Sexual Pleasure and Intimacy Among Men who Engage in “Bareback sex”

Abstract

An ethnically diverse sample of 120 mostly gay-identified men who engaged in “bareback” intercourse was recruited via the Internet in New York City. By study design three quarters of participants were HIV-uninfected and engaged in condomless receptive anal intercourse. In the course of face-to-face in-depth interviews, participants were asked what led them to have their first bareback experience as well as to continue with the behavior. Qualitative analysis identified the pivotal role that sexual pleasure and intimacy have in this population and how drives for sexual satisfaction, adventure, intimacy, and love overpower health concerns and condom use recommendations. Men interested in bareback sex use a variety of defense mechanisms to account for, justify, and exonerate their behavior. HIV-prevention interventions have paid insufficient attention to libidinal drives, a crucial element of psychological functioning.

Introduction

“Barebacking” is the practice of intentional condomless anal intercourse among men who have sex with men (MSM) in circumstances in which there is risk of HIV transmission [1–4]. Given that most human beings appear to value health over illness and that the illness risk associated with HIV infection is well known, especially among MSM in urban centers of developed countries, the practice of barebacking by uninfected MSM in a place like New York City appears at first view to be quite puzzling. Yet other behaviors (e.g., smoking, sunbathing) are initiated and maintained despite awareness of health risks. Therefore, we sought to better understand the mental and contextual processes at play in the case of barebacking.

For the last decade many academic studies have attempted to identify factors associated with barebacking. In a recently published review of 42 peer-reviewed publications [1], Berg summarized prior findings and proposed a conceptual model “for understanding the reciprocal and dynamic relationships sustaining barebacking” (p.761). Consistent with ecological models [5], Berg’s model includes macrosocial, mesosocial, interpersonal, and intrapersonal factors. Macrosocial factors include prevalent ideologies (e.g., heterosexuality as cultural norm), medical advances in HIV treatments, and cultural institutions (e.g., Internet, allowable forms of marriage); mesosocial factors refer to the social context in which the behavior occurs (e.g., community activism, social norms); interpersonal factors involve relationship quality (e.g., connection with partner, desire for and meaning of semen sharing, serosorting) and health communication (e.g. communication about serostatus); and intrapersonal factors include sociodemographic characteristics (including seropositivity), trait characteristics (e.g., desire for pleasure, exhibiting masculinity, romantic obsession, sexual adventurism, sense of self-efficacy in condom use), and health behaviors (e.g., substance use, online sex seeking).

In our study we sought to identify factors that lead HIV-uninfected MSM, especially those of ethnic minority background, to have intentional unprotected receptive anal intercourse (URAI) in circumstances in which there is risk of HIV transmission. For comparison purposes we also recruited a smaller number of HIV-infected MSM. Our research question was: what are the psychological factors (underlying motivations, emotions, justifications) that precede, are concurrent with, and follow barebacking in HIV-uninfected (and infected) MSM? Our team, comprised mainly of psychologists, used a developmental approach to explore how barebacking started and what led to its continuation. Although our inquiry was not guided by psychoanalytic theory, in the course of the data analysis later described we found that Freud’s structural theory of the organization of the psyche [6] was a useful paradigm to organize our findings. Freud conceived his structural theory late in life when he was less engaged in the active treatment of neurosis and “concerned mostly with broadly conceived cultural and human problems of the soul” [7, p.32]. Regardless of whether one supports the larger body of psychoanalytic theory, Freud’s structural theory may provide an apt metaphor to understand the barebacking phenomena. Freud discusses his structural theory in the essay “Das Ich und das Es” [6] where he describes the dynamic interaction among the I, the It and the Above-I (this was poorly translated into English as “structural model of a mental apparatus” and its three components were relabeled by the translator as Ego, Id and Super Ego; for a discussion on this mistranslation, see [7]). Freud describes the It as the reservoir of our basic drives, including the erotic and libidinal drives, that seek satisfaction according to the pleasure principle (i.e., to increase pleasure and decrease displeasure and pain). The It does not recognize moral judgment, is completely illogical, primarily sexual, infantile in its emotional development, and unable to take “no” for an answer; “it is a cauldron full of seething excitations” [8].

