A Dec. 8 blog post in the San Francisco Business Times has sparked another furor over gay men using the HIV drug Truvada to prevent infection with the deadly virus. "San Francisco men shed condoms in favor of Gilead's HIV prevention pill," alleges the title of SFBT reporter Ron Leuty's opinion piece.
Leuty reported on a survey of men in a Kaiser Permanente AIDS-prevention program. More than 500 are taking Truvada once a day as pre-exposure prophylaxis (PrEP). Leuty called the 45-percent increase among men in the study not using condoms "eye-popping" -- which it is. Clearly these men aren't heeding the Centers for Disease Control and Prevention's recommendation to use condoms in addition to taking the drug.
But it's a serious stretch to project the behavior of about 90 men on PrEP in this one study to "all" gay men in San Francisco, let alone anywhere else. Consider this: All 500 men in the study represent only about 0.007861 of San Francisco's roughly 60,000 or so gay and bisexual men.
Unfortunately, there will always be men who push the limits of risk to engage in high-risk sex that is, for them, something of value. Others of us may see it as self-harm, but these guys usually describe it in terms of intimacy and pleasure. Either way, we should be glad these men are making even a partial effort to protect themselves by taking PrEP.
We can argue all we want about whether PrEP provides cover for dangerous behavior. But we aren't addressing the most important questions: Why do some gay men value high-risk sex more highly than they apparently value their own health? Why do some guys seem unable to value themselves apart from their willingness to engage in "anything goes" sex?
At risk of getting stuck trying to understand what even mental-health experts would likely classify as aberrant behavior, I would suggest we step back to get a more accurate picture of how the vast majority of gay men conduct their sex lives. Reframe the statistics that can be blown out of proportion to make it look like "all" gay men have stopped using condoms, or even like "all" gay men engage in anal intercourse, which they don't.
Ron Stall, Director of the LGBT Research Center at the University of Pittsburgh, has identified four interconnected "epidemics" of psychosocial health conditions that disproportionately afflict gay and bisexual men, each one making the other worse: childhood sexual abuse, partner violence, depression, and drug use. Together, their insidious effects are referred to as syndemics. Men who are most strongly affected by any one of these tend to be at high risk for HIV and substance abuse. Those from lower-income or culturally marginalized ethnic groups are especially vulnerable to syndemic effects.
In one study, Stall and his colleagues found that 11 percent of 812 men who reported one problem -- depression, for instance -- had engaged in high-risk sex. Of 129 men who reported three or four problems, 23 percent said they had had high-risk sex.
The numbers are high relative to the so-called general population. But surely no one can be surprised to see self-destructive behavior in people treated as if they don't deserve better.
On the other hand, the numbers tell us something quite astonishing when we look at them from a different angle: that 89 percent of the men reporting one problem did not engage in high-risk sex. Likewise, more than three quarters of the men with three or four problems did not engage in high-risk sex.
These numbers make it clear: The overwhelming majority of gay men are resilient and take care of, protect, and value ourselves. How can this be? In the face of overwhelming pressures and struggles that can give gay men all the reasons we might need to harm or medicate ourselves, how is it that most of us don't?
The short answer: We accept ourselves. Research suggests that our journey toward being resilient gay men who accept and value ourselves begins by accepting our sexual orientation -- overcoming our own self-stigma, what we've internalized from the bullies of our lives. Ron Stall told me in an interview for The Atlantic, "Guys who do the best job of resolving internalized homophobia [or self-stigma] are the least likely to have current victimization, substance abuse, and compulsive [high-risk] sex."
Put a little differently, he said, "Getting a population of people to not hate themselves is good for their health. This is not rocket science." Building up, and upon, gay men's resilience is a challenge for each of us -- and for our families, lawmakers, ministers, teachers, and anyone else who wishes us to be well and fully contributing members of society.
The place to start is in revising the way we think. We need to consider carefully how numbers can hurt us when they are taken out of context. Their "eye-popping" shock value dwindles when they're put into perspective against the bigger number of "all" gay men.
We can hope that gay men who value condomless sex more than they do their own lives will eventually find intimacy and pleasure in sex built upon mutual respect and protection. Until then, PrEP for them is an important step in protecting themselves.
In the meantime, the vast majority of gay men -- who don't abuse drugs or engage in high-risk sex -- clearly value their health enough not to endanger themselves or their partners.
Yes it's shocking to realize that one in four gay men in San Francisco is HIV-positive.
But it's at least as surprising that 75 percent of gay men in San Francisco are not HIV-positive. What can we learn from them about how they have avoided HIV when the virus is so prevalent in the community? What can their experience show us that might even help the guys taking an expensive, powerful, and toxic drug so they can engage in high-risk sex?
Among the lessons, one stands out: Just as the way we frame our personal story can make us feel like a victim of our circumstances or a victor over them, so too the way we present statistics can mean the difference between hope and despair. Increases in condomless sex among a tiny sliver of men already at extreme risk for HIV may be "eye-popping." But so is the far greater number of gay men who choose to view safer sex as the key to real intimacy and pleasure between men who care about themselves and one another.