HETEROSEXUALS AND AIDS - THE SECOND STAGE OF THE EPIDEMIC

FROM:  The Atlantic, February 1987

BY:  Katie Leishman

Last year Dr. Thomas Peterman, of the Centers for Disease Control, in Atlanta, 
oversaw a study concerning transmission of HIV (human immunodeficiency virus), 
the principal AIDS virus, in families of persons with transfusion-associated  
infection.  It was one of the first studies to assess the relative rates of  
sexual transmissions from men to women and women to men.  Not surprisingly,  
among people who did not have sex with infected partners there was no  
transmission.  Among the sexually active couples, of the fifty men who were  
infected, eight transmitted the virus to their wives; of the twenty women,  one
transmitted the virus to her husband.  It is of interest that the partners  who
became infected had all had only vaginal intercourse and reported fewer  
encounters after transfusion than partners who did not become infected.  One  
spouse became infected after only one exposure, another after eight.   
Obviously, the study documented that the disease was transmissible from men to 
women and women to men, but the varying rate of transmission provoked many  
questions.  Do some men and women transmit the virus more efficiently? Or are  
some people more susceptible?  Might someone have sex with a partner hundreds  
of times without transmission occurring, whereas the first time the infected  
person slept with someone else transmission would occur?

The most important question, however, is one with which the study was not  
concerned, and it is a behavioral one, involving those couples who knew that  
one partner was infected.  Why were any of these people -understanding that  
one could transmit a lethal virus to the other - willing to have sex without a 
condom?  There have since been other American studies of transmission rates  
between infected people, such as intravenous drug users and hemophiliacs, and  
their partners, which incidentally document a strange phenomenon: many people  
who know they are at extraordinarily high risk nevertheless dispense with even 
minimal precautions.  Confronted with such data, health officials must blanch 
at  the prospects for influencing the behavior of the millions of people who 
don't  believe themselves to be at any risk of exposure at all.

To travel around this country talking to people about AIDS is to learn quickly 
that most Americans still regard the emergence of the disease, which struck  
gays first, as an act of God.  Even many comparatively free thinkers take the  
attitude that liberal Democrats did as they watched the cast of Watergate  
characters come to trial":  "I could have TOLD you this was going to happen."  
These two notions have survived the introduction of undeniable evidence of  
heterosexual transmission.  Many of the people who hold them continue to hang  
on news of every development related to AIDS. Everyone is waiting:  waiting  
expectantly for news of a cure or a vaccine, although even the National Academy
of Sciences, a circumspect group, has said that no vaccine will be available  
for at least five years; waiting in awful fascination for the news that the  
number of heterosexually transmitted cases has reached some critical point,   
whereupon men and women all across America will return to kissing their dates  
good-night at the door.

In the United States the number of reported domestic cases of heterosexually  
transmitted AIDS has increased by over 200 percent in the past year (while  
cases among gay men and IV-drug users grew by 80 percent).  But the total  
heterosexual caseload was still only 1,079 last December, or four percent of  
the 28,523 cases reported.  It must be remembered, however, that these counts  
are of cases of AIDS in which infection occurred, on the average, five years  
ago.  No one has any idea how many people are infected but asymptomatic, or  
how much transmission is going on.  It has been estimated that in California  
there are sixty cases of AIDS for every reported one, and reporting is more  
complete in that state than anywhere else.

Women are generally believed to transmit the virus less efficiently than men 
- reported cases of AIDS transmitted from women to men in the United States  
represent less than eight percent of all heterosexually transmitted cases -   
but it remains unclear whether this is because men made up the overwhelming  
majority of infected people in the first round of epidemic or because men  
inoculate their partners with a substantial dose of the virus and women do  
not.  For unknown reasons heterosexual transmission appears to occur more  
easily with IV-drug use than with other risk factors:  in a review last year  
of numerous reports of male-to-female transmission, transmission to partners  
of IV-drug users occurred in approximately 30 to 70 percent of the cases but  
to partners of hemophiliacs in only about 10 percent of the cases reviewed.