The I is a coherent organization of mental processes that develops in the interaction between the It and the world. The I represents what may be called reason and common sense, in contrast to the It, which contains the passions. Freud saw the I as a rider who, by and large, follows where his horse, the It, wants to go (an interesting metaphor for our study of barebacking). “In its relation to the It, [the I] is like a man on a horseback who has to hold in check the superior strength of the horse.” “Often, a rider, if he is not to be parted from his horse, is obliged to guide it where it wants to go; so in the same way the I is in the habit of transforming the It’s will into action as if it were its own [6].”

In the course of human development, external coercions and social norms gradually become internalized, and a special agency, the Above-I, takes over. The Above-I comprises that organized part of the personality structure that includes the individual’s ideals, spiritual goals, and the agency (commonly called “conscience”) that criticizes and prohibits his or her drives, fantasies, feelings, and actions. The I is like a slave to three harsh masters: the It, the Above-I, and the external world. The I does its best to suit all three, yet seems more loyal to the It, preferring to gloss over the finer details of reality to minimize conflicts while pretending to have a regard for reality. The Above-I is constantly watching every one of the I’s moves and punishes it with feelings of guilt, anxiety, and inferiority. To overcome this, the I employs defense mechanisms that lessen the tension by covering up impulses that are threatening. In the course of our data analysis, the Freudian structural model became a useful perspective to analyze the data.

Methods

Sample

As part of a larger study (with the field name “Frontiers in Prevention”) that explored reasons for “bareback” sex, we first identified the six most popular free Internet sites used by men in New York City to meet other men interested in this sexual practice (see [9–10] for more details of this study phase). Next, between April 2005 and March 2006, we recruited men who fulfilled the following eligibility criteria: 1) be at least 18 years old; 2) live in New York City or within commuting distance; 3) report using the Internet to meet men at least twice per month; 4) self-identify as a barebacker or as someone who practices barebacking; 5) have had intentional, condomless anal intercourse with a man met over the Internet; and 6) use at least one of the six most popular Internet sites identified in the first phase of the study. By study design respondents were recruited exclusively through the Internet in approximately equal numbers of European Americans, African Americans, Latinos, and Asians/Pacific Islanders. Given that URAI is the behavior that carries the highest degree of risk for HIV infection, we designed the study so that two thirds of recruited volunteers would be HIV-uninfected and report having had URAI in the previous year (see [3] for details on recruitment procedures). Individuals who qualified were scheduled for a face-to-face interview at our research offices as soon as possible after the initial screening.

Procedures

After giving consent to participate in this study, each respondent underwent an in-depth, face-to-face interview conducted by one of three clinical psychologists on our staff followed by a structured Computer Assisted Self-Interview (CASI). This manuscript focuses mainly on the qualitative results of the in-depth interviews. The analysis of the quantitative data collected through CASI on motivation for bareback in this sample has already been published [11] highlighting the presence of two main factors, “Coping with social vulnerabilities” and “Pleasure and emotional connection.” Participants’ visits lasted about two hours in total at the end of which respondents were compensated with $50 for their time. This study was reviewed and approved by the Institutional Review Board at the New York State Psychiatric Institute.

