Does PrEP = a newgay sexual revolution?
by Tim Vollmer and Doug Sebesta
Although in use for years, word is now firmly out about the "first drug that reduces the risk of sexually acquired HIV infection." News of Truvada, the drug approved two years ago by the Food and Drug Administration for pre-exposure prophylaxis, or PrEP, has exploded over social networks and inside the imagination of gay men across the United States over the last few months.
PrEP works on the same basis as PEP (post-exposure prophylaxis), commonly used in occupational settings and the anti-viral therapies used to prevent mother-to-child HIV transmission. Both of these strategies have long been considered very successful and uncontroversial.
What is it about the idea of PrEP for sexually active gay men that's causing such a passionate debate within public health circles and our own community?
Even though many health professionals portray PrEP as being "just another tool" to curtail the HIV epidemic, the charged rhetoric used by those for or against it – terms such as "party drug" or "Truvada whore" – suggests otherwise.
As noted by a New York Times headline, PrEP raises the dramatic possibility of a new "sexual revolution" for gay men. While the idea frightens and even outrages many people, some advocates (including an increasingly vocal new generation of gay activists) are explicitly embracing the idea of less fear and more sexual choice, if not outright freedom.
So far the discussion over PrEP has been mostly geared toward moral questions (will gay men be responsible or not?) and health ones (will PrEP lead to less condom use and/or more sexually transmitted diseases?). While obviously important, these are not the only issues.
Questions about its social impact are just as crucial. Will PrEP change aspects of our sexual identity and our sexual landscape that are not at first obvious? Given the complexity and diversity of gay men's lives, how will these effects differ across age, region, race and ethnicity as well as between negative and positive gay men, top and bottoms and "versatile"?
One way to spark a productive look at the social impact of PrEP is to consider the societal consequences of HIV up to now. Writers and activists like Walt Odets and the late Eric Rofes tried early on to highlight the harm caused by the chronic intense fear of – and focus on – HIV, which in their view was as detrimental to gay men's social and sexual lives as the virus was to their physical health.
As described by Odets, uninfected gay men face an overwhelming and never-ending pressure to maintain a "clean" status all the while feeling in the shadow of the seemingly poz-centric communal focus that quickly formed around HIV's devastating health and social issues. As sero-sorting became more common, boundaries between the psycho-socio-sexual realities of neg and poz became even more pronounced.
For Rofes, years of focusing on HIV transmission inadvertently transformed condom usage into a highly contested symbol of gay sexuality. Today, the power of condoms to frame our sexuality is so strong that their nonuse is often not only a primary expression of the traditional romantically committed relationship, but also a badge of edgy outlaw sexuality.
Sero-positioning (being the top if you're still negative, the bottom once positive) has been another social consequence of the epidemic with a huge but largely hidden impact on gay men's psycho-sexual lives. For poz "tops" and "vers" men for example, sero-sorting has meant a sharply curtailed sense of sexual and social options.
For many HIV-negatives, the association of HIV with bottoming has deterred experimentation, potentially inhibiting a more authentic sexual and romantic life. For those negative men whose desire to bottom is pivotal to their sex life, the intersection of risk, pleasure, love, and identity may have made HIV infection seem so inevitable and unavoidable that precautions seem pointless.
In theory at least, PrEP could "fix" much of HIV's sexual polarization and social divisions by making prevention a pharmacologically routine, normalized, and unobtrusive part of everyday life. The likelihood of this actually happening depends on many factors, not the least of which is the collective view of gay men and their sexuality.
PrEP has become a sort of Rorschach test for people's attitudes on a range of still sensitive topics. After over 30 years of associating gay sex with HIV, it is clear that for many people it is hard to even imagine a gay sexuality focused more on its potential than its problems. It's also clear that gay men can be divided over sexual politics just as sharply as any other group.
The fundamental differences in how we as gay men view our sexuality and the ways we express our desires means that even while PrEP blurs many of the social divisions caused by HIV– between negative and positive, top and bottom, the more sexually active and the not – it threatens to sharpen a whole new set of its own.
A revolution or not, PrEP is poised to upend long held assumptions about our lives as gay men. Many people will see these changes as going dangerously off course and threatening social acceptance and equality. Others will view them as being the future of a freer and more open gay male sexuality.
Now that PrEP is here to stay, how can we maximize not only its potential to limit new infections, but also its potential to liberate gay male sexuality from the epidemic's deep shadow – without sparking a larger cultural war or a wider generation gap in the process?
These are some of the many profound issues that we as a community of gay men need to be pondering and talking about together.
Tim Vollmer, Ph.D., is a cultural anthropologist and Doug Sebesta, Ph.D. is a medical sociologist. Both volunteer for the Gay Men's Community Initiative, which is sponsoring the town hall forum "Does PrEP = A New Gay Sexual Revolution?" at the Metropolitan Community Church-San Francisco, 150 Eureka Street, Thursday, July 24 from 7 to 9 p.m.