Rethinking Risks and Interventions Beyond HIV: The Importance of Contextualizing Collective Sex
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Frank’s (2018) careful analysis of an impressive amount of public health research shows that collective sex environments or the people who attend them are not inherently risky. That is, whether it happens between two people in privacy or among a group in a collective environment, sex may present elements of risks that can be managed. Pointing to commonalities between “transgressive” sexual practices and the general sexual culture, Frank concludes that preventing risk in collective sex environments should be part of a broader project of promoting sexual health in the population at large. We entirely agree with Frank that collective sex is not inherently riskier than dyadic sex in private and that collective sex events are typically not the right place or time to conduct health interventions. However, in our work, we have also called for greater attention to the context of collective sex, to the specific features of group sexual behavior, and to ways of working with people involved with collective sex environments for sexual health promotion (Meunier, 2014, 2017; Meunier & Siegel, 2017). One thing we take away from Frank’s review is that the focus on assessing the inherent riskiness of collective sex environments or the people who frequent them has been a limitation of much public health research on the topic.
“Inherence” implies something permanent, transhistorical, or universal. However, only looking at the past half century (as Frank’s  anthropological work on group sex would attest), the forms of risk associated with collective sex have changed dramatically, at different times focusing on legal or moral sanctions, violence, stigma, sexually transmitted infections (STIs), or HIV. Even the transgressive dimension of collective sex has fluctuated along with changes in sexual mores and politics, constantly altering the psychological and emotional risks and rewards of collective sex. As risks are changing, so do the solutions that authorities, researchers, or collective sex participants themselves find to mitigate them. Therefore, situating risk in its historical, structural, cultural, and legal contexts is not merely a scholarly endeavor, but necessary for finding practical ways to promote sexual health in collective sex environments.
To emphasize the importance to sexual health promotion of contextualizing and rethinking risks, we turn to the case of gay men’s collective sex practices in New York City (NYC) as it is the one closest to our complementary research interests. Siegel, a sociologist who was one of the first social scientists to study the HIV/AIDS epidemic as it began in the early 1980s, has researched the risk perceptions, behaviors, heuristics, and prevention strategies of gay men and other populations at risk for HIV. Escoffier is an historian of sexuality who has written extensively about gay men’s sexual cultures. He also produced many HIV/STI informational campaigns in his former role as Director of Health Media and Marketing at the NYC Department of Health and Mental Hygiene (DOHMH). Finally, Meunier is a sociologist who has recently conducted an ethnographic study of private gay sex parties in NYC and, with Siegel, a survey about the risk perceptions of men who go to these events.
Contextualizing Gay Collective Sex Environments in NYC
The Risks of Collective Sex Before AIDS
Men who experience homosexual desire, growing up isolated in heterosexual family life, have often had to resort to “cruising” in public venues in order to find sex partners. We can trace back collective sex among men in NYC to the late 1800s (if not earlier), when homosexuality itself was illegal and considered a mental illness and the consequences of being known as homosexual could be highly damaging. Few single men lived alone, and even for those who did, bringing a male partner home presented the risk of arousing neighbors’ suspicions. Rapid urban development created an array of places where men turned to mitigate the very risks of homosexual activity—a process best documented by Chauncey (1994). The anonymity afforded by new public places (e.g., restrooms, the subway system, or parks) and the front provided by all-male establishments (e.g., YMCAs and Turkish or Roman baths) made these environment relatively safe places for homosexual sex in a context where it was illegal and considered highly immoral. The main risks of collective sex for men in NYC at that time were those of exposure to law enforcement or the public; indeed, most of the early documentation about homosexual collective sex is from police reports (Chauncey, 1994).
