Stopping Pattern of Unsafe Sex : Health: One researcher says for some male homosexuals and bisexuals, safer practices are a real struggle. Long-term behavior change is critical.
When the AIDS epidemic began, Douglas, like most gay men, vowed to practice safe sex.
“I knew it was going to be hard,” says the Seattle man. “But it was even harder than I thought.”
Douglas says he adopted ineffective strategies: “It was a binge-purge situation. I would say the only way to get myself safe was be celibate. So I would be celibate for long periods of time. Then I felt this is crazy; I really need contact. So I would have contact. I realized that was not at all effective. I needed some strategies that would help me in everyday life.”
Through a notice in a gay newspaper, he learned of a novel research project at the University of Washington in Seattle that attempts to help gay and bisexual men resist slipping into unsafe sexual behavior. According to the project’s director, an alarming number of gay and bisexual men occasionally relapse into unsafe sex.
“Since the early ‘80s, the gay community has done a wonderfully effective job in helping people become safer,” says Roger A. Roffman, an associate professor of social work. “But for a fairly substantial minority, becoming safe is a real struggle.”
In one of the first studies of its kind, in 1990, 19% of the gay men interviewed said they had engaged in one or more acts of anal intercourse without a condom--the riskiest practice among homosexual men.
And, in a 1991 survey of 4,500 gay men from 16 U.S. cities, 31% said they had engaged in unprotected anal intercourse in the previous two months.
Vowing to become safer, or even initially adapting safe behavior, is not a problem for most men, experts note. But consistently maintaining safe sexual behavior is a serious concern.
“There is a lot of pressure to say, ‘Well, gay men have been dealt with’ ” in regards to learning the importance of safe sexual behavior, says Ron Stall, a researcher at the Center for AIDS Prevention Studies at UC San Francisco. “But declaring victory in the fight against AIDS and then leaving the battlefield is a recipe for disaster. You have to think about long-term behavior change.
“There are some folks who would like to use (education strategies) as a way to do some gay bashing,” he says. “But in the entire health education literature we have never seen behavior change as rapid and pervasive as was manifested among gay men. We have very little research, however, on how to help gay men and other groups maintain behavior change over time. We’re having to invent the field as we go along. That is why efforts like Roffman’s . . . are very courageous. They are trying to do something new.”
AIDS has provoked such fear that many wonder how anyone could put themselves at risk for the disease, Roffman says.
“Most people would say, ‘My god, if I were a gay man or an IV needle user and I knew with each time I engaged in the behavior I was risking death, of course I would stop doing that.’ But wouldn’t we wonder the same thing about the cigarette smoker who doesn’t stop or the compulsive gambler or the compulsive overeater who doesn’t stop?”
The difference, Roffman acknowledges, it that for the men in his study, one slip could prove fatal. Still, he says, “Sexuality is behavior, and it can be hard to change like other behaviors.”
The AIDS epidemic has forced health experts to become more sophisticated about long-term behavior change, says the Rev. Margaret Reinfeld, director of education and international programs for the American Foundation for AIDS Research.
“The nature of change is incremental. One doesn’t wake up in the morning and say, ‘It’s safer sex forever; I’m there,’ ” she says.
“What people do is they make an initial commitment to try on a new behavior. Once they have lived that for a while they want to go back to the old behavior to see if it’s still bad for them. You see this pattern of start-and-stop and start-and-stop.”
The problem isn’t a lack of knowledge about what is safe, according to health officials. The key rule of safe sex for both heterosexuals and homosexuals is fairly straightforward: Individuals should avoid the exchange of body fluids.
“The individuals who answer our questions are very well informed about how HIV is transmitted, what the risk factors are for AIDS and which populations are at risk,” Roffman says. “The problem is the person choosing to put on the back burner--or off the stove--a present, immediate awareness of what the consequences are.”
Given that they know how to be safe, many individuals berate themselves for unsafe behavior. In a letter published in the Seattle Gay News a few years ago, one gay man voiced such sentiments:
“Why do I (and many other men in Seattle) continue to play AIDS Roulette by having unsafe sex? Why? . . . I am educated about AIDS. . . . I’ve tested negative seven or eight times. And after being unsafe, I always think and believe I can ‘get urgent’ about being safe. But, I can’t, or haven’t, at least not for very long.”
