Monday, December 18, 2006

Blast from the Past: Bringing Back Community Involvement and Positive Messages in Safer-Sex Interventions among Gay Men - Gadi Niram


The advent of the HIV epidemic among gay men in the 1980s led to strong efforts among gay men to combat HIV infection through the practice of safer sex. These efforts were tremendously successful, and infection rates “dropped precipitously” from the mid 1980s through the early 1990s. (Hammond, 2000). However, as the first generation of men living in the era of HIV have gotten older, the rates of infection among men who have sex with men have climbed, roughly tripling from 4822 new cases in 1993 to 14,819 new cases in 2005. (Centers for Disease Control, 1983-2005).

As the rates of infection have risen, the formerly positive (normative-reeducative) approach taken by those seeking to promote safer sexual practices among gay men has also undergone a drastic change. Early messages were positive in their tone. They recognized men’s need for sexual contact, showed condom use as a pleasurable activity, and addressed the target audience peer-to-peer and man-to-man. Unfortunately, these successful early approaches have largely been abandoned. While recent research has suggested that either a “shocking” (power-coercive) approach (Dahl et al., 2003) or a “rational and direct” (rational-empirical) approach (Marchand & Filiatrault, 2002) would be most effective, this paper will argue, using samples of both early and recent safer-sex messages, that given the fact that such rational or negative ads have predominated during a concomitant rise in HIV infection rates, it is time to consider a return to the earlier strategy of positively-framed HIV prevention messages, delivered from within the target community.

The Role of Human Needs

The early, normative-reeducative safer-sex messages demonstrated a clear understanding of Abraham Maslow’s hierarchy of human needs. Maslow recognized sex itself as a basic human need (Maslow, 1943), a recognition reflected in the early advertisements reviewed below. In these early campaigns, sex is portrayed as pleasurable with and because of—not despite—the use of condoms. “Love and affection, as well as their possible expression in sexuality” warned Maslow, “are generally looked upon with ambivalence and are customarily hedged about with many restrictions and inhibitions.” (Maslow, 1943) The early safer-sex ads recognize Maslow’s observations, and show the sexual needs of the target audience as something inherent to their being, and not as an aberrant behavior to be indulged in only under prescribed circumstances.

The early safer-sex ads also incorporate Maslow’s recognition of higher-order human needs, such as acceptance and self esteem. (Maslow, 1943) They treat the targeted men with respect, and as valued, competent adults. In contrast, the more recent ads reviewed adopt a scolding, coercive tone, fail to support men’s self-esteem as human beings with human needs, and treat them as fundamentally incompetent and in need of supervision in order to care for themselves.

The Power of Positive Messages

Safer-sex messages to gay men in the late 1980s and early 1990s came largely from gay community organizations, and not from public health organizations or practitioners from outside the gay world. The messages represented an in-group perspective, rather than making an appeal from authority. Further, they portrayed—even promoted—sex as a normal, expected behavior among the target audience, and highlighted the pleasure that could be had while still protecting oneself against infection. A 1984 poster shows a naked pair of interracial gay sex partners alongside the caption, “YOU CAN HAVE FUN (and be safe, too)” (San Francisco AIDS Foundation, 1984). A 1990 poster took the message a step further, shifting safer sex from merely being an activity to being a part of a person’s identity. Showing an attractive, shirtless man, the 1990 poster’s caption read, “BE A RUBBERMAN—USE A CONDOM EVERY TIME” (San Francisco AIDS Foundation, 1990). The message: someone who always uses condoms can be sexually desirable, and if you want to be with this “rubberman” you might consider being a rubberman, too.

A 1990 poster, part of a campaign called “red hot + blue”, says it directly: “safe sex is hot sex” (King Cole Inc., 1990). Two naked men are shown in what is clearly a pleasurable embrace. Slogans, including the above, frame the photograph. “USE A CONDOM EVERY TIME”, says the caption, certainly a realistic goal when the result is potentially the pleasurable encounter depicted. (Interestingly, the poster’s Spanish caption translates to “TAKE CARE OF YOURSELF, USE CONDOMS!” with no mention of using them every time. The comparison of English- and Spanish-language messages is beyond the scope of this paper.)

Fear and negativity

The early safer-sex posters carried simple, direct messages that relied on positive images of sex. The posters’ messages used images of the pleasure that could be had in a safer sexual encounter to promote condom use as an inherent component of sexual pleasure rather than as a condition to be fulfilled in order to make the sexual act acceptable. Compare to these earlier messages three more-recent advertisements aimed at preventing the spread of HIV in gay men. A 2001 poster (San Francisco AIDS Foundation, 2001) portrays an unsafe sex act between two men who, from the perspective of preventing HIV transmission, have already failed. In the accompanying caption, each man makes assumptions about the other’s HIV status, based on what he knows about the other man from earlier social encounters, the negative partner assuming he is not at risk of contracting HIV and the positive partner assuming he is not at risk of newly infecting someone. The campaign avoids completely the topic of condom use for protection and instead pleads with its audience to discuss HIV status with their partners before engaging in what it assumes will be unprotected sex. The campaign would appear to have given up, or at least considerably lowered its definition for success among its target audience. This weary advertisement not only promotes risky behavior, but it also subtly promotes the idea that past failure is permanent failure, obviating the need to further concern oneself with matters of health during sex.

