Mediated intimacies: Raw sex,Truvada,and the biopolitics of chemoprophylaxis

Truvada or bust

On 16 July 2012, the US Food and Drug Administration approved Truvada—a fixed-dose combination antiretroviral medication that had been prescribed to HIV-positive people since 2004—for use by HIV-negative individuals (see Food and Drug Administration, 2012). Manufactured by the California biotech company Gilead Sciences, Truvada combines two drugs, tenofovir and emtricitabine, which work together to prevent viral replication by acting as reverse transcriptase inhibitors. (As an RNA virus, HIV requires what is known as ‘reverse transcription’ into human DNA; these drugs stop that from happening, thereby interrupting the virus’s life cycle [see Das and Arnold, 2013]). Gilead Sciences is based in Foster City, just south of San Francisco, one of the original AIDS epicenters, and is the largest producer of HIV drugs in the world, with global sales of Truvada earning the company over US$3b per year (Glazek, 2013). Were it not for the fact that the company declines to advertize Truvada for PrEP, Gilead would be considered part of ‘big pharma’; certainly Truvada is one of its blockbuster pharmaceuticals.

The FDA’s decision to approve this drug for the uninfected has sparked controversy, in part because it appears to concede that advocating condom usage was no longer working as prevention policy. ‘Is this the new condom?’ Out magazine asked in its October 2013 issue, featuring an image of Gilead’s oblong blue pill popping out of a Trojan condom wrapper (Murphy, 2013: 71). High-tech chemoprophylaxis threatens to supersede the low-tech prophylaxis of condoms, with pharmacology taking over where behavior modification has failed. Although the new technology is not meant to displace the old—federal guidelines specify that Truvada should be combined with condom use—almost everyone suspects that it will. Thus, as a shrewd commentator recently noted,

For all the statistical and medical issues I looked into surrounding Truvada, the heart of the question was barebacking. That is what we talk about when we talk about Truvada. That is why we don’t always like to talk about Truvada. (Juzwiak, 2014)

Another way of putting this would be to say that, at least in the United States, bareback now is mediated by Truvada, just as discussion of the drug is mediated, in turn, by the spectre of rampant raw rutting. Officially licensed as a prophylactic, Truvada seems also to license enjoyment without limits. I would argue that condom-free sex is mediated by Truvada even when the participants are not on it, because the drug has crystallized as a mediating idea about what worry-free sex between men in the 21st century might be (see McNeil, 2014b). And it is this idea that has provoked such strong and opposing reactions, especially among gay men. While some observers fear that Truvada will finish off the dwindling commitment to condoms altogether, others celebrate the paradoxical possibilities of risk-reduced bareback. What all the reactions share is a sense that widespread implementation of ‘treatment as prevention’ represents a major new chapter in the history of the epidemic.

At first blush, there is something paradoxical about the concept of ‘treatment as prevention,’ since it entails HIV-negative people consuming one of the daily AIDS medications that HIV-positive people take. ‘Why would you take a pill every day to avoid … having to take a pill every day?’ skeptics wonder. The answer, on an individual level, is that you do not take Truvada as PrEP forever, only while you are at risk for infection, whereas you would need it indefinitely if you became infected (with the associated possibility of longer-term side effects). On a global level, Truvada significantly reduces HIV-transmission rates and thus slows the AIDS epidemic. The World Health Organization reports that approximately 10 million people globally are on some form of antiretroviral therapy, with access to this medication having improved substantially over the past decade; WHO now speaks in terms of a ‘global target of zero deaths for HIV’ (Ford et al., 2013: 1). The fact that combination antiretroviral medications may be taken in the form of a single daily pill, with relatively few side effects, makes such a goal conceivable. And, from an epidemiological standpoint, it is but one logical step to go from ‘zero deaths’ to eliminating HIV-transmission altogether.

Given that epidemiologists view populations differently from how members of those populations see themselves, it is also necessary to consider Truvada from something other than a purely epidemiological standpoint. The Centers for Disease Control and Prevention (CDC), in Atlanta, recently issued guidelines recommending that as many as half a million uninfected Americans go on Truvada for PrEP (see Centers, 2014; McNeil, 2014a). Marking a sea change in how the United States officially regards HIV-prevention, the CDC’s recommendation typifies an epidemiology-based public health approach to viral transmission. Urging everyone who is ‘at risk’ to begin taking Truvada, the CDC is basically saying, We have the technology, let’s use it. Since the announcement of this recommendation, on 14 May 2014, public debate around PrEP has thrown into relief how the epidemiological perspective clashes with other perspectives on sexual risk. ³

