Young Gays Stray From Safe Sex, New Data Shows

He could be any 20-year-old taking a college exam, straining with concentration, pausing over difficult questions. His smile is engaging, his manner is one of awkward innocence.

It is only the topic that is jarring--not because he is talking about sex, but because he is talking about sexual practices that he knows could eventually lead to his death. He engages in them anyway, simultaneously informed and oblivious.

He has agreed to forsake his boyfriend for an hour this Saturday night to take part in a national survey of young men who have sex with men. Echoing various other studies, the preliminary local findings speak to levels of unsafe sex that threaten young and minority gay males with new HIV infection rates two to three times that of their older, white counterparts.

Analysis of the partial Los Angeles County data indicates that about half of the 15- to 22-year-olds had engaged in high-risk, unprotected sex in the last six months. Testing revealed that 10% of the group was infected with HIV, the virus that causes AIDS.

“Not only is that high,” said Wesley Ford of Los Angeles County’s HIV epidemiology program, but “these are kids with relatively short sexual histories. What will this [group] look like 10 years from now when they have another 10 years of sexual behavior under their belt? . . . That’s scary. A lot of them are going to be infected.”

Combined with concern that older gay men are also straying from the safe sex message they know so well, the high infection rates are stirring discussion, and to some extent, a rethinking of AIDS prevention approaches that recognizes the difficulty of sustaining safe sex over a lifetime.

Berkeley psychologist Walt Odets, one of the more provocative voices in the debate, goes so far as to argue that AIDS education has in many ways been a failure, offering a simplistic message that ignores complex emotional needs.

Precautions Ignored

The gay male identity has become so entwined with AIDS in the second decade of the epidemic, Odets contends, that for many, the mantra of “always use a condom” has become an empty chant.

“The issue is not to tell men to use condoms,” he said, “the issue is to help men to clarify why they’re not using them.”

The reasons are many and varied. But ignorance is not, for the most part, among them.

Bobby Gatson, who supervises the team conducting the Los Angeles portion of the multi-city, federally funded young men’s survey, says those interviewed can recite the rules of safe sex like a math table.

Certainly, Mark, the 20-year-old, is aware of AIDS. “I know no one’s immune,” he said.

“I think about it a lot when I’m out here,” he said, sitting in a West Hollywood coffeehouse after giving blood (for an HIV test) and intimate details to the research team. A few feet away, the sidewalk is jammed with men strolling by, garbed in the casual gay uniform of a snug T-shirt and jeans.

“I wonder how many of these people are infected with HIV,” he said. “I just keep my fingers crossed and hope it doesn’t happen to me.”

That doesn’t mean he uses condoms. He and his boyfriend tried them once and didn’t like them. He was tested for HIV four months ago and was negative. Since his boyfriend frequently goes to the doctor for checkups, Mark believes he is negative as well.

And what about past sex partners? “I think I know that the other two were negative,” he said ambiguously during his survey interview.

Mark, (the survey is anonymous and that is not his real name) is in many ways typical of those questioned by the study team, which randomly recruits 15- to 22-year-olds from various street locations in the West Hollywood and Hollywood areas. They tend to be ordinary young men of different ethnic backgrounds who live throughout the county.

Mark, who is Latino, has a full-time job and lives with his mother in an eastern suburb of Los Angeles. He has had five sex partners in his life, two of them female. He is not quite sure what his sexual orientation is but has given no hint to his mother that he has a boyfriend. He thinks it is unlikely that he has the AIDS virus, as do the vast majority of the 236 young men surveyed for the preliminary findings.

“I think some of these kids, when they come up positive, they’re sort of shocked because . . . they haven’t done anything different than they’ve been doing all along,” said Ford, who is running the local part of the project, funded by the federal Centers for Disease Control and Prevention.

“But it’s simply that they’ve been playing Russian roulette and they finally had a bullet in the barrel.”

Now under way in the San Francisco Bay Area, Dallas, Miami and Los Angeles, the CDC survey is a follow-up to a 1993 study indicating that 9.3% of young gay and bisexual men in San Francisco had HIV.

Beyond the CDC work, a number of other studies have underscored the trend of high infection rates in certain pockets of the gay population. (AIDS experts say the annual infection rate for the overall gay male population stabilized in the late 1980s at 1% to 1.5% in major urban areas, down from peaks of 10% or more in the early years of the epidemic.)

A San Francisco household survey found that overall, 17.6% of gay and bisexual men ages 18 to 29 were infected. Minority figures were even higher. Slightly more than a third of black participants had HIV, as did 27% of Asians and 25% of Latinos.

The study’s authors, while concluding that HIV infection rates for young gay men in San Francisco are lower than they were in the early 1980s, warned in a recent American Journal of Public Health article that the current infection rate “threatens to continue the epidemic in the younger generation at a level not far below that of a decade ago.”

In Los Angeles County, an analysis of AIDS data indicates that HIV rates for young gay men are rising. “We’re on the upslope of this curve,” said Peter Kerndt, director of the county’s HIV epidemiology program.

Against such a backdrop, there is a growing willingness within the gay and AIDS communities to acknowledge that unsafe sex is occurring and to consider new prevention approaches.

