The following is the edited text of a presentation delivered by Patrick at "Generation PrEP - Are We Ready" organized by ACCM in November 2014
Saint-AIDS is, in my life and probably in yours, a key moment of reflection. For many of my friends and chosen family, it’s an important time of remembrance. Being part of the post-AIDS generation, and being active in the field for about 10 years now, I find it imperative to engage with tonight’s audience in order to help push forward our collective dialogue on the opportunities that pre-exposure prophylaxis offers in terms of HIV prevention and sexual health.
Over the last year, I made a risky choice. I chose to go somewhat public with my Truvada Whore-ing. Because, you know, going public, historically - hasn’t it been our only way to address stigma?
The choice I made a year ago - I will be performing it tonight: using my subject location and experience to challenge and stress the underlying opportunities that PrEP may offer in terms of social change and perception of human "mis"conduct. (Should I mention that I’m not the only person on prep within Montreal’s AIDS industry?)
I want to bring this dialogue to an understanding that has been frequently silenced: the diversity of lived experiences and diversity of possible intimate relationships.
Before I start, for all of those with curious and naughty minds, I’ll give you some raw data about my year - so - to this day, from the time I started PrEP - 42 weeks ago, I had:
- 58 Sexual encounters (ex: an orgy equals an encounter)
- 34 New partners
- 11 “Old” partners (with whom I had sex with before using PrEP)
- 6 Encounters with the use of condoms
- 38 Encounters where at least one anal penetration without condom took place
- 14 Encounters where no “penetration” took place.
- I had 5 STI screenings.
- as of the results of my last test two weeks ago, I am not diagnosed with any STI.
How it started?
In January 2014, my doctor prescribed me Truvada to ingest every day. This discussion to begin PrEP, on the other hand, had been addressed two months prior. My reflection on this subject started way before this.
My first consultation with her occurred more than four years ago. Our first appointment lasted an hour and a half. Within four years, I’d consulted her over 12 times before actually starting PrEP.
In my doctor’s opinion, I had a “very active” sexual life. I was quick to have regular follow ups for sexual transmitted infections. In four years, only one occurred- gonorrhoea in September 2013. I would often get check ups—every three months or sometimes more. I would usually go to Notre-Dame Hospital in Montreal. I have become affectionately tied to its “blood puncturing factory” aspect, and enjoyed its anonymity, like it’s a space for anybody.
Over these past 4 years, I’ve organized many trips to meet lovers, with whom condom non-usage was agreed upon. I had sex condom-less with close friends. Two or three times, I was taken by surprise by lovers. And fucked guys that were HIV positive and undetectable. During this time I was single, or in a relationship.
I have long come to the conclusion that sex without a rubber (on my penis, to be precise!) was clearly a preference. Looking at my past, it is clear to me that my behavioural marker was anchored on regular testing — I took tests with the goal of staying negative. Along with the results of my last serology, I would reason my choices, keeping in mind the knowledge I acquired from being an activist for many years.
To address my initial dilemma regarding PrEP (because I wasn’t always totally in agreement with this tool), I took the time to think about and write on the dynamic around costs, accessibility and the conceptual/contractual logic that this technology undermined. I also informed myself of the so-called side effects. I also took the opportunity to talk to a few lovers and friends from the States - especially a Boston couple i’ve fucked a couple times that are both using PrEP for about a year.
What was surfacing the most part for me was the absence of significant side effects. That blue pill wasn’t really changing their sexuality, rather it seemed to make it easier.
To make this clear: it is not because I am an uncontrollable inveterate fan of semen that I use PrEP. Actually, if I had to frame the reasons in equation form, we would end up with something a bit funny and slightly complex like this:
- I consider Montreal as a bottom city.
- I have a good dick
- Men often see me as the one who has to take charge (and over the years I have begun to like this)
- I need time to reach orgasm while I fuck guys.
- Rubbers generally make me lose my erection.