In the 1960s and 1970s, several factors would change the place of collective sex in gay male urban communities: the emergence of gay social movements, the resistance to police raids at Stonewall Inn in 1969, the removal of homosexuality as a mental disorder from the second edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), continued migration of gay men and lesbians to urban centers, and changes in attitudes about sex due to the sexual revolution. Claiming public space was a political act aimed at justifying the right for LGBT communities to exist in the public sphere, and public sex could be conceived as an extension of that project (Escoffier, 2017; Moore, 2004). The abandoned and crumbling West Side piers in Greenwich Village were public places where gay men engaged in nude sunbathing and outdoor sex (Baltrop & O’Brien, 2015). Commercial sex venues like bathhouses and sex clubs were not inconspicuous anymore and became visible establishments in then publicly acknowledged gay neighborhoods (Bérubé, 2003). In this period, sexual affirmation, experimentation, and exploration were a positive part of self-acceptance of gay individuals and communities (Escoffier, 2017; Gove, 2000). “Gay is good” was a slogan of gay activists at the time, and by extension, gay sex was good and there were no reasons not to have as much of it as one desired. Gay-identified men in cities like New York were not as concerned with legal or moral reprisal as predecessors had been, and the greatest risk was that of STIs. However, these were easily treated, and the pleasures provided by the newly found sexual freedom far outweighed these risks. In retrospect, it became clear that the primary risk was, in fact, HIV/AIDS, first observed in 1981.
HIV/AIDS and the Invention of Safer Sex
The discovery of a disease that led to the death of so many sexually active gay men encouraged the hypothesis that the disease was the result of the gay lifestyle, in particular sexual promiscuity (Epstein, 1996; Escoffier, 1998, 2011). Gay men (and anyone else) suddenly perceived sex—even more so homosexual sex—as extremely risky and life threatening. Collective sex environments were thus early targets for prevention and many jurisdictions moved to outlaw them. In 1984, New York State added a clause under its sanitary code—still in effect today—to forbid sexual activity in commercial establishments on the grounds that doing so constituted “a threat to the public health” and “a public nuisance” (New York State, 2000).
As knowledge about HIV and its transmission took shape, it became clear that AIDS was not caused by a lifestyle but by a virus transmittable through specific behaviors, for instance, anal sex. Sex in itself was not dangerous as long as measures—most importantly, the use of condoms during anal or vaginal penetration—were taken to prevent transmission of the virus. Gay grassroots organizations were the first to develop safer-sex guidelines and to promote them in the community (Epstein, 1996; Escoffier, 1998), and collective sex venues played an important role in disseminating that information (Bérubé, 2003; Rubin, 1997). An important component of public health consisted of providing accurate information about how to prevent HIV, mostly through health communication materials (Siegel, Grodsky, & Herman, 1986). A fundamental premise of HIV prevention efforts at this stage was that if people had correct knowledge about safer sex, they would practice it to protect themselves from the disease. Unsafe sex, many assumed, had to result from inaccurate information or accidents due to a lack of skill using condoms or for negotiating their use with sex partners.
The invention of safer sex showed that sex in collective environments is not inherently riskier as long as adequate precautions are taken. Nevertheless, the ravages of AIDS put an aura of fear and stigma around these environments that would be hard to shake and maintained, as Frank (2018) shows, the perspective that collective sex environments are inherently risky. As such, besides a strategy of safer-sex education, there remained one of prohibition. For at least 25 years after the onset of the epidemic, the DOHMH played an active role in closing commercial sex venues on the grounds that they were sites of high HIV risk (Elovitz & Edwards, 1996). However, many feared that closing these environments would only displace collective sex to places where prevention work might be harder to conduct, a situation in which “the focus shifts away from what is safe or unsafe, to what one can get away with” (Gendin, 1996, p. 113). Indeed, from the beginning of the AIDS epidemic until today in NYC, collective sex has moved from bathhouses and commercial sex clubs to dark corners of gay bars or events popularly known as “private sex parties.” The proliferation of private sex parties was in large part a response to the stance of public health authorities—many sex-party organizers have been gay men who believed that collective sex environments could help promote sexual health and who wanted to offer a safe space for their community (Blotcher, 1996).
