How to Have Sex in an Epidemic: One Approach is a 1983 manual by Richard Berkowitz and Michael Callen, under the direction of Joseph Sonnabend, to advise men who have sex with men (MSM) about how to avoid contracting the infecting agent which causes AIDS. It was among the first publications to recommend the use of condoms to prevent the transmission of STDs in men having sex with men, and has even been named, along with Play Fair!, as one of the foundational publications in the advent of modern safe sex.Trickett, Edison J., and Willo Pequegnat. Community Interventions and AIDS, Oxford University Press, 2005, p. 60. . Retrieved 13 December 2017.
Background Authors The booklet was co-written by Michael Callen and Richard Berkowitz, with scientific advisement from Dr. Sonnabend.Callen, Michael, and Richard Berkowitz. How to Have Sex in an Epidemic, News from the Front Publications, 1983. Retrieved 13 December 2017. Callen's partner Richard Dworkin was the editor.France, David. How to Survive a Plague: The Inside Story of How Citizens and Science Tamed AIDS, Knopf Doubleday Publishing Group, 2015. . Retrieved 13 December 2017. Both Callen and Berkowitz had been diagnosed with AIDS when they wrote the booklet and had a thorough knowledge of the sexual culture of gay and bisexual men in New York City. Sonnabend describes the symbiotic relationship between the three as one in which he contributed medical and scientific information while Callen added the more political points and Berkowitz, who had educated himself with Sonnabend's scientific archives for the sake of his own treatment, synthesized the two.Sonnabend, Joseph. "The First Safe Sex Guidelines Proposing The Use Of Condoms For AIDS Prevention," POZ Blog. http://aidsperspective.net/articles/Callen-Berk_collaboration4.pdf . Retrieved 13 December 2017.Berkowitz, Richard. Staying Alive: The Invention of Safe Sex, Basic Books, 2003. . Retrieved 13 December 2017.
HIV/AIDS epidemic
In May 1983, when How to Have Sex in an Epidemic was published, the AIDS epidemic in New York City has only recently begun and panic about the unknown causes, means of transmission and potential for treatment for AIDS was spreading rapidly. The misconception that there was something inherent in the lifestyle of all gay men that put them at risk for infection was common at the time and led to the development of a stigma surrounding both the disease and gay sex. Doctor Sonnabend wrote that "it may be impossible for those who did not directly experience the uncertainty and terror of the early years of AIDS to appreciate the circumstances under which these guidelines [for safe sex] were constructed."
At the time when How to Have Sex in an Epidemic was written, there was no consensus on the cause of AIDS, but two main theories existed: the "new agent theory," which was increasingly the scientific consensus, and the "multifactorial theory," which Callen, Berkowitz and Sonnabend adopted as their basis for sexual education around AIDS transmission prevention. The new agent theory proposed that AIDS was caused by a single, previously unknown pathogen, likely a retrovirus similar to the Human T-lymphotropic virus (HTLV). According to the multifactorial theory, however, continual overexposure to semen, specifically cytomegalovirus (CMV) in semen, lead to an eventual state of immunosuppression that characterized AIDS. This was based on prior scientific studies that revealed the role that CMV can play in causing cellular immune-related abnormalities.Holmberg, Scott D.. Scientific Errors and Controversies in the U.S. HIV/AIDS Epidemic. How They Slowed Advances and Were Resolved Praeger: December 2007. First Edition. https://books.google.com/books?id=nf-xokXdGegC&q=cmv+causing+cellular+abnormalities+1980s+causing+aids.&pg=PA21 Retrieved 13 December 2017. The multifactorial theory espoused in the manual has since been disproven; the majority of scientists are now in agreement that AIDS is caused by the transmission of the retrovirus HIV.
As a result of the lack of agreement on AIDS cause and transmission, it was difficult to determine the risk of various forms of sexual contact. Berkowitz, in the introduction to his autobiography, describes how, in the early years of the epidemic, risk categorizations were rewritten every few months: "anal sex with a condom became an endless back and forth dance, from high risk to medium risk to low risk to possibly safe." It was this confusion that prompted the authors to create a safe sex manual that clearly outlined for men having sex with men the dangers of each type of contact and various methods to protect oneself from exposure.
LGBT culture and politics
After the Sexual Revolution and the Gay Liberation in the 1960s and '70s, sex in urban gay epicenters was not only newly acceptable, but also often seen as key to gay identity and resistance to heteronormativity. AIDS brought up a renewed fear about negative media coverage and the civil rights violations that LGBT people might face from targeted quarantines and a denial of basic healthcare services. As such, the issue of safe sex was a contentious one, and any arguments criticizing frequent sex were poorly received by the majority of the community. A large sector of LGBT community leadership worried that raising awareness about AIDS and gay sex would be off-putting to the straight majority and damage the image of the subculture as a whole.Escoffier, Jeffrey (1998–99). "The Invention of Safer Sex: Vernacular Knowledge, Gay Politics and HIV Prevention." Berkeley Journal of Sociology: 43, 1–30. . Retrieved 13 December 2017. Activists still deeply entrenched in the battle to protect the political gains of the past decade tended to overlook the AIDS crisis as a political attack, a topic too controversial to address, or an overreaction by self-hating gay men.Sonnabend, Joseph. "A doctor in the trenches." AIDS Perspective. http://aidsperspective.net/articles/adoctorinthetrenches.pdf . Retrieved 13 December 2017.Duberman, Martin. Hold Tight Gently: Michael Callen, Essex Hemphill, and the Battlefield of AIDS, The New Press, 2015. . Retrieved 13 December 2017.
