eli_saunders_immoral minority

THE IMMORAL MINORITY
by Eli Sanders

Thanks to the behavior of a small minority of gay men in the Seattle area, syphilis is at extremely high levels, HIV infections are spiking, cases of gonorrhea have doubled, and cases of chlamydia have tripled. What is the gay men's health movement doing about the problem? The Stranger asked local gay health leaders, and concluded they're making excuses and ducking tough questions as the problem gets much, much worse.

We will get to the gray-haired man in the black leather thong in a moment, as well as the STD hotline sting operation and the cheese class. But first, a few facts. They are alarming enough.

Fact: After years of decline, the number of syphilis cases among gay men in King County has recently risen to extremely high levels, according to the county's department of public health. The years of decline began in 1981, when AIDS scared gay men away from the orgiastic sex practices of the 1970s. By 1988, with AIDS devastating the gay community and safe sex or abstinence seemingly the only alternative to death, syphilis almost disappeared among gay men in this area. Eight years later, it had disappeared -- in 1996, there were zero syphilis cases among local gay men. Then in 1997, the year that powerful new AIDS drugs became widely available, the number of gay men with syphilis began to climb. If the upward trend continues, there could be as many as 120 new cases of syphilis among local gay men this year. In other words, thanks to many gay men going retro in their sexual behavior, the rates of syphilis among gay men in this area are now at levels not seen since the early 1980s--levels that are more than 100 times those found among the area's heterosexuals.

Fact: It's not just syphilis that's making a comeback in the gay community. King County's director of STD control, Dr. Hunter Handsfield, says that chlamydia and gonorrhea are also at extremely high levels. Between 1997 and 2002, Handsfield estimates, the number of cases of gonorrhea among local gay men at least doubled, and possibly increased as much as fourfold. In the same period, the number of gay men appearing in the King County STD clinic with chlamydia more than tripled. Syphilis, gonorrhea, and chlamydia are all treatable, but their increased prevalence among gay men is alarming because the same behaviors that transmit syphilis, gonorrhea, and chlamydia also transmit HIV--for which, by the way, there is still no cure. "Things are trending in a bad direction," says Dr. Bob Wood, director of the HIV/AIDS program at Public Health--Seattle & King County, the county's public health department. "We know that people don't get these STDs without having unprotected sex."

Fact: A study of nearly 1,000 Seattle gay men conducted at health clinics between August 1999 and May 2000 found that more than one-third of the HIV-positive men and nearly two-thirds of the HIV-negative men had recently had sex with guys whose HIV status they did not know. Not surprisingly, this study found that many of the guys who were not asking for their sex partners' HIV status were also not telling. Nearly half of the HIV-positive men in the study reported being inconsistent in telling their sex partners they were positive. The nightmare scenario would be if these don't-ask-don't-tell men were having lots of unprotected anal sex, which is one of the most efficient ways to transmit HIV. And that's exactly what the study found: More than 80 percent of all the gay men surveyed reported having had anal sex recently, and more than two-thirds of the men who were HIV-positive reported using condoms inconsistently; one-third of positive guys said they never used condoms at all.

Fact: The department of public health estimates there are about 42,500 gay men in King County, and more than 2,500 of those men are living with HIV. Since the early 1990s, the county estimates, the rate of new HIV infections in gay men has remained stable at about 400 a year.

But this week, the county announced what had long been suspected, given the rising STD rates and the behavior gay men have been reporting: Over the last two years, there has been a spike in the number of people diagnosed with HIV in county health clinics. Between 2001 and 2002 there was a 40 percent increase in new HIV diagnoses. If this year's pace keeps up, the increase between 2002 and 2003 will be 60 percent. This strongly suggests we are experiencing a wave of new HIV infections, health officials say. And with fewer people dying from AIDS thanks to the new drugs, and the rate of new infections climbing, more and more people are going to be living with HIV in our community over the coming years. Add to that the increases in reported unsafe behavior among gay men--both HIV-positive and HIV-negative--and health officials see what's coming: even more new HIV infections.

What does all this mean? It means that in 2003, more than 34 years after Stonewall, 22 years after AIDS was discovered, and after two decades and tens of millions of dollars have been invested in HIV prevention campaigns and safe-sex messages, the gay community is still a bastion of disease and unhealthiness. In Seattle and other gay centers, gay men are still getting infected with HIV and contracting other STDs at higher rates than any other group. According to the Centers for Disease Control and Prevention (CDC), gay men are largely responsible for the fact that syphilis, which seemed on its way out of existence in this country, is now resurgent. And although we have new drugs that help those of us with HIV live longer, many of us seem to be intent upon using the existence of these drugs as an excuse to re-create the conditions that allowed AIDS to flourish in the gay community in the first place: high rates of multipartnerism, high rates of unsafe sex, high rates of drug and alcohol use.

