Promiscuous Gay Nerd: Is It Time to Abandon Serosorting?

May 16, 2013, by Jake Sobo

Editor’s note: We are excited to launch this new monthly column on 21^st-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.