Risky Business: Personal harm reduction strategies among NYC's MSM 

"It is almost like a math problem. I look at the person, think about what we are probably going to do and then decide how we are going to do it." Bill*, worker at a gay-oriented healthcare center.

Bill, who is HIV-negative, says he "knows all about safe sex." But there are times when he has unprotected anal intercourse with a self-disclosed HIV-negative "top" because the man "doesn't look sick," and Bill figures, men who assume the penetrative role in anal sex are less likely to be HIV positive.

For other partners, Bill insists on condom use regardless of how "clean" they look. If a potential partner admits he is HIV-positive or if Bill knows that the man is HIV-positive, he won't have sex with him.

Like Bill, many gay men make unsafe decisions about their sexuality by weighing the rewards against the risks of engaging in particular behaviors with particular partners. For this research, I conducted more than a hundred interviews with ethnically diverse HIV-positive and HIV-negative men who have sex with men (MSM) between the ages of twenty and forty, living in New York City. The paper focuses on their sexual decision-making by exploring their personal harm-reduction techniques.

Lost Messages

U.S. authors of safer sex messages aimed at MSM lay down a strict set of guidelines regarding what constitutes safer sex and what does not. They recommend condom use for every sexual act. In addition, they promote abstinence and advise limiting one's number of sexual partners. As the Centers for Disease Control and Prevention puts it, "The surest way to avoid transmission of sexually transmitted diseases is to abstain from sexual intercourse, or to be in a long-term, mutually monogamous relationship with a partner who has been tested and you know is uninfected."

While MSM are told to use a condom every time, in reality many are practicing "lay epidemiology," adapting aspects of the prevention lexicon to personal risk/reward choices. This concept was described by D.A. Lawlor in "Smoking and Ill Health: Does Lay Epidemiology Explain the Failure of Smoking Cessation Programs Among Deprived Populations."

It is important that those working in the community to prevent HIV transmission understand the forethought that goes into sexual decision-making. Some MSM who are trying to practice preventative behavior may actually employ personal harm-reduction strategies that increase their risk of HIV transmission and other sexually transmitted infections.

"I know the risk for oral sex is much lower, so I never use condoms for that."

Almost every man I spoke with said that he generally does not use condoms when giving or receiving oral sex. The only exception was an HIV-positive man who said his partners were worried about catching "other strands" of HIV and insisted on condom use for oral sex.

While most men expressed some concern about becoming infected through oral sex and "knew it was risky," many crave skin-to-skin sex, so they take the risk and forgo using condoms. The pervasiveness of unprotected oral sex stands in direct contrast to the safer sex mantra, "use a condom every time."

"My partner and I both tested negative, so we don't use condoms together, but when we have sex with anyone else, we do use condoms."

Another risky strategy that was frequently mentioned by men in long-term or steady relationships was the practice of forgoing condoms in the primary relationship, but using them for casual encounters. "My boyfriend and I want to have condom-free sex, but we also want to be with other people, so we decided that this arrangement works best for us," was a sentiment that was shared by those men who had negotiated sexually plural relationships.

"I won't ask a guy his HIV status, but if he tells me he is positive I'm sorry to say that I wouldn't have sex with him."

MSM should have a personal "Do ask, Do tell" policy. But while safer-sex guidelines tell people to assume that everyone is positive, the men I interviewed made no assumptions about status. And they indicated that more often than not, they do not inquire about status. They only decide to forgo an encounter if their potential partner states he is HIV-positive.

Another surprising finding was the degree to which many men attempted to have sex with men with compatible HIV status. For the most part, HIV-negative men wanted to avoid having sex with HIV-positive partners. HIV-positive men generally preferred to have sex with other HIV-positive men, explaining that if they knew their partner was positive, they would not have to use condoms for anal sex and would not have to worry about transmitting HIV. As one said, "If I have to use a condom, it just reminds me that I'm sick and contagious." Like the other decisions these men are making, this practice is risky. Someone who is HIV-positive could become infected with another strain of the virus, thus further compromising his health.

Continued study on the sexual decision-making of MSM is needed to lower the infection rates in gay communities. Findings could be adapted to create dynamic and meaningful HIV/STD prevention messages that reflect the range of safer sex comfort zones and the realities of diverse sexual worlds.