A 2003 poster from an Irish organization has the familiar photograph of attractive men, but a radically different tone to its text (Southern Gay Men's Health Project (Ireland), 2003). It adopts the power-coercive tone of a scolding mother whose words carry an implicit assumption of failure: “If you want to be HIV positive”, the caption begins, “you can”:
  1. Fuck without a condom
  2. Assume everyone you have sex with is HIV negative
  3. Assume it will never happen to you

“HIV infections,” it concludes, “are on the increase in young gay men.” The message is both fatalistic and discouraging, almost daring the target audience to violate its tenets. While this and the previous message are from gay or largely-gay organizations, they fail to adopt the in-group perspective of the earlier safer-sex campaigns.

The State of New York, in a 2005 campaign, also denies its target audience a sense of potential safety. “Age won’t protect you from AIDS” says the poster showing a well-dressed older man sitting in front of his birthday cake (New York State Department of Health, 2005). After the poster presents some alarming statistics, there comes this warning: “HIV prevention is a lifelong job.” The individual is told by a judgmental outsider that he has a job to do, with potentially lethal consequences should he fail.

The Limits of Fear

Given the respective changes in HIV infection rates during the reign of each approach, the normative-re-educative safer sex strategy used in the late 1980s and early 1990s would appear to be more effective than the currently recommended rational-empirical and power-coercive strategies used to communicate the benefits of a safer-sex and condom use. Focusing on the positive, communicating from within the target group, and designing messages to resonate primally rather than cognitively may allow future safer-sex campaigns to achieve the success of their predecessors.

Social psychologist Stephen J. Blumberg notes that:

increasing fear and anxiety [in HIV prevention messages] can have unintended consequences. The self-protective behaviors that are stimulated by fear may be fashioned to reduce directly the anxiety itself rather than the risk of contracting the disease (Blumberg, 2000).

Blumberg cites Morris and Swann, who demonstrated that when shown a fear-based HIV-prevention film,

sexually active college students (but not abstainers) reported reduced perceptions of risk for HIV infection, reduced interest in additional information about AIDS, reduced desire to be a peer AIDS educator, and reduced memory for AIDS-relevant information from the film. (Morris & Swann, 1996)

Morris and Swann’s experiment shows that if a fear-based message does not provide a realistic method of countering the risk it presents, the likelihood of these counterproductive behaviors increases (Devos-Comby & Salovey, 2002). Some HIV-prevention messages, including the aforementioned State of New York message targeting older men, fail to present any method of countering risk, or present only the option of abstinence (Ibid). Abstinence is an outstanding method of avoiding sexually-transmitted disease risk, including the risk of HIV, but abstinence is an expression of an existing value, induced by deep personal beliefs (Holman & Harding, 1996). For those people who do not hold abstinent values, an abstinent approach ignores Maslow’s characterization of sex as a basic human need, either physiologically or as an expression of love and affection. (Maslow, 1943) An advertisement or brief film is unlikely to induce sexually abstinent values in a sexually-active target audience, and a fear-based abstinence argument may have an effect opposite of what is desired. The weaknesses of today’s fear-based appeals are compounded by the fact that they very often originate or appear to originate from an authority figure or group external to the target of the prevention appeal.

The Appeal of Community

Community-based appeals have proven effective not only in the early HIV prevention campaigns, but also in communicating other public health messages. When disseminating information about a toxic chemical hazard, community members, including

unofficial local opinion leaders, the media (local and national), and networks of relatives and neighbors […] may have as much credibility with the public as official messengers. In fact, they often enjoy greater credibility (Fessenden-Raden et al., 1987).

A 1999 community-based project to increase mammography among African-American women discovered that when mammography was introduced essentially as a community value through the women’s churches, the participants “significantly increased…their practice of breast self-examination and mammography…compared with the women in the control [group] (Irwin et al., 1999).” The personal experiences of breast cancer survivors, presented to church members after worship as a regular church activity, helped dispel doubts the women had about the ability to cure cancer, and led them in greater numbers to seek medical approaches to dealing with cancer risk (Ibid).

Similarly, the message that gay men should use a condom every time they have sex can be effective (as it was in the past), but not when presented as a judgement by an authority figure external to the target population or as a goal that becomes useless after even a single failure to comply. Instead, as was done in early anti-HIV campaigns, condom use should be presented as an exciting, erotic option, suggested by a member of one’s desired or potential sex-partner pool.


