WHO AM I? PART 4
Or
So Now What?
In trying to read the local tea leaves on this I believe I sense a growing recognition of the need to return or at least refocus more HIV prevention activities on the various gay male communities locally. There is even a sense of urgency on this matter from not only local health officials but from some gay men themselves. Many, though not all, of these gay men are in some way connected either to public health departments or the AIDS industry already. Let me say right off that this is not the optimal source for this concern, better that it was more grassroots in nature. I am not necessarily saying we should hang out to see if the grass grows regarding this issue but we must always be cognizant of where we are coming from. Perhaps the public health department can provide water and fertilizer but this would only be in part helpful if these resources do not come with two many constrains. If it comes with lots of strings attached and a definition of gay men as MSM nothing much will change. For long term change to happen and AIDS become a non-issue in the gay male world we must address who we are and what we are about and this needs to start early in the life of little queer people and not at age 20 when testosterone rules. I do think though that even at twenty some positive changes in how we as queers perceive ourselves can occur but probably not in the local bar with two or three cocktails under our belt.
From here on out I will break up the discussion of HIV prevention for gay men into two parts: essentially them and us, with “them” being Public Health entities and the “us” being the multitude of gay male cultures, coming of course in all colors and classes. I am not sure that my suggestions will provide a solution to the problem of ongoing HIV infection in the various gay male communities in the short run, but one of my observations is that we must look at this from a long term perspective. Periodically yelling that the house is burning down does not cut it down the road so let’s stop doing this!
Some things local Health Departments might consider:
1) Ditch the very resource intensive and wasteful approach of partner notification and contact tracing around newly diagnosed HIV infected gay men. Men out having sex with other men know that this carries the real possibility of HIV infection even in these days of very limited prevention messages directed their way. All gay men may not be aware of the seemingly endless points of view on the risk of oral sex but I dare you to find me one who does not know that taking a load of cum up your ass puts you at risk for HIV! Having dealt with hundreds of gay men over the years I have rarely, if ever, met one who was truly surprised by the news that they had HIV infection. A much better use of the considerable resources and very knowledgeable and talented staff involved would be to put them to work in more productive prevention efforts. Contact tracing and partner notification could be continued for the very rare heterosexual situation, but why direct so much of our approach and effort around a population saturated with virus, better to spend those bucks on a productive prevention message or easy and rapid HIV testing (see below)!
I have felt for a long time that contact tracing and partner notification, necessarily fueled of course with accurate name reporting around the infection in question, might be useful either very early in an epidemic or very late in an epidemic when going for the knock out punch. It is a rather ludicrous approach though around a virus that has saturated a community. However, with syphilis definitely on the wane, aggressive contact tracing of this disease might be quite beneficial whether the infection is in gay men or anyone else in this country.
As an aside, sort of, I think that a very critical look at the “unexamined assumption” that “traditional public health interventions” have been successful in bringing other epidemics under control is in order. Give me some examples please of where partner notification and then aggressive contact tracing has made a significant difference with any disease other than tuberculosis maybe ( and world wide TB is totally out of control) and even there we need to take a good look at what we are doing in the way of prevention. Again I would refer you to Paul Farmer’s Infections and Inequalities. We seem to spend so much time running around sticking our fingers into the most recent leak in the dike with the whole structure about to collapse on our heads.
So much of public health effort seems to be reactionary. Reaction to something of course implies that “prevention efforts” if they exist all will be after the fact for many and that certainly begs the question: “why bother at that point?”!
Before I leave this point I would like to make a few additional comments on the current rather aggressive efforts to follow up on new gonorrhea cases in gay men particularly if they are HIV positive. Talk about a phenomenal waste of resources! Whether we like it or not, negotiated “unsafe” sex is quite common with many gay men these days. It is paternalism at its most extreme to take the position that maybe one partner is unsuspecting and the communication between the two was less than optimal. I do believe that much of the current gonorrhea being seen is being passed from one HIV sero-positive gay man to another. In fact I think the small core groups engaging in lots of risky behavior are having very minimal if any impact on new HIV infections. Better again to take the significant resources being used in this area and redirect them to more productive prevention messages which can certainly be aimed in part at those continuing to party hardy. We need to redirect focus from the spectacular to the much more mundane, your average gay man in the street.