How did we get here? Amnesia on the part of gay men and irresponsibility on the part of gay men's health organizations. In the span of a few years, gay men seem to have forgotten how bad AIDS was (and is--just ask the guys who have it) while at the same time neglecting to realize that our present behavior makes our future bleak. As gay activist Gabriel Rotello wrote in his book, Sexual Ecology, which was published six years ago, just before the new AIDS drugs became available: "Almost every researcher studying the [AIDS] epidemic is convinced of one overarching fact: that if gay men ever re-create the sexual conditions of the seventies, the same kind of thing will happen again with other microbes." Sure enough, earlier this year a mysterious, drug-resistant form of staph infection emerged in the Los Angeles gay community. Other new infections and illnesses are surely out there, waiting to wiggle into our disease-friendly group. Which, as Rotello wrote, raises "the grim, almost unthinkable possibility that for gay men, sexual freedom leads inexorably to disease."

You might expect a "gay men's health movement" to be outraged about this state of affairs. You might expect them to be shouting and stopping people on the street and shaking them and saying, "Do you realize what's going on? Do you realize what's going to happen to our community if we keep this up?" You might expect that people like me--young, gay, single, and living on Capitol Hill--have been told that there are extremely high levels of STDs among gay men in Seattle, and you might expect that we've heard this from the local gay health organizations that claim to serve us. Since the problem is so serious, you might expect these local gay health leaders to be responding seriously: making serious statements, promoting serious prevention initiatives, going to serious national conferences, and behaving seriously. Well, if you expect all this you will be disappointed.
Which brings us back to the aging man in the black leather thong. He was standing on the stage in a ballroom in the Sheraton Hotel in Raleigh, North Carolina. And an employee of Gay City Health Project, which describes itself as the leading organization devoted to queer men's health in Seattle, had his tongue in the man's ass crack.
The occasion was the third national Gay Men's Health Summit, a gathering of people who are supposed to be using our public money and your private donations to help combat the scourge of STDs and HIV in the gay community. I had come to the conference to watch our local gay health leaders in action, unaware of just how much action I would see. Lifelong AIDS Alliance was there. King County Public Health was there. A researcher from the University of Washington's HIV Prevention Trials Unit was there. Other members of smaller local gay men's health groups were there. And much of the leadership of Gay City, including the rimming exhibitionist, was there. We are not going to judge this Gay City worker, or his tongue, or his "daddy"--although we will report that the judges at the event, a pool party overseen by the conference's "cruising director," awarded the couple two gold crowns. (Don't believe me? Check out the pictures posted on the conference website. Go to www.gmhs2003.org/code/photos.htm and click on "links to other albums." As of press time, the albums were filled with pictures from the pool party, including the ass-licking money shot.)

Still, we are not going to judge this public display of analingus, because the gay men's health movement teaches us not to. The mantra of the gay men's health movement goes like this: no judgment, no shame, no sex-negativity. Eric Rofes, the gay writer, professor, and community health guru who presented a keynote address at the summit, was very clear about what his ideal gay men's health movement is, and what it is not. The ideal movement, he said, is holistic, informative, trusting, celebratory, community-building, and grassroots. And it is not focused on HIV, directive, fear-based, moralistic, or professionalized. This is the type of movement that most of the gay health leaders who attended the conference are trying to build; when Rofes finished speaking, they all applauded loudly.

Here's something else this gay men's health movement is not: When it comes to preventing STD and HIV infections, it's not working.
BAKING WITH SWANSON

The day after the pool party, I am sitting in a brick-paved courtyard in front of the Sheraton in Raleigh and baking in the hot sun with Fred Swanson, executive director of Gay City Health Project. I am a little miffed because a summit session I was looking forward to, "Chi Kung Wakeup Exercises and Self Pleasuring at Sunrise," had been canceled because the "erotic pleasure activist" who was supposed to lead it failed to show up. But I am happy to finally get a chance to sit down with Swanson, a short man with a shaved head and a soul patch. He was born on Whidbey Island but raised all over the country and came back to Seattle in 2001 to head Gay City--which has a $550,000 operating budget and nine full- and part-time staff members--after working as a director at Howard Brown Health Center, the largest provider of HIV/AIDS services in the Midwest.

I first ask Swanson for his understanding of the current STD situation in Seattle. "I'd look to the health department for the epidemiology," he replies, deflecting the question. I had only recently found out about the statistics myself, after I was asked to write about gay men and STDs. Swanson doesn't seem much more informed than I was before I got the assignment--which is odd, considering he's the head of an agency whose mission is to combat the spread of STDs and HIV among gay men in Seattle. (Later, back in Seattle, I asked him this question again. He said he was aware of the rise in syphilis and gonorrhea, but was unclear on the exact situation with chlamydia, and he didn't offer any stats or numbers for any of these STDs. He also said he thought it was unclear whether HIV rates were rising or falling.) As we eat lunch, I tell Swanson the facts--the rising rates of syphilis, gonorrhea, and chlamydia, the near certainty (made even more certain by this week's health department's announcement) that HIV rates are also rising. I ask Swanson what Gay City is doing about the problem.