In-depth interview

An interview guide provided the basic structure for the in-depth interview. It started by inquiring about the participant’s motives for study participation and followed by asking about his use of the Internet to meet other men for sex, preferred Web sites, and strategies used to meet men. In the course of this initial discussion, the participant would generally use the word “bareback.” If he did not use it, the interviewer would remind the participant that the purpose of this study was to explore the behavior known as “barebacking” among men who have sex with men. Subsequently, participants were asked what their personal definition of barebacking was (a separate publication [3] covers this and related topics). Next, participants were asked: “Given the definition of bareback you gave me earlier, tell me about the first sexual experience you had that you would call ‘bareback’?” This was followed by probes, used at the discretion of the interviewer, exploring thoughts and feelings associated with that first experience. After the initial barebacking experience had been thoroughly discussed, the interviewer then turned to subsequent barebacking experiences. Probes focused on changes over time, factors sustaining the behavior, and feelings about it. The sequence in the inquiry (“Tell me about your first bareback experience,” followed by “Tell me about your other bareback experiences”) reflected our assumption that factors leading to the first occasion could in some way relate to those contributing to the continuation of the behavior at a later date.

Qualitative Data Analysis

Audio recordings were transcribed, and transcriptions were checked against the former for accuracy. A first-level codebook was developed following the major topics covered in the interview. One such primary code was “Bareback Experience” defined as “Description of sexual experiences labeled as bareback by the participant” including “Contextual information leading to participant’s first bareback experience; length of time engaging in barebacking; feelings about having bareback sex.” Using the software package NVivo, independent coders reviewed transcripts identifying data that fell under this code. Intercoder comparisons were made until consensus was reached. Next, four investigators read the coded material and independently developed second-level codes based on the topics discussed by the participants. The independent codes were unified in a single codebook with definitions and examples. These second-level codes focused on first barebacking experience, reasons leading to it, subsequent experiences, positive and negative feelings about them, compulsivity, and reactions to overt requests for bareback sex. Once two trained coders reached 80% “intercoder convergence” [12], all the interviews were coded by a single coder. Finally, code reports for secondary codes were generated independently for HIV-uninfected and infected participants so as to compare their content. Four co-investigators identified modal responses in each secondary code with quotes from respondents selected by the first author. After successive readings of the material analyzed, the data were organized under a theoretical model that appeared to be coherent with the findings.

Results

Demographics and sexual behavior

The demographic characteristics of the sample are presented in Table 1. It shows that participants were 120 men of whom 89 reported being HIV-uninfected. HIV-infected men were older and had lower income than uninfected men. Most of the respondents self-identified as gay. The men had an average of almost 14 sexual partners in the previous two months, and they reported about seven occasions of unprotected anal intercourse in the prior two months. HIV-infected men were significantly more likely to have more partners and more URAI than HIV-uninfected participants.

Table 1.

Sociodemographic characteristics and sexual behavior by HIV status.

Variable	HIV− (n=89)	HIV+ (n=31)	Total (n=120)	t/Fisher’s
Sociodemographic Characteristics
Agea	32.03 (9.83)	37.97 (7.58)	33.57 (9.63)	−3.46***
Education (in years)a	14.85 (3.06)	14.58 (2.43)	14.78 (2.90)	0.45
Income (in thousands)a	30.59 (25.03)	20.44 (18.67)	27.95 (23.89)	2.06*
Race/Ethnicity				7.80
White	24	11	35
Latino	22	9	31
Black	19	9	28
Asian/Pacific Islander	16	1	17
Other	8	1	9
Sexual Behavior in the prior two months
Number of male partnersa,b	11.83 (11.27)	18.61 (26.10)	13.58 (16.57)	−2.19*
URAI occasionsa,b	4.71 (5.97)	13.32 (25.30)	6.93 (14.21)	−2.93**
UIAS occasionsa,b	5.29 (9.70)	5.13 (7.78)	5.25 (9.23)	−0.08

^*p ≤ .05;

^**p ≤ .01;

^***p ≤ .001

^aMean (SD)

^bVariables were log-transformed prior to statistical tests due to skewed distributions

HIV-Uninfected Participants

The main population of interest for our study was HIV-uninfected men who engage in URAI in circumstances in which there is risk of HIV transmission. We started by asking these participants what led to their first barebacking experience.

