Aging And HIV Risk Among Gay Men

James Murray, AIDS Committee of Toronto, Toronto, Ontario
Barry D Adam, Department of Sociology and Anthropology, University of Windsor, Windsor, Ontario

ACKNOWLEDGEMENTS:
Robert Ray, AIDS Committee of Toronto Volunteer Recorder
Correspondence concerning this paper should be addressed to:
James Murray, Gay Men's Community Development Coordinator
AIDS Committee of Toronto
399 Church Street, 4th Floor
Toronto, Ontario
M5B 2J6
(jmurray@actoronto.org)

ABSTRACT:
This study reports on one-on-one interviews and focus groups with gay and bisexual men over forty, concerning their vulnerability to HIV. Respondents report a range of age-related issues that impact on safer sex decision-making including decreased attractiveness, widowerhood, loss of support networks from AIDS, and anticipated future quality of life, as well as strengths and satisfactions that decrease their risk. Respondents typically attributed unsafe sex in other men to popular discourses around (1) condom fatigue, (2) treatment optimism, and (3) inserter invulnerability, but deny that these ideas explain their own behaviour. They identify their own risk situations with: depression, impending mortality, trading off safe sex, and the effect of condoms in keeping erections. Community-building projects that begin to address risk situations have followed from this research with the AIDS Committee of Toronto.

Key words: aging, gay men, HIV risk

After a lengthy period of declining HIV rates among men who have sex with men, public health authorities in Ontario (Remis, et al. 2000) began to report an upturn in sero-conversion in Toronto in 1998 and 1999. Though a good deal of attention has been devoted to gay youth as a population particularly vulnerable to HIV transmission, this new trend appeared to include older men as well as younger. In response, the AIDS Committee of Toronto initiated a series of interviews and focus groups among gay and bisexual men over forty to gain some insight into their HIV prevention needs and concerns. The central focus of the project was to explore the sexual health concerns of older men to see if it was possible to discern how aging and HIV risk may be linked in this ostensibly well-informed population.

Much of the existing research literature on older gay and bisexual has been of an exploratory nature (Vacha 1985; Lee 1989; Berger 1996; Grossman, D'Augelli and Hershberger 2000). Almost nothing has been published on older men and HIV risk. These interviews document primarily issues around sexuality and relationships, as well as views about HIV risk. While many of the concerns expressed by older men are shared with other older women and men, whether lesbian or heterosexual, their concerns also have particularities and nuances associated with being gay. For example, while some anticipated a declining standard of living associated with loss of income due to retirement, in common with other people of the same age, they looked - without a great deal of optimism- toward reliance on the gay community (rather than to family) for support and quality of life. While many study participants remarked on their growing sense of mortality, no doubt similar to their same-age peers, sero-positive gay men had particular apprehensions related to the long-term effectiveness of therapies for HIV disease.

METHODOLOGY
A flyer advertising a ‘focus group for gay men aged 40 & over’ to ‘talk about their experiences being 40 & over in Toronto's gay community’ was distributed in Toronto gay bars, bathhouses, and other community venues. An advertisement was placed in Xtra! (a gay community newspaper), a fax was sent to more than twenty AIDS-related service organizations in Toronto, and direct requests for participants were made to front-line HIV prevention staff at some ethno-specific AIDS service organizations. Recruitment material indicated a $20 payment for participation in the study. Interested men were asked to contact James Murray at the AIDS Committee of Toronto (ACT).

Potential participants were included in the study if they identified as men, were aged 40 or over, and had sex with other men. Participants were given the option of selecting a focus group or a one-on-one interview, in order to allow those who may be uncomfortable participating in a group context to participate in the study. Focus groups had a preset time and location; the one-on-one interviews occurred at mutually satisfactory times for interviewer and participants.

The parameters for participation were kept open (men who have sex with men, rather than gay or bisexual identified men), and ethno-specific AIDS service organizations were contacted directly, in an effort to obtain the insights of men from various ethno-cultural communities in Toronto. Still, this study was not successful at recruiting a significant sample of men from ethno-cultural communities. Men from ethno-cultural communities may share some of the concerns or issues identified in this sample; however, further research specifically targeted at a diverse range of communities in Toronto is needed to ascertain where the needs of men from ethno-cultural communities are similar and where the needs are unique.

Participants were asked read to a ‘Consent Form’ to clarify their rights and ACT’s responsibilities in the collection of information. Participants were then asked to fill out a ‘Demographic Survey’ and a brief ‘Written Survey’ before being asked to respond to the facilitator's questions.

Two focus groups were conducted – September 27th, 2000 (n=9) and October 4th, 2000 (n=10). Twenty-seven (n=27) men chose to participate in the study through one-on-one interviews. Both focus groups, and all one-on-one interviews, were conducted at the AIDS Committee of Toronto, and were facilitated by James Murray. Robert Ray, an AIDS Committee of Toronto volunteer, worked as a note taker for the focus groups.

All focus groups and one-on-one interviews were recorded on tape. James Murray carried out the transcription. Data coding was carried out by Barry Adam and data interpretation by both authors. Transcribed interviews were analysed by an iterative process of constant comparison to identify both recurring themes and the range of variation and nuance in respondents’ narratives.