What may be involved in regarding oneself as ‘at risk’ is less straightforward than the CDC appears ready to concede. For gay men to identify themselves as ‘at risk’ entails their acknowledging a desire for raw sex that goes against community norms. To acknowledge this desire is potentially a risk in itself, because it compromises our image of the responsible gay man who always practices safer sex. To inquire about Truvada for PrEP may be felt as a sign of failure or a confession that one wishes to behave in a way that the mainstream gay community has coded as immoral. Truvada eliminates the excuse factor in bare sex (‘I was too drunk’/‘too high’/‘too turned on’) and thereby forces us to own our fantasies in the cold light of day. Whereas condom use happens in the heat of the moment—a man must be aroused when he dons protection or decides not to—taking Truvada happens in a state of non-arousal; it requires one to admit ahead of time that his commitment to risk-avoidance may be at best equivocal. Gay politics in the United States has become so wedded to respectability that taking this mental step represents a real challenge for many gay men.

The difficulty is captured by Juzwiak (2014) when he observes that,

. . . there are plenty of us who occupy a gray area, in which barebacking isn’t exactly a lifestyle, and in which contracting HIV doesn’t exactly seem like an inevitability. For those of us in that group, the kind of introspection that Truvada requires is hard.

Rich Juzwiak is one of a small number of men in North America who have had the courage to pursue this kind of introspection publicly. Like others who have discussed their decision to try Truvada for PrEP, Juzwiak does not identify as a barebacker—which is significant because many people, including those who have unprotected sex, are inclined to dismiss PrEP as ‘only for barebackers.’ ⁴ The extent to which bareback has become a ‘lifestyle’ in the United States exacerbates the disjunction between how individuals self-identify and how they are categorized by epidemiologists. Here again the nomenclature we employ for our ways of having sex makes a material difference.

These issues may be illuminated by noting that the idea for pre-exposure prophylaxis emerged from that of post-exposure prophylaxis (PEP), a decade-old practice of prescribing antiretroviral medications such as Truvada to uninfected individuals who feared they might have been exposed to HIV through a needle stick, a broken condom, or unprotected sex (see Smith et al., 2005). Known colloquially in some circles as ‘the gay morning-after pill’ (Morgan, 2013), PEP actually entails a month-long course of medication to prevent infection from taking hold—although if treatment is successful one cannot be sure whether viral exposure occurred in the first place. While the effectiveness of PEP is hard to measure, the effectiveness of Truvada for PrEP has been demonstrated in a series of major clinical studies. The most notable of these is the iPrEx study led by Robert Grant, a virologist at the University of California, San Francisco. Using drugs donated by Gilead, Dr Grant and his team worked across four continents with 2499 ‘high risk’ HIV-negative men (and transgender women) who have sex with men. Truvada’s efficacy in preventing HIV infection was calculated initially at 44% (Grant et al., 2010: 2587), although that figure is somewhat misleading.

The iPrEx study was a randomized, double-blind, placebo-controlled trial—which means that half of the eligible test subjects received a placebo rather than Truvada. Nobody knew what they were getting or how effective the drug might be; all test subjects were counseled in safer sex practices and condom usage. Instructed to take one pill each day, people in the trial claimed that they did so fairly consistently. But when researchers tested drug levels in the participants’ blood, they found a different story. Truvada stays detectable for as long as two weeks after a dose, yet among test subjects who became HIV-positive during the study only 9% showed any trace of the drug. They seroconverted because they stopped taking the medicine while continuing to have risky sex. On that basis, Truvada’s efficacy in preventing infection was calculated at 92% (Centers, 2014: 14). This much higher success rate has been confirmed by additional studies among various populations. ⁵

The iPrEx discovery that ‘although reported pill use was high, drug exposure that was measured objectively was substantially lower’ (Grant et al., 2010: 2597) has provoked concerns about adherence. The fear is that gay men who are prescribed Truvada for PrEP will not only stop using condoms, but also skip their medications once too often, with disastrous consequences. They will think they are protected when in fact they are at greater risk than ever. Michael Weinstein, Head of AIDS Healthcare Foundation, the world’s largest AIDS organization, has been especially vocal on this score, prophesying a public-health catastrophe if the CDC’s recommendations are widely adopted (McNeil, 2014a). However, concern about drug adherence elides the larger problem of condom adherence. Researchers have had to rely on self-reporting when it comes to measuring condom use, and they have been reluctant to admit just how unreliable this measure is. What I find intriguing about chemoprophylaxis is that the reliance on self-reports of adherence may be qualified by more objective measurements of drug levels in plasma. Sexual surveillance now can bypass subjectivity altogether by going directly inside the body to elicit information. In this way, the new technologies make visible a chasm between what gay men are willing to tell medical or scientific authorities and what they are actually doing in their everyday lives.