First barebacking experience

By eligibility criteria, men had to self-identify as a barebacker or as someone who practices barebacking and to have had intentional, condomless anal intercourse. Nevertheless, the fact that participants did not share a common definition of barebacking [3], and that many individuals identified it simply as “sex without condoms” (regardless of intention or HIV risk potential) created some degree of confusion when participants were asked to recall, based on their personal interpretation of the word, their first barebacking experience. Some reported that it had happened before AIDS existed. Yet most reported that barebacking happened in circumstances in which they were aware they should have used condoms.

In general, no single reason or set of circumstances led to the first barebacking experience. Rather, a combination of factors that potentiated each other was usually mentioned, as exemplified in the following quote:

I was kind of sort of dating this guy, older Italian guy. We were going—we were pretty hot and heavy in the bedroom situation, and we were out of condoms. And we were—both of us were rock hard and ready to go, and we were searching the room everywhere for condoms, and we were covered in lube, so we were right in the middle of it, you know. … So we just decided to do it, just real quick. A little bang-bang here, and then I would pull out, and then he would stick it to me that way. And we did it like that. No one came. Well, we came by jerking off. That was a barebacking experience, pretty much my first one. (#014) 38, White, HIV-negative

Several factors are at play in this scene: a certain emotional involvement (“sort of dating”); a likely power differential (“older Italian guy,” although we do not know if the younger or the older partner holds the power); arousal (“hot and heavy”); contextual constraints (no condoms available); contextual facilitators (“covered in lube”); an alleged decision (“decided to do it”); and a supposed risk reduction strategy (“pull out,” “no one came.”). Such multiplicity of determinants was typical of the scenarios that most participants reported as shown again in the following quote.

He rimmed me. And then he was—took his, his dick and was rubbing it against my ass. Then he just put the head in a little bit. And um, next thing he was, he was fucking me. And, uh, actually, probably the first time I enjoyed bottoming… I think it had a couple things to do with it. A, I was really into him. And, um, every time I’ve, up until that point, when I bottomed, I guess I was irritated by the condom. (#114) 31, White, HIV-negative

In this case the participant reports arousal (progression in foreplay), relinquishing of control (“next thing he was fucking me”), emotional involvement (“I was really into him”), pleasure (enjoyed bottoming) and a cost-effectiveness assessment (avoided irritation, gained enjoyment). The assessment is not likely to have taken place in the actual moment of intercourse, but rather to have been a post hoc assessment of the experience.

Many other reasons were mentioned as leading to the first bareback experience. They included: curiosity; heat of the moment; engaging in foreplay that culminated in unprotected intercourse; not having condoms available, having condoms but not using them, or having condoms that broke; not stopping sexual activity when condoms broke, were not available, or the partner did not use them; feeling irritated by condoms and therefore not using them; thrill-seeking and fantasy fulfillment; having used alcohol or drugs (although substance use was infrequently mentioned); being tired or depressed; being in a context that appeared safe (e.g., country where it happened, in a group of friends); feeling that AIDS was no longer a death sentence; or partner-related reasons such as being persuaded by a partner, trusting him, wanting to please him, letting him take control; or being paid to have condomless sex. In several cases barebacking behavior had started in the context of a relationship, although length of relationships before first barebacking experience could include as early as a second date. In relationships sometimes mutual testing had occurred before bareback sex took place, but most frequently this was not the case. In two cases rape was mentioned, which, not surprisingly, happened without condoms.