A total of 46 men participated in the study. Nineteen men participated in focus groups, nine in the first group and ten in the second. Twenty-seven men chose to participate in one-on-one interviews. Demographics listed here relate only to the one-on-one interviews.

    • Participants ranged in age from 40 to 71. The mean age was 45.4. The median age was 46.
    • Twenty-six participants identified as gay. One participant listed both gay and bisexual.
    • The majority of participants were single (N=17) but a significant number were in a relationship (10). Two men who were single also identified themselves as widowed, while one stated he had recently ended a long-term relationship.
    • Ten were HIV positive, fourteen were HIV negative, and three participants identified that they did not know their HIV status.
    • The overwhelming majority of participants were white, listing their ethno-cultural background as Western European, Eastern European, or of mixed origin (N=21). Some participants were non-white, and stemmed from an ethno-specific community. These included Caribbean (2), East Asian (1), and South American (2).
    • The vast majority of men said that their first language (21) and the language in which they would prefer to receive sexual health information was English (24). A small minority of men listed another language as their first language (6). Interestingly, all of these men preferred English as the language to receive sexual health information, with one man listing either his first language or English as his preference.
    • Just over half the participants were university educated (16). Of the rest, some had completed education at the community college level (7), and some at the high school level (4).
    • The greatest number of participants was employed full-time (10), with a significant number of men on long-term disability (8). The remainder were either self-employed (2), retired (2), students (2), working part-time (1), or looking for work (1).
    • Eight participants reported an income greater than $45,000 per year, with another seven reporting income between $35,000 and $45,000 per year. One participant reported an income between $25,000 and $35,000. Five earned between $15,000 and $25,000, and another six earned less than $15,000.

The only demographic difference between individual interviews and focus groups was the greater number of men living with HIV who attended focus groups in comparison to HIV negative gay men. Out of ten men in one focus group, only one man was HIV negative. This could strengthen the proposition that men who participated in the study were men familiar with the AIDS service organization (ASO) and comfortable attending events sponsored by and held at the ASO. These are men who are more likely to be HIV positive and to be gay men who are out and active in Toronto's gay community. Although the general themes captured in the focus groups and one-on-one interviews were quite similar, the one-on-one interviews facilitated more in-depth disclosure for some men in relation to risky sexual activity. As a result, the bulk of this report is based on the transcripts from the one-on-one interviews.

Because participants were recruited for a study that was clearly identified with an AIDS service organization, and because the recruitment was done through promotional strategies typical of the way ACT promotes its services, it is likely respondents were more typical of men who historically access the services of an ASO, or who would be comfortable attending a meeting at a building associated with HIV/AIDS. Respondents were significantly involved in Toronto's gay community, both socially and in its service organizations. They were men who were likely regular readers of Toronto's gay media. This serves ACT well, as the goal of the study was to identify ways that ACT could better serve its clients and men encountered in Toronto's gay community spaces. However, the data should be understood in light of the demographic nature of those attracted to the study. This set of study participants is likely less representative of gay men in Toronto who are not actively involved in Toronto's gay community, who come from ethno-specific communities throughout Toronto, who have sex with men but do not have a gay or bisexual identity, or who spend most of their time in rural or suburban communities outside of Toronto.

Given the ways in which men came in contact with this study, and given the general difficulty in achieving genuine representativeness in any sample of gay men, it is not easy to determine the degree to which the concerns expressed here are widely shared, or whether this study, by its very nature, attracted those more likely to have experienced unhappiness with the aging process. Comparing those who volunteered for this study with other samples of gay men reported in the social science literature, this sample appears to have higher representation of men who are HIV-positive. Still, with these qualifications in mind, the men in this study illuminate a range of pressing problems for which there are few remedies, whether in the form of social services or community mobilization.

CONCERNS ABOUT AGING
Public images
Many men commented on the idealization of youth common in the gay scene, citing the imagery prevalent in videos displayed in bars, advertisements in the gay press, even HIV prevention hand-outs. Many perceive commercial venues as catering to the young, and express a growing apprehension about their displacement from the social spaces available to gay men.

There's this sort of putting men on this pedestal - putting gay, young men on this pedestal - and almost glorifying [them], and in particular men who are well built, physically endowed, muscular. And I think there are also some very European characteristics that go with that, and I don't want to say 'white' because I don't think that's necessarily true, but being white does have benefits. I think ‘exotic’ is probably a better word to use. You know if you look like you're seventeen different cultures rolled into one, and you've got the physique - you don't have to put a sentence together, you know - and watch what the world does. (47, Caribbean)

Commercial imagery, which is the most widely accessible imagery that gay and bisexual men encounter, combines age and race with a particular vision of social class to construct the gay male subject as the quintessential consumer (Altman 1982; Simpson 1994).

All over the place whether it's Xtra! or Fab! or the Advocate or whatever; if you're looking, even the ads for HIV drugs and everything else, everyone is young and buffed and they have the money to have nice clothes and they've got nice cars and they go travelling - in theory - but there doesn't seem to be a lot of marketing out there [for men over 40]. (57, West European)

In the absence of many alternatives, this singular ideal exerts a powerful influence upon the imagination and practices of gay men:
People are doing their best to present as perfect: young white male, 20s, university educated, professional career, athletic record, whatever, because they watch what happens to the older fags. (51, West European)

This man, who feels some distance from this ideal as a member of a long-term relationship, nevertheless observes:
the images of the body beautiful are in our community and men can become preoccupied with that to the extent that they have lower self esteem, or they compare themselves unrealistically to these images, to the body beautiful. I think that has a very strong negative impact on self-perception. (48, West European)

Some participants felt there are particular subcultures where older men can be more comfortable, such as the leather scene and the “bear” groups.