"I think that we'll continue to cling to our model," he says, "which is to provide resources and infrastructure and opportunity for men in the community to become engaged and invested and define what is a healthy gay male community." Gay City is going to keep doing what it has always done: coffee talks, a gay summer camp, community forums, and the annual Gay City University. "We need to make sure people have good information--concrete information," he says. This is Swanson's mantra: Give gay men the information they need, along with a safe space in which to feel good about themselves, and they'll make healthy, informed choices.
While Gay City's social programming is nice--and while Swanson has surveys that show many of the guys who attend Gay City events come away feeling better about themselves--Gay City is not really living up to Swanson's mantra. The agency doesn't give concrete information about the extremely high levels of STDs among gay men in Seattle. The group just put out a new STD pamphlet ("Action--A Handy STD Guide for Gay, Bi and Trans Men") but the new pamphlet doesn't mention the problem--it doesn't tell gay men that STDs have risen sharply among gay men in Seattle, information that might lead some gay men to make different choices about who they have sex with or how many guys they have sex with. When I asked Swanson why this information wasn't in the pamphlet, he replied, "It would be difficult to print an action guide that had the very latest information." An action guide without the latest information sounds like an oxymoron to me--and information about STDs without any context doesn't seem particularly helpful. After all, gay men are aware that STDs exist. What many gay men in Seattle aren't aware of, however, is how prevalent they're becoming.
"I don't disagree with you that information needs context," Swanson told me.
But the agency Swanson heads gives out neither the information gay men need about the current STD problem, nor contextual information that would make campaigns such as its new STD pamphlet relevant. This is not just a problem with Gay City's pamphlet. The take-home message in Gay City's old but well-known ad campaign--"We're All in Bed Together"--is so oblique as to be nearly useless. One of the ads from that campaign does mention the rise in STDs locally, but the ad appears to be out of circulation; the only place I saw it around Capitol Hill was deep in a poster archive on Gay City's website. That website, by the way, reached 125,000 people in 2001, according to Gay City. But in 2003, six years after STD rates began rising in the gay community in Seattle, there is still no current, concrete information about the STD problem on the Gay City website. I asked Fred Swanson if a gay man in Seattle who wanted to know more about the high levels of syphilis, gonorrhea, and chlamydia would be able to find current, concrete information anywhere in the materials Gay City gives out. Swanson answered by saying that such a man could come to the Gay City offices and they could help him find the information online. In other words, the answer is no.

In addition to its website, Gay City mails out a newsletter every month to over 4,000 gay men. I asked Swanson if he had ever mentioned the STD problem in that newsletter. He told me he had, in a column he wrote for the March newsletter. I asked him to send me a copy of the column. He did, and it contained nothing about local STD rates. It was about mainstream media coverage of bug chasers--gay men who want to get infected with HIV. About the "buzz" surrounding bug chasers at the time, Swanson wrote: "I wonder how much of this is more about avoiding tough issues than really providing helpful information."

I wondered the same thing when I went to Gay City University on May 17. This was to be one of Gay City's major events for the year. It was held at Meany Middle School, and some 200 gay men attended, taking "classes" that ranged from the cheese class to others with titles such as "Men's Aromatherapy," "Bar Etiquette," and "Aging Gracefully." In the morning assembly, the "school nurse" stood up and announced that free STD screenings would be provided during the day. But he didn't provide any information on the context in which the screenings were being offered--the extremely high rates of syphilis, gonorrhea, and chlamydia in the community. There were mentions, however, of hepatitis A and B vaccinations (subliminal message: get these shots and you can lick as much ass as you want) and HIV vaccine trials under way at the University of Washington (subliminal message: don't worry, a cure is coming). The "school nurse," Arnold Martin, a disease intervention specialist with King County Public Health, told me that he didn't tell the assembled gay "students" anything about local STD rates because, "You might lose the audience's attention--they're here to have fun." Predictably, only five or six of the 200 gay men at Gay City University that day showed up for the free STD screenings.

"We didn't view the day as specifically focused on that particular aspect of gay men's health," Swanson said after the event. "That wasn't the focus of the day.... If it had been a forum about STDs we would have talked specifically about those issues," he said.
Here's the last message the guys at this year's Gay City University heard: "Thanks for this great day, and I'll see you at Manray!"

THE CORE
To explain why it isn't blanketing the community with messages about the current STD situation in Seattle, the gay men's health leadership point outs, correctly, that when you look at gay men as a whole, it's a minority who are engaging in the unsafe behaviors that are leading to the STD problem and the rising HIV rates. This is true, but it's always been true. These small "core groups" of highly promiscuous gay men existed in the late 1970s and early 1980s, too, and though they were also the minority then, they are thought to have been the reason that HIV took hold so swiftly in our community.

Core groups are like incubation chambers for diseases. The trouble really starts when members of core groups mix with people outside the core, and disease begins to spread throughout an entire population. The gay community, with its high rates of multipartnerism and anonymous sex, is particularly susceptible to this phenomenon. If a gay man who doesn't have frequent one-night stands has an unsafe one with a guy who happens to be in the core group, and then goes on to have occasional unsafe one-night stands with people outside the core, presto, the whole community's got a problem.
The other thing core groups of unsafe people do is sustain the presence of diseases such as AIDS well past the point when the community knows how to prevent their spread. As the writer Gabriel Rotello notes, this is not unique to the gay community: "Groups that form self-sustaining cores of STD infection include college students, gay men, crack cocaine users, people who live in pockets of urban poverty, and prostitutes and their customers...."