An underlying theme, either explicitly or implicitly present in the explanation for reasons leading to the first barebacking experience, was the issue of pleasure. Participants frequently expressed their enjoyment of the accompanying sensations as well as how they felt excited, sexually satisfied, thrilled, fulfilled, and intimate with the partner. This is shown in the following quotes:

He felt [the condom] break, I felt it break. But at that moment the sensation and the feeling was just too good. I didn’t want to stop. (#083) 29, African-American, HIV-negative

When you’re in high school, if you are with someone else who’s willing to try something which you haven’t tried before, and you find him very attractive, and you think, “I have no idea when I’ll get a chance again” … ’cause I live with family, they don’t know about me—that kind of situation. So whatever he wants to do, you let him do it. … And you get all excited. … I just let it happen. ‘OK, I don’t care.’ Uh, I wanted to give him pleasure.” (#143) 27, Asian/Pacific Islander, HIV-negative

In a few cases participants also expressed the awareness of the possible negative health consequences of barebacking. Yet such awareness was not sufficient to prevent the occurrence of new instances of barebacking.

Subsequent involvement in bareback sex

The first bareback experience was often a turning point that led to more frequent engagement in the behavior and progressive desensitization to the risks involved. Some participants alternated between abstinence and avoidance of condomless intercourse and bouts or “binges” of barebacking. At times, the new period of barebacking would be triggered by meeting a new partner who proposed it or who was under the influence of drugs or alcohol. For others, barebacking was taking place within a relationship and was then extended to other people with whom one or both partners had sex; or barebacking was resumed after a separation.

Some of the same factors at play in the initial barebacking experience (e.g., trust, excitement, wanting to relinquish control to a partner, believing the AIDS crisis was over, drugs, money, depression) were mentioned as sustaining subsequent experiences. Some men believed that they were good at screening and selecting partners, eliminating risky ones (e.g., choosing those who got tested frequently, who had insisted on condom use before, or who were married); yet others acknowledged that they had no idea of the partners’ serostatus and that their screening procedures (e.g., knowing someone for one week before having bareback sex) were of little use. At times, rules were established (e.g., no inside ejaculation, making sure there were no cuts or abrasions, restricting barebacking to a network of friends), but such rules were inconsistently followed.

Most frequently, barebacking occurred without discussion among the parties involved. HIV testing or status also were infrequently discussed. Some participants relied on the information posted in Web profiles, but they also acknowledged that missing status information was not a deterrent from barebacking. Additionally, several participants said that if someone included in his profile that he was looking for bareback sex, they would reject that person as being too “piggish.”

Frequently, participants were self-critical about their decision-making process concerning barebacking. They often made contradictory statements with full awareness (e.g., that they would not engage in bareback sex in a first encounter, but then they did – this topic is further explored in Frasca et al., in preparation). Reasons for bareback sex appeared to be post-hoc rationalizations to manage the apparent contradiction or maybe alleviate the discomfort about voluntarily engaging in a behavior that could be harmful.

Counteracting concerns brought by the unsafe behavior, participants discussed the thrills, satisfaction, intimacy, spontaneity, passion, excitement, euphoria, wish to be wild and free, and feeling of adventure that accompanied bareback sex. They also discussed the meaning that bareback sex had in their lives, such as it being an act of sharing emotional, spiritual, and physical energy with someone; and sharing love. This is exemplified in the following quotes.

If someone doesn’t put [the condom] on, then I actually get a little more excited. That, oh my god, he’s actually going to fuck me without a condom. And at that time, it doesn’t really come in my mind that, oh, I should talk to him first if he’s negative, or… like, the risks involved, or does he do this often? Like, any of that stuff. I’ll say, like, no, no, no—it will just kill the moment. Let’s just do all that later.” (#143) 27, Asian/Pacific Islander, HIV-negative

R: I like for the person to be a big cummer. I like to be able to feel it. […] With no condom it’s like you feel each and every pulse […] it’s just a good feeling. [laughter] I: So from what you're telling me it sounds as though you like people to cum inside you? R: Yeah, I do. (#050) 25, African-American, HIV-negative

So the person gets off, and it’s like—it’s like it’s more satisfying. It’s just different. … I don’t care what people say. I don’t care how thin you make the condom. There’s a big difference in having sex with a condom on and having sex without a condom on. (#039) 29, African-American, HIV-negative