Relations with younger men
The youthful orientation of the commercial scene communicates invisibility and invalidation to many men over forty; however, their own experiences with younger men are more mixed. Many recall critical incidents, overheard conversations, or direct rejection which initiated or reinforced their sense of “being old,” but this sense is often tempered by not-so-distant memories of their own attitudes and perceptions as young men. Several men recalled their own intolerance of older men when they were young:

When I was 20, I thought people who were 40 were senior citizens and there was no way I would hang out with them, and when I met straight youth, they wanted to be with their peers in their own age groups....they're afraid of old people. They're afraid of being taken advantage of. They're resentful of authority figures that up until that point in their life have probably been from an older generation, teachers and parents. (44, West European)

When I was young I wasn't thinking that way. I wasn't thinking, “Oh well, I'll be old one day so why don't I be nice to some geezer and that way maybe when I'm old somebody will come visit me in the old folks home.” (51, West European)

Others had valued, or still enjoyed, being mentored by men older than themselves, and sought to extend a hand to the upcoming generation. This respondent celebrated the experience of young men moving from feeling vulnerable, isolated, and devalued in the dominant society, to feeling admired, connected, and valued in the gay world:

I had my time, and it was fantastic. And in doing so I still have my time....First of all for anyone to just step into the beginning of adulthood, it's an immense universe ...it's overwhelming. So if we need to encourage and allow them to focus on their looks and their beauty and their cologne, and their places to meet and gather, fancy restaurants, that's wonderful. That's the beginning of connection, building self-esteem. (43, Canadian)

He sought to position himself as a mentor and “older brother” sympathizing with the difficulties of being young and gay, and easing the way into adulthood. Others remarked, somewhat wistfully, on the opportunities now available to young men, that they had been denied in their youth.

They're more confident. They're flaunting a boyfriend situation, and I'm very jealous that I didn't have that, say, 25 years ago. I would have loved to have a boyfriend when I was 19 and away from home at university, but that didn't exist. (41, East European)

A few still felt included in the attentions of younger men (Adam 2000):
I mean percentage-wise they would be quite a minority, but having said that, there are quite a lot of younger men who go where older men go, because they like to be around older men. A lot of young guys like me, or want to have sex with me, or whatever it is. (57, West European)

A sizeable number of study participants preferred peers as partners, complaining at times about men their own age who seek younger men:
There is something really nice about having sex with a really wise, experienced partner, who knows how to pay attention to someone else's needs but also satisfy their own at the same time. That's quite a good experience. So, I think there are things that older men have that young men don't, but you don't see that played up very much. (46, West European)

Desirability
Gary Dowsett (1996:148) found in his study of Australian gay men that “to have one's sexual desire acknowledged by other men was important to all the older men in the study, and this issue must rate as one on which modern gay communities are failing in their challenge to more general sexual conventions.” The loss of attractiveness and of sexuality with age was described as an “essential dread” by one study participant. Another described middle age as going back into a closet where age had to be camouflaged. Men with HIV disease struggled, as well, with the effects of Kaposi’s sarcoma or lipodystrophy on their appearance. Many described a sense of immanent loss, and some felt an urgency to exploit their desirability while they could. Said one,

I was never much of a drinker, but you know I could pick up guys in bars or guys would pick me up in bars when I was young. That wouldn't happen now, not in years and years and years. I had a lot more choice of partners and more choices of venue. Now, I don't get laid if I don't go to the baths...I work at extending my shelf-life and get laid a lot for an old guy. Although I fantasize about love and a partner, I don't really expect to find either...It's a fantasy, but it's not a realistic expectation for me, 'cause I think I'm over the hill. So, what I'm doing is I'm fucking on borrowed time and any time it may end. (51, West European)

The fear of no longer being welcome is clear in this narrative:
If I go to a bar I'm always assessing if I'm too old for people, if I'm harassing people, if they don't want me around, if I don't fit in, because of my age a lot of the time. (46, West European)

And another,
In my 20s, if I had an encounter with a man, and I often did, it would resonate with me for over a month. I would savor that moment, the smell, the time we spent together, for over a month, before I would even think about having another partner.... And then in my 40's I started going [to the baths] quite a bit, and I think a certain amount of sex panic set in because I could see the light at the end of the tunnel, and I'm not as attractive as I used to be - - all the clichés come out... “Get the hay while the sun shines most,” and all this lunacy about “Well I better seize the day.” (48, West European)

Many described intensive efforts to forestall the effects of aging through working out at the gym. As this respondent concluded,
I don't think that gay men have very many role models as far as what's a healthy and graceful and attractive way to addressing old age as a gay male...I'm trying to figure out how I'm going to grow into this in a way that I don't become alienated and even more unhappy. (46, West European)

A generation marked by AIDS
The experiences of the men over forty in this study are shaped not simply by age but by a particular socio-historical circumstance. Sometimes referred to as the “Stonewall generation” for their initiation of the “out and proud” phase of the gay movement, these men have lived through two decades of the AIDS epidemic, including the early years of public panic, the death of many of their peers, and years of ineffective treatments. A prolonged sense of bereavement and immanent mortality became a central theme of a good deal of gay fiction of the 1980s and 1990s (Nelson 1992; Murphy and Poirier 1993) and has been documented by researchers (Mayne, et al. 1998; Springer and Lease 2000). Widowerhood, isolation, and insecurity are recurring themes in stories of the men who turned up for this study.