As Los Angeles city AIDS coordinator Ferd Eggan noted, safe sex campaigns were invented “during a period of time when people were hoping as hard as they could that AIDS would be cured and that if they could just hold on with white knuckles everything would be OK.”

That is now clearly not the case. Safe sex is not a temporary prescription. It is always and forever.

“That’s an extraordinarily difficult thing to ask of people,” said Eggan, one of many in the local AIDS field who attended a Los Angeles “Safer Sex Summit” in June to discuss issues surrounding the high HIV rates.

For some, the standard safe sex message is simply too absolute, Eggan said. “If the message is abstinence or death, or use a condom every time or abstinence, people who can’t do that have no help at all.”

HIV-Negative Men

One alternative message he suggests revolves around the concept of harm reduction: Use a condom, but if you can’t always do that, at least do it for the riskiest behavior. Refrain from taking drugs and alcohol when you’re having sex, but if you’re not going to, at least plan ahead and make sure condoms will be in easy reach. And so on.

An increasing number of AIDS groups are also starting support groups for HIV-negative men, a notion that was long considered heretical. The common wisdom was that focusing attention on negative men would be divisive, further stigmatizing the positives and robbing them of attention and resources.

Odets has been a leader in challenging that line of reasoning, arguing that HIV-negative men have pressing emotional needs of their own that must be attended to to keep them negative. So thoroughly has AIDS colored the gay male world that the uninfected often feel depressed, lonely and ignored. On an emotional level, many of them feel ambivalent about their own survival.

The author of a new book exploring the impact of AIDS on HIV-negative gay men, Odets tells of a 27-year-old patient who recently came to him worrying that he was already past middle age for a gay man in San Francisco and lacked a sense of direction. Although he was negative, he had an underlying sense of inevitability that he would become infected.

In his book, “In the Shadow of the Epidemic,” Odets writes of “the notion that being gay means having AIDS, or at the very least, that one’s life be defined by the epidemic.”

To deal with such attitudes, Odets says, AIDS education must become more sophisticated and psychologically informed.

He further contends that the drop in unsafe practices in the 1980s was primarily a product of fear and the belief that safe sex was a short-term solution while waiting for a quick cure.

“Education has taken credit for a lot that I don’t think it deserves,” Odets said.

He argues that a message of universal condom use--even for relatively low-risk activity such as oral sex--makes men feel hopeless and turns safe sex into an overwhelming task.

Odets’ ideas have influenced programs at various AIDS organizations nationwide. But they are controversial.

Thomas Coates, professor of medicine and director of the Center for AIDS Prevention Studies at UC San Francisco, flatly rejects the idea that prevention has failed, saying that rates of unprotected intercourse are about 30% of what they were before the epidemic.

“Overall,” Coates said, “HIV prevention has worked pretty well for men over 30. It hasn’t worked so well for younger gay men and hasn’t worked so well for gay men of color.”

Coates agrees that it may make sense for long-term partners who are negative and in a monogamous relationship to skip condoms. But to otherwise stray from their use is “beginning to tread very dangerous water,” he said.

For one thing, he noted, people are medically at their most infectious in the months immediately after they have contracted the virus. Yet they are least likely to know they are positive then because it takes an average of six months before antibodies can be detected in an HIV test.

Recognizing that men are falling off the safe sex wagon and don’t necessarily know their status, AIDS educators are turning to peer pressure.

“We want to change the norm so that it’s no longer acceptable to have penetrative sex without a condom,” said Susan Cohen, director of education for the AIDS Service Center in Pasadena.

Prevention specialists also say specific efforts are needed to reach young and minority gay men.

“When men of color see ‘gay,’ they say, ‘It’s not me,’ ” said Paul Davis, director of health education for the Minority AIDS Project in Los Angeles.

Even at funerals of minority men who have died of AIDS, Davis said, “the ‘A-word’ is simply not mentioned.” Instead, the death is passed off as the result of cancer or pneumonia.

To get around that mental wall, Davis’ organization takes indirect approaches. The agency sends prevention workers to heterosexual bars that are known as places where men can meet other men. The outreach pitch is framed in general, rather than gay, terms.

A Problem of Denial

Just as minority men see AIDS as a white disease, young gay men perceive it as an older man’s disease. “A lot of young men feel that safe sex means don’t sleep with anyone over 30,” said Robert Hays, a research psychologist at UC San Francisco’s Center for AIDS Prevention Studies.

Hays, who has been involved in a five-year study of young gay men in Santa Cruz, Santa Barbara and Eugene, Ore., says the research points to a variety of factors in their failure to practice safe sex.

Because of the long incubation period of HIV, young men do not see AIDS in their peer group. Their sense of sexual identity is still evolving, so they do not necessarily think of themselves as gay and do not believe they are at risk.

Sitting on a West Hollywood curb at the end of his survey duty one recent night, Dean Decent thought of the people he has interviewed for the CDC young men’s study: Only a couple of them had always practiced safe sex. And he remembered a young AIDS educator friend who became HIV-positive while preaching safe sex.

“I think it’s just human nature,” he mused. “I don’t think there is an answer. It’s like smoking. People know it’s bad for them and they smoke.”