One last issue deals with something I hear frequently and that is that this extremely narrow but very aggressive focus of resources around HIV contact tracing and partner notification is essentially being mandated by either state law or departmental expectations imposed by “higher” state authorities and even more silly that this is a directive we have from society to control HIV. Again a redirection, or at least a serious reexamination, of these efforts seems to be in order. I do not think for a minute of course that the Owens’s (Colorado’s current governor) regime will buy into state monies being used to “promote queer sexual culture”. However a return to a more specific well focused messages on safe sex and the gay reality of AIDS would be refreshing instead of the current rather deafening silence on the matter. I will address it further on but of course I do not think than any effort by any health department will result in the profound cultural changes necessary to bring HIV under control in the gay world. All it will do is provide jobs for a few “prevention” workers until the day they retire, a seemingly endless gravy train.
Let’s be real, the only mandate around HIV is to keep it contained within the throw-away risk groups where it currently is, which seems to have happened all on its own. It is a point I have made for nearly 20 years now and that is: there will/would be draconian measures around HIV only if it threatened the straight white males running the show. Fortunately, I think, the epidemiology of HIV in America appears to be nearly written in stone. It has not and I venture to say will never sweep the middle and upper classes in this country. They are at more risk of dying from anthrax!
The recent anthrax scare should remind us all that tremendous resources can be mobilized very quickly when those in power feel threatened. Again fortunately I think HIV does not fall into that category. So to fall back on the weak argument of societal mandates calling for the control of HIV using the “traditional public health interventions” of contact tracing and partner notification is ridiculous, society does not care much here folks! Again, and I will address it soon I promise, the reason it doesn’t matter how much government responds to HIV, certainly in the gay community, is that no efforts on their part are ever likely to make much difference. The change that will affect the epidemic among gay men must be the result of internal queer cultural adjustments.
2) If we are going to use government monies let’s refocus a significant amount of those public health dollars and resources on the primary issues affecting the health of gay men: alcohol and tobacco! I find it curious that “public health” so often seems narrowly defined in Denver around issues of sexually transmitted diseases. Emphasis on gonorrhea as a significant health issue affecting gay men for example is a little like rushing up to someone who has just had their throat cut and offering them a band aide. There is pretty good data available for example that gay men smoke tobacco at rates significantly higher that matched heterosexual controls. A real fuel for the extensive problems with drugs and alcohol is of course that the primary places for gay men to begin socializing with other gay men and forming “gay identity”, still in 2002, remain bars. Think for a minute of the phenomenal resources available to facilitate the growth and development of heterosexual identity and the lack there of for queer folk.
In the HIV clinic where I have worked for 13 years now, on any given day since the advent of effective antiviral therapy, the primary cause of morbidity and mortality is much more likely to be alcohol and not primarily HIV. I often wonder if all AIDS prevention efforts existing today could not be dumped and all those resources redirected to alcohol abuse, treatment and prevention and that we would not then be much further ahead in the game when it comes to preventing not only new HIV infections but unnecessary progression of existing ones. Drunken people do not often take complex pill regimens on schedule as prescribed and frequently forget where they put the condoms!
3) Encourage or perhaps even reward the discussion of sex and specifically safe sex in all primary care settings where HIV patients are seen. That sex is a neglected topic in most primary care setting is it seems a given. Now that we have realized that some folks already in care for their HIV may be sources of new HIV infections perhaps it may be time to address this issue with these individuals. This has been done locally by the ID Clinic at Denver Health and the discussion of issues of sexuality and HIV transmission were enthusiastically embraced by the clients when approached. In order for this to be a cost feasible effort in private settings in the age of managed care a monetary subsidy seems to be imperative.
An important caveat here is that those bringing up the issue of sex with gay men be familiar with varied and complex sexual communities and practices across the spectrum of diverse gay male communities. I am frequently amazed and appalled by the lack of knowledge around the rich diversity of gay male sexual practices among even providers with years of caring for gay men. Some educational workshops on this issue seem to be in order.