Recovery from the death of a partner and a renewed search for intimacy pose many challenges; men in this study talk of the death of partners they had, some for as long as twenty-one and forty-three years.

When my partner and I were together I had a little less sex, but I was a lot more fulfilled in terms of my emotional needs, you know. I had known him for about eight years and we were more or less partners for six years, and during that time we spent a great deal of time together...I was off work actually for about six months after he died...I still don't know what I'm doing socially, so consequently I just stay home a lot...He loved going to the bars. We had to go out every Saturday to the god-damn bar. It was great. I loved it; you know because he liked it so much...I don't do any of it now. I don't miss it. I miss him. (55, West European)

This study participant describes the challenge of looking for connection with other men in the six years since the death of his partner.
It's been very challenging, first couple of years, more to do with grieving and financial difficulties, but it's been wonderful to learn things about myself and to explore areas of sexuality I never even imagined I had. I was very happy, you could say, with vanilla sex, and my guy, and coffee in the morning with the cats, and the English garden, and going to my work, and coming home and having dinner parties and friends over, and it was wonderful. I wish more guys would give it a try and not be so afraid to see what they have inside them. (43, Canadian)

Other men faced similar problems following the end of a long-term relationship.
For widowers and single men, AIDS may have had a devastating effect on their friendship networks:
There's an issue of isolation in this as well, because I am 46, I've lost three best friends. Most people in my generation fall into one of three categories: they're dead, they're HIV-positive and either on disability or really kind of impoverished, or they're - which again leads me to barebacking - 'How dare you give me my life back.’ I ran up my charge cards. (West European, HIV-positive)

And another:
Nobody else has gone through it: lost the number of friends that we have, been so deeply impacted by the losses from AIDS, and our friends getting sick. Nobody else can understand that really...I always thought that these men that I was friends with would be around for me when I was older. I'm the only one of my friends that hasn't died. I have a picture at home that was taken. There were ten of us...we took a picture of us all together. I'm the only one of those guys that's still alive. That was my family. So, my family that I thought was going to be around for me when I was older, they're not there. (57, West European)

As a result, “isolation” and “loneliness” are recurring issues for some men.

Search for intimacy
Several men have partners and have found the intimacy they wanted:
We have as much of one and others company and trust as we want. Let's put it that way. I know that if I need him all I have to do is call and he feels the same way about me. (68, West European)

But others find their chances for love and relationship to be diminishing with age. This man, who has a partner, observes a search for intimacy among his friends who regret the limited avenues open to them:

There's resentment to people that are in relationships. I get that a lot. And, for some of the people that I know it affects the way they act sexually, in that they go to the baths for intimacy...[one wants to go to the baths and spoon all night.... And they want to talk at the baths. And this is a place [where] sex gets them close and they hope to get the intimacy from it. I think that's related to age and the clock ticking and the need to meet somebody. [44, West European]

Some describe passing through gay venues for many years, enjoying sexual relationships, but not connecting with a man in a more profound way despite a desire to do so.

When I was about five or six I knew I liked boys...and when I was growing up my favourite teacher was always a male teacher and I never really figured out why I bonded with them until...I got to university...One of the people in my dorm took me to a gay bar and I discovered all this, but as I'm getting older I don't want sex, I want love, and I want the sort of “normal relationship” as a man and the wife would have...Even when I was younger and every Friday and Saturday night going out with a few friends and having a few drinks and maybe eyeing someone, I never ever wanted to just go and fuck someone and kick them out an hour later. It was always thinking, “Well, we're going to have something to eat, we're going to go to a play, and he's going to be my boyfriend.” That never ever, like, materialized. (41, East European)

Satisfactions of aging
Despite these many problems and challenges to growing older, the narratives of these men over forty also reveal a range of discoveries, satisfactions, and pleasures that have improved with age. Many men consider their lives to be better than before, or at least identify areas of greater satisfaction. For example, this judgment may be arrived at through comparison with earlier insecurity and guilt in youth:

It's much better. I'm much more sexually active now. It's taken a long time, but I've been at a place where I can negotiate what I want with my partner, with my long-term partner. I don't feel guilty like I did when I was younger. (44, West European)

While some of this change may be associated with emotional maturity, it is also linked to living through a historical period of growth and assertiveness of the gay community.

