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Promiscuous Gay Nerd: Is It Time to Abandon Serosorting?

, by Jake Sobo

Editor’s note: We are excited to launch this new monthly column on 21st-century gay men’s sexual health by self-proclaimed “promiscuous gay nerd” Jake Sobo. You may know Jake from his outstanding previous column, “My Life on PrEP.” He brings the same mix of personal experience and science smarts to BETA with this new series.

When I moved to San Francisco for graduate school in the mid-2000s, I was a young, bright-eyed twink fresh to the big city from a quaint college town back East. At the time, I was an aspirational “100% condom user” (key word: aspirational). There weren’t yet really any other options for guys like me who liked to have a lot of sex but wanted to stay HIV negative. We were told, ad nauseam, to rubber up or expect to test positive. All condoms, all the time.

Back East where I grew up, there was a certain expectation that guys you met would at least feign a desire to use condoms (a community norm, if you will). While most of the time I did use condoms as a wee whore-child, it was okay to slip up from time to time as long as you felt really, really bad about it afterwards: “Oh gosh, we really should have used a condom. Sorry!”

It quickly became clear that this norm was a thing of the past in the Gay Bay. I would invite guys over, we’d start making out, and suddenly they were trying to stick it in me without a condom and without a question.  Naive and blonde as I was, I was routinely surprised by their presumptiveness: Where were they getting this notion? Did I just look like a slut who liked it raw? Well…maybe. But I surely didn’t identify as a “barebacker” and my profiles all explicitly said “safer sex only.” So what gives?

I soon figured out that I needn’t look any further than my own online profile to find the culprit. Without thinking much about it, I casually noted in most of my profiles that I was “neg 4 neg.” At the time, the idea of having sex with an HIV-positive person seemed anathema. My education in HIV prevention was underwhelming—talking openly about getting fucked was barely an option, much less getting fucked by a poz guy. My casual use of neg4neg wasn’t informed by science—just plain old stigma, fear, and misinformation.

It turns out that a bottom describing himself as “neg for neg” in San Francisco was a tacit code for “fuck me raw.” Guys were showing up at my door looking to breed me because—unbeknownst to me—I had given them the green light in my profile.

HIV prevention researchers ended up zeroing in on this practice and labeling it “serosorting.” Despite the fact that they were basically describing the same people and the same practices as the researchers studying “barebacking” (a fact brilliantly evidenced by Kane Race; no really—read that paper ASAP), the concept was nonetheless radical at the time because it seemed like a strategy for preventing HIV without relying solely on condoms.  Barebackers, it turns out, weren’t just reckless, depressed crazies rushing to get infected; under the rubric of “serosorting,” they were rational, harm reduction–practicing, good gay citizens trying to prevent transmission.

On the surface, the concept is rather simple. Instead of using a condom every time, couldn’t you just decide to have sex only with guys of the same HIV status? Poz guys fuck poz guys. Neg guys fuck neg guys. Boom! HIV prevention.

In my first column here at BETA blog, I thought I would kick things off with a discussion of what is now a canonical concept in prevention. We’re all talking about it, and yet sometimes I get the sense we (myself included) don’t have the foggiest idea of what we’re talking about. But beyond just making sure we’re all on the same page, I’m questioning whether the concept might just be outdated. In an era of pre-exposure prophylaxis, treatment as prevention, and undetectable viral loads, does it make sense to talk about serosorting anymore?

When the term “serosorting” was coined in the mid-2000s, it felt like a dose of relief in an age of shaming and blaming in HIV prevention. Because of all the whore-baiting that had gone on in the barebacking wars (which are still, sadly, being waged), it almost felt like a political statement to talk about serosorting.

Despite serosorting’s radical promise, two things happened that gave me pause. First, I moved to the frozen tundra in some flyover state for more grad school. I was whisked away from a gay whore’s paradise where HIV testing rates were high and HIV stigma was relatively low, to the polar opposite. Suddenly, asking a guy if and when he was tested last was about as reliable as shaking a Magic 8 Ball: “Reply hazy try again.”  Not to mention the fact that I live in a state where they love to imprison HIV-positive people whose only crime is not disclosing. HIV-positive guys are treated like lepers where I live; it makes any expectation of disclosure completely unrealistic. In short, it’s the perfect climate for serosorting to fail miserably.