4) Let’s make getting tested for HIV easy! By CDC estimate nearly one-third of the 2.1 million persons tested yearly in public clinics do not return for results. This statistic is from a Wall Street Journal article by Geeta Anand (12/20/01). The problem according to this piece may be related directly to the fact that Bio-Rad Laboratories Inc. controls the patent and has refused licensing rights to small companies who would sell the rapid tests in the US. Quoting directly from the piece: “Critics at the CDC and the military say Bio-Rad and its three licensees – Abbott Laboratories, Chiron Corp. and Johnson and Johnson – have little incentive to sell a rapid test domestically because they already dominate the $200 million US market for the slower, lab based tests.” A little activism around this issue from local Public Health doctors might be refreshing! All sorts of change can happen rapidly when the right folks get behind something. I would remind everyone of the significantly reduced government negotiated price for Ciprofloxacin around the recent anthrax scare. An interesting sidebar to this Cipro/anthrax affair was the challenge, again by the US government, to the supposedly sacrosanct drug patent issue. Threaten the big boys and mountains can be moved and quickly! I am reminded here of a comment from John James in his newsletter. Slightly updating it the jist was there have been to date 5 deaths from anthrax and there were 8,000 deaths worldwide yesterday from AIDS. I would refer you back to the quote from Paul Farmer on “social position” and suggest that poor Africans dying of AIDS are at the bottom rung when it comes to social position.
5) Consider getting out of the business of HIV prevention in the gay community all together.
Some things the local homosexual communities might consider:
1) We need to “re-gay” AIDS (again) and quick! Anyone looking the least bit critically at the local HIV/AIDS statistics has to come to the conclusion that this is a real problem for homosexual men in this community and there is the distinct possibility that it is getting worse! Let’s start dealing with the immensely pleasurable activity of anal sex in an open and honest fashion that not only acknowledges it for its wonders, but also its real role in the spread of HIV in a population with lots of HIV.
If for a minute you look at the world wide AIDS pandemic it is, outside of the US, Western Europe and Australia, an overwhelming heterosexual disease affecting primarily the poorest of the poor. So why does it continue to be an issue with homosexual men. We no longer fit in the larger scheme of it all. Even using Paul Farmer’s analysis that it is a cultural phenomenon strongly dictated by social position it doesn’t really completely fit for gay men. Though I want to emphasize that many gay men are poor, of color and lower social position many are not and we are the only significant exception to this rule when it comes to who is getting infected with HIV.
Unprotected anal sex in a population with lots of HIV is a prescription for disaster. Before I provoke a “sex panic” with these statements let me say that I love getting fucked and have not set it aside because of my HIV infection. We must though address the reality that assholes are not vaginas so the whole trip needs to be fine-tuned not abandoned! Equating the asshole with the vagina may seem politically correct however it denies a bit of biological reality that plays a real role in HIV infection. Like it or not certain components of gay male sexual behavior when combined with multiple partners has created a unique nitch in which HIV is able to thrive. Truly one of our great challenges as a community is to get the HIV monkey off our backs while continuing to celebrate our wonderful sexual diversities.
For a stimulating analysis of the ecology of HIV among gay men I would refer you to Gabriel Rotello’s excellent book from 1997, Sexual Ecology. Rotello’s well thought-out analysis deserved and still does today a much more thoughtful response and ongoing dialogue that it received. The hysterical screeching around the book revealed a community in many ways unable to grapple with the hard issues around AIDS and struggling mightily with issues of identity. What little thoughtful critical engagement of the work there was was drowned out by a bunch of hyenas totally preoccupied with their own dicks I guess. There is a crying and urgent need for open and honest discussion of gay male sexual behavior and how it fits into the broader scheme of gay male health, particularly within the gay male communities.
We do not do any formalized sex education in our community that I am aware of. Telling young gay men or anyone just coming out sexually that there is risk out there so always use a condom is absolutely criminal in view of the complex realities involved. Where are our surviving well fucked elders on this issue?