And when I'm getting fucked, if I really like the guy, I have this thing where I don’t know, it’s, it’s—I think it’s an emotional thing. … I have this feeling like the guy is in me, and … I don’t mind being ‘seeded’ or ‘breeded.’ … The main reason why I like it without a condom [is] I like having him come in me. … It feels like you—he’s giving you something. It’s like a gift, and this guy really likes you. So you want him to come in you. And you want to have this feeling like, you know, “I got him inside of me.” [chuckles] (#088) 32, Native American, HIV-negative

I think part it’s intimacy, part it’s feeling, and part it’s the idea that sex should be uninhibited and intimate without all these precursors of thought restricting you. You think that sex and sexuality are expressiveness and sharing. And you have to go through all these stumbling blocks or precautions. And it takes away from that. (#142) 34, White, HIV-negative

But, it just also felt—it felt good and felt more intimate it felt like I was closer to somebody. I sound like a teenage girl, but, you know. That’s, that’s how it felt. … I felt emotionally close to this person which, I know logically, was not true. (#095) 29, African-American, HIV-negative

As these quotes show, condom use was seen as a barrier to expressing and experiencing intimacy and passion. Only a few participants stated that following barebacking they felt guilt and remorse.

HIV-Infected Participants

Our sample also included a smaller number of HIV-infected men for comparison purposes.

Barebacking prior to seroconversion

The barebacking experiences that HIV-infected men had had before seroconversion included many of the same situations discussed by HIV-uninfected participants. Some men were in relationships, at times with HIV-infected men, or had regular sexual partners who inspired comfort and trust that led them to stop using condoms. Others felt that other concerns were more pressing at the time than HIV and that the availability of medications made HIV less threatening. Some said that fear of doing something risky added to the sexual excitement. A few men discussed a progressive warming up to the idea of bareback sex, watching images on the Internet, reading stories, and gradually becoming more interested in having the experience.

Barebacking after seroconversion

Following seroconversion those men who were interested in bareback sex often thought “Why not?” When they started to have condomless sex, they reported experiencing a sense of liberation, lack of worry, and enjoyment (“the shackles were off”). Yet some felt it was a double-edged sword, that while physically enjoyable it could have negative consequences for them and for others. From a personal safety perspective, although infected individuals were aware of the possibility of contracting other STIs or becoming infected with a different strain of HIV (“superinfection”), these were not sufficient deterrents to having condomless sex. From the perspective of responsibility towards others, there was a full range of opinions from those stating that each person should watch after himself to those making it a point to disclose their seropositive status before having sex with any new partner. As in the case of HIV-uninfected men, rules about seroconcordance were established or at least attempted, i.e., that they would only have bareback sex with other HIV-infected men. Yet actual discussions about serostatus before having sex were not the norm.

It’s sort of those two conflicting things where I enjoy it, but I know it’s not very healthy. So it’s sort of being ripped in two different directions. (#033) 32, White, HIV-positive

Physically, I love it! I like the way it feels. There’s a certain level of intimacy, a certain level of sharing that you can’t get with a condom. And I like it. I know it’s socially irresponsible. (#045) 35, Latino, HIV-positive

“… about three years ago I met somebody, actually … his profile very specifically said that he was in into barebacking and I was like, “Fuck it, why not?” And I remember thinking, Fuck it. I’m so tired of playing the game in hospital [sterile] conditions. … And then I just stopped worrying about it at all. I got to a point after—it really only took a few months, “Why did I ever live another way?” A, a lot cheaper [laughter] and B, it’s just so much less worrisome. In a lot of ways it was very liberating. (#036) 29, Latino, HIV-positive

HIV Counselors

Among the participants in our study, there were some who were HIV counselors. These men were very well informed about HIV risks, ways to prevent them, and skills required. Yet they engaged in barebacking. Their explanations are quite revealing.

