serological preference?

A new portmanteau word has been circulating among observers and people directly involved with AIDS prevention in the gay community: serosorting. It was originally used to describe individual protection strategies revolving around the preventative norm according to which condoms were used in every case of anal penetration. More plainly: let’s negotiate before having sex, according to our respective serological statuses. If there’s serodiscordance we’ll use condoms and avoid anything risky, or forget about having sex. If there’s seroconcordance, let’s romp without worry or protection.

Some brothels in the United States have been known to organise no condom nights under the banner of serosorting – seropositives over here, seronegatives over there. Those who practice serosorting see it as a sensible and rational risk reduction technique that is consistent with strategies advocated by relevant institutions and charities. There is growing debate among these organisations about how serosorting should be integrated into prevention discourse and policies. One could stress the danger of a practise that is based on uncertain knowledge about each person’s serological status, warn against the segregationist tendency it suggests, and reaffirm the technical and ethical efficacy of condoms for every penetration scenario. On the other hand, one could also consider these techniques for selectively bypassing condoms as tacit endorsement of the idea that the “always use a condom” message has failed, and promote serosorting as a prevention tool, a least-risk system that, though not safe in all circumstances, would offer those who completely reject the use of condoms the possibility of avoiding infection.

In San Francisco, where one quarter of homosexuals is HIV seropositive, the Department of Public Health recently opted for this second solution. Seeing that the annual rate of new infections within the gay population had stabilised since 1999, whereas unprotected sexual relations had increased, in November 2006 it launched a campaign called Disclosure, which portrays serosorting as a “harm reduction strategy”. It also promotes screening and encourages people to make serological status discussions standard practice, in order to help them “make the most informed decisions possible [1]”.

In a city that is still in many respects a laboratory for the epidemic and the community struggle, this kind of institutional warning was bound to feed the polemic between those who praise the inventiveness of a prevention policy that is willing to change so that it is based on the real practices of homosexuals, and those who lament a harmful regression signalling the defeat of a community culture that has traditionally revolved around advocating safe sex and rejecting of all forms of discrimination. This debate has crossed the Atlantic, as the many French translations of the word ‘serosorting’ testify. Those who subscribe to it, like the website Warning [2], suggest two words: séroadaptation, which designates choosing the form of sexual contact, protected or unprotected, according to partners’ serological status, and sérochoix (serochoice), which refers to choosing partners based on their serological status. Those who are against it, first and foremost the activists of Act Up-Paris, prefer a literal translation of “serosorting” that indicates its brutality: sérotriage, a word that resonates with the echoes of a sinister “serological preference”.

The debates continue among French associations, and it will take time before there is any positive translation of “serosorting” in prevention messages. Its meaning and the issues it raises can probably be better understood if it is examined in light of the longer history of community strategies relating to preventing the risk of HIV transmission.

It is important to remember that during the first fifteen years of the epidemic, the gay community’s AIDS prevention workers shared a consensus: priority should be given to information on how HIV is transmitted; condoms should be promoted as the only means of preventing infection in case of penetration; alternatives to anal sex should be advocated, as well as regular AIDS testing; each person’s individual responsibility should be emphasised, whatever his serological status, and shared responsibility should be stressed in case of infection. This system made it possible to stand up to every kind of moralising criticism (it should be possible to contain the spread of HIV without questioning a gay sex culture defined by multiple partners and the importance of sexual consumption places) and discrimination (the many vague tendencies to hold those infected responsible for spreading the epidemic). As long as a seropositive diagnosis was more or less considered a short-term death sentence for lack of a sufficiently effective therapy, this set of preventative norms was never called into question, however intense the debate about the best way to implement them might have been. Some prevention failures were put it down to the gay community’s continued use of high-risk practices and the persistence of imaginary means of protection (choosing partners based on appearance, age or disposition, the metaphysical belief in the virtues of a love that protects), said to be the result of inadequate information, insufficient effort by civic authorities and the persistence of a homophobia that paved the way for the epidemic - all things that needed to be combated if a rational prevention strategy was to prevail. No one can deny the effectiveness of the gay community’s action at the time, which made it possible both to contain the spread of the epidemic within the population initially the most affected by AIDS and to stabilise the rate of new infections. In the mid-nineties, activists participating in the struggle against AIDS took obvious leadership in terms of gay expression and culture, to the point that the collective assertion against risk changed the notion of pride: gay, lesbian, bi and trans pride was, among other things, pride in having responded to the epidemic as a community. “Proud to wear them” (condoms), as an Act Up banner said.