Intentional Risk-Taking and Syndemics
Early on, public health researchers realized that knowledge, in and of itself, about the consequences of HIV/AIDS and about safer-sex would not necessarily translate into behavioral change (Siegel, Bauman, Christ, & Krown, 1988). This realization led to call for more research on how to motivate gay men (and other people) to use condoms more consistently. However, the models of HIV prevention would be challenged further in the late 1990s with the realization that some gay men deliberately chose to engage in condomless anal sex—a phenomenon that would be known as “barebacking” (Gauthier & Forsyth, 1999). Especially concerning were certain subcultural elements of barebacking that involved men who developed self-identities and group affiliations based on deliberate risk-taking and HIV transmission (Dean, 2008; Moskowitz & Roloff, 2007). This subculture increased concerns about collective sex as there was growing evidence of bareback parties where condoms were prohibited and even speculation about seroconversion parties, where HIV-negative “bug chasers” purportedly sought to get infected by positive “gift givers.”
Much HIV prevention research thus turned to investigating why some gay men disregarded their own sexual safety. Syndemics, which emerged in the mid-1990s, would have an important influence on this body of research. According to this approach, the reason why some gay men do not protect themselves despite knowing how to do so is because they are struggling with other issues, namely mental health problems like depression and anxiety, sexual compulsivity, alcohol or drug addiction, and self-destructiveness resulting from internalized homophobia or childhood trauma (Stall, Friedman, & Catania, 2007). Promoting sexual health among gay men therefore required more complex interventions than safer-sex education, such as psychotherapy, substance abuse treatment, and even broader cultural changes to fight homophobia and foster a sense of self-acceptance among gay men (Stall et al., 2003). Ironically, however, research from the syndemics perspective may have a pathologizing or stigmatizing effect by depicting gay men who engage in collective sex (or have many sex partners) as psychologically troubled. For example, in Meunier’s (2016) research, participants who went to sex parties reported being judged for it by other gay men and stereotyped as drug addicts, sexual compulsives, or reckless barebackers.
Barebackers may have created a public health panic, but in reality they may not necessarily have been self-destructive risk-takers but merely people who made rational harm-reduction choices (Race, 2003). That is, they relied on serosorting, strategic positioning, and what would come to be known as treatment as prevention (TasP).1 Bareback parties and “poz parties” (Clatts, Goldsamt, & Yi, 2005) were, in fact, incentives by party organizers to help gay men of same HIV status or prevention strategies find one another. In conjunction, other party organizers would have strict condom-use rules; for instance, one NYC party venue was forbidding barebacking and throwing out those who did not comply (Meunier, 2016). Much HIV research has tried to understand how many people had bareback sex at parties and why they did so, but overlooked how the availability of venues and events with different norms and guidelines might have influenced behavior. Indeed, a simple way to promote sexual health in collective sex environments might have been to encourage party promoters to have clear guidelines around condom use (whether bareback or safer-sex) and to ensure that men who did not want to bareback knew about safer events; however, such incentives are difficult to realize when collective sex venues are forced to operate in a clandestine manner.
Changing Risks in the Era of Biomedical Prevention
The advent of pre-exposure prophylaxis (PrEP) and the growing evidence supporting the efficacy of TasP have decreased concerns about barebacking. Condomless sex is not synonymous with unprotected sex anymore as people can now choose from a “menu” of prevention strategies. For HIV-negative men who do not use condoms, HIV prevention does not focus so much on making them change their behavior, but instead on making them realize their behavior puts them at sufficiently high risk to warrant PrEP. In this context, collective sex can present minimal risk if HIV-positive men are virally suppressed and HIV-negative men are on PrEP. Indeed, some NYC sex parties that used to forbid barebacking now have a policy stating that condomless sex is acceptable as long as those involved in it are on PrEP or virally suppressed (but leave participants to make assumptions about who may or may not be complying with this policy). Interventions have also been changing; for example, Daskalakis has developed an on-site testing program at sex venues, aiming to diagnose infected men as quickly as possible in the hope of preventing transmission during the most infectious phase (Daskalakis et al., 2009). Daskalakis eventually became Deputy Commissioner for Disease Control at the DOHMH. His appointment represented a major shift in the agency’s stance on collective sex environments: working with them at promoting sexual health rather than shutting them down or trying to get gay men to avoid them.