The authors of How to Have Sex in an Epidemic were aware of the political risks they took in creating the booklet: Berkowitz noted in his autobiography the possibility that their writing could be used as ammunition by homophobic institutions and leaders. However, their advocacy was motivated by the increasingly critical state of the health crisis and their shared belief in what Callen described as the danger of "put[ting] political considerations over the tragedy of even a single gay man's death."
Before the AIDS epidemic, condoms were mostly advertised and used for preventing pregnancies and therefore were not considered a viable safe sex or STD prevention tool among the LGBT community: David France estimates that less than 1% of men who have sex with men in New York City used them regularly in the 1970s, despite the fact that many other sexually transmitted diseases, including cytomegalovirus and hepatitis B, were already at "endemic" levels. Sonnabend writes about condoms at the time: "I think most gay men said, 'Oh thank god, that's one thing we don't have to worry about,'" and many didn't know how to use one.Baumann, Jason. "A Prophecy Before Our Time: The Gay Men's Health Project Clinic Opens in 1972, Part Two: A Wasted Opportunity" New York Public Library. December 20, 2013. https://www.nypl.org/blog/2013/12/20/mens-health-project-clinic-opens-wasted-opportunity. Retrieved 14 December 2017. However, as Callen, Berkowitz and Sonnabend would show them, condoms really were something to worry about and could be an easy way to prevent disease and death while continuing to have a normal and fulfilling sex life.
Along with Play Fair!, its San Francisco counterpart written by a drag group called the Sisters of Perpetual Indulgence, How to Have Sex in an Epidemic was the first sex-positive manual for safe sex—in other words, it did not present sex in a negative, shameful or moralistic light. Sonnabend writes in the introduction to the booklet that one of their goals was to "explore the many different forms of sexual expression open to gay men." As David France later recounted, the authors actively tried to avoid condescension or arrogance in their writing (despite the fact that Callen himself had acknowledged that telling people how to have sex is inherently an arrogant thing to do), instead attempting to establish a dialogue, "queen to queen," between themselves and the people for whom they created the manual. Callen even educated himself about different philosophers, including Hannah Arendt, to get an idea of the best way to productively use writing to influence people through rhetoric and written arguments. The independent and community-driven nature of this approach to LGBT-related safe sex, according to Cindy Patton, can be traced back to the "self-help model" promoted in the women's health movement.Gould, Deborah B. Moving Politics: Emotion and ACT UP's Fight against AIDS, University of Chicago Press, December 15, 2009. . Retrieved 13 December 2017.
Content
The primary message of How to Have Sex in an Epidemic is 1) to use protection (i.e., condoms) during sex and 2) to limit the specific sex acts one performs to those with a lower risk of contagion. It was a model that attempted to challenge traditional anti-promiscuity and anti-gay viewpoints in previous safe sex education and AIDS prevention—as Callen and Berkowitz argued, it's what you do, not how often you do it or who you do it with. In other words, they had searched for, and come up with, what they termed the possibility of "life-affirming sex."
The categories below contain summaries of the chapters of How to Have Sex in an Epidemic and the arguments presented therein:
What causes AIDS? The authors introduce the two presiding theories of AIDS transmission and present their arguments for the multifactorial model. They describe the role of CMV in causing abnormalities in immune cells, as well as the potential for gradual immune overload by semen and harmful immune complexes resulting from the binding of antibodies to antigens on other STDs. This section presents evidence against the "new agent theory" but acknowledges that in either case, AIDS is likely sexually transmitted and therefore the best method of prevention will be the use of protection and more critical choice in which sexual acts to perform.
CMV in connection with AIDS In this section, Callen and Berkowitz elaborate on the multifactorial model to provide a basis for later applications of safe sex practices. They cite the New England Journal of Medicine study that found that traces of CMV were found in 94% of MSM in a New York City cohort in 1981, but later estimate that CMV was present in ¼ of sexually active gay men in 1982–83, which, when factoring in the average frequency and diversity of partners in the population of sexually active gay men in New York City, would still amount to a high number of exposures per year. The reasoning behind their support of the multifactorial theory was the concurrent epidemics of AIDS and CMV in the same sexual networks and locations; they called it the "one common link found in all gay men with AIDS." They summarize the characteristics of CMV and its links to AIDS as the following: Cytomegalovirus itself is a type of herpesvirus that is present in bodily fluids. It remains in the body for more than a year after the immune system has fought off its initial effects. It often manifests again in people with severely compromised immune systems (i.e., those with AIDS). It was also found in some KS tumors of people with AIDS, and can activate the Epstein Barr virus, causing lymphoma and lymphadenopathy (both common symptoms of AIDS).