actually touched on something important about the current relationship between HIV prevention and gay culture.

I don’t think what Rafi is afraid of is HIV, or at least, no more so than any rational person is “afraid” of contracting any incurable disease. Nor do I think he is afraid of HIV-positive individuals. When Rafi realizes that all seven men of color with whom he had recently gone on dates were positive, he writes: "I was pissed and disappointed and confused and tired. I just don’t understand why so many of us are still being infected given how easy it is to just NOT have unprotected sex.” The prevailing affect in this statement is not fear, but disappointment.

I want to think more with Rafi about how disappointment, in the context of a community, is different from fear or stigma. I also want, with him, to ask why we feel that we are no longer “allowed” to be disappointed in each other.

8

Here is another relevant scene:

In college, my closest friends were all gay men, and we engineered it so that we could live together junior and senior years. At one point during that wonderfully messy and productive time, we found ourselves residing in a sort of duplex dorm: The upper floor comprised the living room and kitchen, while the lower consisted of a long hall containing the bedrooms and a shared bathroom.

We also found ourselves bringing boys home with some frequency. One particular lucky night stands out: I had just deposited my handsome guest in my room and had opened the door for some reason, likely to go to the bathroom or get water. W, the most nurturing of our crew, slunk out of his bedroom at the same time. With little more than a smile and a quiet, congratulatory chuckle, he pressed into my hand a condom and a packet of lube.

No matter that I already had both in my bedside drawer, or that, knowing me, he could safely assume that I did. This was about communal care, about taking a moment to remind me (tipsy) that the gay sex I was about to have was bound up in a social fabric that stretched beyond the sheets on my bed. This imbrication was not (or was not only) a shadowy, heavy thing—that condom reiterated to me the risk of disease, yes, but also the strength of my connection to W, another man who understood what it is like to live enmeshed.

I am trying to describe how condoms feel. I am trying to describe why pills do not feel the same.

9

The older gays in my life are, generally speaking, wary of PrEP. They worry, for one thing, about a reinvigorated gay petri dish (done up in ’70s décor) giving rise to a new epidemic. Contra the youth culture, I think we should listen to older gays more, or at least just hear them out. They might know something we don’t.  

10

Group Project: Compose a song about what the AIDS crisis actually looks like today. Title it: “AIDS Ain’t The Normal Heart No More.”

You write the lyrics, since I failed to. Please reference straight women, poor people, trans people, people of color, and various combinations thereof—the people for whom internecine debates among A-gays about the pleasures of sheaths and pills may not seem all that important.

11

A condom tells you two things about a guy: That he has slept with or socialized enough with well-adjusted gay men to know that others will expect him to have some on hand; and, based on brand, how big his dick is.

A pill tells you that a guy is really worried about catching HIV from his sex partners, that he is probably HIV-negative, and that he has good insurance.

I only mean to point out that these are different kinds of information.

12

Categories That Have Arisen in the Context of Truvada

People I am happy for:*

  • People who are in sero-discordant couples or want explicitly to be with HIV-positive individuals.
  • People who are sex workers.
  • People who are in abusive, consent-challenged relationships.
  • People living in low-access/education, high-risk communities who somehow seek out or encounter a benevolent doctor with a prescription pad.

*Theoretical, since it is unclear how many of these people are actually getting PrEP.

People I am not mad at, but just sort of confused by:

  • People who were already having (or could have been having) safer sex without difficulty.
  • People who have the wherewithal to navigate lots of insurance paperwork and check-up scheduling conflicts, but who view condommed sex as impossibly complicated.
  • People who present “but it feels better” like it’s a behavioral axiom.   
  • People who were apparently always deeply terrified of other gay bodies even though they wanted to have sex with them.
  • People who just seem kind of neurotic about sex in general and appear to be trying to treat that.
  • People who talk about “condom fatigue” like it’s a natural phenomenon and not something the culture (cf: porn) encourages.
  • People who will automatically dismiss this sort of inquiry as sex-negative.
  • People who are well-off, well-connected, white, gay, and male and who act like drug-assisted bare-backing is second only to marriage as the hallmark of equality.
  • People who won’t allow that fear-based anything might be useful, depending on what it is we’re meant to be afraid of. 