You have to bear in mind that when I was 25 the whole scene was not nearly so open as it is now, and the penalties for getting caught were much greater, so it was an entirely different sort of ball game. Not that it wasn't there, but it just operated quite differently and besides people in my age group very rarely took for granted in their teens that they were gay...There was a pretty strong expectation that it was part of your duty to keep at least one woman off welfare, which explains why you have so many men who are now in their 60's who are divorced. They did what was considered to be their duty when they were young, and only later on did they come to terms with the fact that wasn't what they wanted. (68, English)

For some study participants, the repression and discrimination directed against gay men a generation ago led to a retreat into respectability.
I would consider myself to be representative of gay men who came of age in the early 70s and were not able to establish a functioning gay lifestyle successfully, and they did whatever: they became celibate or they got married, or they went into the closet. They did whatever they did, and then they came out much later, you know, 35, 40, and you have to start all over again. So, in some ways, and I think that's not uncommon among gay men of my generation, they didn't really ever get to experience what it was like to be a healthy gay man. (46, West European)

A more accommodating climate for lesbians and gay men made possible the realization of repressed homoeroticism:
I'm a lot more sexually active than I was as a straight man. I was straight and married for 20 years and that's very different. This is better. laughs)...I became gay very late in life. I was 45. I feel like I've had two complete lives, and each one of those lives was great. I'm having a great time now. (55, West European)

Despite the range of anxieties expressed around potentially diminishing desirability and sexuality, many report that the quality of their sexual lives is better than before.

There's sensuousness, and I think that comes with maturity. It comes with knowing more about who you are and what you want in someone else. (47, English)
For me it's far more and far better than it ever was...In my 20s it was fast and often...As I've grown older it's less frequent, but I've found, generally speaking that the whole intimacy thing becomes far more important, and just getting off is not what sex is all about where[as] it used to be. (Focus group)

Some described sexual desire as now less urgent, but nevertheless more satisfactory as they were now in control rather sex being in control of them.
I'm sure at 43, where I am now, my body is not asking for the same amount of sex as it was when I was 23. I'm sure there's a lot of difference there. For myself personally, I consider it a plus, that you don't need as much sex anymore. (Latin American)

RISK DISCOURSES
Attributing motives to others
Study participants were asked specifically about their views on three kinds of popular explanations of HIV transmission that were in current circulation. These were: (1) condom fatigue, (2) treatment optimism, and (3) inserter invulnerability. Perhaps more remarkable than their agreement or disagreement with these popular presuppositions was that none of the men in this study reported that these explanations had any validity in explaining their own practice of protected or unprotected sex, rather those who endorsed popular discourses consistently attributed them as motivations for other men.
For those who spoke about their own behaviour or that of friends or acquaintances they knew personally, “condom fatigue” was rejected as an adequate explanation of unprotected sex.

I don't think there's a phenomenon called 'condom fatigue' itself. If a person comes across something routinely that is good for them for five years, they are not likely to stop unless there's some change that affects them. (46, West European)

Others gave credence to the “condom fatigue” hypothesis in speaking generically about other men's behaviour:
You would think that people that age would know better. At least I think that way. But I certainly think they're a bit complacent and maybe it's overkill or fatigue of the whole thing. (41, East European)

Asking about condoms did lead to discussion of a range of obstacles and inhibitions about their use (reported in the next section) but not to a generalized claim for “fatigue.”

A similar pattern emerges in response to the idea that unprotected sex is on the rise because AIDS is now seen as a treatable disease.
I've never heard anybody state any relationship to using a condom but I know that's what people think, and yeah it's discussed, and things look better, they look better. I don't believe it personally, but they do. (44, West European)

And again, this study participant endorses the “AIDS optimism” hypothesis for other men:
So they see their friends managing and doing well, in fact, some of them are going back to work, so they're thinking, “Oh, it's not too bad, and I'm tired of using condoms.” (No age reported, English)

But the distinction between self-motivations and other-motivations is clear:
I think that that [AIDS optimism] is possibly, probably [the case] for some people. I don't feel that myself. I have seen what the cocktail can do, and...I'm not less concerned about sero-converting because of all the treatments available. (57, English)

Respondents make the same sharp distinction in regard to the view that the partner who inserts is not at risk for HIV infection. All reject the claim for themselves, but some are willing to believe it as a motivator for others.

These three popular risk discourses raise several vexing epistemological questions. Is it that these rationales for unprotected sex do motivate men “at some level” but they are unwilling or ashamed to admit them? Does this pattern of response speak to the kind of men who may respond to a study associated with an AIDS service organization, that is, men who are already well-informed about the AIDS epidemic, do not rely on these myths to guide their own behaviour, but are aware of “other” men who do rely on them? Or alternatively, do these risk discourses have the status of what Aaron Cicourel (1964) calls “observer's rules”? Observer's rules are discourses generated by observers precisely to make sense of other people's behaviour, but which at best have an unknown relation to other people's own explanation of themselves, and at worst, are entirely irrelevant to the question of “motivation.” These epistemological questions plague much of the research that is carried out in this area, as observer's rules are frequently confused with motivation (Adam Forthcoming). The implications of these questions for HIV prevention work are far-reaching, as prevention campaigns devoted to debunking observer's rules may very well be greeted with considerable satisfaction in communities who believe that “other” men responsible for HIV transmission are being addressed. But as HIV prevention tools, such programs may be entirely ineffective as there is no audience receiving a message that speaks to themselves rather than to perhaps putative others.

