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‘Bareback’ – definitions and identity1
Constructs’ limitation for HIV-prevention research
Alex Carballo-Diéguez, Ana Ventuneac, José Bauermeister, Gary W. Dowsett, Curtis Dolezal, Robert H. Remien, Iván C. Balán and Matthew S. Rowe
The term ‘bareback’ appeared in the gay press in the mid-1990s referring to intentional condomless anal intercourse, mainly among HIV-infected gay men (Gendin 1997). However, by the time Silverstein and Picano published The Joy of Gay Sex (2003), bareback was defined simply as condomless gay sex. Researchers who saw the need to operationalise the term chose ‘intentional condomless anal intercourse in HIV-risk contexts’ (Carballo-Diéguez and Bauermeister 2004; Suarez and Miller 2001), noting two key elements – intention and risk – that might distinguish the term from other less precise definitions. Others defined it as: ‘intentional anal sex without a condom with someone other than a primary partner’ (Mansergh et al. 2002); ‘intentionally seeking or engaging in unprotected anal sex among HIV-positive gay men’ (Elford et al. 2007); ‘intentional unprotected anal intercourse regardless of serostatus or partner type’ (Halkitis et al. 2003, Tomso 2004); or any ‘sex that occurs without the protection provided by a condom’, not limited to gay men (Gauthier and Forsyth 1999).
Lacking a standard definition of, and consensus on, the role that intentionality of condomless sex and HIV-transmission risk (or lack of it) play in bareback sex, some researchers went back to the sources, i.e. asking gay men what bareback sex means. Brief surveys, sometimes no longer than five minutes, were administered online or to community samples asking respondents to define bareback sex or presenting scenarios with degrees of intentionality (Halkitis 2007; Huebner et al. 2006). Yet respondents were not asked to describe their understanding of the term, and the HIV status of protagonists was not included. As a result, proportions of respondents endorsing different definitions vary widely. Given this definitional imprecision, there is difficulty in comparing findings and developing evidence-based prevention responses.
Researchers have also tackled a related topic: bareback identity (Halkitis et al. 2005; Wolitski 2005). Based on the idea of a distinct bareback identity, studies have compared individuals who identify as barebackers with those who do not (Halkitis et al. 2005; Halkitis 2007). However, the operationalisation of the term ‘barebacker’ as identity is also not clear in the literature. Our Frontiers in Prevention study was designed to explore the perspective of men who report engaging in bareback sex on the meaning of bareback sex, which words besides ‘bareback’ are used to name the practice and whether respondents identify as barebackers. Furthermore, we sought to redefine the term within a conceptual model that could orient future work.
In the first phase of the work, we identified the six most popular free internet sites used by men in New York City to meet other men interested in barebacking (see Carballo-Diéguez et al. 2006; Dowsett et al. 2008). Next, between April 2005 and March 2006, we recruited adult men who self-identified as a barebacker or as someone who practises barebacking (‘Are you into bareback, or do you consider yourself a barebacker?’); had had intentional, condomless, anal intercourse with a man met over the internet; and use at least one of the internet sites identified in the first phase of the study. Men were recruited exclusively through these internet sites in approximately equal numbers of European Americans (EA), African Americans (AA), Latinos/Hispanics (LH) and Asian/Pacific Islanders (API). We also stratified the sample to include about two-thirds who reported both being HIV negative and having had unprotected receptive anal intercourse in the previous year. Qualifying individuals were invited to attend face-to-face interviews conducted by one of three psychologists on the research team. (For more details on recruitment, methods and data analysis, see Carballo-Diéguez et al. 2009.) The interviews lasted about two hours, and respondents were compensated with US$50 for their time.
Participants were 120 men, of whom 31 reported being HIV infected. Their average age was 34 with HIV-infected men being, on average, seven years older and earning about US$10,000 less per year than uninfected men. Respondents had, on average, two years of college education. Thirty-five per cent were European American, 31 per cent Latino/Hispanic, 28 per cent African American and 17 per cent Asian/Pacific Islander. Most of the respondents self-identified as gay. The men had had, on average, between 13 and 14 sexual partners in the previous two months, and they practised unprotected anal intercourse frequently.
Defining bareback
Lack of condom use
I: If I were to ask you for a dictionary definition of bareback sex, what would you say?
R: Sex without condoms.
I: Is there anything else in the definition or just that?
R: Just that.