Fred Swanson of Gay City doesn't like to see gay men as members of core groups or as potential disease spreaders. "We're actually looking at the whole being. When someone comes in, we don't look at them as simply a vector of disease and a viral receptacle.... Epidemiological approaches and public health approaches using the medical model are not necessarily good for community health."
But ignoring the fact that many gay men are vectors for disease, and that every person on this planet is a viral receptacle--along with being suspicious of "professionals" and "medical models" and "epidemiological approaches"--is, judging from the local STD rates, not good for community health, either. Gay City, like other gay men's health groups, won't define what a healthy gay male community would look like. So when people in the community are behaving badly--as the studies and public health data clearly show they are--Gay City refuses to come down on them.

"We don't seek to provide answers," Swanson says of his agency's programs. "We seek to provide an environment where people can ask questions. We're not in the business of making broad statements about 'This is what it is to be healthy.'"

This kind of talk incenses some gay public health people, including a gay CDC researcher I talked to. When I told him about the uninformative, nonjudgmental messages being sent to gay men in Seattle, the researcher directed my attention to an article in USA Today about the "fight against fat." Message: Being fat is bad, and bad for your health--so don't be fat. This is what most good public health movements do: They tell you what behaviors are bad for your health, and they tell you not to engage in them. "Don't smoke, it's bad for you." "Don't ride without a helmet, it's stupid." But for fear of alienating or marginalizing or stigmatizing gay men, Swanson and others in the gay men's health movement won't say, for example, "Hey you HIV-positive assholes who are knowingly spreading HIV: STOP."

The CDC researcher wishes Swanson would. He wishes the message from gay community groups would be less coddling and obtuse, and instead more direct. He suggests: "Snap out of it. We're tired of holding your hand."
WHAT ISN'T WORKING

"We're in agreement--what has been happening isn't working," says gay men's health guru Eric Rofes. We're sitting at a table in the Sheraton's bar where Rofes, a big bear of a man, is explaining to me that the health problems gay men are experiencing represent a failure of the world to fully adopt his approach to gay men's health, rather than a failure of his approach.

"I do think there will be more STDs [in gay men] absent core changes in our work with gay men and gay men's health," he says. But the problem, he says, is not so much gay men's behavior as it is "blaming gay men and repressing gay men rather than creating techniques that would protect gay men and support gay men at the same time.... The only place we see this 'Please shame your community' is around gay men."
Here's the Rofes solution: Massive sex education for gay men when they are children, a campaign against sexual shame, the repeal of sodomy laws, free condoms, free treatment, free needles, and "creating community structures and rituals that promote things other than sex."

These are of course noble goals, but given the reality of the culture, they are also long-term goals. Aside from the possibility that sodomy laws will be repealed by the Supreme Court this summer, no one expects any of Rofes' other ideas to be universally accepted any time soon. He knows that. He's thinking long-term. "We need a 100-year approach to this," he says.

One would hope that a great deal will have changed for gay men in 100 years. But setting that hope aside, one wonders: In the immediate future, while we're dealing with extremely high levels of STDs among gay men in Seattle and gay STD problems around the country that seem to be fueled by unsafe behavior among gay men--particularly HIV-positive gay men--wouldn't a little more shame and blame help? Shouldn't some gay men be ashamed?

Fred Swanson doesn't think so.
"I don't find that it's productive as a health-promotion strategy to divide people and say there's good and there's bad," he says. Here's a paragraph that will probably disqualify me from ever working in the field of gay men's health:

Virtually every time a gay man gets an STD--or HIV--it is because another gay man gave it to him. And the data clearly show that there are gay men in Seattle--many of them HIV-positive--who don't care about spreading STDs or giving other gay men HIV. In terms of the health of our community, it seems to me that there very clearly is "bad" and "good." It is bad to have guys out there knowingly spreading HIV and STDs. It would be good for all of us if they stopped. One simple epidemiological fact is that people who don't have HIV can't spread HIV, and people who don't have STDs can't spread STDs. That doesn't mean people who are STD- and HIV-free have no responsibility to protect themselves. But it also doesn't absolve people who have STDs and HIV of their responsibility to protect their sex partners, and it certainly doesn't change the epidemiological facts. So why won't Gay City target the people who, epidemiologically speaking, are causing the problem--say, the HIV-positive men who are knowingly putting their sex partners at risk of HIV infection?
"To single out HIV-positive men and to hold them fully responsible for disclosure... I don't see that that's a productive way of reducing HIV transmission," Swanson says.

The CDC seems to think otherwise. Realizing that if you stop HIV-positive guys from spreading HIV, you stop the epidemic, the CDC is now asking health departments to, in the words of Dr. Ronald O. Valdiserri, deputy director of the CDC's National Center for HIV, STD, and TB Prevention, "place the highest priority on prevention programs for people living with HIV... [and] reduce the spread of HIV by increasing the number of individuals who are aware of their status and linking them to the appropriate prevention and treatment services."
Translation: If you want to solve a problem, you have to target the people who are causing it.

FASCINATING QUESTIONS
When you confront people in the gay men's health movement with the simple facts of the problem in Seattle--that despite their efforts, STD rates are at extremely high levels and HIV rates are rising--they usually respond with long discourses on how complicated the world is (message: this problem is just too big and complex for us little old gay organizations to solve).

"I think that people that are being unsafe with each other, they're doing it for a variety of reasons."