Queer as Folk is a show with its problems but every once in a while they hit on a real issue and in one of the pilots (now available on tape/DVD) the youngest member, Jason, looses his virginity to an older gay man. The absolute power of that moment was not the actual soft-core porn version but occurred later when he was describing the incredible nature of the experience to a female friend. A condom was used but anyone who has experienced such a thrilling moment of passion should be able to relate to the possibility that “safe sex” is often not a first priority.
2) Once we have re-owned the nasty beast (HIV) we need to appropriately reincorporate it (see above Rofes quote) into the much broader issue of gay men’s health. The definitions of what constitutes issues of gay male health can only come from the queer male communities affected and absolutely not be left up to the local health department, no matter how enlightened and well meaning they may be.
Again I would refer you to the work of Eric Rofes on this matter. In 1999 and 2000 there were two well attended conferences on gay male health issues held in Boulder. Significant efforts were made at each to stimulate nationwide, but always locally specific, gay men’s health movements, addressing a wide array of issues and concerns inclusive of but much broader than just HIV. I would love to stand corrected on this but to my knowledge very little has happened locally, outside of Boulder, as a result of these conferences.
Any queer community based organizations need a variety of diverse, active and ongoing programs that address the total needs of the queer individual: spiritual, physical, social and cultural. This is obviously a tall order but I think we can begin simply by addressing very intensely the fact that we are more than the sum of our sexual behaviors, granted as important as those are. In order for AIDS to ever be addressed appropriately in our communities it must come back into our organizations to be addressed by ourselves and the sooner the better. Their will be significant resistance to this often cloaked in the guise of political correctness but when examined closer this opposition is really nothing more than self-serving attempts to continue to feed at the AIDS trough. Below are some strong words from a friend (sorry my friend must remain anonymous) on this very matter that point to some of the root issues that keep queer male AIDS and prevention thereof from ever being adequately addressed by the existing AIDS organizations locally. It is an angry piece but has enough merit to warrant a serious discussion of the issues raised.
“Bottom line, if all the money that’s been drizzled on AIDS organizations for the past 10-12 years suddenly disappeared, so would the controversies. The loudest and most difficult clients of the HIV/AIDS epidemic have become the staff level whiners who are on/have been on/want to be on the AIDS meal ticket. Part of my own difficulty with CAP for years has been its willingness to foster an entitlement mentality, picking up the slack for what government and other social welfare agencies have refused to continue to do. It’s more about food banks and private welfare and feel good fluff than it is about fostering a sense of individual responsibility and genuine community caring. It’s almost created a culture that makes being HIV positive an attractive option. I’m so sick of hearing “AIDS is not over yet.” In my truly cynical moments, I’m inclined to believe that it’s not over because there are people who make deliberate decisions to not let it be over. Part of that has to do with the utter failure of the systems at many levels to deal with prevention effectively.”
3) In a recent piece I wrote to Westword (which will never see the light of day, but I have attached) I addressed in very cursory fashion the issues of class and race in local homosexual communities. These are big and very poorly addressed issues across all queer communities but they are even more so when talking HIV and prevention of new infections. Recent commentary on this says that in certain large cities 3 out of 10 gay men of color are already HIV positive compared to 1 in 10 of comparable white homosexuals.
My work environment may be unduly influencing me here but I also detect a class shift in the queer world when it comes to new HIV infections with lower and more disenfranchised classes being disproportionately affected. I would refer you back to Paul Farmer’s comments on “social position” being a major factor in who gets HIV and apply that to the gay male world as well.
A personal anecdote that seems to perhaps substantiate this class shift is in regards to who goes to bath houses these days. In the late 70’s the baths were I think much more egalitarian, crossing all class and race lines (and I and others contend a major factor in the explosion of HIV among gay men), much more so than today. Granted my bathhouse attendance was measured in hundreds of visits in the 70”s and only 3 since 1995 (all asexual outings by the way). I was struck by the difference in clientele; these observations are possibly influenced by the vagaries of aging, as is so much of life these days, but I think they are not that far off. Several of the local bath houses are frequented often by patients in the ID clinic and these folks are not upper middle class business men I assure you.