- And, mostly, I am a fan of piss play. I love pissing in someone’s ass. (Have you ever tried to do that with a condom on?)
For all of these reasons, I was using my last test as the marker of my serological status, then deciding what or "who" I could "do" afterwards. Now, if another technology allows me to reach the same goal, why would I refuse it? PrEP allows me to make an inversion of the way I “live” risk. Rather than thinking of HIV as a threat, it allows me to conceptualize my body as a space that is now biologically protected from HIV.
The Slut Stigma: Failure of the Activists?
With our carefully crafted prevention ideology over the last thirty years, we created a school of thought embodying a very clear idea: condom = zero risk. We created a model condom-citizen. Meanwhile, a diversity of practices were silenced, as well as many important facts on sexual health. For example, many STIs can still be transmitted even with religious use of condoms. Overall condom effectiveness is around 70%, not 100%…
In this regard, the Truvada Whore controversy in the United States is equally as interesting as it is disconcerting. Aren’t we once again in front of the same absurdity and the same political judgement on sexual promiscuity that was existent in the early days of AIDS?
In a Foucaultian perspective, we must question the conditions of possibilities that are allowing statements about « reality » to make sense. For example, very simply, when Michael Weinstein, President of Aids Healthcare Foundation in Los Angeles has claimed:
"If something comes along that's better than condoms, I'm all for it, but Truvada is not that. Let's be honest: It's a party drug."
This is a great example of the system of thought that frames our perception of sexuality in a moral context, blocking all opportunity to reason how or why people have these practices. We are facing a moral inquisition dynamic, facing the good old linear/binary/theologic, this system that draws a line between the "good" and the "depraved". This is the same system of thought that forces people I know on PrEP in Montreal to keep a low profile and closely guard their anonymity. Their key worry: the stigmatization process. This process works in ways to destroy one’s reputation and frame you in infamy. It works by internalizing your fears.
Slut shaming is still prevalent in 2014. Sadly, this great revolution of thought and openness sought after by AIDS activists in the 1980s was one that was fruitless. What to do with this now?
Lets talk about stigma baby
Being in front of tonight’s audience, isn't it exciting to address a key concept that has been so over processed in the field? We address seropositive stigma constantly. It's part of our framework. We’ve integrated it in our programming and actions. But what about stigma against slutty gay men? Haven’t we silenced that issue in order to concentrate on resources and funding?
The question could be asked: Is it a real stigma? Is Quebec’s situation different than the one in the States? My first point - This fear of stigmatization is as real for me as it is to my peers, but how do we begin to uncover this tension? There is a very long dialogue possible here. But in short, there is a constant force that divides those would-be victims of HIV and those who take wilful risks.
This has become ambiguous in HIV prevention discourses and responses. To illustrate my point, I’ll cite the most recent official stance of the Ministry of Health and Social Services of Quebec- taken from Une épidémie silencieuse (2010) document published by the SLITSS - from whom we have a dear representative with us tonight.
They illustrate their conceptual framework in which sexually transmitted and blood borne infections exist mainly in "more affected groups" and conceptualize the intentional victim in the following manner :
To the notion of risk groups, we need to add the notion of vulnerability. This concept refers to psychosocial characteristics that are influencing the individual ability of one to protect themselves. Difficult living conditions, a precarious personal state, a lack of maturity or experience, an unstable environment, effect, sometimes, for people to relegate their protection and the one of others at a secondary level, making them vulnerable and more at risk of contracting an STI (p.23).
Do I have difficult living conditions, am I in a precarious personal state or lacking maturity or experience, or am I in an unstable environment?
Is it here that PrEP poses its actual problem? PrEP is reversing the logic promoted by the AIDS bureaucracy. People on PrEP are aware of their risk and vulnerability, they want to protect themselves “before”, because their risk is self evident to them. But, at the same time, they confess to be risk takers. How does our Missionary Society find its balance in this spectrum of reality?