This is how David Richart, the education director for Lifelong AIDS Alliance, views the problem.

"Lots of the time people are under the influence of alcohol," he says, "or other drugs--party drugs. People are being unsafe because of child sexual abuse...."
I tried to ask Richart what he makes of the data showing a large number of HIV-positive men engaging in unprotected anal sex with partners whose HIV status they do not know, and without informing these sex partners that they are HIV-positive. I must have used a judgmental word in my question because Richart was taken aback:
"The way that you sort of worded it, there are these sort of evil, disease-spreading, almost... criminals. That was sort of shocking to me. I think there are other things that are factors, and what I'm saying is that as an HIV prevention program you have to be.... What we try to encourage people to do...."

It seemed like Richart was about to say something directive, something like, "In an HIV prevention program you have to be this," or, "We try to encourage people to do that." But perhaps recalling that the fashionable ideal in the gay men's health movement is to be nondirective, Richart stopped himself and began his sentence again.
"We don't dismiss the fact that people are unsafe," he said. "What we are saying is, 'We are going to give you the information and tools to be safe if you want to, but we can't make you.'"
For the record, in some states a guy who knowingly exposes another guy to HIV without telling him is a criminal. In this state, anyone who knowingly exposes another person to an STD other than HIV--including syphilis, gonorrhea, and chlamydia--is breaking the law. When it comes to HIV, anyone in Washington who knowingly exposes another person to the disease "with intent to inflict great bodily harm" is guilty of first-degree assault. The "intent" piece of this law makes it very hard to enforce. One public health official recalled a single case in Eastern Washington: A man was found guilty of violating the law because he had HIV, knew it, and had unprotected sex with people anyway. The judge's reasoning, the public health official said, was that the man knew he was carrying a harmful disease, and therefore having unprotected sex constituted intent to harm.

But back to Richart. Like Gay City, Lifelong AIDS Alliance says it is in the business of giving people information. According to the organization's tax filings, Lifelong spent $623,500 on "prevention education" in 2001, and $300,000 on "community awareness." But is Lifelong really giving gay men the information they need and making the community more aware?
Richart said he knew about the rise in syphilis, gonorrhea, and chlamydia among gay men in Seattle, though he said he had heard that gay HIV rates are actually going down, which they are not, as the health department announced this week. To combat the rise in STDs, Richart said Lifelong has been training its outreach staff in STD education, doing prevention work at bathhouses, and also counseling HIV-positive men (in a nonjudgmental way, he noted) about safe behaviors. Richart also spoke of the success of an ad campaign Lifelong helped put out last year--the one with a black background and white text reading: "We're Doing a Pretty Good Job of Infecting Ourselves." Richart said the campaign, which included "Get Tested" as its call to action and offered the number of an STD hotline, had resulted in a 30 percent increase in calls to that STD hotline.

"That's sort of a huge indicator that the campaign was effective," he said.
It sounded good. But then I asked him what 30 percent meant in terms of real numbers. Less than 50 people had called the STD hotline as a result of the campaign, which cost more than $60,000. Think about that for a minute: It cost more than $1,200 a person to get those people to call. The campaign would have been more effective if Lifelong had just gone to Manray and other gay venues and passed out hundred-dollar bills and cell phones and put up posters that said, "Call the STD hotline and we'll give you $100. Get tested and we'll give you $100 more." They could have reached five times as many people before the money ran out. So Lifelong's "effective" campaign doesn't sound highly effective to me, and Richart's citation of the 30 percent increase as a "huge indicator" doesn't give me much confidence in Lifelong's ability to recognize what's an indicator of what when it comes to gay men--but maybe I'm just being judgmental.

Perhaps the campaign was so ineffective precisely because its nonjudgmental message was uninformative, to put it nicely. "We're Doing a Pretty Good Job of Infecting Ourselves" tells you nothing about the current STD situation--most people probably thought it was referring to AIDS, when in fact the campaign was spurred by the rise in syphilis, gonorrhea, and chlamydia. The campaign did have other messages that it put out in addition to "We're Doing a Pretty Good Job of Infecting Ourselves." For example: "Your Life, Your Responsibility." Again, what does this tell me about STD rates in my community? Nothing. And then there were two campaign messages Lifelong probably thought were really edgy: "Lesions Anyone?" and "Syphilis Anyone?" To which most gay men probably replied, "No thanks," and kept right on walking. Again, those messages contain absolutely no usable information.
This year, Lifelong is helping to put together another ad campaign set to launch in time for this month's Gay Pride celebrations. But somehow I doubt the new campaign will risk saying things like, "Syphilis Rates Among Gay Men Are Now More Than 100 Times Those Among Straight People," or, "Gay Guys Who Knowingly Spread STDs and HIV are Immoral."
"I don't see us using the word 'immoral' any time soon," Richart said.
To illustrate the perils of injecting morality into gay men's health, he offered this parallel: "Do you feel that having an abortion is harmful to a woman, and if you do, do you feel that it is your right to tell a woman that she should not have an abortion?"
His point, I guess, is that what one person thinks is harmful and immoral can seem just fine to another. But the analogy doesn't work when applied to gay men who are knowingly spreading HIV. In the abortion debate, both sides have constructed moral arguments that can be plausibly supported. Does Richart think there's a plausible moral argument that can be made to support the actions of HIV-positive men who have unprotected anal sex without revealing that they are HIV-positive?