(Mark, male, EA, HIV+, 43 years)
Lack of condom use was often the first and the only element mentioned. Sometimes, this was referred to as ‘flesh on flesh’ or ‘latex-free’ sex. Some defined it without reference to any type of sex and encompassing both heterosexual and homosexual acts:
R: In the sexual context, this means, um, just not using a condom, and having intercourse, whether anal, vaginal or, or oral. Not using a condom.
(Darryl, male, AA, HIV-, 33 years)
At other times, definitions were restricted to anal intercourse without condoms and to sex among men only, for which some respondents considered that intrarectal ejaculation should also be included in the definition:
R: A person who not only gets – has sex without using a condom but who also lets a guy come inside his anus or whatever you want to call it … That’s what the true barebacker [is] in my book.
(Sergio, male, LH, HIV-, 24 years)
Last, respondents sometimes noted the words ‘natural’ and ‘intimate’ as key to their definition:
R: [sighs] Dictionary definition of bareback sex. Hmm. Wow. [laughter] Uh, the nitty gritty, the ultimate feeling of intimacy between two people … The way sex was meant to be … I consider it being truly intimate with somebody. There’s no barriers … It feels so much better than a condom.
(Bernard, male, AA, HIV-, 25 years)
Intentionality
A few individuals spontaneously included intention not to use condoms as a required element of the definition:
R: I would say, the deliberate-less, the deliberate condom-less act of sexual intercourse, especially anal, um, what would you say? With the intent of enhanced pleasure.
(Wayne, male, EA, HIV+, 32 years)
However, most respondents did not mention intention. Therefore, we asked: ‘If two guys are having sex with condoms and the condom breaks, would you call that barebacking?’ About one-third of the respondents rejected this and, instead, introduced into the definition intention to have condomless sex or lack of intention to protect (not necessarily the same thing). This was referred to, for example, as ‘prior agreement not to use condoms’, or ‘knowledge’ or ‘awareness that no condoms were used’. About one-third of respondents, however, qualified the ‘condom breakage’ scenario:
R: No, that’s – no. Not if they don’t realise it or they’re, you know, I think if they realise it breaks and they choose to go without, then yeah, then it is barebacking.
(Daniel, male, EA, HIV+, 45 years)
Therefore, the intentionality was brought into the definition by the failure to stop having intercourse at the point of becoming aware that the condom broke. This nuance was not, however, without its reservations:
R: Technically, I guess, briefly, unless they don’t pull out or if they continue, then yeah. But barebacking is usually a conscious choice. But I understand that is kind of complicating the situation. But if the condom breaks, then no, I don’t think so, because I think that barebacking isn’t by accident. It’s a conscious choice, unless the person’s fucked up and doesn’t know what you’re doing.
(Paul, male, EA, HIV-, 31 years)
Awareness of risk
Some respondents volunteered that bareback sex was risky:
R: Um. [pause] Condomless, unprotected sex, with knowing, with the knowledge that you could be having sex with men who have sexually transmitted diseases, or who don’t know their HIV status or who are HIV positive.
(José Luis, male, LH, HIV-, 25 years)
To explore the issue of risk further, we asked: ‘If two people are HIV negative and monogamous, and they decided that they’re going to have sex without condoms, would you call that bareback or not?’ Many respondents said they would consider this bareback sex. Other respondents stated that condomless sex between an uninfected monogamous couple should not be considered bareback sex:
R: That’s not bareback … [I: ‘Why not?’] It’s not because these two guys are in a relationship. They’re in a monogamous relationship. They love each other. They’re both HIV negative. They know their status. They’ve – it’s natural, I mean, for the gay world … But it’s just natural for them to have sex without a condom, if they know neither one has HIV or has an STD or whatever, and they’re not sleeping around on each other.
(Albert, male, AA, HIV-, 41 years)
In other words, were it not for HIV and AIDS, condomless sex would not only be the norm among gay men, it would not even be considered an issue.
Some ethnic minority respondents said that bareback was a term used by ‘white folks’, whereas:
R: Oh, black guys, you know, mostly just say ‘raw’, you know, or ‘skin-to-skin’ [laughs].
(Courtney, male, AA, HIV-, 29 years)
There were richer metaphors too:
R: ‘Raw dog’, ‘raw sex’, um, ‘I wanna flood your hole’, um, a lot of fusion of hip-hop language, you know, applied to, to the sexual terms, um … ‘I’m going to give you nutt’, as opposed to, um, ‘I’m going to give you my load’. So, what ‘cum’ meant – well, rather, ‘cum’ and ‘load’ is analogous to ‘nutt’, n-u-t-t, for Black and Latino men. The word ‘nasty’ is used, you know.