Second, I became a “Truvada Whore” and started pre-exposure prophylaxis (PrEP)—basically, a pill a day to help prevent HIV. I wrote a 19-part series about “My Life on PrEP,” so I won’t rehash here. But needless to say, my experiences with PrEP made me think long and hard about the clinical science of HIV prevention today. Part of what motivated me to start PrEP was the sense that serosorting where I live was basically destined for failure.

It’s clear that the world of prevention is changing. Consider, for a moment, the underlying assumption of serosorting: that, for negative guys, choosing to have condomless sex with other negative guys is less risky than having condomless sex with poz guys. In an era of treatment as prevention, at some point doesn’t that assumption become untenable? Especially in cities with low testing rates and high levels of HIV stigma? Serosorting only works when you can rely on an HIV-negative status to be accurate. In my experience, that reliability varies from city to city, and is likely a function of HIV stigma.

Obviously, this gets into sticky terrain that I will admit is still being sorted. But there is some evidence to back these claims up—modeling studies suggest that many (if not most) HIV infections are the result of having sex with someone who thought they were HIV negative. More pointedly, I can’t help but notice that most of the research on serosorting has been based in cities that fit the model: San Francisco, Seattle, Sydney, etc. (for a nice review of the literature and the development of the concept of “serosorting,” see the background section of this paper). Hello, selection bias! If you only look to see if something works in places where the conditions for it to work exist, call me crazy, but I have a sneaking suspicion you’ll find that it works. It should raise red flags for anyone thinking about applying the concept in different social contexts. It doesn’t mean that it doesn’t work, but it does mean that we should pretend like there are big red brackets around the evidence.

Finally, I can’t help but reflect back on my own experience with serosorting. My decision to only have sex with HIV-negative guys wasn’t part of some rational, well-thought-out HIV prevention strategy. It was a decision that was primarily informed by stigma and fear. After all, I was “neg 4 neg” and using condoms most of the time! You just can’t justify that based on HIV science.

In all fairness to researchers, a quick glance at the studies being pumped out suggests that they have already abandoned the term “serosorting” in favor of a broader concept of “seroadaptation” (the French have been arguing for this for years now). This is basically a fancy way of saying serosorting plus a few other things, namely “strategic positioning” (neg guys choosing to top when they have sex with poz partners, for example) and, perhaps, differentiation based on viral loads or strains.

But once we’ve diluted the concept to such a watery, slippery substance, don’t we just end up with something like “gay men making decisions about sex based on a variety of things including HIV”? Isn’t that just HIV prevention in action? It’s unclear to me what value the concept of “serosorting” has moving forward, and I hope in the comments here we can engage in a discussion about that question. What value do you find in the concept, if any? What better ways can we devise to talk about gay men’s harm reduction strategies for HIV prevention? As always, leave a note below or send me an email at mylifeonprep@gmail.com.

Jake Sobo is a pen name used for anonymity. Jake has worked in the world of HIV prevention for nearly a decade. He previously published a 19-part series documenting his experiences on pre-exposure prophylaxis (PrEP), “My Life on PrEP,” for Positive Frontiers magazine, which was picked up by Manhunt, translated into French, and widely read in the HIV prevention world. He has spent the better part of his adult life having as much sex as possible while trying to avoid contracting HIV. 

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12 Responses to Promiscuous Gay Nerd: Is It Time to Abandon Serosorting?

  1. Guys thinking they are negative….wishing, hoping, hedging their bets. Anything but actually having to know for sure. All because with a test, they might –suddenly–become one of THEM…one of the guys they have been rejecting and stigmatizing with a joie de vivre rooted in a self-righteous approach to prevention. Over the long years testing at the baths, I came to realize that it was this HIV stigma we enforce on ourselves as gay men that kept most from taking a quick test. Not fears for their health. Not even a fear of dying. Only the worst fear: becoming one of the guys that they personally have treated poorly, rejected, dismissed, snickered at. It’s shameful, and ripe with karmic repercussions for every last one of us. keep on keepin’ on, Mr. Sobo….. xo xo, m

  2. Evan says:

    I have been struggling with this question for myself over the last few weeks. I basically completely stopped using condoms after I realized using them 30% of the time wasn’t really doing any risk prevention. Truvada gave me nasty side effects so that doesn’t work. I have always been a “neg 4 neg” guy until I realized that I am going to get HIV from someone who is poz but thinks they are neg, not a healthy, poz undetectable man.

    I am at a point where I want to serosort on the other end, where I feel safer having bareback sex with somebody who is poz undetectable over somebody who thinks they are neg.