However, the therapeutic revolution that began in 1996 drastically changed that established order. In a country where treatment was readily available, AIDS soon came to be regarded as a chronic illness, even if it ultimately remained a fatal one. This led to reduced awareness of the risks associated with infection. The difficulties of a life in the shadow of HIV and the burden of treatment and side-effects did not have the immediate resonance of the threat of short-term death. The consequence: a crisis for associations and community action, less discussion about prevention and fewer people promoting it out in the field, despite the fact that the infection rate was higher than ever and continuing to increase. To complete this rather brief history, we should also mention that the resulting widespread feeling that time was opening up again led some of those infected to express a certain a priori apathy about their duty to use condoms for the rest of their lives, and it even led some of those not infected to express the belief that the best way to rid themselves of their fear of infection was to get infected. In this context, it is not surprising that all surveys found that the use of prevention practices was flagging (knows as the “relapse”) among the gay population, and that the rate of new infections was increasing.

This was the climate in which three debates arose relating to the gay community’s management of the risk of infection, debates that caused divisions among those battling AIDS to the point of eroding preventative norms that had once been a matter of consensus. The subjects of these debates shed light on the current discussion about serosorting: the emergence of a risk-taking ideology, the increasing power of the “harm reduction” message, and the calling into question of the concept of shared responsibility through the criminalisation of HIV transmission, something that is becoming more and more common throughout the world.

A risk-taking ideology

In sexual terms, “barebacking” refers to the choice to engage in unprotected sexual relations. It is difficult to assess the increasing prevalence of high-risk practices, or distinguish between deliberate barebacking and the “relapse”. Barebacking refers to a set of words and representations that are mostly used by introduction networks [3] and in publications (to mention two French examples: the autofiction of Guillaume Dustan and Erik Rémès). This sexual sub-culture has its own rules (such as a ban on condoms) and a detailed lexicon, the nature of which becomes clear with only a few examples: HIV is called the gift, an uninfected person seeking infection is called a bug chaser, an infected person seeking to infect an uninfected person is a gift giver, etc. Even if this theoretical consistency does not impress, barebacking discourse claims a kind of coherence that we will attempt to reconstruct as honestly as possible.

Barebackers put pleasure before all else. Their justification is twofold. They dispute the claim made by some prevention workers that condoms do not affect the intensity of sexual pleasure; and they claim there is something erotic about the risk, even a loving positivity in transmission, frequently explained in terms of impregnation.

Barebackers claim to possess a certain knowledge. They say they are aware of the means of infection and all of the current medical knowledge, though they sometimes offer an interpretation that is biased or incomplete. They stress that current treatments make it possible to live with the virus, and they will remind you that there are post-infection prophylaxes that limit the risk of seroconversion, and enumerate all of the existing STDs to which they are exposed. They justify themselves mainly by pointing to uncertainties in scientific knowledge relating to, among other things, the danger of an infected person getting re-infected, or of an uninfected person getting infected by a strain of the virus that is resistant to available treatments. In other words, barebackers claim “measured” risk-taking.

Barebackers say they are defending an ethic based on individual responsibility (the right to decide for yourself what is good for you) and the mutual consent of partners (even if it is consent to infect). They proudly brandish the banner of sexual freedom before those who support moral policing, particularly those they call prevention “cops” who want to shame them.