I: And how open are you with others about barebacking? R: To others that practice barebacking, very open. To those [who do] not, I clam up [inaudible]—I don’t want discrimination, I don’t want recrimination. I don’t want people to call the hotline, put the condom police on me. It is my, you know, it’s my First Amendment right. That’s how I feel it. Because of all the debate going on. The supervirus here and there, me, as a health care professional, that I’m a hypocrite, and, you know, not practicing what I preach. … A lot of finger-pointing, a lot of shaming. A lot of, how dare you spread your disease to others? That sort of thing. And a lot of convincing, coaxing us. Like, save your saliva. I’m not changing it for the world. I: They’re trying to convince you to use condoms? R: Yes. (#074) 38, Asian/Pacific Islander, HIV-positive

I: OK, and do you consider yourself a barebacker? R: Yeah, I do. I: Yeah? OK. Is that something that people know? R: No, they don’t. Only the people that I hook up with, and once again, I don’t consider them my friends. … I don’t want to disclose to my friends because I’m supposed to be the, you know, prevention expert, and I’m always trying to encourage people to get tested, to use barriers, use condoms or female condoms, and just, modifying their risk behaviors, and I’m doing the exact opposite. I: Okay, and in your perception, are your friends using condoms, or do you think they’re also barebacking? R: They’re reporting that they are using condoms, but maybe they could be lying like I am. I do know that some of my coworkers … are also engaged in barebacking. … So I know that there are a lot of professionals that are out there that are promoting safer sex that aren’t using it personally. (#152) 43, African-American, HIV-negative

The old proverb, “Do as I say, not as I do,” comes to mind. In the narratives of these counselors, there appears to be a strong motivational force based on pleasure that overcomes their knowledge about HIV prevention and their and behavioral skills to enact condom use.

Freud’s structural model

As stated above, although prior to the data analysis stage Freud’s structural model was never part of our team’s discussions, as we proceeded with data analysis the model became a useful paradigm for the organization of our findings. The first barebacking experiences that our participants describe appear to show the struggle of the I to negotiate the competing demands of the It, the Above-I and the world. Participants describe experiencing potent drives from the It (“things got heated up,” “the feeling was too good,” “it was thrilling,” “the allure of it”), the judgment of the Above-I (“it was irresponsible,” “am I really doing this?”); and the pressures of the world with its availability of substances, willing partners (“let’s just have raw sex”) technology (Internet); and deficiencies (“we didn’t have a condom”). To deal with this, the I displays mechanisms of defense such as rationalization (“In Manila it’s safer,” “AIDS is less of a death sentence now”), denial (“it was nothing that was in my head to use a condom”), and idealization (“I have no idea when I’ll get a chance again”). Many of these mechanisms are not in the participants’ awareness at the time of engaging in barebacking; rather, the It gets its due, and the I is left with explaining the deed a posteriori.

Subsequent barebacking experiences continue to display the same dynamic in which the drives from the It stampede toward satisfaction (“it snowballed”, “it was free-for-all,” “it’s a point of no return,” “you want to be wild and free”) that the world may facilitate (“he introduced me to drugs”), the Above-I censors (“I don’t bareback with the abandonment that I used to”), and the I, the rider on the horseback … barebacks (“I did things I never thought I would”). To deal with contradictions and the censorship of the Above-I upon the recurrence of barebacking, the I appeals to defense mechanisms such as rationalizing (“I’ve done all the screening,” “there are unspoken agreements”), using avoidance and denial (“we don’t really talk about it”), externalizing (both being high, money, or greed), and sometimes paying the price imposed by the Above-I (“really guilty afterwards”). While the I distracts the Above-I and the world with these defense mechanisms, the drives of the It attain their goal. Infected men add a new twist to this dynamic: there is no longer the danger of becoming infected (at least not primary infection), and therefore their I’s can be more permissive.