In the late 1980’s and early 1990’s the gay sexual icon of the day was the ACT-UP kid. Clad in jeans, a t-shirt with a safer-sex message, and often sporting a necklace of freedom rings, a set of rainbow-colored rings that symbolized gay pride, these young gay disciples of the AIDS Coalition to Unleash Power conveyed a simple message: They were attractive, and they were potential sexual partners, but they would not engage in sex without the use of a condom.

The late 80s to early 90s was a period of remarkable success for safer-sex messages, as measured by decreasing HIV infection rates; indeed for the ACT-UP kids, the message crossed over from a health message to an essential component of their identity and even their fashion choices. Today, when HIV infection rates are rising, and safer-sex messages are failing to resonate with their target audiences and induce them toward safer sexual behavior, it is essential to reexamine the early period of anti-HIV campaigns and draw lessons on how to repeat that success today.

Among homosexually active men, HIV is perceived as less of a threat than it once was because therapies have improved, men communicate less with their partners about the risks involved in their sexual congresses, and community norms have shifted such that unsafe sex is no longer unacceptable (Morin et al., 2003). Shifting the public health message back to a sex-positive, community-based approach that makes safer sex once again a communal value is an important step in reversing the increase in new HIV infections. As author Douglas Crimp opines,

…AIDS will not be prevented by psychic damage to teenagers caused by ads on TV. It will only be stopped by respecting and celebrating their pleasure in sex by telling them exactly what they need and want to know in order to maintain that pleasure (Crimp, 1987).

Works Cited

Blumberg, S. J. (2000). Guarding against threatening HIV prevention messages: An information-processing model. Health Education and Behavior, 27(6), 780-795.

Centers for Disease Control. (1983-2005). HIV/AIDS surveillance reports.

Crimp, D. (1987). How to have promiscuity in an epidemic. October, 43(AIDS: Cultural Analysis/Cultural Activism), 237-271.

Dahl, D. W., Frankenberger, K. D., & Machanda, R. V. (2003). Does it pay to shock? Reactions to shocking and nonshocking advertising content among university students. Journal of Advertising Research(September 2003), 268-280.

Devos-Comby, L., & Salovey, P. (2002). Applying persuasion strategies to alter HIV-relevant thoughts and behavior. Review of General Psychology, 6(3), 287-304.

Fessenden-Raden, J., Fitchen, J. M., & Heath, J. S. (1987). Providing risk information in communities: Factors influencing what is heard and accepted. Science, Technology, & Human Valued, 12(3 & 4), 94-101.

Hammond, T. (2000). U.S. AIDS cases, deaths, and HIV infections appear stable: Center for the Advancement of Health.

Holman, T. B., & Harding, J. R. (1996). The teaching of nonmarital sexual abstinence and members' sexual attitudes and behaviors: The case of latter-day saints. Review of Religious Research, 38(1), 51-60.

Irwin, D. O., Spatz, T. S., Stotts, R. C., & Hollenberg, J. A. (1999). Increasing mammography practice by african american women. Cancer Practice, 7(2), 78-85.

King Cole Inc. (1990). Safe sex is hot sex.

Marchand, J., & Filiatrault, P. (2002). AIDS prevention advertising: Different message strategies for different communication objectives. International Journal of Nonprofit and Voluntary Sector Marketing, 7(3), 271-287.

Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50(4), 370-396.

Morin, S. F., Vernon, K., Harcourt, J. J., Steward, W. T., Volk, J., Riess, T. H., et al. (2003). Why HIV infections have increased among men who have sex with men and what to do about it: Findings from california focus groups. AIDS and Behavior, 7(4), 353-362.

Morris, K. A., & Swann, W. B., Jr. (1996). Denial and the AIDS crisis: On wishing away the threat of AIDS. In S. Oskamp & S. Thompson (Eds.), Safer sex in the 90's understanding and preventing HIV risk behavior. New York: Sage.

New York State Department of Health. (2005). Age won't protect you from AIDS.

San Francisco AIDS Foundation. (1984). You can have fun (and be safe, too).

San Francisco AIDS Foundation. (1990). Be a rubberman.

San Francisco AIDS Foundation. (2001). How do you know what you know? Phase 2.

Southern Gay Men's Health Project (Ireland). (2003). If you want to be HIV positive.


Blogger Michael Siegel said...

This is a very important paper that hopefully will be read by all public health practitioners working in the HIV/AIDS prevention area, especially those focusing on delivering safe sex messages to gay men. Your use of Maslow's hierarchy of needs is insightful and convincingly demonstrates why a failure to consider the issue of homophobia leads almost inevitably to program failure. This is a nice complement to Stephanie's critique as well. Together, they provide a critical perspective that could greatly improve HIV/AIDS prevention initiatives.

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Anonymous Anonymous said...

Thank you Michael very nice ..I'm the blk-guy in that safe sex poster 1984..Robert Gray.

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