If the CDC’s new recommendations about Truvada tacitly acknowledge how much bareback sex is happening, then that would account in part for the controversy. Much of the debate around this shift in public health policy has focused on the pragmatics of Truvada, including its efficacy and cost, along with doctors’ reluctance to prescribe PrEP and gay men’s hesitation to embrace the new prophylactic technology. I want to briefly consider these pragmatic issues before turning to broader concerns that thus far have been overlooked in the public debate. Truvada is expensive in the United States—around $1200 per month—because it is still under patent, although generic versions are manufactured elsewhere in the world for a fraction of the price and supplied to developing countries. While US health insurance companies mostly cover Truvada for PrEP (it remains cost-effective by comparison with a lifetime supply of medication for those who test positive), many of the populations at greatest risk still do not have health insurance. However, state Medicaid programs cover Truvada, and Gilead has a payment assistance plan to help defray out-of-pocket expenses for those whose health insurance covers only part of the cost (see Juzwiak, 2014; McNeil, 2014a). Given how expensive the drug is, it has been made surprisingly accessible. Public health authorities—and Gilead—are eager to get Truvada into the bodies that they think should be taking it.

According to Gilead, about half of the relatively small number of prescriptions for PrEP in the United States are given to HIV-negative women who have HIV-positive partners (McNeil, 2014a). ⁶ Some of these women want to become pregnant, and Truvada turns out to be ideal for this purpose, because it enables conception while blocking infection. These women are, in turn, ideal for Truvada in the sense that anti-HIV drugs lose much of their stigma when enlisted in the noble task of heterosexual reproduction. Health authorities have noted with concern that HIV-negative men who have sex with men are not signing up for PrEP in large numbers, even as evidence suggests that their condom use is declining. Those who have signed up for it are often stigmatized as ‘Truvada whores’—a term that has been quickly re-appropriated by the queer community as a T-shirt slogan and a badge of pride (Glazek, 2014). Sex-related medicine is socially approved for reproduction of the species but not for what is regarded as promiscuity; Truvada needs to facilitate the right kind of ‘breeding.’ The general view of PrEP shifts as soon as the spectre of someone else’s erotic enjoyment rears its rebarbative head. We want Truvada to be about health, not about pleasure.

Pragmatic issues of access, cost, and uptake are all important; they deserve the extensive public discussion that they have started to elicit. Yet, I am struck by what has not been articulated in the various media reports and online debates around Truvada. Broader ethical questions about the expanding medicalization of sexuality—and about what it means to have our erotic lives mediated by pharmacology—remain under-examined. Behind the unavoidable question of Truvada’s efficacy lies the issue of pharmaceutical power. How should we apprehend a biopolitical dispensation that encourages sexually active gay men to begin taking chemoprophylaxis on the order of women taking birth control pills? Given that Truvada for PrEP comes with a requirement for frequent blood testing, how might we assess the entailments of having gay men’s bodies so closely monitored by medical authorities? What, in other words, is at stake in either embracing or resisting this new health imperative?

A biopolitics of resistance

One of the issues with imperfect drug adherence is viral resistance—in other words, that HIV might become resistant to Truvada if people fail to take it exactly as prescribed. But my concern here lies with forms of political resistance to Truvada, some of which come from conservative quarters in the gay community while others hail from an opposing direction. The septuagenarian playwright and gay moralist Larry Kramer exemplified a reactionary position when, in the wake of the CDC’s recommendations, he opined:

Anybody who voluntarily takes an antiviral every day has got to have rocks in their heads. There’s something to me cowardly about taking Truvada instead of using a condom. You’re taking a drug that is poison to you, and it has lessened your energy to fight, to get involved, to do anything. (quoted in Healy, 2014)

Like Weinstein’s fulminations from the pulpit of the AIDS Healthcare Foundation, Kramer’s complaint passes an unabashedly moralizing judgment on generations of gay men whose realities differ from his. The half century that separates him from young gay men today seems to prevent him from imagining their lives as anything but versions of his own. Kramer’s sanctimony aside, there may be other grounds, based on different political rationales, for resisting Truvada. ⁷

In Unlimited Intimacy, I claimed that one way to grasp the emergence of an organized subculture of barebacking in the US was as a form of resistance to the encroachment of health-and-hygiene imperatives into every zone of contemporary life. Drawing on the later Foucault, scholars from various disciplines have examined how biopower seeks control over human populations increasingly through practices of health and wellness (Cederström and Spicer, forthcoming; Cohen, 2009; Metzl and Kirkland, 2010; Rose, 2007). Biopower persuades us that it is in our own best interests to regulate diet, exercise, and pharmaceutical intake so as to optimize our overall health. Specifically sexual health is central to this endeavour because, as Foucault (2003 [1997]: 252) put it, ‘sexuality represents the precise point where the disciplinary and the regulatory, the body and the population, are articulated’. ⁸ If drugs for sexual health entail both the disciplining of individual bodies (through monitoring for adherence) and the regulation of whole populations (through epidemiological intervention), then refusing those drugs would be legible as biopolitical resistance. From this perspective, adopting Truvada risks defeating the purpose of bareback as a practice of resistance to mainstream health norms. Let me add that it is not necessary to have read French philosophy to inhabit this perspective: many who bareback with strangers understand what they are doing as a deliberate refusal of normalizing health policies. Nobody wants to be told by a government agency how they may have sex.

