Structuring Sexual Pleasure: Equitable Access to Biomedical HIV Prevention for Black Men Who Have Sex with Men

What comes to mind when you hear the words “Black men” and “sex”? If you answered “risk,” “danger,” or “HIV/AIDS,” your response aligns with the primary finding of our critical review of social and behavioral science research on US Black men’s sexualities.¹ We analyzed 668 articles on Black men and sexuality before 1981 (before the HIV/AIDS epidemic) and between 2006 and 2016, and found that the vast majority (84%; n = 559) focused on sexual health and sexual risk (mostly HIV), and on Black gay, bisexual, and other men who have sex with men (GBMSM), a group disproportionately affected by HIV/AIDS. Research on sexual pleasure, by contrast, was virtually nonexistent for Black men regardless of sexual identity. With few exceptions—notable for their emphasis on love, satisfaction, affection, sexual intimacy, and pleasure—risk, danger, and deficit, not sexual pleasure, were the primary frame for Black GBMSM’s sexualities and sexual health. For Black GBMSM, our focus, the implications of this negative emphasis are grave because it ignores possibilities for Black GBMSM to develop healthy, emotionally intimate, trusting, and sexually pleasurable relationships with partners regardless of HIV status.

Sexual pleasure is inextricably linked to sexual health and sexual rights.^2,3 Sexual health, according to the World Health Organization’s (WHO’s) definition,^3(p5) is

. . . a state of physical, emotional, mental and social well-being in relation to sexuality . . . not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence.

Contrasted with WHO’s attention to sexual pleasure, conventional US public health approaches tend to emphasize problematic aspects of sexuality: sexually transmitted infections, unintended pregnancies, and sexual violence. Implicit in the title of the prevailing standard of sexual health in the United States, the 2001 US Surgeon General’s Call to Action to Promote Sexual Health and Responsible Sexual Behavior (https://www.ncbi.nlm.nih.gov/pubmed/20669514), is the notion that morality (i.e., “Responsible”) and individuals alone—not individuals in conjunction with social–structural context—shape sexual health.

Public health discourses have historically conceptualized sexual pleasure primarily as an individual-level experience, something achieved alone or with others, rather than an experience structured by interpersonal practices, policies, and laws (e.g., discrimination, stigma). There are numerous examples of the latter. These include laws criminalizing certain sexual behaviors among consenting adults (e.g., sodomy before the 2003 US Supreme Court Lawrence v. Texas ruling); the lack of legal protections against discrimination for sexual and gender minorities (e.g., 26 states provide no explicit antidiscrimination protections for lesbian, gay, bisexual, and transgender people); laws that criminalize HIV-positive people’s sexual expression regardless of HIV disclosure; and restrictions on insurance coverage for contraception (e.g., a 2017 executive order paved the way for federal rules—since overturned by courts—that would have exempted contraception coverage based on moral or religious objections). Inequitable access to biomedical HIV prevention methods represents another structural barrier to Black GBMSM’s sexual pleasure.

STATE-STRUCTURED ACCESS TO SEXUAL PLEASURE

The historical legacy of Black sexuality in the United States is largely a state-structured one. Slavery and systemic racism denied Black people agency over their own bodies and, in turn, their sexual pleasure. During slavery and after slavery, negative stereotypes of Black people as hypersexual bolstered White supremacy. Evidence that some health care providers have used hypersexual stereotypes about Black GBMSM in deciding whether to prescribe them preexposure prophylaxis (PrEP) affirms that these sexual toxic stereotypes persist and that public health practice generally regards Black GBMSM’s sexualities as problematic rather than just human. We contend that inequitable access to biomedical HIV prevention methods, namely PrEP^4,5 and treatment-as-prevention (TasP), represents the latest manifestation of how the state structures not only sexual health inequities but also Black GBMSM’s access to sexual pleasure.