Discussion

Earlier research has identified a variety of factors associated with barebacking. Many of those factors were mentioned by some of the men we interviewed, but not by others. Furthermore, each participant generally voiced multiple reasons leading him to barebacking, not all of them present at the same time, not all of them producing invariably the same effect. Thus, we were unable to identify distinct typologies of men who engaged in barebacking or distinctive patterns of factors leading to barebacking. There was no homogeneity that could identify a clear point of intervention for behavior change. Yet, the issue of the pleasure and intimacy experienced having condomless sex, already highlighted by prior authors [13], was very frequently present, either implicitly of explicitly, as a potent force that men could not or did not want to control. This brought to mind Freud’s structural model, as explained before.

Is this model too individualistic? We do not think so. Although the I of the individual is the scenario in which different forces interact, we see at play much more than individuals’ drives and desires; the world is ever present with its censorship, open possibilities, enabling sexual partners, availability of substances. The Above-I acts as an internalization of the world. Furthermore, if rather than reifying the metaphor of the structural model in an individual, we apply it to a group (maybe using labels as the It, the Us and the Above-Us), we can see how social norms may come into conflict with a desire of expression and satisfaction of subcultures such as the culture of men practicing barebacking who then develop mechanisms (e.g., same-serostatus sex parties) to balance competing demands.

Should every man who engages in barebacking undergo psychoanalysis to be able to manage drives more effectively? Obviously not, although some individuals who experience depression associated with barebacking could benefit from treatment. Yet although a few of our participants discussed feeling distressed or guilty about their behavior, the majority did not and had come to terms with what they were doing.

The value of using Freud’s structural theory to understand the barebacking phenomena is that it warns us against attempting to use what appear to be straightforward public health interventions to counteract barebacking (e.g., provide information on superinfection, reinforce social norms for condom use, improve condom negotiation skills, condemn use of designer drugs). Such interventions mainly seek to strengthen rational aspects of mental functioning, the power of the world, the repressive mechanisms of the I, and the censorship of the Above-I. But they forget to pay attention to the It, to the libidinal and erotic desires of individuals, and to their satisfaction.

In contrast, prevention approaches that seek alternatives to condoms [14] may acknowledge the power of the libido while seeking to promote safer ways of attaining sexual and erotic satisfaction. Strategies such as pre- or post-exposure prophylaxis, the use of rectal microbicide gels or douches, or even rapid HIV home tests that could provide almost instant HIV results, all strategies currently under development, may not be experienced as opposed to sexual pleasure but rather neutral or even facilitating it. The impression derived from the analysis of the narratives of the participants in our study is that for an HIV-prevention intervention to be successful in this population, it should impinge as little as possible on sexual pleasure and sexual satisfaction.

Our results are congruent with those reported in other publications. Crossley [15], who criticizes the health behavior models centered on individual choice and rational behavior, proposes instead that “contemporary ‘barebacking’ behaviour may constitute one manifestation of a ‘resistance’ or ‘transgressional’ ‘habitus’ that has remained a consistent feature of gay men’s individual and social psyche since the early days of gay liberation.” (p.225) Crossley also states that social influence attempts such as health promotion can backfire and have a “boomerang effect”: “If health promotion attempts are perceived as an attempt at censorship, reactance theory would predict that health promotion messages will actually increase the motivation to engage in ‘unhealthy’ or ‘risky’ behaviours” [16 p.50]. Holmes et al. [17] state that men meet to share semen, and healthcare workers try to ‘stop’ the sharing, to repress the barebackers, and to territorialize them. But “repression leads to acting out, and territorialization results to deterritorialization.” (p.12)

There are several limitations to our study. First, the sample may have biases introduced by our eligibility criteria and participant self-selection. Second, the professional specialization of the team of researchers may have led us to favor one theoretical approach over others. Third, the qualitative methods used allowed us thorough in-depth exploration but limit the generalizibility of our findings. Nevertheless, within these limitations this study focusing primarily on ethnic minority MSM with high levels of sexual risk behavior offers unique insights into psychodynamic mechanisms that may further our understanding of barebacking.