Barebacking discourse — sometimes formulated by former fellow travellers from the AIDS movement — appears to take up some of the basic motifs of discourse against AIDS only to turn them against those who are still promoting them in a time they call “post-AIDS”. Signifiers once employed in the context of risk-free sexuality are used to promote risk-taking that is understood to be positively assumed.

Under these conditions, it isn’t surprising that the hostility these arguments engendered among those fighting AIDS was inhibitive, sometimes to the point of paralysis. So there was an urgent need to rearticulate risk-free sex discourse so that notions of pleasure, knowledge and ethics were taken into account, at a moment when these were being invoked in the service of a risk-taking ideology. Before 1996, everyone seemed to agree on the need to eroticise prevention practices, but they were forced to acknowledge that this often did not go beyond the declaration of intentions, with the notable exception of “jack off parties”, epic collective masturbation sessions organised by the group Santé et plaisir gai (Gay Health and Pleasure). But with their harsh lights, blacklist and comprehensive supervision, these did not always meet high expectations, except in leather and S & M circles, whose sexual culture had long been built around formalised practices, experimenting with erogenous zones, and exhibitionism. So rethinking the link between safe sex and pleasure involved conceding that there was a certain pleasure in unprotected sex, but this pleasure was reinterpreted in light of its consequences (its ultimate fatality; living with the side-effects of treatment – diarrhoea, lipodystrophies, pain, etc.). In other words, the pleasure was measured against the cost of the real risks. This response also addressed the knowledge mentioned above. As for the way in which barebacking put forward contradictory information on re-infection and the transmission of resistant strains, the response was to stress the virtues of caution.

However, the most fierce and painful debates among those fighting AIDS revolved around ethical issues. The enlightened view, summed up by Act Up’s beautiful “J’ai envie que tu vives” (“I want you to live”) – which made condoms the ultimate ethical objects, since concern for oneself was also concern for others – absolutely remained the order of the day, though it did not resolve all problems. Was it acceptable to shame people if it meant vindicating barebackers’ accusation against the “new sex police”, and taking an accusatory approach that the association Aides, for example, considered counterproductive? While reaffirming the notion of shared responsibility, was it necessary to define responsibility specific to people who were infected, when this risked appearing to vindicate discriminatory stances and the vague desire to penalise HIV transmission, and risked representing those infected as “viral bombs”? Was it necessary to recognise the inadequacy of a consent ethic, and replace it with a higher conception of community morality? Act Up responded positively to all of these questions, not without tensions and schisms. Some left the association in protest against what they considered a new moral order. Others left (like its founder Didier Lestrade, and those who created Warning) because they considered it too timorous.

In 2007, the debate has not been resolved. In a way, the serosorting controversy is its legacy. Even if it is true that not all of the people who practice it consider themselves barebackers (far from it), it is equally true that barebackers often portray its institutionalisation as their victory: serosorting is a presentable version of barebacking, in the sense that it rejects the cheap pleasure of the Russian roulette between serodiscordant partners. And it is impossible to deny that those who subscribe to the principle see it as a way to reintegrate barebackers into the risk-reduction field.

Promoting risk reduction

Starting in the late nineties, voices could be heard calling for the resumption of discussions on prevention, which was the only way to confront the “relapse”. To anyone who pointed out that national campaigns promoting condom use were inadequate or even non-existent, or that the price of condoms was prohibitive to some, the retort was often that neither information, nor making protection available would be enough to translate into safe practices. A critique of condom-centred prevention discourse came to be asserted, intended to help people who could not make up their minds about condoms to limit the damage. Here one could take inspiration from risk reduction successes among drug users.

In a preceding article, Aude Lalande explained the ambiguity that has always attended the French translation of “harm reduction” into “réduction des risques” (“risk reduction”). Was the point to categorise dangers and get rid of those that could simply be eliminated (for drug users, a clean syringe fully protects against the risk of contracting HIV)? Or was it rather to probabilise the risks based on statistical knowledge? When stressing the importance of risk reduction in relation to preventing sexual transmission, it is the probablist hypothesis that carries the day. Doubtless there are indeed sexual practices that are statistically less likely to transmit HIV, but they remain infectious.