One cannot speak about transmission rates in the general public until a large  
pool of infected individuals has formed at one remove from the primary risk  
groups.  That pool is forming now.  Even if heterosexually transmitted cases  
continue to be a secondary feature of the epidemic in the United States, the  
crucial questions that men and women outside of monogamous relationships - and 
many people in them - must ask themselves are, Am I at any risk of exposure  to
the virus? and, more frightening, since ten years can pass before someone  
exhibits any visible sign of infection, Have I ever been exposed?  Whether the 
risk is one in ten or one in ten thousand, the risk is there.  Interviews  with
sexually active men and women across the country are reminiscent of  
discussions with openly gay men several years ago, when statistics related to  
AIDS infection in their communities were low but too significant to ignore.   
People perceive themselves to be immune and, moreover, possessed of an  
intuitive power that enables them to chose safe partners.  The strength of  
that self-assurance varies, of course, and can assume as many forms as there  
are lovers at large.

Each month yields new revelations from the behavioral research related to  
AIDS, much of it coming out of San Francisco and almost all of it concerned  
with gays.  Public-health officials around the country must assess that  data, 
keeping certain questions in mind.  How do people behave when they know  they 
are infected or at risk?  What is the value of AIDS education programs?   What 
impact does the discovery one's antibody status, or of a partner's  antibody 
status, really have?  Is it easier to affect the behavior of people  for whom 
the risk of exposure can be reasonably estimated than it is to affect  those 
for whom it cannot be?  Finally, to what extent can the behavior and  attitudes
of homosexuals be related to those of heterosexuals?  Many people  believe that
the intensity or quality of homosexual drives is unique,  while  others argue 
that the ability to control sexual impulses varies  extraordinarily within 
groups of any sexual preference.  Much about the  epidemic already suggests 
that ironclad distinctions between gays and  straights serve no one and may 
cost some people their lives.

The investigation of why people respond differently to the same information  
about health has become one branch of epidemiology, the study of the  
occurrence of disease and the factors responsible for its frequency and  
distribution.  Behavioral epidemiology, the study of the relationship between  
behavior and disease, is less than forty years old and is still controversial.

One of its first applications was the development of programs for disease  
prevention, as opposed to single-minded search for cures.  These programs  
first gained national attention with the 1964 Surgeon General's report on the  
dangers of smoking.  The government launched mass-immunizations campaigns  for 
polio and influenza throughout the sixties and an education program about  high
blood pressure, sponsored by the National Institutes of Health, in the  
seventies.  The concept of behavioral control over health now seems a  
commonplace.  Nonetheless, any decision to devote public funds to health  
education rather than research is controversial, because evidence that people  
are willing to change their behavior remains unconvincing.  AIDS may provide  
the ultimate test of strategies for behavior modification.

For almost thirty years studies have been compiled on the subject of decision-
making related to health.  Some of the earliest research was based on  
interviews with citizens concerning their attitudes toward participation in  an
x-ray screening program for tuberculosis conducted by what is now the  American
Lung Association.  After reviewing that data Dr. Godfrey Hochbaum,  at the 
School of Public Health at the University of North Carolina, in   1956 devised 
a theory of four critical health beliefs that individually or in  combination 
may lead someone to alter his behavior:  the belief in  susceptibility (which 
young people are notoriously unable to entertain), the  belief in the severity 
of the outcome, the belief that one can have something  and not know it, and 
the belief that the action that has been recommended will  achieve the desired 
end.

What Hochbaum determined to be the critical factor in people's decision to be  
x-rayed was their belief that they could have something and not know it.   
Similar findings emerged in studies of participants in the NIH's high-blood-
pressure programs.  "The greatest barrier to action is the absence of  
symptoms," says Dr. Lawrence Green, the director of the Health Science Center  
at the University of Texas at Houston. "Someone tells himself, `If I have high 
blood pressure, I should have a headache.' Once people are persuaded they may  
have something and not know about it, you have to be able to assure them you  
can offer them help if they take steps to find out they do have something."  
That assurance can hardly be offered regarding AIDS - a lethal disease for  
which the true incubation period is unknown and for which there is no cure.

AIDS as it relates to heterosexuals presents an additional problem for  
behavioral-modification theorists:  the risk cannot be defined.  In general,  
the higher the degree of risk that can be projected for a particular  
individual, the easier it is to affect his behavior.  The perception of a high 
risk and a catastrophic outcome combined might be expected to induce the  
greatest motivation to change, while a low risk and a negligible outcome  
should have little impact.  When the perceived risk involved is as low as it  
is for most heterosexuals thinking about AIDS, the perceived severity of the  
outcome may not matter. According to Green, people can take probability into  
account "as long as it is in their own betting experience - anything per ten  
or hundred."  He adds, "But once you are into the thousands, it doesn't make  
much difference if it is one in one thousand or one in ten thousand.  Most  
people can't relate to it, and it is easy for denial to take over.  For those 
people who do perceive a risk at those levels, it will be a go or no-go  
decision to change."

