Condoms, PrEP & TasP? Oh my!

The meaning of “safety practices” on gay hook-up apps

In late 2015, the gay hook-up… uh, I mean “dating,” app Scruff changed its “safety practices” drop-down menu to allow users to choose more than one option. Previous “safety practices” menus allowed users to select only one of: condoms, PrEP, or Treatment as Prevention (aka “TasP”). Now, users can select more than one practice or to leave this field blank altogether.

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“Guys next door” grid of Scruff. Image courtesy of Scruff.

The change followed intense lobbying by the app’s users and HIV-prevention specialists. It was immediately lauded for promoting HIV-status disclosure, reducing HIV stigma, and bringing the app more into line with the current “prevention landscape.”

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Scruff’s “safety practices” drop-down menu. Image courtesy of Scruff.

Predictably, Scruff’s change sparked a good deal of debate — on its Facebook page and other digital spaces where the app’s users — mostly bisexual and gay men — congregate.

That debate revealed disagreement about the meaning of “safety practices” and the limits of apps (like Scruff) for promoting gay men’s sexual health.

For those living under a rock (in a cave, in Clueless-stan...) since 2012, PrEP (acronym for Pre-Exposure Prophylaxis) is a relatively recent HIV-prevention strategy that involves taking HIV treatment drugs before exposure to the virus to prevent HIV transmission. In this sense, PrEP is analogous to the birth control pill, a prescription drug taken before sex to prevent pregnancy.

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Truvada (made by Gilead) the only drug approved for use as PrEP in the U.S. Photo © 2018, Michael J. Murphy

(The biochemistry is complicated but, basically, with a PrEP drug already in your system, HIV can’t set up shop, replicate, and overwhelm your immune system making you vulnerable to diseases that ultimately end in death.)

Currently, the only drug approved for use as PrEP in the U.S. is Truvada, but generics are available overseas and other HIV-treatment drugs are in trials to see if they can also work as PrEP.

When taken daily, Truvada for PrEP has been shown to reduce the risk of HIV transmission by up to 99% in gay/bi men and transgender women. For more information check out What is PrEP? and for alternative dosing regimens (like on-demand and intermittent PrEP) check out I Want PrEP Now. The Facebook group PrEP Facts: Rethinking HIV Prevention & Sex is a great resource, with a large, global membership.

Treatment as Prevention (“TasP”) is a recent HIV-prevention concept that views successful HIV treatment as a form of HIV prevention. HIV-treatment drugs are now capable of reducing the amount of virus in an HIV-positive person’s blood to nearly undetectable levels, making it virtually impossible for them to transmit the virus to sexual partners.

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Statement by U.K. medical journal The Lancet on “U=U”

TasP has given rise to the meme “U=U” (“Undetectable = Untransmittable”) meaning: if an HIV-positive person has an undetectable viral load, they can’t transmit the virus. A large and growing number of public health agencies, AIDS service organizations, HIV/AIDS activists, and medical researchers endorse the efficacy of TasP and validity of U=U.

Condoms are those pesky little wrappers you wear on your willy before you take it swimming. Or, you should be wearing, right? RIGHT?! To save us both further embarrassment, please watch this video:

Sexy YouTube video for how to put on a male/external condom

Condoms were actively taken up by gay men as an HIV-prevention tool starting in the mid-1980s but they’re not 100% effective (against pregnancy or STIs) and most gay men (if they’re honest) only ever use them irregularly — depending on their (and their partner’s) HIV status, sexual position (top/ bottom, oral, etc.), and partner type (main or casual).

Now, condoms are recommended as a front-line defense against HIV, but also to PrEP-sters and TasP-ers to help protect against STIs other than HIV (like syphilis, gonorrhea, chlamydia, HPV, herpes, etc.)

To sum up, PrEP is a sexual-health strategy used by HIV-negative guys to protect themselves against HIV transmission, whereas TasP is one used by HIV-positive guys to protect their sexual partners. Condoms are recommended for use instead of, or in addition to, these strategies: to prevent HIV and other STIs. Thus, PrEP and TasP are mutually-exclusive strategies, to which condoms may or may not be added.