Accounting for unsafe sex
When gay and bisexual men construct narratives about their own moments of unprotected sex, quite another set of explanations come into view (Adam, Sears and Schellenberg 2000). The following narrative expresses a nexus between self-valuation and exposure to transmission, where the referent is to friends or self rather than to anonymous others:

People that I've talked to who have sero-converted it's been around times when they've not been feeling great about themselves and they're drunk or just using sex to try and pull themselves out of a slump, and they're not so vigilant about what happens. And I really believe that's the issue. I believe that if you don't feel good about- I believe this very strongly - if you don't feel good about going to the baths, if you already feel like you're a bad person for going to a place like the baths, or having sex in a park or a washroom, then you're less likely to stand up for yourself, because in my mind the logic is, “Well I'm already bad. I don't deserve to be in control or the one who says no. I've brought myself down to a level where what I get is what I deserve.” I really believe that. I think that in a sex-positive environment people are much easier at negotiating safe sex. (44 West European)

Study participants refer to a range of conditions and trigger events that stimulate a feeling of worthlessness and disable self-protective action and thus safe sex. This man refers starkly both to societal homophobia and to a lack of support within gay communities:

Everyone spits on us. We spit on each other...We do tend to carry a lot of this self-loathing with us. And, in the gay community we don't let each other off the hook very much. Our expectations are pretty high. (51, West European)

Most of the stories in these interviews trace links between problems discussed above and increased feelings of worthlessness. Feeling marginalized and devalued by the youthful ideals promoted in the commercial gay world, apprehensions about declining desirability, widowerhood, the loss of friends from AIDS, loneliness and isolation, all enter into “not feeling great” about oneself.

Depression is a recurring theme throughout the narratives of the men who volunteered for this study. This respondent, who recounts a lengthy history of treatment for depression, remarks:

I don't have a partner anymore. I'm promiscuous. It distracts me from my loneliness and isolation. That's how I get through. I wish things were different. I would like to have a partner. (51, English)

Sex is a medium through which a great many needs may be addressed. Sex provides an especially male language for talking about, and thinking about, a range of human desires and concerns around intimacy, communication, and personal connection.

I also know from first hand experience when I had gone through episodes of being depressed, and I needed to be touched, and I needed to be around the community, you can walk up and down Church Street and you can go into a bar, but you're not getting what you need, and sex becomes the urge and it's so easy to walk into, you can go to the baths if that's what you are into. (47, Caribbean)

“Trading off” safe sex
There is widespread consensus among the participants in this study that a sense of social devaluation sets the stage for the “trade-off” (Adam, Sears and Schellenberg 2000) of sexual safety for emotional needs. A focus group participant remarked that as he got older, he had less control in sexual situations because if he found someone who wanted to have sex with him, it was almost like he should be thankful. The men over forty in this study report feeling less able to assert themselves with younger men, and strongly tempted to accommodate their desires even if they included unsafe sex. The “trade-off” scenario came up as applicable to both themselves and to others.

Number 1, of course, is the assumption that this young, virile individual can't possibly have the virus. Secondly, there's just a rush of joy when an older man has a younger man, and I'm speaking quite personally now, and [in] that rush of joy you may take greater risks than you would with someone who is older or perhaps more aged. There is a desire more to please, to please that young man, to do all sorts of things that you wouldn't do with someone who is older. (48, West European)

Another speculated, in a reversal of the usual portrayal of the dynamics of older and younger men, that it may be older men who are more vulnerable to HIV exposure than younger.

I'm wondering whether an increase of HIV transmission is because they're [older men] doing bareback because that's what the young people are attracted to now, and they don't feel they are in a position to say “No, I want a condom” because they'll just say, “Well, fuck you, I'll go find another old man.” (44, English)

This same respondent identifies a parallel scenario where the politics of desire is reversible:
The daddy thing has a lot of problems to it, but one way it's good, in terms of the HIV thing, is that you know you have a younger guy who wants you to be his daddy. You set the rules. So whereas in other situations where you might feel quite out of it by saying, 'No, we have to use a condom,' that's a position where you don't ask. You just put on a condom. So, that's one way gay men I know my age have been able to meet people who are younger and still keep certain control over their sexual practices.

Still, age is just one of several statuses where men may perceive themselves as disadvantaged and thus vulnerable to trading off. Men of colour wonder if rejection is linked to their culture or ethnicity.

In a sexual situation and someone rejects you, you wonder, “Is it my age, my body, my race?” (42, Chinese)
And other men living on fixed incomes find lack of money a barrier to participation in the “scene” and a disadvantage in impressing other men.

Condoms Vs erections
While HIV prevention research has long demonstrated that negative attitudes towards condoms are associated with less use of them, there is much less in the research literature on why condoms may be held in low regard by some men, but not others. These interviews with men over forty show an age-related dimension. Many men report a declining ability to have and sustain an erection as they age, and they find that condoms exacerbate their inability.

There are nevertheless mitigating factors in changing erectile responses. Several men spoke of shifting their sexual practices toward more diffuse, body-centred sensuality, or more receptive sexuality, and away from a singular focus on orgasm. They did not consider this shift a problem of “erectile dysfunction” but rather a maturation, and even a qualitative improvement, in the experience of sexuality.