History of sex and moralization
From the beginning of my thinking about PrEP and sex, I had an impulsion - the desire to go back to basics. And, for that reason, I engage us with the thoughts of Gayle Rubin’s - Thinking Sex: Notes for a Radical Theory of the Politics of Sexuality (1984). Take a moment - reflect on this time period. There was not yet a prevention organization in Montreal. Our neighbours to the south lived in the grip of denial politics.
The text has the following aim: Human sexuality, beyond the ¨categorizations¨ used in medical and psychological discourse, is, at its core, based and shaped upon political reasoning. She used Jeffrey Week’s notion of ¨moral panic¨:
“Moral panics are the ‘political moment’ of sex, in which diffuse attitudes are channeled into political action and from there into social change.”
Of these moral panics, Gayle Rubin cites many examples like the anti-homo wave in the 1950s under McCarthyism. For Rubin, moral panics are moments where fear crystalizes on an ¨activity or a sexual group.¨ Media, State, police interventions, new laws are being put in place. The groups using these new objects justify their pressure tactics and their mission. Rubin offers us clear examples of American far right movements that used AIDS to propagate the homophobic ideals.
With a contemporary reading, shouldn't we give the example of the criminalization of HIV exposure with its media-justice system complex, this sweet duo helping the reinforcement of the representation of people living with HIV as people that should be seen as perpetual potential assaulters.
Am I trapped or contained within this moral panic device as a PrEP user? Is our AIDS exceptionalism part of a still existing moral panic complex?
To return to the question that I began with ¨what to do with this, now¨? Let’s make a stop in the early 2000s and have a quick refresher. And, I’ll dare to speak about, you know…barebacking. Let's recall. This became to be known within Quebec’s public sphere through Eric Rémès. His book Serial Fucker- Journal of a Barebacker was infamously provocative. This 2003 drama was loud enough to force the COCQ-SIDA, Quebec’s coalition of ASOs, to launch this surprising press release:
"The Quebec Coalition of AIDS Service Organizations questions that such a marginal phenomenon as barebacking should take up as much space in the media. "In Montreal, the Omega Cohort (which affected about 1,800 HIV-negative gay men during five years) has already demonstrated that in a population of 482 men, 1.2% had unprotected anal intercourse in a premeditated or spontaneous way" said Mario Fréchette President of COCQ-AIDS.
"Some extreme sports are just as suicidal as barebacking and they do not make the headlines," said Lyse Pinault, CEO.
The concept of barebacking has since been formally defined within the epidemiology discourse. As an example for Quebec, lets use the Argus cohort, Quebec’s branch of M-Track. Two years later - in 2005 - we see this concept being used and defined in the following fashion:
"11.8% have had "intentional" unprotected anal sex (barebacking) with more than one occasional male sexual partner more than one time."
Within two years, the allegory of statistical indicators had risen by more than ten percent. Is it people’s voice that suddenly grew louder? Is it the sudden relapse?
Intention- When does it start? How does it begin? Can you tell me?
So, the problem, the malaise, is clear : what counts is the intention of the individual, and to this you add the notion of irresponsibility. Just like in the Criminal code, right?
Shall we plan for a media frenzy around Truvada Whores in Quebec?
What issues, challenges and themes will the media focus on? Who or what will bring on this controversy? And, the most important…When?
I’m attempting here to demonstrate the importance of taking a step back in our collective reflection on HIV prevention. A mutation is needed: there is a different reality today. This reality is conceptualized as: Post-AIDS. It is a reality where, in the western/rich world, when treated early, one does not die of AIDS. A reality where everyday issues of people living with HIV are different. A reality that impacts the life and the zeitgeist of affected communities, and not to simply mention, the sexuality of its members. Such a mutation requires an end. The end of the disciplinary prevention system based on fear and stigma. In this matter, let's give closer look at the narratives of medicine around HIV. The hypocrite dichotomy is self-evident:
- No, it is important to remain HIV-negative because you’ll be at risk of so many things. You’ll get anal cancers, it will be so much more difficult to live, life will be so complex and heavy...