Or, so you would think…

“Mannequin Love” Photo by Lode Van de Velde/CC0 Public Domain license

Much of the discussion surrounding Scruff’s change to its “safety practices” menu revolved around the exact meaning of the choices offered. And it’s clear from that discussion that the app’s users disagree on this point.

Do options in the “safety practices” menu describe the profile owner’s own safety practices? Those he requires from partners? Or, those he supports as legitimate sexual health strategies? In other words, if a user selects the “condoms” option in the menu, does that mean he uses condoms for sex, expects partners to use them, or that he views condoms as a legitimate safety practice?

Some argued that, since the profile was created by the user (and most of the other fields involve user self-description: age, height, weight, etc.), the “safety practices” field referred to the user’s sexual health strategies. In other words, if the profile listed “condoms” under “safety practices” that meant the guy pictured in the profile used condoms during sex to reduce STI risks.

But that view reflects a pretty limited understanding of the term “safety practices.”

Photo by Kevin Grieve on Unsplash

In partnered sexual activity, “safety practices” are collective not individual. They’re behaviors partners do together to increase or decrease risk of pregnancy, STIs, and physical and emotional harm. Which safety practices, when and by whom, are often the subject of communication and negotiation. Even those undertaken alone, like starting PrEP or HIV treatment, affect our sexual partners — whether they know it or not.

And, even if we are unaware of our partner’s safety practices — because we’re not comfortable talking about sex or we make unwarranted assumptions about their sexual health — willful ignorance is still a safety practice — just not a very effective one. (OK, its more “risky practice” than “safety practice,” but you get my point!) And it’s one we practice together with sexual partners, who allow our ignorance to go uncorrected.

Because, even in 2018, sex is still something people do together.

This understanding of the term “safety practices” as collective was implied by those who argued that Scruff’s options indicated the kinds of choices a user was willing to rely upon when practiced by partners. In other words, selecting Scruff’s “condoms” or “PrEP” choices wasn’t necessarily a statement about a profile owner’s own safety practices, so much as it was an assertion of his confidence in his partners’ use of condoms or PrEP.

Presumably, his choices also signaled his criteria for partner selection and expectations of partners. Such a user was stating he was open to guys who used condoms, were on PrEP, and/or were HIV-positive (but had an undetectable amount of virus) because those practices also protected him. In effect, then, his partner’s sexual health strategies were also his own.

It is this latter sense that the potential conflict between selecting both PrEP and TasP as Scruff “safety practices” disappears. As an individual practice, they are irreconcilable: PrEP usage implies a guy is HIV-negative; TasP relates to guys who are HIV-positive. But when viewed as a statement of confidence in these practices by one’s sexual partners, selecting both options on Scruff’s “safety practices” menu makes perfect sense.

Choosing “condoms” (as a statement of confidence in the “safety practices” of others) seems relatively straightforward. If your partners use condoms, it’s less likely they will transmit an STI to you. Ticking the “condoms” option on Scruff says, “I have confidence in another guy’s use of condoms to protect me from HIV and other STIs.”

But there’s a world of assumptions behind relying on another Scruff user’s indication that PrEP and TasP are among his “safety practices.”

“On-demand” PrEP dosing (not approved in U.S.) Graphic courtesy www.i-Base.info

There are several known dosing regimens for PrEP drugs. All recommend a full screening for STIs prior to starting PrEP, and quarterly or biannual testing for STIs (including HIV) and undergoing any necessary treatment. It does not seem reasonable to assume that those following “intermittent” or “on-demand” options, or those acquiring PrEP drugs directly from a mail-order pharmacy (unlike in a physician-controlled setting), will always adhere to these protocols.

Asserting confidence in a sexual partner’s use of PrEP as a personal “safety practice” also entails confidence in his knowledge of, and adherence to, a PrEP regimen— all of it, not just popping a little blue pill. Asking to see a guy’s bottle of pills or recent STI test results is no guarantee of adherence to a PrEP regimen.

TasP is more straightforward: if a guy living with HIV is virally-suppressed for at least 6 months (aka “durably undetectable”) and continues to take his HIV treatment meds, there is negligible chance of him transmitting HIV to his partners. Plus, those living with HIV and in treatment are likely to have a greater knowledge of sexual health practices and their own sexual health — due to their regular engagement with the healthcare system. However, there are now media reports of the challenges of treatment adherence when living with HIV long term due to stigma, depression and fatigue.