When public health officials wonder why gay men have not embraced either PEP or PrEP as enthusiastically as predicted, they overlook how sexual subcultures tend to cultivate norms and values that are at odds with those of the mainstream. While many gay men in the US could not be happier to regard themselves as part of the mainstream—as ‘virtually normal,’ in Andrew Sullivan’s (1995) terms—the point of subcultures is precisely to develop and instantiate values that counter ‘the normal.’ The concept of ‘subculture’ functions as a potential mediator of sexual behaviour, allowing sex to be considered—by both researchers and participants—in other than individualistic terms. Having developed this conceptual mediator in Unlimited Intimacy as part of a critical strategy of depathologizing bareback, I wish to acknowledge here that naming something as a subculture is part of the process of forming a subculture; the conceptual model has a performative as well as a descriptive dimension. Especially when they do not manifest spectacular visual styles, subcultures require a kind of discursive identification to help bring them into existence. As the first work to characterize bareback as a specifically subcultural practice, Unlimited Intimacy contributed to the process whereby ‘UAI’ became recognizable as the basis for a form of organization that social theorists call subcultures—or, indeed, ‘post-subcultures’ (see Muggleton and Weinzierl, 2003). In my view, it is only from a subcultural perspective that we can make sense of those ‘young, intelligent gay men who are educated, bright, upper-middle class [and who] refuse HIV meds because they’re proud of their viral load’ (McCasker, 2014). If we cannot consider such men as articulating a minority perspective on ‘health’ that challenges the mainstream perspective, then we tend to default to either a pathologizing framework that regards them as sick and deluded or a moralizing judgment that dismisses them as privileged and irresponsible. The point of ‘subculture’ as a conceptual mediator lies in its offering a less moralistic—because less individualizing—take on human sexual variation.

If a small minority of gay men who are HIV-positive refuse Truvada, then we should not be surprised that some who are HIV-negative also resist it, and for a whole host of reasons (see Glazek, 2013; Tuller, 2013). Early in the epidemic, one of the mantras of AIDS activism was ‘drugs into bodies’ (Crimp and Rolston, 1990: 76). Now, however, a queer politics is developing around resistance to exactly that imperative—just as there is queer resistance to the homogenizing social imperative to get married. As with marriage, in other words, there is resistance to Truvada from a progressive as well as a conservative direction. To be clear, I am not arguing that gay men should not take Truvada, only that there exist biopolitical side-effects (in addition to physiological ones) to mass compliance with pharmaceutical mandates. We need to take account of these potential side-effects and thus to consider the full complexity of gay men’s relation to drugs (see Race, 2009). As queer studies scholar Kane Race (2001: 93) further suggests, ‘we need a strategy for engaging with biomedical knowledges in a manner that also allows for a critique of biomedicine and its methods’.

In my view, we also need a way of thinking about gay sexuality that goes beyond the biomedical paradigm without discounting it. What US public health officials seem unable or unwilling to grasp is that sex between men is not exclusively a physiological encounter amenable to pharmaceutical intervention. Instead, sex involves fantasy: it involves bodies less as organic entities than as extensions of subjectivity. As Patricia Gherovici (2010: 52) puts it, ‘a body is not just a collection of organs, but a place onto which culture inscribes itself’. When bodies come together for sex, they bring with them entire subjective worlds that both incite and mediate the carnal. Their intimacy may be mediated pharmaceutically—via antiretrovirals, sildenafil (Viagra), crystal methamphetamine, or any number of other drugs—but it is also always mediated by fantasy. If the drugs interrupt the fantasy rather than facilitating it, they will be rejected as readily as condoms.