It's a whole body experience, less than a penis experience, and that's okay, but they [partners] are self-conscious because that's the norm, or what we understand from...wherever we get our information. If you don't have an erection, you're not having fun. And, yet, more and more people are like that. (44, West European)

Another remarked,

I'm basically a bottom, so for me if I don't get an erection it's not such a big thing. But, it's the way other people react to it, “Oh you aren't getting hard...” especially in the baths. (52, West European)

A focus group participant characterized it this way.

It seems to be very important to them [partners] that you have an erection while you're engaging in sexual activities because that seems to be the signal to them that you're turned on by them. We have to have a few little conversations about the fact that I'm having a wonderful time thank you very much. Don't worry about that.

For one man, Viagra had provided him with a range of sexual options:

I can be a top now, where I've been a top very little for five to ten years...Sometimes I wanted to be a top and haven't been able to cut it, and you get more stigma from that too because we're all supposed to be sex machines, and a lot of us turn into bottoms more and more because as we get older we have more problems with our sexual function. (51, West European)

Mortality and self-preservation
The inner narratives that are rehearsed and reworked in everyday life are infrequent subjects for research, and largely inaccessible to the standardized check-off lists typically employed in survey research, yet offer stark illumination into the ways in which risk may be assessed and acted on. It is, then, surprising how little HIV prevention programming rests on systematic exploration of sexual narratives. While an immense amount of research turns on the question of what kinds of people fail to practice safe sex (and then produces few answers to that question), HIV prevention programs must communicate in order to be effective. HIV prevention relies on the presumption that everyone always already wants to preserve themselves into the future, and that the expected future quality of life will be as good as, if not better, than it is now, and that because of these things, life-threatening disease will be avoided. The failure of this presumption among many street youth and injection drug users has hampered conventional HIV prevention messages, and it is a presumption that cannot always be taken for granted among lesbians and gay men. Depression and worthlessness may enter into situations of vulnerability to unsafe sex (and also into the adherence practices of HIV-positive people on medication (Adam, Maticka-Tyndale and Cohen In press)). Existential ruminations about the value and meaning of life and death figure into day-to-day decisions about preserving oneself. And effective communication must engage the inner stories that men tell themselves about the meanings and directions of their lives if they are to engage risk assessment and HIV vulnerability.

Lesbians and gay men grow up in societies that have long withheld admirable or, at least, viable examples of longevity among lesbians and gay men from the public eye. This absence in the larger society is scarcely remedied even inside gay and lesbian communities, where so much of its press and public presence remains youth-oriented. The public annihilation of favourable life trajectories generates a fear of the future and an inability to imagine oneself on a satisfying or valuable pathway into ageing. This structured absence impacts the young, and among men over forty, there is still little indication of an abatement of this fear of the future. They too cannot imagine themselves aging very much more. It is by this calculus, that risk-taking is assessed.

As I age I'm conscious of how much time is left in my life...I'm smoking again cause - you know what?- I only have 25-whatever years left, and hopefully it will take me that much time to get cancer, and I'll drink again where I wasn't drinking very often before. I'll drink more now because I'm thinking, yeah - you know what? - this body isn't going to last a long time, and actually this is the logic, foolish as it might be: I'm not here for a long time but I want to have a good time with what's left of my life, and I don't see a point. It's not about quantity, it's about quality, and I don't see a point of sitting at home, you know, isolating myself, so I can preserve this body, so that I can live to be 80, 'cause by the time I'm 80 nobody will want to be with me, and most of my friends will probably be dead anyway, and who knows what the world will be like?....I've even thought about HIV and I've thought, as horrible as HIV is, “If I am one of the lucky ones after contracting HIV that it takes 10 years to develop into an opportunistic infection, then that's already going to take me to 55. If there's some treatment available and I can maintain life for another ten years, now I'm at 65.” It's not 85, and it's not what I desire, but as I get closer to what I see as the end of my life it becomes less important to preserve my body. (44, West European)

Of course, not everyone indulges in this logic, but this respondent encountered it in others:
I have had one man tell me in, well this was in connection with using poppers, where he had reached an age where he was bound to die of something pretty soon. And I thought, “Well, you may well be right but that doesn't mean you're going to do anything to me while you're about it.” (68, English)

And again,

I mean I'm not looking forward to retirement. I won't have much to live on. I'll be alone. I may be alone. So, why not end it early, and have fun while you're doing it? I've thought that myself but I've never put it into practice. (49, West European)

These kinds of existential ruminations demonstrate the very limited foundations of the leading “knowledge-attitudes-behaviour” (KAB) model of human behaviour that makes up the orthodoxy of HIV research today. Based on a “rational man” conception of human action, the KAB model presumes that rationally processed information will lead to behaviour change, without engaging the autobiographical narratives and the social context in which this information processing is to occur (Adam, Sears and Schellenberg 2000). It may be that the social annihilation of gay men as they age is a significant factor in their mortality, and HIV is itself an “opportunistic” agent of a social mechanism.

