It is hard to imagine what gay culture might have looked like today had it not been so dramatically derailed by the AIDS epidemic. The golden age of sexual adventuresomeness was short lived — maybe a decade long — when AIDS struck. By 1983, informational campaigns within local gay communities in large cities began to disseminate information publicizing the link between certain sexual acts and a new lethal illness afflicting gay men. First known as GRID (Gay Related Immune Deficiency), what eventually became known as AIDS began to force many gay men to realize that they would have to change their sexual practices dramatically. As these educational efforts proliferated, it became obvious to mental health professionals working with this population, and to public health professionals attempting to help stop the spread of HIV, that many gay men were having great difficulty modifying their sexual behaviors. There were several reasons for this, including initial disbelief that whatever was causing gay men to become ill was sexually transmitted. Additionally, some psychotherapy clients were reporting confusion over the risk-reduction guidelines.

Therapists whose practices were almost or exclusively composed of gay men noticed in their clients increased anxiety, depression, and isolation as well as other signs of emotional disturbance. This was all directly related to the growing health crisis within the gay men’s community. As AIDS became less an abstract statistic and took on faces of the sick, the dying, and the dead, it had a pervasive impact on the emotional lives of gay men. Therapists heard client after client describe fears about their own health and the health of friends and lovers. Men of all ages were grappling with grief and mourning as more and more lovers, friends, neighbors, ex-lovers, and acquaintances sickened and died. As the epidemic advanced, grief counseling became a familiar part of the practice of every gay and gay-affirmative therapist during the height of the epidemic. Gay-affirmative psychotherapy in the 1980s increasingly included working with men who were ill and dying as well as with men who were not sick, but were terrified (known as the “worried well”), overwhelmed with caring for sick friends and partners, and at the same time grieving for loved ones who had died. Psychotherapy became an important venue for men to cope with all this stress and to start to understand the broader impact it was having on their inner and communal lives. This was markedly different from the content of sessions before AIDS, when many urban gay men used therapy to discuss sexual self-actualization and sexual exploration, in addition to other issues. Many gay men who, prior to AIDS, had never given serious consideration to entering therapy began to seek out therapists for support, using counseling as a haven where they could unburden themselves.

Among the multiple levels of loss that gay men were struggling to comprehend were a host of losses related to sexual expression. While this might not have been foremost in the minds of someone nursing a partner or close friend through the final, painful stages of AIDS, eventually this issue would emerge as this individual struggled to get his life back together in some way. Even for those who did not directly experience the death of someone close, gay sexual culture — the possibilities it represented and its centrality to so many in that generation of gay men — had been decimated. Therapy became a place for discussing and sharing concerns about sex in the age of AIDS. Gay men sorely needed a therapeutic environment that would not exacerbate any negative feelings they were having as a result of AIDS being sexually transmitted. There are parallels between Robert’s history and how the relationship of gay men and therapy evolved that may help shed light on understanding Robert’s beginning to bareback. Initially, gay affirmative therapy began by helping gay people feel good about being gay by providing them with mental health treatment that did not make an issue out of their sexual orientation. After the onset of AIDS it helped men cope with the stress brought on by the epidemic and provided a place to grieve the multiple layers of loss in culturally sensitive ways. Among these losses was the need to mourn the change in gay men’s ability to have sex as they had prior to the epidemic. Eventually, therapy became a venue where men wrestled with what level of sexual risk was acceptable to them. Gay-affirmative therapists needed to remain nonjudgmental even in the face of AIDS concerning the importance of anal sex to many gay men. As I validated Robert’s losses and urged him to talk about how they impacted him physically, emotionally, and socially as well as sexually, he began to grieve these losses during our work together. Once Robert had mourned his friends as well as the pre-AIDS “life-affirming” role sex had played for him in his life, he began to progressively have sex that was increasingly higher risk.