(José Luis, male, LH, HIV-, 25 years)
Other words or phrases used were ‘uninhibited’, ‘natural’, ‘pig’, ‘unwrapped’, ‘uncovered’, ‘unprotected’, ‘raunchy’ and ‘down and dirty’. A few respondents used the word ‘freak’. One Latino respondent even used crudo, the literal translation of ‘raw’ in Spanish.
‘Seeding’ and ‘breeding’ were terms that appeared to denote ejaculation:
I: What other words do you use for barebacking?
R: ‘Raw’. And ‘bareback’. They’re the only two now. I mean, you see guys using euphemisms, but they usually refer to transmission of HIV. ‘Breed me’, ‘seed me’, give me the ‘taint’. So they really go beyond that definition. Anything beyond ‘raw’ and ‘bareback’, it means fucking bareback with someone you know to be HIV positive.
(Peter, male, EA, HIV-, 53 years)
This is an important distinction. ‘Bug chasing’ and ‘gift giving’ are terms related to bareback sex that have caused much media fervour. These terms did not arise spontaneously in the interviews, and when probed, many respondents did not know about them and simply inferred their meaning:
R: Bug chasers! Ah, yes. Those poor, deluded people who romanticise getting HIV.
(Fernando, male, LH, HIV+, 35 years)
Bareback identity
When we asked respondents if they considered themselves barebackers, most replies focused on condomless sexual practices. Based on that, men responded either affirmatively or negatively or qualified how the term would apply to them. A few respondents queried whether having condomless sex sufficed to define someone as being one thing or another.
About one-third of the respondents labelled themselves as barebackers – more often HIV-positive men:
I: Do you think of yourself as a barebacker?
R: Yes.
I: Is that an identity?
R: That’s an identity. That’s the truth. The truth … is the light. So I’m a barebacker, baby. And I ain’t going to sugar-coat [it] – I’m a barebacker [singing], I’m a barebacker! [laughter] […] I feel … it, it, it gives me a sense of empowerment, so to speak. I feel good about [that] shit. Yeah, I like the ass, I like to fuck, and I like to get fucked. You know, and I like to be explicit. And I can get to the exact nature of what I’m about, so it empowers me. Barebacker, huh? You know, that is that term.
(Ricky, male, AA, HIV+, 38 years)
About one-quarter of respondents rejected labelling themselves as barebackers. At times, this was related to the stigma associated with the behaviour, particularly for HIV-negative men:
I: What keeps you from considering yourself that?
R: I guess just the stigma attached to it. The stigma and – I’m not going to have bareback sex with every guy I meet. That’s why I don’t consider myself a barebacker.
(Philip, male, API, HIV-, 26 years)
Others said they did not consider themselves barebackers because they ‘did try to use condoms’ or it was not ‘the biggest part of my sexual experience’ or because labelling oneself as such would make others think, ‘Oh, sure, he’s a barebacker, so he’ll accept my dick inside him’.
A few respondents said that the label applied to them only partially or sometimes. Some contradicted themselves in trying to explain why:
I: Do you consider yourself a barebacker?
R: Sixty percent of the times, yes, I do […] I do … my best to practise safe sex, but once, you know, I meet a certain person or – it’s like – it’s like something that will go off in me that I’ll be, like wow, I would just love to feel him inside, you know? Or I would just love to run up in them and – stuff like that.
(D’Angelo, male, AA, HIV-, 29 years)
One uninfected Latino young man reasoned that he was only 40 per cent a barebacker because that was the proportion of times he had condomless sex with strangers, whereas the other 60 per cent of the time he did it with people he knew.
Discussion
Our methodology for this part of our study relied exclusively on qualitative interviews so as to gain a deeper understanding of the phenomenon of barebacking without imposing preconceived notions. Since we specifically recruited men who identified as barebacker or someone who practises barebacking, and furthermore, someone who had had intentional, condomless, anal intercourse with a man or men met over the internet, we expected some consensus in their accounts. Instead, responses varied widely, including among ethnic minority men.
We did not define ‘bareback’ for respondents, but they were in broad agreement that bareback refers to intercourse without condoms. This would seem to support investigators who reported that the colloquial term originally used mainly for HIV-infected individuals may have lost its early specificity (Halkitis 2007). However, generalisation has not occurred; we found much variation among respondents in the interpretation of everything beyond this initial phrasing. Our findings reveal pitfalls in considering bareback as a simple reference to condomless sex and to question the validity of some research undertaken thus far.