Feelings of low self-worth, loneliness or anxiety sometimes lead to risky behavior, Roffman says:
“The individual simply cannot find another way to cope. The immediate gratification is so strong, and the adverse consequences are so delayed.”
For Douglas, unsafe sex was often linked to certain emotions.
“Loneliness. Stress on the job. There was some kind of release from negative feelings (through sex),” he says.
Even the fear of AIDS can cause the kind of emotional discomfort that leads to unplanned or unprotected sex, says Reinfeld: “Fear is a tricky thing. On one hand, you need to recognize enough danger to yourself to raise tension and move away from unsafe behavior. But if you get too frightened, you can shut down emotionally and deny you are at risk. It becomes too big for you.”
Another problem for some is lack of assertiveness with their partners, Roffman says. And Reinfeld says practicing safe sex can be more difficult for men who are in a long-term relationship: “They perceive condom use as interfering with intimacy. And they feel they don’t need safe sex anymore.”
Drugs or alcohol can also interfere with safe behavior.
“A fairly substantial number of people will say, ‘I find that my judgment and resolve to set limits and use condoms and use certain behaviors get diluted when I drink or use drugs,’ ” Roffman says.
In the Seattle study, a four-year, $2-million project funded by the National Institute of Mental Health and called Project ARIES, counselors provide ways to help men deal with the various triggers during 14 weeks of anonymous telephone counseling.
Each weekly conference call is attended by two counselors and six participants.
“We don’t say, ‘Just say no.’ We don’t say, ‘Surrender yourself to a higher power,’ ” Roffman says. “Those are ideas that might work with some folks. We say, ‘If you want to change, let’s figure out what will get in the way of your ability to change.’ ”
Douglas says he had low expectations that Project ARIES could help him. But, he says, he’s now safe all the time:
“One thing that helped me was to discuss the consequences if we weren’t safe. We talked about the fact that you could die from this, and we discussed friends we had who had died. We pictured that this could happen to one of us if we’re not more careful. And we also discussed that we could be passing HIV on to someone else.”
Jason, a Seattle bisexual, is married with children and his wife is pregnant. “So it’s all the more important for me to be very safe,” he says.
Project ARIES helped him deal with unplanned sexual encounters and the guilt that accompanied unsafe behavior.
“When you have behavior you don’t like, it’s easy to go off into a tailspin and say. ‘It’s too late now,’ ” Jason says. The project “had a real good plan on how to handle that by emphasizing that it’s the future that is important. The guilt feelings are a problem when you slip. The program helps build back the positive self-image.”
The telephone and the promise of anonymity are crucial in reaching unsafe men, Roffman says.
Research shows that gay men who are closeted, teen-agers and bisexuals (especially married bisexuals) are most likely to relapse to unsafe sex.
“We’ve been finding that the people who are most successful in changing sexual behavior are out in the community and are getting a lot of social support,” Roffman says. The folks having the hardest time are staying closeted and are in conflict or are isolated or are in areas with less infrastructure in the gay community.”
The results of Roffman’s study could help public health departments improve their safe sex campaigns. Relapse is also a significant problem among heterosexual and homosexual teen-agers and prostitutes.
“I think a lot of educators are beginning to adopt a whole-life model of safer sex,” Reinfeld says. “At different points in your life you need different information and skill building. There really is no such thing as a . . . general AIDS education program.”
Project ARIES: Help for Men Project ARIES is open to gay and bisexual men age 18 and older who would like help in maintaining safe sexual behavior. The project consists of 14 weekly telephone counseling sessions with two counselors and five other participants, plus several individual counseling sessions before and after the group sessions. Each group session lasts about 1 1/2 hours. Participants can enter the project anonymously or with their identities kept confidential. There is no fee. The project is operated by the University of Washington in Seattle and is funded by the National Institute of Mental Health. For more information call (800) 999-7511.