- But if you become seropositive, don’t worry. Your life expectancy will be as long as everyone else. Everything will be ok.
The Care of the Self, and the Care of Others
Analyzing the PrEP question solely from a biomedical sphere would be equally hypocritical. We have to consider the social, political, cultural and legal aspects that are organizing the redistribution of resources (human, financial, technical and medical).
Is the choice to take a prevention pill my own to make? I certainly have been able to make this choice in our current social and legal system. I did this by being a good citizen and neoliberal actor, having a decent upper middle-class income, enabling me to pay for my co-insurance. I did it as a Quebec resident, subject to its medical law system, in which covering it is an actual "obligation" for my insurance.
What both fascinates me and upsets me at the same time: it is easy nowadays to advocate that choice of contraception or abortion belongs to women. But my choice to chem up my prevention is easily a choice that can be put to question. Is it because my 30 monthly pills are costing $907 to my insurer? If this is the case, let’s get together and work on this issue! The same pills are costing 30 cents in India!
To my dear Public Health friends and their classic "prep wont protect you from other STIs if you don’t fuck with a rubber" position, I will answer: yes, of course. But let’s take a broader perspective. PrEP is a strategy, a new strategy, to promote and facilitate access to care- probably one that would work for the many guys who don’t access us at the moment.
With PrEP, taking your pils, is a conscious act. It is a form of engagement. An engagement in your personal health, an engagement I hope everyone will take ownership in. Being on PrEP requires regular testing and follow-ups, as often as every three months. This allows all the STIs and other the bugs one may catch to be treated every three months. Per se, to any public health aficionado and professional bug chaser, isn't this extraordinary enough?
Let’s not forget : the iPrEx Open Label Extension was clear. On daily PrEP, the risk protection is 100%, by taking 4 to 7 pills a week. This means: you forget your pill one day, you are still protected. If you forget a condom one day, you are at full risk!
From a gay men’s health perspective, I see PrEP as an opportunity. One to take a step back and reclaim what we mean by sexuality. It is an opportunity to rethink and review what we collectively mean by self-care and care for others. It is an opportunity to redefine what we mean by sexual health, and a healthy sexuality.
To my long standing activist and poz friends, I am curious facing your cynicism. Are we afraid PrEP will reverse or change the current equilibrium of power? Are we concerned the agenda wont be the same anymore? Are we scared some voices will be shoved to the side, while new meaningful voices are being heard?
If we want PrEP to be something else than an upper middle-class-white-gay-men-thing, lets starts advocating now because Quebec’s system will create this mess. Access to a PrEP regimen will fall under the same conditions than any other expensive/chronic medical treatment. The health inequalities and gaps will be the same for many.
Let’s see this moment as an opportunity to reaffirm the diversity and complexity of lived experiences throughout our communities. Lets see this moment as an opportunity to rethink what a risk subject or a risky subject is. Let’s us construct a new agenda beyond what has been defined by the medical discipline. Don’t forget: Medical discourse won the "war of expertise" about AIDS at the Vancouver AIDS conference by announcing the first highly efficient HAART regimen in 1997.
Please don’t take my sharing as one that is the one of every person in our communities. My story is not the only ideal. I am not a poster boy for PrEP. I am rather a sero-concerned empowered autonomous subject using his privilege to speak up.
Special thanks to Zachary Grant Whittaker, Marc-André Leblanc, Gregorio Pablo Rodríguez-Arbolay Jr and Jean Hardy for their insightful help on the traduction and comments.
About the author: Patrick is a Foucault trained grad school drop-out turned bureaucrat. He works in a completely different field while performing his sociology of knowledge kinks and radical thought on boards of directors in the sexual health field. Being a full raging member of The Warning, he comes tonight to share his own reflective process that made him get PrEPed and part of the very few who came out publicly about it.