Moreover, the reification of barebacker from one who practises a behaviour to one who has a specific identity has exacerbated the confusion. Our respondents eloquently argued for and against the barebacker label. For some, identifying as barebacker might be interpreted as defiance of mores that restrict sexual freedom, but it is doubtful that it functions as the organising principle for a sexual identity. For others, the label was an uncomfortable one that they either rejected outwardly or accepted partially with different rationalisations to explain their views. There was evidence that stigma associated with intentionally having unprotected anal sex affected HIV-negative men in different ways from HIV-positive men.
Yet, it is more complex than that. In fact, there was no single definition embraced by all men, and assertions from researchers or practitioners that there is a prevailing community-held consensus on what bareback means are not supported by these men, the very ones practising bareback sex regularly enough to anticipate consensus. Neither was there evidence of an overwhelming uptake or positioning of barebacker as a dominant or functional identity. These findings pose challenges for research and HIV prevention.
First, we focus on research implications. Researchers are not simply reflecting larger confusion existing among gay men or in gay community discourse; researchers have played a part in creating this confusion. As Junge (2002) argues, noting Farmer’s (1996) call for a critical epistemology of emerging infectious disease:
Farmer (1996) has focused particularly on how publication of AIDS research in peer-reviewed scholarly journals provides a site of discursive production wherein choices in lexical representation may reinforce stigmatising or essentialising conceptualizations of certain populations.
(Junge 2002: 196)
Researchers, in arguing for a certain take on barebacking, bolstered by certain data, are involved in a discursive practise that exercises constructive power over the phenomenon – no research merely ‘reports’. As Tomso (2004) argues:
[B]ug chasing and barebacking exist as phenomena [emphasis in the original] largely because of what Foucault would call the constitutive, disciplinary operation of scientific, activist, and popular discourses about them. This is to say that those who are currently investigating and writing about these phenomena, as much so if not more than the men whose sexual lives are the subjects of these investigations, are epistemologically accountable for the emergence of bug chasing and barebacking as social ‘problems’.
(Tomso 2004: 88–9)
Second, we must note the interaction between researchers and our findings, with those responsible for designing and delivering HIV prevention. For researchers are not the only ones responsible; other social actors are involved too – activists, advocates, educators, commentators, the media and anyone else who proclaims on the issue. Within this interaction, the men who bareback lose their voice and the right to constitute bareback as it pertains to their lives. This can lead, inter alia, to a barebacker becoming a stigmatised ‘other’, an outcome that conceals rather than reveals the nature of the phenomenon and related prevention complexities.
Supporting evidence-based prevention is a central purpose of this project – called ‘Frontiers in Prevention’. We believe the idea of bareback needs to be reconceptualised to focus public health discourse and inform its practice. However, Huebner et al. (2006) warn:
Studies that fail to define barebacking for participants might be inquiring about any number of behaviours, depending on each participant’s individual understanding of the term. Additionally, even studies that do define the expression might encounter problems among participants who understand barebacking differently and ignore researcher definitions when responding. Even if participants can be compelled to suspend their own understanding of the term and to report about barebacking as defined by researchers, the external validity of such research is questionable given that definitions are constructed in the study that might not exist in the real world.
(Huebner et al. 2006: 70)
Yet, if no attempt is made to clarify this definition of barebacking, then confusion will continue, research incomparability will grow and evidence-based prevention will be even less possible.
Therefore, we propose an operationalisation of terms graphically presented in Figure 22.1. We distinguish condomless anal intercourse that is intentional from that which is unintentional, as well as those acts that carry risk for primary infection from those that do not. We think it useful to distinguish intentional condomless intercourse in HIV risk contexts (our preferred definition of bareback, quadrant I) from other condomless sex that may involve risk of primary infection but is accidental, unintentional or non-consensual (quadrant II), and from condomless sex that is risk free, whether intentional or not, such as between monogamous seronegative individuals or those non-monogamous couples who practise ‘negotiated safety’ (Kippax et al. 1993) (quadrants III and IV). We think that a specific focus is offered by quadrant I, which includes condomless anal intercourse that is intentional and may result in primary transmission of HIV, whether it is called ‘barebacking’ or not, and whether its practitioners identify as ‘barebackers’ or not. This category includes ‘strategic positioning’ (whether the infected partner takes the receptive role with a partner of the opposite status) irrespective of intrarectal ejaculation, which may further qualify the risk. The issue of awareness of appreciable risk is central to this category – the risk calculus is done and condomless sex proceeds anyway.