Class may be a bit easier to address than race for the queer world but both present many of the same challenges as these issues do for the larger society. I actually may see more African American gay males than any other provider in the ID clinic and I have learned a lot from these guys. Many face additional issues of discrimination that I as a white middle class queer never had to deal with, but a real confounding factor for many seems to be that they have not ventured far from their biological base. Their families are here in Denver and because of real racism in both the broader gay community and society as a whole they stick closer to home. That makes coming out gay much more difficult. I have always thought that the ease of coming out is directly related to how many miles from “home” you are, i.e. the farther away the easier it is!
That does not explain everything though when it comes to dealing with the lack of color representation in the queer social and political worlds. This summer I was honored to be invited to the marriage of two black men both of whom are patients in the ID clinic. What an amazing event. There were all sorts folks there from across the spectrum of gay and biological family. It was one of those phenomenal change creating events that do gay liberation proud. Neither of these men is in anyway connected to the gay political establishment of Denver but their holy union did more for gay liberation that a 100 Human Rights Campaign Fund Dinners, regardless of who the keynote speaker is or the amount of money raised!
So my challenge to the queer power structure of Denver is to take a long hard look at your own shit when it comes to class and certainly race and try to address these issues a little more honestly than we have to date. I am not for a minute saying we can all be one big happy family. One of our over used calls to action is “celebrate diversity”. The real challenge I think invoked with that is to do it within our own communizes, and it is not going to look like “Will and Grace” or “Queer as Folk” all the time.
Let me address class issues for just a minute. One of the most insidious homophobic attempts to control us is to portray ‘gay people’ as only privileged, white and largely middle/upper class. I will grant that for those falling into those categories it may be a bit easier in certain cultures to come out, but it in no way does justice to the reality that queers really do come in all colors and from all classes and every culture on earth and that everyone’s coming out process is not equal. I have long thought of us as the gold threads in the tapestry that is humanity, but I digress. I think that the gay power structure has only played into this over the years and this gets exemplified with the tedious and endless message” we are no different than you are except for who we choose to have sex with.” Jesus, how pathetic is that! I would challenge any queer on earth who says they are no different than George Bush, except for whom they choose to fuck, to go sit quietly in a corner until you get it!
I have wondered a bit here and you appropriately may ask how this all relates to HIV prevention, well very directly I think. Gay men of color do not get HIV any differently that white queers do! So let’s address the issue in ways that honor how most of them have dealt with their homosexuality in very courageous fashion and not dilute it with all the “men who have sex with men” shit and then have “safe sex” messages delivered by hetero people of color. These heteros of color have no clue what it means to be queer and to face the challenges that come with being gay, but there are gay men of color out there who do. How do they get involved in all of this?
4) I am now led to my final exhortation for the queer world in this piece, but by no means my last. You will have to read the book to get the complete ranting on all of this (tentatively titled of course “Better than Peyote”.)! We need a very comprehensive overhaul of the “coming out ‘process and how those folks already out and working in queer community based organizations can best facilitate this for those just beginning the journey. To cop just a bit right now from Ken Wilber (but a lot more in the book) we need to begin addressing our queerness in relation to our inner (drives, hopes, desires, fears) and outer (food, clothing shelter) needs with both getting adequate attention. And how then do we incorporate our queerness with the inner needs of society (shared beliefs and goals and world view) and the outer needs of society (education, economic structure etc.)? What in each of these areas do we bring to the table as queer folk? Plenty I think!
The first and most vital step of course is to totally abandon the belief “that we are no different from them except for what we do in bed”. Something Harry Hay said to me in my kitchen late one night back in the 70’s was the “only thing we have in common with straight people is what we do in bed”. A thorough challenge of the post modern deconstruction that reduces us to what we “choose” to do with our genitals is in order or we will never get the AIDS monkey off our backs.
Time constraints around getting this piece done limit my expansion on this but if you read all that came before you start to get my point, hopefully. If it’s really only all about sex then we are in big trouble and maybe Jerry Falwell is right, but I don’t think so!