No, he said, he does not. And then he conceded that the debate over whether to describe some actions as simply unacceptable is perhaps an important one.
"It's a fascinating question... Seems like really good fodder for a community debate. Maybe we should do that."
Yeah, maybe you should.

NOT SO EASY

A not-so-subtle point that Richart, Swanson, Rofes, and others made repeatedly in our conversations is that solving the gay STD and HIV problem is not as easy as simply talking about responsibility, boundaries, acceptable behavior, and morality. When I asked Swanson whether it was frustrating that over the past six years, despite all of Gay City's efforts at improving self-esteem and the gay sense of community, STD rates among gay men in Seattle had risen so dramatically, he replied, "What frustrates me most is the way that people look for simplistic ways to describe what's happening and look for simplistic and knee-jerk responses."
Fair enough. Everyone agrees that human behavior is the problem here, and everyone agrees that human behavior is a complex thing to address, especially among complicated human beings like us gays. But then again, sometimes human beings--even us gays--are very simple. Sometimes, as in the early years of the AIDS crisis, we get so scared that we change our behaviors real fast. And sometimes, when the fear of death isn't so close, we look for other things to guide our actions.

Imagine a young gay man who is recently out and searching for a sense of his new community's acceptable limits. Imagine an older gay man who has gotten himself into a bad situation and wants to be told how to get out. Imagine gay men of all ages looking for role models in leadership positions to tell them how to navigate the pitfalls of gay life.

Or, if you don't like to imagine, go online and buy The Gift, a documentary on bug chasers that was screened on May 24 at the Seattle International Film Festival (www.thegiftdocumentary.com). This horrifying movie, made by lesbian filmmaker Louise Hogarth, features Doug, a young gay man who came from the Midwest to San Francisco looking for a strong, accepting gay community and found that the people most willing to accept him were the ones who wanted to give him HIV. So Doug became a bug chaser, and guess what? Now he has AIDS. When he explains why he courted HIV infection, he offers a damning indictment of the current gay men's health leadership. He says no one ever told him getting HIV was bad. He says that in the nonjudgmental universe created by gay men's health leaders, the only message he ever heard was that being HIV-positive is--well, positive. He says he wishes the gay community would stand up and say what he now knows: That being positive is not positive; it is negative, a horrible condition that you shouldn't want and you shouldn't spread.

Doug is an idiot for not realizing this on his own, but his statements show how irresponsible it is for gay leaders to think that their nondirective, nonjudgmental approach to health promotion is sufficient. Kids like Doug, who have fled often awful family situations and are looking to the leadership of the gay community for guidance, can't get by on just cheerleading proclamations of gay positivity. They need the gay groups to act in loco parentis--as de facto parents. These guys need--and, as Doug proves, want--someone telling them how to behave, someone telling them what's good and bad, someone telling them who the assholes in the gay community are, how to spot them, how to avoid them, and how not to become one themselves.

THE SEX CHECK STING
Wondering what would happen when gay men like Doug--or any gay man looking for direction and help in making judgments--encountered the nondirective, nonjudgmental world of gay men's health in Seattle, I decided to conduct an experiment. I had some gay men call Seattle's new Sex Check hotline, which is funded by the National Institute of Mental Health and run jointly by Gay City and the University of Washington School of Social Work. The hotline promises "supportive, non-judgmental and multicultural" advice, for free, to gay men who "have questions or concerns about their sex life, HIV or other STDs."
When one gay man called--we will call him Billy--he gave this story: He was HIV-positive and had recently had sex with a guy whose HIV status he didn't know. Billy didn't tell this casual sex partner that he was HIV-positive, and during sex he came in the guy's eye. Now Billy is wondering if he might have infected this guy, and what he should do.
The counselor who answers the phone at the Sex Check line tells Billy it's possible to transmit HIV through the eye, since it's a mucous membrane, but that the probability is very low. HIV-positive

Billy is relieved, but then he begins to ask about the risks of some of his other behaviors.

Billy: Is it okay if I sometimes fuck people without condoms, as long as I pull out before I come?

Counselor: Is that okay? That's a question I'm not able to answer for you. I think it's a question only you can answer for yourself.

Billy: Is it okay that I'm not telling guys I fool around with that I'm HIV-positive?

Counselor: Determining what level of risk you're willing to take for yourself or for your partner is something you have to determine for yourself. It's not a question I can answer for you. It's really up to you.

Billy: Is it illegal?

Counselor: I think it might be illegal in five states. I don't know, that seems kind of wacky to me, but... [the counselor pauses to ask other people in the room about this]... as far as I understand, there are states where it is illegal to do stuff like that.... I may be wrong, you know.

Billy: Is it illegal here?

Counselor: As far as I know it's not. And I haven't been arrested yet.... I really say to everyone, "Go with the level of risk that you're comfortable taking for yourself."

Billy: Am I a bad person if I put other people at risk?

Counselor: Oh, dude. You're asking me a question I cannot answer....