Here, as elsewhere, I am trying to emphasize the idea of unconscious fantasy as an indispensable component of any account of human sexuality. The emphasis remains necessary because, as Leo Bersani (1995) argues, scholars of sexuality ‘have become extremely sensitive to the danger of looking too closely at our fantasies’: ‘“fantasy” has become a politically incorrect word’ (1995: 103–104; 65). The situation that Bersani diagnosed two decades ago has not appreciably altered since then. What spurred me to write Unlimited Intimacy was my dissatisfaction with the way in which all the explanations for barebacking (scholarly as well as journalistic) proceeded as if fantasy were not at stake—as if, indeed, it made sense to talk even about bareback pornography without acknowledging the constitutive role of erotic fantasy. The unwillingness to discuss sexuality as anything other than essentially rational behavior is astonishing. This unwillingness perpetuates a climate in which sexual activities that do not appear as expressions of individual self-interest tend to be pathologized. So much about sex becomes either invisible or unintelligible when the dimension of fantasy is methodologically quarantined.

The category of fantasy should not be regarded as incompatible with the emphasis on ‘subculture’ as a conceptual mediator, since the fantasies to which I am referring are collectively articulated. Bareback fantasy is central to the practice of ‘UAI’ because it helps to bind subcultural participants together: the purpose of this kind of sex is not merely to seek ejaculatory release without the hassle of condoms but to create intimacy among a group. The shared substance—in this case, semen—is fantasized as bonding sex partners together analogously to how the shared substance of blood is imagined, in mainstream culture, as binding people together as kin. Fantasy enables a collective to be virtually present even if the sex occurs between just two people. Far from individualizing or private (as we tend to think when we reduce it to a psychology of illusion), fantasy works to de-individualize subjectivity by linking it to the public world of others (Laplanche and Pontalis, 1986 [1968]). Indeed, the dimension of unconscious fantasy reveals the notion of individual autonomy as itself illusory. Thus, ‘fantasy’ and ‘subculture,’ although drawn from different disciplinary domains, belong together in the critical analysis of non-normative intimacies. By thinking them together we can begin to appreciate how one may participate in a subculture’s fantasies without necessarily being a member of it.

Convinced of the explanatory force of fantasy as a category, I remain skeptical about the widespread commitment to biophysiological explanations of erotic activity. This commitment became clear in those accounts of bareback that described it in pharmacological terms, as a response to the availability of highly active antiretroviral therapies, on one hand, and the popularity of crystal methamphetamine, on the other. Gay men bareback with strangers primarily under the influence of drugs, it was claimed, because otherwise why cultivate such practices of risk? The addiction narratives that US culture adores were invoked to bolster these biophysiological explanations, since only ‘addiction’ can account for what from a rationalist perspective appears as the inexplicable abdication of self-interest (see Moskowitz and Roloff, 2007). If your understanding of human sexuality contains no conceptual room for fantasy or the unconscious as mediators of self-interest, then the notion of addiction is epistemologically irresistible because it explains how autonomy, self-preservation, and good intentions all become compromised biochemically. ⁹ Needless to say, such explanations dovetail very neatly with the ambitions of the pharmaceutical industry.

In the United States, problems around sexuality aspire to pharmaceutical solutions largely as a result of the hegemony of science in knowledge production. Humanistic or non-scientific accounts of sex barely register on the public radar because they lack social authority. Scholars of sexuality should bear in mind that powerful economic interests have a stake in ensuring that any explanation of controversial sexual behaviours such as barebacking will be automatically disqualified if not couched in scientific terms. The political economy of the modern research university strongly disfavours non-biochemical or non-physiological models of sexuality. This situation has a particular history in the United States that goes back to the Cold War, when the National Defense Education Act of 1958, created in response to Sputnik, ‘put the federal government, for the first time, in the business of subsidizing higher education directly, rather than through contracts for specific research’ (Menand, 2010: 66). The Cold War period saw the establishment not only of the National Science Foundation and the National Institutes of Health (both of which funnel unprecedented federal funding to universities), but also of a more pervasive ethos that made science the model for academic research tout court. ¹⁰ Although homosexuality had been medicalized since the 19th century, medicine tightened its grip on sex during the 1950s by means of the ramifying cultural authority of science (see Terry, 1999). What Foucault (1978 [1976]) diagnosed as scientia sexualis has taken a historically specific form in the postwar United States.

Pharmaceutical power

It was also during this period that biopower extended its reach inside human bodies via drugs that regulate sexuality at the molecular level. Here, I am referring to the pharmaceutical development of synthetic hormones that led to the contraceptive pill and a massive postwar reorganization of sexuality. Considering PrEP in light of Preciado’s (2013 [2008]) account of the emergence of ‘pharmacopower’ at mid century allows us to grasp how the CDC’s recent recommendations derive genealogically from an historical moment that actually precedes AIDS. The birth of ‘the Pill,’ a chemical condom for heterosexuals, anticipates that new form of chemoprophylaxis called Truvada.