(The original title of this section was “Who is Truvada for?” but then I decided that declarations are sometimes cheap.)  

13

Sometimes I worry I was born too late to ever satisfy my particular craving for gay community. For me, being gay seems only incidentally about having sex with men. As I get older, it’s the queenly brotherhood that I increasingly cherish: The ability to touch down in most any far-flung city or po-dunk town and suss out, with more or less effort, a group of men who will readily understand, at least to a basic degree, my experience of the world. I usually think of this bond as a phenomenon of sensibility, as an orientation to culture slightly akimbo; but this Truvada thing has brought another aspect of the connection—and its apparent frailty—into relief.

Perhaps I am an outlier in that, even as a late twentysomething, condom use was part-and-parcel of good gay citizenship among the men I came out with. (On the level of rhetoric anyway; I’m not a voyeur.) Using one was not discussed as some kind of metaphysical barrier or even really as an inconvenience. It was just a step in the sexual progression, like moving your kisses from wet lips to scruffy neck. But now, I read almost daily that a significant portion of my gay generation does not share this sense of condoms as going-without-saying, a necessary and useful utensil in the sexual encounter, a sign of basic gay civility, as unthreatening and unremarkable as a fork. To the contrary, these men seem to view them as, at best, a marginally tolerable “tool” and at worst, as some kind of malicious prophylactic against self-actualization.

I feel alienated from these men, perplexed by the disjuncture between our perceptions. And, because they are also my brothers, I feel a certain amount of sadness about that. Is it weird to say that my primary emotional reaction to Truvada has been melancholy? What a bizarre way to feel about a pill.

But then, that’s not really fair to Truvada. It’s not a combination of Tenofovir and Emtricitabine that’s causing my melancholy; it’s the failure of my admittedly utopian notion of a gay ethic of mutual care—concretized, perhaps naively, in a half-empty bowl of free condoms in a sleazy bar—to align with the reported reality.

An impatient activist just interrupted: But how many people were infected while you were composing these precious “feelings”?

Fair enough. I can only confess that when it comes to cultural politics, I have always found aesthetics (the way things would ideally look) to be more meaningful than strategy (the way things must be managed). Activism isn’t for everyone. 

14

Much of this essay is somewhat elliptical—which is appropriate, because as I orbit many of the points, my distance from certainty is constantly shifting. But I want to be direct about one thing.

This idea that bareback sex is more “intimate” than condommed sex? It’s weird. It’s straight-acting. It partakes in a logic that’s fetishistic, and it’s dishonest for not admitting that. It reduces human connection to a Scissor Sisters lyric. It reeks of phallocentric, top-superiority privilege. It lacks imagination. It denies the felt intimacy of a thousand other modes of physical contact, many of which do not rely, crutch-like, on penetration. It’s lazy. It tells us more about the tiresome sexual script of the person espousing it than about what a condom might or might not “mean.” It’s assimilationist. It misuses the language of love to pathologize a neutral piece of latex. It smuggles a creepy Luddite ideology into people’s rectums in the guise of “naturalness” and “freedom.” It’s rude, it’s an insult to human sexual creativity, and it’s cultish in its lurid devotion to Pure Friction. It’s not cute.

There is no hierarchy of intimacy when it comes to how people fuck.

15

You can literally reach your hand inside the door of my local gay bar and grab enough condoms that, when used correctly, will be very effective at protecting you from a range of sexually transmitted infections for, say, eight to 12 sexual encounters (fist size may vary) and put them in your pocket, no matter who you are, for free. According to those who have tried it, you must jump through many medical and bureaucratic hoops to get your first three-month prescription for Truvada and still more to avoid paying for it out-of-pocket—retail price: $1,500 per month. (You may or may not have sex on any of those 90 odd days.) Individuals may choose either, both, or neither.

“Just take the fucking pill.”

We are not in grade school math, but this is a word problem, all the same.