  3. Gus Cairns says:

    Serosorting does help, up to a point – see http://www.aidsmap.com/page/2287223/ – and I’ve reluctant to discourage ANY behaviour that contributes to at least containing HIV infections.
    Part of the problem is language. ‘Serosorting’ can mean anything from rigidly observed negotiated safety agreements to the loosest of cross-your-fingers-and-hope ‘seroguessing’. See http://www.aidsmap.com/page/2079364/.
    So: good piece, bad title.

  4. Jake Sobo says:

    Thanks, Gus, as always, for your comment. But you seem to have missed the point. I don’t doubt that it might be effective — but my point was that it may be only effective in certain, highly bracketed social contexts. So the point is that it’s really not a “behavior” to discourage or encourage — but a practice that is embedded within a social context. So if I say “serosorting” is partially effective based on data from San Francisco, that may lead someone in Detroit to think it will be similarly partially effective in Detroit. But I argue here that this interpretation would be wrong. In Detroit, I wager that it would be a colossal failure.

    • Gus Cairns says:

      ‘Faliure’ meaning what, exactly? If you mean ‘failing to reduce HIV infections’ then yes, almost certainly. If you meaning ‘stopping enough infections to prevent HIV incidence getting any worse than it already is’, then some evidence suggests it’s one of the factors that helps to do that, admittedly to a greater or lesser diegree in different places. I don’t think we should be *promoting* serosorting as such – that happens already – but we should be encouraging, where possible, things like disclosure and help to do it that m,ake it possible. Evidence from places like Bangkok shows how HIV can rocket up in a place where there isn’t any culture of disclosure.
      Serosorting – in its strict meanings of restricting condomless sex, or any sex, to partners with the same HIV status – is not the only prevention measure gay men attempt to do which hasn’t formed part of the ‘orthodox’ suite of options usually promoted by prevention campaigns. The Manunt survey 18 months ago found, for instance, that while gay men like cum and think it’s hot, they actually in the main avoided cumming in their partner/not letting them cum in them – a strategy only promoted sporadically. And a lot were ‘seropositioning’ too. Both strategies were actually more consistent than 100% condom use. In themselves, doing those things consistently, if you can, and if you had reliable info about partners’ status, would actually make a considerable difference to your individual risk of HIV. But even taking into account all the problems you rightly cite about gay men’s inaccurate knowledge of their partners’ status, they are probably serving to contain HIV in many populations to some degree.
      The only HIV prevention options I think we should actually be ‘abandoning’ or actively discouraging are ones that are demonstrably counter-productive: abstinence-only programs, fear-based campaigns, criminalising IDUs being examples.

  5. Jim Pickett says:

    I prefer the term “seroadaptation” which engages more than just the HIV status of sex partners and looks at behaviors. Depending on status, known or questioned, you can do/not do certain things that would reduce your risk of HIV exposure (e.g. not bottoming, not cumming inside). Serosorting is fraught, at least for 2 guys who believe they are negative, and sounds a lot like sero apartheid.

  6. Here’s what I’ve said previously in a discussion about my decision to start PrEP:

    I started serosorting, but not in the conventional sense. More and more, I’ve been dividing guys up into 3 categories.

    1. The first category is small. With HIV-negative guys I know and completely trust, we arrive at a form of negotiated safety—if we have been tested for HIV and all STIs recently, and not yet had sex with others, we usually have condomless sex.
    2. The second category has been steadily growing—positive guys. We have discussions about treatment, viral load, STIs and decide how to proceed from there. Sometimes without condoms.
    3. The third category is basically everyone else—HIV unknown or undisclosed, and HIV-negative men I don’t know well. I consider guys from this third category as potentially being in the acute infection phase, whether they know it or not. This is the category of men with whom I am most adamant about condom use. All too often, their prevention strategy is dubious at best (e.g., “r u clean? how big r u? wanna bb?”). If I see another highly stigmatizing “disease free”/”no poz” message on an online profile, meant to be some kind of stand-alone, ill-informed HIV prevention strategy, I might reach through the screen and cyber-throttle someone.

    So gradually, I’ve found myself feeling much less worried about having condomless sex with a positive guy after a conversation with him about treatment and viral load and STIs than about having condomless sex with a guy who says he is negative, but could be in the acute infection phase with sky-high viral load without even knowing it.

    Paranoia? Rational, effective, evidence-based risk-reduction strategy? Both? You be the judge.”

    • Jake Sobo says:

      I totally feel you, Marc! I feel similarly about dividing guys up into such categories. Definitely a mix of rationality and gut judgement :) That’s the name of the game!