Connections between Truvada and oral contraceptives have not gone wholly unremarked. A pair of doctors in New York, together with one of the best mainstream journalists (Donald McNeil, Jr, of The New York Times), all observe similarities between the public debate surrounding ‘the Pill’ half a century ago and that around PrEP today (McNeil, 2014b; Myers and Sepkowitz, 2013). As with Truvada, concerns were voiced about the efficacy, cost, and effects on sexual behaviour of Enovid when it was first approved, in 1960, for use as a contraceptive. Before the FDA approved it for birth control, Enovid had been officially prescribed to treat infertility since 1957. Now with Truvada we have a drug that, approved for treatment of HIV-infection since 2004, has just been recommended for prevention. In both cases, the switch from treatment to prevention occurred within a context of intensified political struggle around women’s and gay men’s sexuality. If the Pill helped to inaugurate the sexual revolution of the 1960s, then what should we expect of Truvada, the new contraceptive for gay men? ‘Are we ready for HIV’s sexual revolution?’ is the title of McNeil’s (2014b) cogent article on the subject.

Foucault’s (1978 [1976]) history of sexuality, written before AIDS, counsels skepticism about the prospect of sexual revolution. A Foucauldian perspective helps us to see how Truvada raises questions about not only potential changes in sexual behaviour but also biopower’s intensifying hold on human bodies via sex and, increasingly, sex-related pharmaceuticals. The struggle against sex/gender oppression should beware promises of ‘liberation,’ especially those predicated on realizing one’s authentic sexual identity. Building on Foucault, Preciado (2013 [2008: 78]) develops the counterintuitive claim that today ‘power acts through molecules that incorporate themselves into our immune system’. Biopower gets inside us not only through psychological mechanisms of identification (as we figure out who we truly are sexually), but also through the pharmaceuticals we ingest to become the sexual beings we aspire to be.

Considering the history of artificial hormone synthesis, Preciado describes the diversification of biopower into what she calls ‘pharmacopower.’ By her lights, it is no coincidence the FDA approved Enovid as a treatment for infertility in the same year—1957—that US psychiatrist John Money, researching endocrinology for transsexualism, coined the term ‘gender’ as we understand it today, that is, as distinct from ‘sex’ (Money et al., 1957). The Pill and ‘gender’ were made in America at the same moment out of the same constellation of forces. The Cold War period witnessed not only massive federal investment in scientific research but also an industrialization of pharmacology in which the development of endocrinological techniques for modifying sex played a crucial role. Within just a decade of its FDA approval, the Pill became an object of mass consumption and a source of big business. As Preciado (2013 [2008]: 28) puts it,

The invention of the contraceptive pill, the first biochemical technique enabling the separation between heterosexual practice and reproduction, was a direct result of the expansion of endocrinological experimentation, and triggered a process of development of what could be called, twisting the Eisenhower term, ‘the sex-gender industrial complex’.

Although it has nothing to do with endocrinology, Truvada comes out of this same complex.

Preciado makes evident how, long before Truvada, sex became mediated pharmacologically. It is her cogent analysis of ‘pharmacopower,’ quite as much as the recent public health policy shift on PrEP, that has altered my perspective on the significance of drugs in the development of bareback. Testo Junkie is, in my view, the most important work of queer theory to appear in the last decade; those who have pronounced queer theory dead are in for a surprise when they read it. Maximizing the conceptual resources of Continental philosophy, Preciado is also far from squeamish about sex—especially by comparison with her US counterparts. While I cannot do justice to Testo Junkie here, I want to emphasize that what it adds to a history of the connection between Enovid and Truvada is a profound understanding of the complex power relations that connect the two. Her account of pharmaceuticals shows how pills are biopolitical entities. In addition, Preciado situates her analysis of pharmacopower in a narrative about her biographical relationship with Guillaume Dustan, one of France’s most notorious exponents of bareback sex (Dustan, 1998 [1996]). Although she never mentions Truvada, the possibilities of bareback breeding and kinship lie at the heart of Testo Junkie (see Evans, 2015). ¹¹

The interest of Preciado’s relationship with Dustan should not distract us from how pharmacopower operates at once on the global scale of multinational corporations (‘big pharma’) and the nanoscale of molecular engineering. Pharmacopower is not to be understood primarily on the level of the individual and his or her agency: its mechanisms function on both a much larger and a much smaller scale than that, even as they work their way inside individual human bodies. As Preciado (2013 [2008]: 79) puts it, ‘We are gradually witnessing the miniaturization, internalization, and reflexive introversion (an inward coiling toward what is considered intimate, private space) of the surveillance and control mechanisms of the disciplinary sexopolitical regime’. If panopticism still functions in the 21st century, it is because we have swallowed it whole in the name of health.