Rethinking Risks Beyond HIV
The uptake of biomedical prevention strategies has raised concerns among public health scholars about “risk compensation”—an increase in condomless anal sex with different partners that could lead to more STIs or even HIV infections if people are not adherent. HIV researchers have started looking into whether men on PrEP are having more condomless sex; however, trying to assess risk compensation before inquiring into how gay men now perceive risk seems problematic. “Compensation” assumes replacing one risk by another as if the new risk was of the same gravity, but we do not know if gay men even perceive STI risk as appreciable risk or, rather, as a negligible cost they accept for the rewards they get from sex. That is, men on PrEP engaging in condomless sex may feel like they practice risk reduction rather than compensation. From a public health perspective, STIs are a problem, but no intervention is likely to be successful if we do not pay greater attention to the perceived burden or costs of these infections by those most “at risk” of contracting them.
For instance, regarding collective sex, a question probably on the minds of many gay men and HIV prevention workers alike is whether being on PrEP or virally suppressed makes it safe, for example, to have condomless sex with multiple partners at a sex club. In our recent survey with men who went to sex parties in NYC, 82% of HIV-positive-undetectable men and 70% of HIV-negative men on PrEP had had condomless anal sex at parties in the prior 6 months, significantly more than 43% for HIV-negative men not on PrEP (Meunier & Siegel, 2017). STI rates were also significantly higher among the first two groups, although these differences may be due to more frequent testing during routine visit with their prescribing providers. Yet, we know little about how gay men now perceive risks (if any) of such behavior, or how their perceptions might be changing after PrEP initiation (or reaching viral suppression) or after experiencing different STI diagnoses and treatments. For instance, a recent article found that some men discontinued PrEP after being diagnosed with STIs and realizing they could not rely solely on the medication (Whitfield, John, Rendina, Grov, & Parsons, 2018). As gay men are navigating between different HIV/STI prevention options, they are themselves rethinking risk, and public health researchers also need to do so.
Factoring in Psychological Risks and Rewards
The new “menu” of HIV and STI prevention strategies invites gay men to ask themselves what level of sexual risk-taking they are willing to tolerate. This leads to question about how gay men factor into that equation different rewards related to specific sexual practices. For instance, how does one come to feel like having condomless sex with multiple partners at a collective environment is worth the risk of STIs, provided that one is on PrEP? Current data about gay men’s perceived benefits of collective sex are scarce, but mention opportunities for sociability, acceptance, and group belonging besides, of course, sexual pleasure (Hurley & Prestage, 2009; Mimiaga et al., 2010). Questions arise regarding whether PrEP and TasP might change the perception of, and participation in, collective sex among gay men and the LGBTQ community at large. We still do not know whether changing perceptions of risk might make collective sex more “normal” or whether stigma will persist. Public health researchers need to pay attention to changing community attitudes regarding collective sex, as they can be the motor for change. For instance, in the documentary film Gay Sex in the 70s (Lovett & Kaminsky, 2005), several of the men interviewed felt that the sense of community that developed among those active in collective sex environments was the foundation of the gay community’s monumental response to the AIDS epidemic.
The psychological and emotional rewards of collective sex have been under-investigated, but so have their related risks. That is, these practices provide opportunities for sociability and group belonging, but also for rejection. The risks that gay men perceive when going to a sex party include those of being turned away at the door, of not being able to find sex partners, or of being excluded from social interactions (experiences that further carry psychological risks). Further, although the literature on heterosexual swingers has often looked at how couples negotiate committed relationships and collective sex (de Visser & McDonald, 2007; Harviainen & Frank, 2016), little has been done in the same vein for gay men. There is an emerging literature on gay men’s non-monogamous arrangements (Adam, 2006; Mitchell et al., 2016; Parsons, Starks, Gamarel, & Grov, 2012; Philpot et al., 2017), but we still have much to learn about how they try to reconcile relationship desires with the sexual adventurousness provided by collective sex culture. For example, in Meunier’s (2016) research, many sex-party goers struggled with a perceived incompatibility between committed relationships and collective sex, and some mentioned having a hard time finding a romantic partner who would accept their sexual lifestyle. The psychological dimension of collective sex can have a direct influence on risk-taking, as someone may feel the need to use drugs or alcohol in the space to cope with social or emotional anxiety, or decide to forego safety in order to find acceptance. For instance, in our survey with sex-party goers, 35% agreed with “I have felt influenced or encouraged by other men there to take more risks than I otherwise would” (Meunier & Siegel, 2017). Yet, despite the fact that collective sex has been part of gay life for so long, little public health research—let alone interventions—has found it relevant to address the social, psychological, and emotional dimensions of the practice. In fact, few have tried to understand group sex as group behavior.