16

Zachary Quinto said, “How gay men have sex with each other was unilaterally redefined for nearly two generations as a result of AIDS. I was simply trying to assert my belief that we need to be especially vigilant and accountable to ourselves and one another at this moment in our evolution.”

Zachary Quinto suggests that we might owe something to one another.

Accountability, starring Zachary Quinto.

Zachary Quinto makes a good point.

17

Did you use protection?

Condoms and PrEP are both effective forms of protection (among others), but they protect differently.

One quietly acknowledges our mutual vulnerability in a shared moment. It attempts to protect no matter what microbes or privileges we do or do not bring to the encounter.

The other presents itself as a shield—it bestows one of us with cellular invincibility against a single threat and boasts of a hard-won defensive posture toward the encounter. The situation of the other becomes largely irrelevant.

Neither of these forms of protection is necessarily “bad.” Again, I’m just trying to describe how they feel.

18

Actually, I want to tweak something I said earlier. There is no intimacy hierarchy in fucking, but fucking with condoms maybe makes me feel more intimately connected to a larger sense of gay community and history. Maybe that sounds grandiose. (Highly possible.) Maybe no one else feels that way. (I bet some do.)

19

If Truvada becomes a “party drug”—and it’s looking like it might; soon we may be advised to take it just before and/or after the party occurs—does that change any of this? And who will be able to afford the cover charge?

20

The Truvada Miracle: “I have lost the culturally programmed fears that I used to have about sex.”

The writer presents this as a good thing. I understand what he means: It’s playfully called the “Walk of Shame,” not the “Walk of Fear.” But then, I think it is possible to conceptualize sex as something of a big deal—or how about a distinctly intense moment in the flow of life—without falling into sentimentality or slut-shaming. (Some people may desire more intense moments than others!) And if you do that, doesn’t a little fear come into play? Not abject terror, no, but the kind of healthy pause that accompanies any brush with intensity, especially when other vulnerable human beings are involved?

Regardless of how the code was received, I’m not sure I want to lose that kind of fear.

21

What are you afraid of?

For the past 30 years or so, gay men have had to move in and out of bedrooms and back alleys carrying along an anxiety that most straight people don’t share (appropriately or not). Most of us embraced condoms and a safer sex ethos as a way of assuaging that fear, though it never entirely dissipated—the culturally programmed guy clearly continues to feel it.

However, that fear and the subsequent response brought on other, extra-medical consequences. “The experience of AIDS as a homosexual experience created bonds and loyalties and solidarities that homosexuals had never experienced before,” Andrew Sullivan wrote in 1996, the year of the protease inhibitor. This was the plague’s silver lining, this awareness that we had a responsibility to each other, that our individual sex lives did not play out in a vacuum. It is perhaps the only positive thing the AIDS juggernaut left behind as it plowed on into other communities and continents.

But now, as memories fade and new gays come of age in an era in which HIV is not fatal for those with access to the right resources (Americans always think they will have access to the right resources), those bonds are weakening. To steal another Sullivan line, there is “a whole new generation of post-AIDS gay men [who] have no understanding of the profundity with which their own lives have become suffused.”

Truvada is a medicine, and like all medicines, it should be taken as directed. But it does not feel profound. It feels, despite being a clear solution to a specific medical problem, like something of a patch-job. It feels consumerist and corporate. It feels elite. It feels like a privatization of a responsibility that used to be public. It feels like a straight bureaucratic approach to a queer communal problem. But above all, it feels, to me, like false advertising.

I do not mean that it doesn’t work; no serious person is debating that.

I mean that the pill has been sold as a way to take away our fears, a means by which to “lose” them in the blissful haze of scientific certainty. But in the final analysis, does it not instill an orientation toward sex and other gay men that is, ironically, more fearful? Don’t trust yourself or him to negotiate safety in the moment, with hard-won social standards as your backup. That’s tricky, maybe awkward. Better to wield your protection secretly, in your blood. No discussion, no confrontation—no real connection—required.

There are different kinds of fear, and they have different effects. We used to be afraid of killing each other. Now it feels like we are afraid of each other.

And all this, at a moment when we are told that gay community is over and gay culture is dead.

Strangers are always scary.

Can a treatment also be a symptom?