Elaborating a post-Foucauldian theory of biopolitics, Preciado develops her concept of pharmacopower by drawing also on Derrida’s (1981 [1972]) reading of the pharmakon. Her neologism takes the ‘-power’ [pouvoir] from Foucault but the ‘pharmaco-’ from deconstruction, which finds in the pharmakon an emblem of undecidability or radical ambiguity. In ancient Greek, pharmakon meant ‘poison’; but it is also conversely the medicine or remedy. ‘The only difference between a poison and a medicine,’ argues Preciado, ‘lies in the dose’ (2013 [2008]: 140). Since pharmakon holds the potential to be either toxic or medicinal, it elicits a fundamental ambivalence. Here, we might recall Larry Kramer’s characterization of Truvada as ‘a drug that is poison’ (in Healy, 2014). It is certainly the case that earlier antiretrovirals such as AZT were highly toxic, and even the second-generation anti-HIV drugs, introduced in the late 1990s, had many serious side effects. Truvada has been approved for widespread use in the United States because the dose of tenofovir it contains is sufficiently low to tip it in the direction of remedy rather than toxin. Nevertheless, the insight lurking in the shadows of Kramer’s otherwise regrettable statement concerns the way in which any pharmakon possesses an ambiguity that cannot be completely eradicated or resolved. It is not just that all drugs have potential side effects but that the difference between poison and antidote is a difference of degree rather than of kind. This aspect of the pharmakon helps to explain the unease people feel at the prospect of prescribing Truvada to the uninfected en masse. ¹²

The ambivalence of pharmacopower is compounded when Preciado connects it with the development of pornography in the United States since the 1950s. Her book’s subtitle, Sex, Drugs, and Biopolitics in the Pharmacopornographic Era, suggests that sex today is mediated not only by pharmaceuticals, but also by porn and our proliferating technologies for accessing it. Yet, her neologism pharmacopornographic means more than this. The form of power that Preciado analyzes is not simply about controlling various populations through medicine but also about actively inciting erotic desire. As Preciado puts it, ‘the goal is not the production of pleasure but the control of political subjectivity by means of the management of the excitation-frustration circuit. The purpose of porn … is the production of frustrating satisfaction’ (2013 [2008]: 304, emphasis in original). Our sex is hypermediated by technologies—pornographic as well as pharmaceutical—that give biopower full access to our bodies and their desires in the service of economic profit. Provoking our lust, this constellation of power relations operates by making us want it. Here, power works by prompting a libidinal investment that encourages us to feel our deepest satisfaction lies in embracing it. Far from imposed, it is desired.

Invisible condoms

The US porn industry is very interested in Truvada because, as chemoprophylaxis, it promises to deliver on the magical idea of invisible condoms. Porn actors may be protected from HIV-infection via PrEP without having to use rubbers (which often cause physical irritation to the performers and certainly induce irritation in viewers). This pharmaceutical possibility comes at a moment when the porn industry in Los Angeles is still recovering from a new law that mandates ‘actors in pornographic films to wear condoms during any filming that takes place within city limits’ (Medina, 2012). Instigated by Michael Weinstein, president of the LA-based AIDS Healthcare Foundation, the law works through California’s Department of Industrial Relations, Division of Occupational Safety and Health (Cal/OSHA) in the name of HIV-prevention. A prime example of health as the new morality, this law utilizes employment legislation rather than, say, obscenity legislation to regulate pornography.

Among the many absurdities of the law is the question of enforcement. ‘The new mandate will allow the Los Angeles Police Department to perform spot checks on any set once a film permit is issued’ (Medina, 2012). Since the presence of condoms in a box on set would be insufficient to prove they were being used, ‘enforcement’ conjures the prospect of members of the LAPD inspecting porn star penises at the moment of insertion. (Nice work if you can get it.) Surely this is a basis from which any number of pornographic plot scenarios may be spun. The more serious issue, however, concerns the state’s capacity to insinuate itself into our most intimate bodily moments and, indeed, its pleasure in doing so. Here we confront the libido of biopower.

At the same time as his is the loudest voice protesting CDC guidelines on Truvada, Weinstein has extended his anti-porn campaign north to San Francisco, where Paul Morris’s bareback company, Treasure Island Media, has become his latest target (see AIDS, 2013). As discussed in Unlimited Intimacy, straight porn produced without condoms in the United States follows a different set of precautions from gay bareback porn (in which most of the performers are already HIV-positive). It is remarkable that the 2004 case I analyzed—in which Darren James inadvertently infected three women on set (Dean, 2009: 97–102)—stands as the last recorded instance of HIV-transmission in straight porn, despite an estimated 350,000 condom-free sex scenes filmed in the decade since (McNeil, 2012). No matter the demonstrated effectiveness of straight porn’s system of mandatory frequent HIV-testing, Los Angeles passed the law requiring condoms in 2012.