The next gay man who I had call the Sex Check line pretended to be cheating on his boyfriend. This gay man--we will call him Charles--thinks he is HIV-negative but recently had a three-way with two guys he didn't know. After the three-way, it came out that the guys were HIV-positive, which shocked Charles. He hadn't asked, assuming they would tell him if they were positive. And the positive guys told Charles that they hadn't told him because his failure to ask about their HIV status made them assume he was also positive. Charles' boyfriend, who has told Charles their relationship is over if either of them cheats on the other, is coming home in a few days.

A new counselor answers the Sex Check hotline. After offering Charles a number to call for HIV testing, the conversation moves in the direction of what to do about Charles' boyfriend, who is HIV-negative. The counselor asks if they use protection for sex. Charles says they don't because they trust each other to remain clean, and he says he can't start using condoms because his boyfriend would know something is up.

Counselor: Maybe before he comes back, maybe something you could work on thinking about is finding someone to talk to. It sounds like you don't want him to know about the three-way you had.

Charles: Oh, no. No way. Counselor: And it also sounds like since he's someone important to you, that caring about your health and his health is also a factor for you. [The counselor now offers Charles two other numbers, one for a crisis health care center and one for an AIDS support group.]

Charles: I was hoping you would tell me what to do. I'm not gonna tell my boyfriend.

Counselor: Yeah. Unfortunately, the only person who can tell you what's important to you and what works for you is yourself.... Charles: What should I do? Counselor: I'm not sure what kind of answers you're looking for from me. I think "should" is a really subjective word, and I'm not gonna tell you what you "should" do for you and your relationship.... I definitely hear you say you would rather not confront the situation, not get tested, and not share that info with your boyfriend. And it is not a decision I can make for you. It's not something I can do.

The nondirective, nonjudgmental world of gay men's health in Seattle was incapable of telling Charles to do the right thing: Tell your boyfriend what happened, and don't have unprotected sex with your boyfriend until you have been tested and know you're negative. If Charles were real, and he ended up infecting his boyfriend, then wouldn't the gay men's health universe have been complicit in the creation of yet another HIV-positive gay man?

A CONSPIRACY OF SILENCE
Joseph Sonnabend, a doctor treating people with AIDS at the beginning of the AIDS crisis, had this to say in 1982 about the gay men's health leadership: "A desire to appear non-judgmental, a desire to remain untinged by moralism, fear of provoking ire, have all fostered a conspiracy of silence. For years no clear message about the danger of promiscuity has emanated from those in whom gay men have entrusted their well-being."
Then, as now, the roots of the gay leadership's reflexive refusal to be judgmental, or moralistic, or directive, are fairly obvious. Gay men have been persecuted by moralists, judged unfairly, blamed improperly, shamed unnecessarily, told the behaviors that define us are unnatural. It has harmed us tremendously, and continues to harm us. It keeps us in closets, it destroys our self-worth. But in response, many of us--including many gay men's health leaders--seem to have completely rejected all morality, all forms of judgment, all blame, all shame, all suggestions of proper behavior. These people seem to think it is possible to build a healthy community without such things, though much of human history--not to mention the current state of the gay community--argues against this proposition. Theirs is an understandable, but unsophisticated, response to persecution. And it is also dangerous. It ends up giving license to the immoral minority; the people in our community who are harming themselves and others by doing things that are undeniably wrong, irresponsible, and shamelessly reckless.

Now listen to what Dr. Hunter Handsfield, the director of STD control for King County, says today, 21 years after Sonnabend:

"I think a legitimate argument can be made that there has not been the level of leadership needed coming from within gay communities about gay men's responsibility and what behaviors are acceptable with regard to AIDS or HIV risk.... The bottom line is that without behavior change among [gay men], nothing public health or the medical community has done or can do will ever do much more than nibble around the edges of the problem."
Public health officials like Bob Wood and Hunter Handsfield don't yet know exactly where the core group (or groups) are in this community, but they can feel the contours of the core: It includes people who are not talking about their HIV status, people who are having unprotected anal sex, people who are mixing unsafe sex with lots of sexual partners, and people who are mixing sex and drugs. These health officials say they have shared the information about the rise in STDs with the county's health care providers, and with gay health leaders. And they say they are disappointed that the gay health leadership hasn't come down harder on the problem core behaviors.

When gay health leaders talk about who is actually responsible for helping gay men deal with the problem of STDs and HIV in their community, they talk about a triad of care: local gay community health organizations, public health departments, and individual doctors. (They basically give up on gay men's families, though they shouldn't.) Because of a perceived legacy of mistrust between the gay community and the institutions of public health that dates back to the government's slowness to respond in the early days of the AIDS epidemic, in Seattle, the local health department likes to let gay community organizations shape and put out the bulk of the prevention messages. Both sides see benefits to this arrangement. It keeps the health department from seeming too "big brother" and it gives the gay health leaders--who are theoretically most in touch with their community's needs--control over prevention messages. It also gives these organizations a lot of public money. In 2002, King County Public Health gave more than $500,000 in public money to Lifelong AIDS Alliance so the agency could build community and prevent HIV transmission. And it gave almost $180,000 to Gay City for essentially the same purposes.