A precursor to the idea of creating a risk-reduction-based prevention policy was the idea of codifying a risk scale on which all possible sexual acts would be ranked from safest to least safe according to epidemiological knowledge. “Jack off party” organisers have been attempting this since the late eighties, but with a completely different goal. Since the idea was to eliminate all infection risks, it was necessary to distinguish between risk-free practices (safe sex) and least-risk practices (safer sex). And yet condoms can sometimes break, especially when used without lubricating gel—this is why every kind of penetration was banned at the first jack off parties, even if protection was used. Those who promote risk reduction work with this same kind of data (a risk scale combined with a protection coefficient) to produce, on the contrary, reduction ratios for prevention standards.

In France, it was Aides, particularly its Provence arm, that chose to distribute prevention information directed at homosexuals who solely subscribed to the principle of risk reduction. It distributed a series of flyers explaining that although condom use was still “the most effective means of protection” (in small letters), if you were going to go “without a condom” (in big letters), it was best to limit the number of partners, avoid sperm during oral sex, use lubrication gel during anal sex, withdraw prior to ejaculation, penetrate instead of being penetrated, etc.

Mounting a campaign of this kind was no doubt justified by the real practices of the majority of gay men. No matter what the tenets of prevention, using a condom during oral sex is rare, even when the risk of infection is known. But the fact remains that a risk reduction policy presents a series of problems, and updating it gave rise to fierce conflict. To mention only one of these problems, remember that reducing the risk of sexual transmission requires combining an epidemiological strategy within the scope of public health with a prevention approach directed at individuals. Going by the law of averages, you find that more people become infected by being penetrated than by penetrating. If we are more concerned about individuals, this distinction doesn’t much matter, since you’re never 20, 30 or 40% seropositive, you either are or you’re not. In other words, you cannot base a prevention policy on a probablist calculation.

In fact, Aides’s incursion into the of risk reduction field with their flyers almost backfired. But it still sheds light on the beginning of the emergence of serosorting, which, if it is to be instituted as a prevention option, can only be defined as a new method of risk reduction.

A tendency to criminalise HIV transmission

It had long been brewing. In 1991, as part of a revision of the penal code, the Senate adopted an amendment that proposed the imposition of a three-year prison sentence and 300,000 franc fine ($67,200/£33,600) “in case of careless or negligent behaviour, by any aware and informed person, leading to the dissemination of a transmittable epidemic disease”. The amendment was defeated on second reading at the National Assembly after lobbying by associations. They pointed out that criminalising transmission was dangerous for both individual and public health, mainly because it was an obstacle to encouraging voluntary screening. To avoid being accused of responsibility for infecting others, it would have been better to not to know your serological status.

In 1991 it was a legislative initiative. But over the past few years, it is the complaints of those infected that have rekindled this idea and contributed to legitimising it. For lack of any other characterisation of HIV transmission in French legislation, these complaints have fallen under “poisoning” or “endangering the lives of others”. In Marseille, a group of women set up an association called Femmes Positives (Positive Women), to push for penalising “wilful infection”. Though all of the “old” associations stood up against a dangerous tendency that would divest seronegatives of responsibility for prevention, some seasoned AIDS activists brought Femmes Positives some public support, invoking the defence of seropositives’ demands.

In 1998 the Court of Appeal established that exposure to HIV could not be qualified as poisoning, even if intentional. But in Strasbourg in 2004, when, for the first time in France, a seropositive man received a six-year prison sentence without the possibility of parole for having infected two young women through unprotected sex, the charge was “administering a noxious substance”. Others have been sentenced since, as a result of civil suits brought by Femmes Positives.

Obviously the tendency to criminalise HIV does not stop at France’s borders. The GNP+Europe association network (Global Network of People Living with AIDS) recently published a list of lawsuits in the EU, and just about all European countries were included. Among those that have adopted legislation specifically dealing with HIV transmission, some, like Sweden, Norway and the Netherlands (the list is not exhaustive) provide for penalising risk-taking, even if no infection has been proven. Beyond Europe, a number of countries have been caught up in this passion for repression. A recent example: last July, the California Supreme Court ruled that “people who carry the virus can now be held legally liable, even if they do not know they are infectious.”