For Black GBMSM, HIV-positive and HIV-negative alike, two very effective tools are now available to facilitate sexual expression and sexual agency and enable the pursuit of sexual relationships without fear or shame: PrEP⁶ and TasP. Daily or on-demand (i.e., “event-driven”) PrEP dosage affords Black GBMSM men control over negotiating condomless sex for enhanced intimacy and sexual pleasure. PrEP offers newfound opportunities to eschew sexual-risk-only–centered perspectives in favor of more strengths-based and sex-positive considerations for Black GBMSM’s pursuit of sexual pleasure, intimacy, agency, and sexual expression (e.g., assertive sexual partnering). As an extension of evidence that TasP reduces infectiousness—and galvanizing the Undetectable = Untransmittable global campaign—there is now definitive empirical evidence that sustained viral suppression among people living with HIV dramatically reduces risk of transmission to sexual partners.⁷

And yet, Black GBMSM lack equitable access to biomedical HIV-prevention technologies.^4,5 Compared with White GBMSM, Black GBMSM are significantly less likely to report PrEP awareness, having discussed PrEP with a health care provider, and PrEP use.⁴ For Black GBMSM who choose not to use condoms by mutual agreement with sexual partners—based upon personal preferences or for purposes of conception—persistent inequities in HIV treatment and PrEP uptake⁵ produce structural inequalities in access to sexual pleasure. In essence, by virtue of having greater access to PrEP than Black GBMSM, White GBMSM have more access to condomless sexual pleasure unencumbered by fear of contracting or transmitting HIV.

PrEP is generally only accessible by prescription. As such, medical providers’ stigma about Black GBMSM, PrEP, and HIV are critical barriers to PrEP uptake. Moreover, stigma curtails Black GBMSM’s ability to negotiate and achieve sexual pleasure regardless of their own or their partners’ HIV statuses. Because sexual pleasure is central to sexual rights and sexual health,² we challenge public health practitioners and medical providers to adopt more sex-positive frames that acknowledge the variety of ways that Black GBMSM express their sexualities, including, but not limited to, sex in emotionally intimate partnerships, condomless sex, sexually exclusive and nonexclusive partnerships, voluntary sex work, and sex with women and transgender partners. Concomitant with equitable population-level PrEP scale-up and to capitalize on TasP’s well-established effectiveness, we also encourage researchers to abandon the exclusively sexual risk frame that characterizes most research on Black GBMSM by incorporating questions about sexual pleasure, satisfaction, intimacy, and affection.

Reconceptualizing public health approaches to Black GBMSM’s sexual expression aligns with the federal plan to End the HIV Epidemic and other efforts to reduce inequities in HIV treatment and PrEP uptake cascades. Structural-level interventions—such as expansion of Medicaid under the Affordable Care Act, inclusion of emtricitabine/tenofovir alafenamide and emtricitabine/tenofovir disoproxil fumarate in Medicaid PrEP formularies, offering new PrEP regimens over the counter (e.g., as recently signed into California law), and same-day treatment initiations for individuals newly diagnosed with HIV—will further enable researchers and practitioners to jettison pervasive risk-only–centered approaches to Black GBMSM’s sexual expression.

PROMOTING ALL BLACK PEOPLE’S SEXUAL HEALTH

Black GBMSM are the focus of our editorial, but hardly the only group of Black men for whom issues of equitable access to biomedical HIV prevention and sexual pleasure apply. Critical race theory and intersectionality perspectives highlight the importance of centering the needs of marginalized groups at different intersectional positions to understand and address their specific concerns. Accordingly, there is a dire need for more research and programs that address commonalities and differences in sexual pleasure for Black men at intersectional positions of sexuality and gender over the life course, namely cisgender heterosexual men and transgender men. Substantial empirical gaps exist. Take, for example, the exclusion of transgender men from the US Food and Drug Administration’s approval of emtricitabine/tenofovir alafenamide for PrEP.⁶ The exclusion is based in part on the implicit assumption that transgender GBMSM engage in receptive vaginal sex only, not receptive anal sex, as well as limited clinical trial data on efficacy among transgender men—yet another example of how the state structures sexual pleasure for Black transgender GBMSM. Ensuring that Black GBMSM and, indeed, all Black people, have equitable access to biomedical HIV prevention is vital to improving their sexual health and sexual pleasure and affirming the value of all Black people’s lives.