Yet Public Health is itself now having to sound the alarm about STD problems in the gay community, and having to say things like this: "I've thought that it might be very helpful if leaders of the gay community would stand up and say, 'This is not helpful, this is not acceptable.'" That's Dr. Bob Wood speaking, the county HIV/AIDS program director, who himself is gay and HIV-positive. "How can we expect the larger community to respect us if we don't even respect ourselves?" Wood asks. "We don't disclose our infection, we have anonymous partners.... We need [the gay health leadership] to work with us. I'm not trying to point fingers at them, but none of the gay leaders are speaking up on these issues.... I don't know why they're not speaking up, because I know that they're all fully aware of the seriousness of this problem."

If that's how people working at King County Public Health feel about the efforts of Gay City and Lifelong AIDS Alliance, why doesn't the county yank their public funding? Or tell these gay community health organizations to get serious or get off the public dole? If Public Health wants the gay community groups to do better, maybe it should start holding them to higher standards.

The main argument that you get from gay health leaders against coming down hard on problem behaviors is that it could backfire.
"I don't believe that public outcry around sex does what people think it does," says Eric Rofes. "I don't believe shaming or stigmatizing or targeting around something you don't have direct control over--like sex--I don't think that leads to less problems.... For many people, what you are told not to do or shamed into not doing, you want to do."

So what's the answer?

"I think the large number of people--including myself--don't need guilt or shame or direction. They need...." Here it comes again: "...information."
But the Seattle gay health leadership has been demonstrably bad about getting out the information, and anyway, we're not talking about "the large number" of gay men. They're not the problem, everyone agrees on that. The problem is the minority, the core, and places and times when the core group members have unsafe sex with non-core members.
And the argument for targeting the core with strong messages of opprobrium is twofold. One, perhaps it could change the behavior of some people in the core, though this is unlikely. And two, perhaps it could keep future generations of gay men from joining the core.
"The fewer such people there are at any one time," Handsfield says of core members, "the better off a community as a whole will be. To an extent it's true that any ethically based health message is not going to be 100 percent effective. But that doesn't mean you don't try to shift the balance."

Gay men's health leaders often insinuate that to be gay and promoting messages of sexual restraint smacks of internalized homophobia. They say that to target specific subgroups within the gay population smacks of discrimination. They say, like Rofes, that presenting gay people with a strong message will prompt us to behave like children, indulging in the very behaviors mommy and daddy tell us to avoid. Now, which is really the anti-gay, discriminatory, infantilizing stance: The position that says gay men should be told exactly what is going on, no matter who it offends, and held to the same basic moral standards for behavior as everyone else? Or the position that says gay men are incapable of dealing with issues of morality and the truth about the health of our community? Which of these two positions really smacks of internalized homophobia?

Coincidentally, as this article went to press, the health department issued a press release warning gay men about the rising HIV rates and the extremely high levels of STDs in our community. The release urged gay men to take responsibility for protecting themselves and others. It noted that "community partners" were--finally--joining the health department in sounding this alarm. And its instructions to gay men suddenly sounded urgent and directive: Get tested for HIV and STDs frequently, use condoms, always disclose your HIV and STD status to your sexual partners. Considering what's going on, the new directives are nice--but way too late and still too timid.

PRINCIPLES, VALUES, BELIEFS
Oddly enough, even before this week's press release, the gay health leadership did make normative judgments, did issue directives, did take value-based stances all the time--but mainly on topics other than the sex lives of gay men. At the Gay Men's Health Summit in Raleigh, the Gay City leadership ran a session titled "How to Lose the Excuses and Discover the Key to Relevant Social Programming for Queer Men." And during the session, the topic of ageism came up.

"We need to kill this ageist bullshit crap that's going on in our community," said Brian Davis, one of Gay City's community organizers. Sounds like a pretty strong directive to me. So the gay men's health movement wants to denounce a younger gay man who makes older gay men feel bad. But if that same young gay man wanted to infect older gay men with HIV, no judgment?

Later, executive director Fred Swanson talked about how Gay City stood up to the health department when it threatened to pull its funding from a controversial quit-smoking campaign because the campaign pictured people smoking cigarettes.
"It's really about having principles," Swanson said, "and having values and really believing in those." But only when it comes to pictures of smokers?
The day before Swanson used the word "values," the conference organizers had arranged a showing of a documentary called Fight Back, Fight AIDS: 15 Years of ACT UP. The screening was meant to inspire the gay men's health leaders at the conference. In one scene, a gaunt gay man stands in front of a large rally and rails against the slowness of the medical and political establishments to respond to the early AIDS crisis. He says he hopes that his generation will not die in vain--that their activism will lead to better AIDS drugs, and perhaps a cure. Little did he know that a decade or so later, powerful AIDS drugs would exist, and the problem would not be their absence, or a lack of scientific knowledge about how AIDS is spread, but the continued willingness of gay men to put each other at risk for infection--and the unwillingness of the gay men's health movement to confront them.
And can you guess what the fiery ACT UP activists pictured in the documentary were shouting at the doctors and politicians who they felt, at that time, were the major threats to their community's health?

They were shouting: "Shame! Shame! Shame! Shame! Shame!"
Back to the beginning

FRED SWANSON: Executive Director of Gay City
Beb Reynol

DR. BOB WOOD: Director of HIV/AIDS programs for King County
Casey Kelbaugh