Moreover, given the recency of the concepts of PrEP, TasP, and U=U, it’s not at all clear that some Scruff users understand what these terms mean…

Ultimately, reliance on a Scruff guy’s assertion that his “safety practices” include PrEP and/or TasP requires confidence in the veracity of user profiles on online dating apps.

Hot dog (with a few extra “Scruff inches”). Photo by Annie Spratt/Unsplash

Prior experiences with exaggerated or misleading stats— ok, some were outright lies — about height, weight, and genital size, and the use of old/doctored profile photos, can cast a shadow of doubt over other parts of a guy’s profile, like his “safety practices.” Especially when those don’t square with other information in his profile (such as the date of his last STI test…)

Like it or not, seasoned app users now approach profiles, and their owners, with a skeptical eye…

Understandably then, debate about the various meanings of Scruff’s “safety practices” quickly devolved to assertions that the only reliable “safety practices” were those a guy, himself, could control — using condoms, starting PrEP, fewer partners, sero-sorting, less risky sexual positions/activities, etc.

Sadly, this was a turn away from collectivist thinking about the motivations and value of sexual health practices, as something that could not only benefit oneself, but also one’s partners and one’s community.

Gay men’s sexual health messaging loves clarity and simplicity: Wear Your Rubbers! Get Tested, Get Treated! U=U! But what the discussions around Scruff’s evolution demonstrates is there’s no consensus among gay men about the meaning of “safety practices” — as used by Scruff or otherwise.

To be blunt, that’s partly a function of ignorance. PrEP, TasP, and U=U are very recent developments and there’s a lot of confusion and misinformation about what they mean. Anyone even remotely involved in sex education, sexual health outreach, or HIV/AIDS-prevention work is aware of the ongoing challenge of communicating accurate information, to those who need it most, in a form they will understand. Not everyone is comfortable talking about sex, shares a common vocabulary about sexual anatomy, or understands the basics of epidemiology.

Being at risk for HIV or other STIs does not mean you’re well-educated, well-informed, or free from shame or moralizing about sex.

Party hats! Photo by Bru-n0/CC0 license. Image courtesy Pixabay.

Moreover, men who have sex with men have been constructing highly personal sexual safety strategies in the wake of HIV/AIDS since before we knew how the virus was transmitted and how to prevent it. Some of these strategies were based on sound science; some were not.

‘Bumper sticker’ sexual-health messaging targeting gay men has never reflected the real world complexity of our safety philosophies or sexual practices. Creative interpretations of terms like “safety practices” on a gay hook-up app really should come as no surprise.

The debate about Scruff’s changes also suggests some of the limits and challenges of using hook-up apps for sex education and HIV prevention.

In Scruff’s defense, the platform does provide free advertising via its “Benevolads” program that connects users to sexual health information and services. And it’s also not the only such app that has attempted to provide a means for users to communicate their “safety practices.”

Although these apps meet high-risk populations “where they are,” their options and language about sexual health and “safety practices” are open to user interpretation. Hopefully, this ambiguity leads to more-detailed discussions between users about personal sexual health practices (via internal chat features or after meeting face-to-face).

But ambiguity would seem at odds with users’ oft-expressed desire for clarity and certainty about prospective sexual partners (hence all the frustration with duplicitous pics and stats). Perhaps those are unreasonable expectations of a gay hook-up app. Or any other means of locating sexual partners.

And that’s because sex always involves risk: sometimes physical, sometimes emotional. It’s not risk free. (And, for some of us, that’s part of what makes sex sexy.)

Perhaps we just need to be more honest about that fact.

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Michael J. Murphy, PhD, is Associate Professor of Gender & Sexuality Studies at the University of Illinois Springfield. He is the author of many book chapters, and encyclopedia and journal articles. Most recently, he edited Living Out Loud: An Introduction to LGBTQ History, Society, and Culture (New York: Routledge, 2019). He tweets @emjaymurphee.

Professional homosexual. Professor. Writer. Scholar. Activist. Husband.

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