The usefulness of this typology lies in its capacity to focus attention where the epidemiological importance lies. By definition, behaviours in quadrants III and IV carry no epidemiological importance from the perspective of primary HIV transmission. HIV prevention education is still needed in these cases – mistakes can be made, judgement can be poor – but it needs a different kind of education. This includes strategies that stimulate correct and consistent condom use as well as strategies for dispensing with condoms in certain situations and after clear precautions,
Figure 22.1 Bareback deconstruction.
e.g. sequential HIV testing, negotiated safety, serosorting and HIV-seroconcordant monogamy.
Quadrant II includes a well-known cluster of prevention problems that HIV prevention researchers and educators have uncovered and grappled with as the epidemic progressed and which have enhanced epidemiological importance. Adam (2005) details some of the behaviours to be included in this category but not in the bareback group:
[B]arebacking is distinguishable from the wider range of unplanned, episodic, unprotected sexual encounters that men in interviews attribute to a variety of circumstances such as: a resolution to erectile difficulties experienced with condoms, through momentary lapses and trade-offs, out of personal turmoil and depression, or as a by-product of strategies of disclosure and intuiting safety.
(Adam 2005: 334)
There is increased risk of primary infection here, but the risks arise from a very different set of circumstances from the other categories and warrant their own prevention agenda, e.g. post-exposure prophylaxis.
This leaves quadrant I as a clear – although not entirely new – target in which the condomless anal intercourse with appreciable risk that may result in new infection is intentional. This is the category we call ‘bareback’, and we believe the use of that term should be restricted to this category, first by researchers and subsequently by practitioners. It is this specificity that will lead to targeted prevention responses, ones that may not always be condom focused, such as risk reduction (Suarez and Miller 2001), strategic positioning (Kippax and Race 2003), microbicide use when it becomes available (Carballo-Diéguez et al. 2007), pre-exposure prophylaxis (Nodin et al. 2008) or others.
Barker et al. (2007) argue that there is a ‘non-equivalence’ between barebacking and unprotected anal intercourse in HIV epidemiology. Furthermore, it behoves researchers not to muddy the waters for both research and for the development of targeted HIV prevention or related health promotion with imprecise or inapplicable usage of the term ‘bareback’ for all sex acts in all four categories.
Our typology acknowledges that some gay men regard all condomless anal intercourse as bareback; others say not all condomless intercourse is bareback; and there are those who use the term merely as shorthand. Nonetheless, our typology prevents the confounding of prevention education targeting in deploying any overarching notion of barebacking that cannot offer sufficient specificity. It recognises that while all who call themselves barebackers practise barebacking, not all who engage in barebacking call themselves barebackers. Most importantly, our typology maintains a focus on contextualised sexual behaviour by focusing on the many kinds of ‘relational nexus’ (Riggs 2006) that are negotiated by men in sex (sometimes correctly, sometimes incorrectly in terms of HIV), rather than reifying risk as a single characteristic of individual personalities or psyches. After all, as Junge (2002) points out, a couple having condomless sex may include one partner who does it intentionally and another who is unaware of the situation or is responding to pressure. It is the sexual relations between people and how these influence behaviour – rather than the terms adopted or identity – which may, or may not, facilitate primary HIV infection. Such sexual events may be understood as belonging in different categories at the same time and so require different approaches to prevention.
There is heuristic value in focusing scientific inquiry on bareback internet sites, on sex clubs that sponsor bareback events or offer bareback rooms, and on serosorting networks that facilitate condomless intercourse. However, in developing evidence-based prevention focused on the terms ‘barebacking’ or ‘barebackers’, the target of these efforts would be less than specific and quite dispersed unless the definition is restricted as our typology suggests. Moreover, if norms concerning condom use relax, e.g. with the increased effectiveness of highly active antiretroviral therapies, and as the use and meaning of the term is unevenly distributed, the word ‘bareback’ may fade from being useful in understanding what is driving the epidemic in the USA – and maybe elsewhere. Until that happens, the focused usage we suggest may reduce the current confusion.
Our study has some limitations. It focused on a moving target – the use of a vernacular term – but one that is also discursively constructed in research. Our conclusions are likely to be time bound by where the debate is to date and should be considered with caution. The use of qualitative methods precludes generalisations to all gay men. Our findings may also be affected by sample specificity and may not reflect what is currently happening outside the USA or among all men who engage in intentional condomless sex in risk contexts. Clearly, there is more to discover about the contribution of serostatus and ethnicity and of ‘bug chasing’ and ‘gift giving’, but space limitations have prevented us from exploring that here.
Nevertheless, our findings emphasise the importance for researchers, as a start, to define and operationalise the terms we use carefully to reduce confusion. This is important if the evidence offered by researchers is to help prevention workers develop programmes where bareback sex may be implicated.
Note
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