Understanding Group Sex as Group Behavior
As related by Frank (2018), studies of collective sex in the 1970s came from the symbolic interactionist perspective. Sociologists working at that time saw collective sex environments as unique sites to observe interactional norms of sexuality as they were played out. In NYC, sociologists Delph (1978) and Levine (1998) observed multiple public and commercial spaces where gay men had sex and/or socialized, describing how sexual practices were woven into the space of the city, urban life, and gay culture and communities. Since then, however, research on collective sex has made very little use of any type of theory to understand the group components of the practice. Indeed, quantitative studies have hardly conceptualized sex in collective environments as anything other than a sequence of dyadic sexual encounters.
As shown in Meunier’s (2014) ethnography of a sex party, these can be extremely crowded environments where sex is ubiquitous. People constantly move from one partner or group of partners to another, sometimes for very brief sexual activity. Sexual initiation is often very direct and involves no verbal (and sometimes even no nonverbal) communication. Collective environments for sex are unique settings that are likely to challenge the typical interactional and sexual scripts one brings from the outside. For decades, social scientists have theorized about group behavior and group psychology (Thompson & Fine, 1999), looking at crowd behavior (Drury & Reicher, 1999), social contagion (Wheeler, 1966), deindividuation (Diener, 1979), or threshold effects (Granovetter, 1978), to mention only a few. Yet, we can only speculate about how being in a crowd, witnessing others’ behavior during group sex, or being carried away by the movements of the group might influence people’s behaviors and their perceptions of risk in the moment and after.
Sexual Health Promotion and Intraventions
We agree with Frank (2018) that collective sex environments and their attendees are not inherently risky. However, we maintain that collective sex differs from dyadic sex in private and that rethinking risk should involve more attention to these distinctions. For example, even if the rates of HIV infection were the same in all contexts, this would not mean that there are no factors leading to risk-taking, or competencies required to prevent it, that are unique to collective sex environments. The psychological, social, and emotional aspects of collective sex and the legal and structural contexts surrounding the practice differ from other forms of sex in many ways, and thus, so should the patterns of risk. Further, as we have shown through this short history of gay collective sex in NYC, risk behaviors and their meanings are constantly changing. If definitions of risk change, then there may be no inherent risks in a practice. If any sexual health interventions are to be successful, public health research should be more invested in understanding how risk perceptions and meanings are evolving in the populations they study rather than assigning their own definitions and measures of what constitutes risk.
We also agree with Frank (2018) that on-site sexual health interventions in collective sex environments may not be appropriate and that prevention work can often be done outside these contexts. However, historically, sex-venue organizers have generally worked at making their spaces as safe as possible for their patrons, whether this meant protecting them from law enforcement, from violence, from identity exposure, or from HIV and STIs. Public health workers should thus pay closer attention to how collective sex organizers and participants are already promoting sexual health among their community (what Friedman et al.  have called “intraventions”) and work with them to improve or support existing efforts. A major obstacle for any form of sexual health intervention aimed at NYC sex venues remains the public health code that forbids commercial sex venues and leads collective sex into clandestine spaces. This law makes sex-venue organizers suspicious of any form of authority, which complicates public health outreach, but also creates other forms of risks, for example, as venue staff avoid calling police, paramedics, or the fire department when emergencies happen. Thus, the goal of public health should also include policy change to allow collective sex environments to be as safe as possible, and not only with regard to sexual risks.
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