Guest Written by Bobby Box (@bybobbybox) is a freelance writer and editor whose work on sex and culture has been published in countless publications, including: Playboy, Elle, NewNowNext, Billboard, Daily Beast, Them., The Advocate, Women’s Health, Mel Magazine and AskMen.
Since the day I lost my v-card on a beach in Cuba (too much sand in crevices, do not recommend) to today, I’ve always been firm on using barrier methods during sex. I will have bareback sex on occasion, but I’m most comfortable doing so when I’m in a monogamous relationship. But not even that is foolproof.
The first man I dated was nearly 20 years my senior. I felt safe with him, as I was fresh out of the closet and he endured when society was far less forgiving of the LGBTQ+ community. So imagine my surprise when I tested positive for gonorrhea, not once, not twice, but three times just four months into our “monogamous” relationship.
It was the first time I’d contracted an STI, and it happened with the first man I ever had sex with––so I shamed myself into oblivion. By my third visit to the clinic, the doctor and I were practically friends, so she felt comfortable suggesting that my boyfriend may be cheating on me, and she was right.
Because he was on PrEP, he confessed he didn’t use a condom. Though my trust had been broken, I’ve had bareback sex since then. My rule was that I wouldn’t sleep with somebody unless we’d gone on a date first, where I’d inquire about their sexual health (if they’re regularly tested for STIs and HIV, if they’re using PrEP as prescribed, if they have an undetectable HIV status, if they’re using barrier methods, etc.). From there, I’d make a judgement call about the condom. I was on PrEP at the time.
PrEP (pre-exposure prophylaxis), for those unfamiliar, is a prescription medication people take to prevent contracting HIV from sex or injection drugs.
When taken as prescribed, PrEP reduces the risk of getting HIV from sex by about 99 percent and by at least 74 percent from injection drugs, according to the CDC.
Admittedly, there is much less information available regarding how effective PrEP is among injection drug users. In fact, there are many blind spots in PrEP research. For instance, the subjects are predominantly white men who have sex with men (MSM), a community who represents a small fraction of the population who could benefit from the medication.
Given its effectiveness, there’s been public health concerns that those on PrEP may stop using condoms, leading to an increase in other STIs, since PrEP only protects from HIV. As such, many public health guidelines advocate for use of PrEP and condoms, but since many people primarily use condoms to prevent HIV, research has shown there has been a decline in condom use. But the truth is, it depends on who you ask.
“From a bird’s-eye view, research on this topic has been a bit mixed,” Grant Roth, Atlanta-based sexual health educator and public health student, tells Lovers. “Studies have shown that PrEP users who are MSM may have higher incidences of STIs overall and perhaps an increase in STIs once starting PrEP. However, other studies showed that STI rates, while high, remained stable among PrEP users while they increased among non-PrEP users prior to starting PrEP. And another study demonstrated that widespread PrEP use among MSM could actually decrease STI levels.”
Despite this waffling research, Roth makes an important point, noting that people on PrEP generally get screened more frequently than those not on PrEP, meaning we may be diagnosing more asymptomatic infections that would’ve gone unnoticed otherwise, which may result in more positive results.
“In my opinion, PrEP use is incredibly valuable regardless of condom use practices,” Roth says.
“Some use PrEP concurrently with condoms and others use it instead of them. If someone wants to go on PrEP because they want to stop using condoms but are more worried about HIV than other STIs, then that’s their prerogative and their reasoning is totally valid.”
Roth believes that PrEP use, while a factor, cannot solely be attributed to one’s behavioral changes. “We should also consider the proliferation of hookup application usage (i.e., ease of casual sex) and the fact that condom use was declining even before PrEP,” he says.
Since I have a mostly queer following, I published a social poll on Twitter asking PrEP users if they use condoms. Of the 75 votes, 49 percent answered “sometimes,” 36 percent said “never” and 16 percent said “always”. Curious how one determines when or when not to use condoms on PrEP, I quizzed those who voted “sometimes” on their decision-making process.
“If a sexual partner asks me to wear a condom, I will,” Connor, 26, who rarely wears condoms, says. “They may not be on PrEP or they’re more concerned about STIs than I am.”
“It really depends on what the other guy wants,” Steven, 27, agrees. “Some guys want condoms no matter what and I'll always respect that. Others really don't like condoms at all. If you’re super adamant that you won't use them, I'm definitely less interested.”
Nate, 36, is in an open relationship and will wear a condom “most of the time” during a random sexual encounter. “If I am having sex with my partner, or with a regular fuck buddy who is also on PrEP, I won’t wear condoms,” he says. “If we’ve talked for a bit and the vibe is good, I feel OK about going bare,” says Patrick, 33.
“As a prep user I don’t use condoms anymore,” Andrew, 28, says.
“I actually can’t remember the last time I had sex with someone who wasn’t on PrEP, and we all seem to have pretty frank and direct conversations about our sexual health.”
Research more or less shows the same thing. In addition to finding that 80 percent of anal sex among PrEP users in Amsterdam was covered by PrEP alone while condoms and PrEP were used nearly one in five acts with casual partners, the research found that PrEP users chose not to wear condoms for a number of reasons, including the pleasure of condomless sex, the perceived curability of other STIs, condoms not being completely effective in terms of preventing STIs, and the difficulties of returning to condoms after getting used to condomless sex.
Whatever the reason, it’s important we do not shame or judge people for the decisions they make regarding their sexual health unless these decisions are not consensual or can potentially harm others.
While there may be an association between STI incidences and PrEP usage, no research is definitive that PrEP users increase their STI risk compared with non-users. For example, research published in The Lancet medical journal shows that MSM on PrEP had increased from one percent to 16 percent from 2013 to 2016. However, the number of those who aren’t on PrEP and have condomless anal intercourse with casual partners have remained the same, around 30 percent.
Judging by both the research available and the dozens of people I’ve spoken with, most will choose to have bareback sex after they’ve done some risk assessment, often by chatting on apps like Scruff and Grindr. They tend to know the risks they are taking when having condomless sex on PrEP and are prepared to deal with consequences should they arise. If they’re uncertain, they will wear a condom.
While there are concerns that this behavior could lead to concerning antibiotic-resistant STIs––most notably, “super-gonorrhea.” Gonorrhea, in particular, has already developed resistance to a number of medications we used to use to treat it and there is an ongoing worry that it will develop resistance to what we currently use, if it hasn’t already. However, studies are being done on new classes of drugs to treat gonorrhea and even a vaccine that would reduce your risk of ever contracting it.
“In the United States, there have not been any detected cases of gonorrhea resistant to every treatment option available. Nonetheless, no matter where you live, it is a legitimate concern,” Roth says, adding that some people will speak about it in ways that are purposely meant to scare people and/or use militaristic language. “We know that fear does not work to promote public health and you can’t scare people into using condoms. So there is a balance that has to happen with getting factual information out there without fear-mongering, and that is where proper STI and HIV risk reduction counseling can come in.”