The situation of bareback porn is more complicated than that of straight porn because most (though not all) of the actors who perform in Treasure Island Media films are HIV-positive. Paul Morris recently said in an interview that, ‘we’re at a point where it’s altogether possible, given simple strategies like PrEP, to render HIV a nonissue’ (McCasker, 2014). While it is not as simple as that, I find it striking that Morris is considering the possibilities of chemoprophylaxis in the face of Weinstein’s Cal/OSHA legal action against his company. It raises the question of whether bareback on PrEP still counts as bareback if physical risk has been eliminated to the point where HIV becomes ‘a nonissue.’ Morris has tacitly addressed this question in a film released in the wake of the Cal/OSHA lawsuit; the film, one of his most controversial to date, is titled Viral Loads (2014).

The film’s title riffs on the biomedical metric that has been used since the late 1990s to assess the state of HIV-positive bodies. The viral load test, a highly sensitive method of quantifying HIV RNA in plasma, reached the pharmaceutical market in 1996; as Race (2001: 85) observes, the test initiated ‘a broad but decisive shift in HIV clinical practice and consciousness away from an immunologic paradigm, and toward a virological conception of HIV aetiology and treatment’. The antiviral paradigm displaced the immunity paradigm, with VL numbers being compared among HIV-positive gay men as quantifiable indicators of health. This comparatively new biomedical metric, which involves intensive technological surveillance of HIV-positive bodies, has been embraced in bareback subculture with an enthusiasm that nearly exceeds the commitment to penile measurement. Profiles on bareback cruising websites frequently cite men’s VL numbers alongside other vital statistics. The expert terminology of biomedical science has been eroticized in bareback vernacular, not least because of the play on load.

Morris’s recent film title also evokes ‘loads’ in the colloquial sense of deposits of semen: bareback sex involves not merely condom-free intercourse but the giving and taking of loads. Viral Loads makes explicit what cannot be seen but is usually inferred in Treasure Island Media films, namely, the presence of HIV in seminal fluid. The climax of Viral Loads—and the scene that has sparked controversy—occurs when, in Morris’s words, ‘we bring out a brimful jar full of more than 200 poz loads. [The star’s] good buddies Dayton O’Connor and Drew Sebastian carefully squirt every fucking drop up [his] knocked-up ass.’ ¹³ In the film, the jar of liquid is clearly marked on its lid with the words ‘poz cum.’ This scene reaches a new level of explicitness in bareback porn and doubtless will dismay Michael Weinstein.

Now, of course, HIV is killed by exposure to air; semen stored in a jar would not be infectious. The scene is not enacting a risk but hyperbolically staging a fantasy. The fact that this scene will not appeal to everyone’s taste makes understanding it as a fantasy all the more imperative. In his discussion of the film, Morris claims that he intends the title to signify more metaphorically than hitherto suggested:

‘Viral load’ is something that the entire gay world has held on to and labored under for two generations. One of the reasons I made this title was to simply say, exactly as you did, ‘Enough is enough’ … Gay men have completely lost the sense of who they are because they’ve been immersed in terror, because they’ve been living under a viral load for two generations. (McCasker, 2014)

Here load is neither a biomedical term nor a dirty word but a figure for the burden of history. If gay men have been living for more than three decades under a burden of terror, then Viral Loads pictures—in a quite spectacular fashion—what freedom from that burden might look like.

That freedom is a consequence of drugs such as Truvada. It depends on biomedical technologies and their unprecedented potential for monitoring the interior of our bodies. After all, what the antiviral paradigm made possible was a viral-load reading of ‘undetectable,’ which has become both the goal of treatment and a new badge of gay pride. Clinical studies demonstrating that ‘undetectable’ HIV-positive people appear unable to transmit the virus have led some observers to declare that ‘undetectable’ is the virtual equivalent of being HIV-negative (Duran, 2014). In this pharmaceutically mediated utopia, ‘undetectable’ poz guys cannot pass on the virus and neg guys on PrEP cannot get it. If that is how the world of bareback porn functions these days, then what is anyone worried about?

It is certainly the case that the category of ‘undetectable’ disrupts the positive/negative binary (Lee, 2013). The drugs perform a kind of deconstruction on the binary opposition that has organized gay erotic life for decades. Chemoprophylaxis exacerbates this disruption in a way that compels us to reassess what we thought we knew about gay men and viral transmission. We need an expanded vocabulary and further refined conceptual models for understanding ‘raw sex’ today. But we also need to take stock of the degree to which rawness is mediated by biopolitical relations, particularly those of pharmacopower. From a Foucauldian perspective the category of ‘undetectable’ could not be more ironic, since it relies on surveillance at the biomolecular level by an entire apparatus of medical power. Nothing could be less raw.