Surrendering the self
Some men, especially those who explicitly acknowledged repeated instances of unsafe sex, articulate a “cooperative” and unassertive sexual strategy. In some instances, this is characterized as acting on a tacit presumption that if a prospective sexual partner does not indicate an interest in protected sex, then he “must be” HIV-positive himself. The discernment of this unspoken presumption involves some degree of “intuitive” or magical thinking, similar to the “sign-reading” strategies employed by men who seek to guess their partner's sero-status from their age, healthfulness, or manner. Since the surrender of the self may itself be part of the pleasure inherent in some forms of sexual experience (as in being seduced, in receptive sexuality, or self-abasement before a partner who symbolizes powerfulness and authority), this “going along” with unsafe sex may have complex roots. This mode of sexual interaction tacitly transfers responsibility for safety, and thus for infection, to the other, avoiding the implication that every act of unprotected sex requires a willful decision.

There is a 'code' in conversation, pre-sex, where if a man wants it raw he will indicate this. The assumption often is that both parties are HIV-positive....My assumption is- it's kind of the obverse of young guys who are asking, “Are you positive? - and that would be that if they want it raw, it's because they're positive....I mean, my policy is - now this is just me - You want it wrapped? You got it. If not, that's fine too.” I'm not trying to give anyone a difficult time, you know....What I'm doing is, I'm putting myself at risk and that other guy's putting himself at risk, and we're putting each other at risk, and we know that. We're both adults. We both know that we are putting ourselves at risk. (55, West European, HIV-positive)

Another respondent recounts an entirely different take on this kind of interaction.

I'm seeing guys in their 30's who want to practice unsafe sex and this leads me to think that they're infected and they don't care, and they don't care if they put other people at risk. They don't ask, they just try to have unsafe sex....‘AIDS assassins’ is what I call them, and I don't know why they are trying to fuck me without a condom when I'm saying, 'Use a condom.' And, two or three times, I've had people take the condom off when they thought I wasn't looking. (51, West European, HIV-negative)

One man, who recounts one incident of unsafe sex four years previously, asks, “Where was I?” as he recounts losing himself in the excitement of a particular encounter.

We weren't sure what it was, but we both kind of went 'Wow!' at the same time. He ended up coming back to my place. We had a glass of wine. We did smoke a joint, which to me is not very much. It kind of makes me feel a little mellow. I really wasn't what I call stoned. I really wasn't high. We were fooling around and we had this incredible session, and at one point I remember, I didn't know where I was and all of a sudden he was inside of me, and I just remember that moment, and I thought...I was so hard on myself, 'Where the hell was I? What was wrong?' And I'm not sure about that. I still question, 'How did that happen?' So, [I] stopped, stopped him. And realized that I wasn't unconscious or anything. It was kind of that place of bliss, you know, where one body feels connected; it almost felt like one body where you're not sure where your arm ends and his begins. (57, English)

CONCLUSIONS AND IMPLICATIONS
These interviews with gay men over forty raise serious questions about the effects of the larger social context on the health of gay men, and more specifically, about how community-building may be among the most effective things that can be done to advance HIV prevention. In HIV prevention work, this mechanism of exposure tends to be referred to, perhaps a little too glibly, as the problem of “self-esteem.” The self-esteem concept can be rather too comprehensive (Adam 1978) in that men who may have no lack of self-esteem “in general,” at work, at home, and most of the time, may nevertheless be susceptible to stress, episodic depression, or a situational sense of worthlessness that increases HIV vulnerability. Summing up this mechanism of exposure as the problem of self-esteem, or the problem of homophobia, tends to pose the prevention challenge so abstractly, that inaction is the inevitable follow up.

The challenge to HIV prevention work is to communicate sufficiently specific messages that stimulate recognition of situations of vulnerability that can be “guarded against,” without chasing urban myths in place of the discourses that gay men do employ to understand themselves. Effective HIV prevention and health improvement for gay men may mean some very concrete forms of community-building. HIV exposure cannot be divorced from the emotional needs, sense of isolation, and search for intimacy evident in the narratives of many of these men. Says one,

I wish there was a place where people like myself could go where it's not too loud, where I'll meet people like me, I mean my age. (49, West European)

Another muses:
So, you know, why don't we take care of each other? But, we don't do it that often. (55, West European)
Many of the participants in this study spoke of their sense of connection with gay “community,” their personal history of volunteering for community organizations, and their often unrealized hope that the gay community would be the social network and “family” that would support them in aging. It is only in re/building these social networks in the wake of the devastation already caused by AIDS that a culture of support can be brought about and a place that values older gay men can be constructed. With such a re/valuation, this aspiration might become real:

I would like to see more portrayals of hot, middle aged gay men. You don't see that many. You really have to look. (46, West European)

These interviews also suggest quite another practical measure that could effect safer sex decision making. If condom aversion is largely a fear of the loss of erection, then the more questions arise: Can condoms be manufactured in ways that improve sensitivity? By comparing men who have no problems with condoms, to those who do, is it possible to identify condom techniques that minimize loss of erection?

In the wake of this research, the AIDS Committee of Toronto held a series of 'Weekend Primers'. These one-time, Friday evening discussion groups for gay and bisexual men aged 40 and over received a significant response. Two men who attended these events, with the support of ACT, began facilitating six-week support groups for men dealing with issues of mid-life. They have run four such groups to date and plan at least two more in the future. Men who have attended these groups have begun developing informal social and support networks, mixing ex-group members and creating a larger social network of gay men in mid-life. Similarly, ACT sponsored a community forum in November 2001 at which over 80 gay men in mid- and later life came together to discuss their lives, and the need for a greater commitment to developing community for gay men as they age.

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