It is easy to interpret these cases and examples as symptoms of a more general, increasing tendency (that goes beyond AIDS) to allow a repressive reflex to substitute for prevention policies. In any case, the rising power of serosorting and calls for it to be institutionalised should be viewed in this context. When the legal threat hangs over sexual relations between serodiscordant partners from the outset, there can be a strong temptation to restrict oneself to seroconcordent partners.

Let us not forget that serosorting practices unquestionably exist, and have for a long time. If we take up the distinction suggested by Warning, seroadaptation determines the sex practices of numerous couples, according to whether its members have an identical or different serological status. As for serochoice, to continue the example of the couple, it could very well have an affect on the choice of partner. After all, one can, without being suspected of discrimination, prefer a partner who shares one’s serological status. The only issue in the debate has to do with the question of knowing if a real prevention strategy can be defined from incontestable individual acts.

Those who respond positively to this question extol the do-it-yourself inventiveness of individuals, as sharply opposed to the inertia of prevention institutions that rely on outdated methods. According to them, these organizations can find no better response to barebackers than to exclude them and have responded to the “relapse” with impotence. They say that on the contrary, institutionalising serosorting would have the advantage—while respecting the desire to enjoy sexual pleasure without a condom, but also accepting the consent argument—of making those who identify themselves as barebackers more receptive to general prevention messages and information on other STDs (which could weaken the immune system), on re-infection (which could accelerate the onset of illness), on the risks inherent in combining different strains of the virus, etc. They want to make serosorting organised because it would provide, in the spirit of the San Francisco campaign, another way to encourage voluntary screening, information collection and informed negotiation between partners, and could help turn discussions about serological status into standard practice – all things that are characteristic of that empowerment that has been both the lever and the objective of community action against AIDS from the very beginning.

Does this mean the new prevention inspiration they’re applauding is a return to basics, or an overhaul? Not necessarily. Because the efficiency attributed to serosorting has the same hidden ambiguities we mentioned in relation to risk reduction, which relies on a probablist gamble at best. Even if the statistical data available are subject to caution and given to contradictory interpretations, there are people who say that organised serosorting would reduce the actual number of infections. For the comparison to make sense, it would be necessary to evaluate the reduction in the rate of infection that would have been possible through the traditional prevention campaigns that have almost completely disappeared from the public arena in the past few years.

But other data — and other studies — temper enthusiasm. Serosorting’s most serious pitfall is the fact that it is very difficult to know for certain if you are seronegative. A screening test only tells you what your serological status was several weeks beforehand. In the meantime, one may have been infected without the antibodies being detectable yet. When this is the case, the viral load is considerable; and the greater the viral load, the greater the risk of infection. In other words, in good faith one can obtain a seronegative test result, decide not to use protection with a seronegative partner, and in fact be far more infectious than a seropositive receiving treatments that neutralise the viral load. If serosorting were institutionalised, the way it would encourage people not to use protection with seroconcordant partners could end up being even more dangerous than the “relapse”. This would be all the more unacceptable because it would lead to infection between people who believe they are conforming to a prevention strategy. Under these conditions, it is difficult to regard serosorting as a method that enables individuals to rationally evaluate the risks they are taking, because it could amount to defending a new imaginary prevention strategy. In the early nineties, the sociologist Rommel Mendes-Leite compiled a list of justifications people used to explain their choice not to use a condom: a partner’s “healthy appearance”, assumed to guarantee his seronegativity, his youth, or even his carefree attitude. Serosorting might only be a sophisticated avatar of this sort of method, just as fallacious and equally discriminatory. And this might be a piece of good news; serological preference no better prevents the risk of infection than the isolation of seropositives was able to contain the spread of the epidemic. Prevention does not adapt well to segregation.