"Change" in the minds of most heterosexuals well informed about AIDS means one 
thing: the use of condoms.  Condoms have become the talisman against AIDS,  
recommended for use in oral sex as in any other kind, because of the  
possibility that pre-ejaculatory emissions are sufficient to transmit the  
virus and the certainty that ejaculate is.  A study reported last spring in  
the JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION showed that in laboratory  
tests HIV cannot pass through either a synthetic or natural-skin (usually  made
from lambs' intestinal linings) condom.  (Many experts believe, however,  that 
natural-skin condoms are more porous and therefore offer less-effective  
protection.)  Readers were quick to point out in letters that condoms, which  
can break, leak, or be used improperly, are associated with an annual 10  
percent failure rate in pregnancy prevention - and a woman is fertile only a  
few days a month, whereas a person with AIDS virus always has it.  Moreover,  
there was no proof that homosexuals were more motivated to use condoms for  
prophylaxis, let alone use them correctly, than heterosexuals were to use  them
for birth control.   One of the study's authors, Dr. Marcus Conant, who  is the
chairman of the California State Department of Health Task Force on  AIDS, not 
only concedes these problems but also adds that laboratory  conditions don't 
necessarily duplicate the stresses brought to bear on condoms  during sex.  The
same limitations apply to studies concerning the  effectiveness against HIV of 
nonoxynol-9, the spermicide in most contraceptive  gels and foams, and the only
spermicide considered to have any value in  repelling the AIDS virus.

Not long after the JAMA exchange a study was released by Dr. Margaret Fischl,  
the director of clinical AIDS research at the University of Miami.  Among a  
group of twenty-eight AIDS patients whose partners did not have the AIDS  
antibody, sixteen continued to have unprotected sex with their steady  partners
during a one-to-three-year period; thirteen of their partners  seroconverted 
(became anti-body-positive).  Twelve of the patients continued  to have sex but
used condoms.  Two of their partners also sero-converted.

Obviously, condoms are a lot better than nothing.  Yet knowing this may not  
have great impact.  In a follow-up note to the JAMA article, Conant cited one  
study of gay men in San Francisco in which 80 percent of the men indicated  
that they knew that condoms helped prevent transmission of the virus but only  
six percent used them.

The behavior of San Francisco's gay men has been carefully monitored since  
1984 in the San Francisco Men's Health Study, which involves 1,000 gay and  
bisexual men.  The results of the study have been used to celebrate the  
possibility for behavior modification, but they deserve a closer look.  From  
1984 to 1986 men reported dramatic changes in sexual activity related to the  
number of their partners and the practice of passive and active anal  
intercourse; the annual seroconversion rate dropped from 20 percent to five  
percent.  That is welcome news.  Yet one may extrapolate a five-percent  
seroconversion rate to other previously uninfected men:  1,000 men  
seroconverted last year alone in San Francisco, which means eventually at  
least 315 new cases of AIDS.  This number is disturbing in a community already 
profoundly stricken - and it is certainly an optimistic projection, because  
men conscientious enough to participate in an ongoing health study are not  
representative.  So-called cohort bias is a continual problem with such AIDS  
surveys.  Dr. Constance Wofsy, an infectious-disease specialist at San  
Francisco General Hospital and an authority on AIDS, summarizes her  
impressions of the response of the city's gay community to the AIDS crisis:   
"With intense education efforts and extraordinary motivation you can affect the
behavior of some people - in most cases only temporarily."

The preliminary data about the behavior of heterosexuals regarding AIDS is   
hardly more encouraging.  In addition to the CDC study conducted by Dr.  
Peterman, there are numerous others concerning partners of infected persons -  
hemophiliacs who received infected plasma, IV-drug users, recipients of  
contaminated transfusions - in which couples go on month after month having  
unprotected sex.  Moreover, study subjects are not alone in carrying an  
attitude of "We're in this thing together" to death-defying extremes - if  that
is, in fact, what they are thinking.  Public-health directors and AIDS  doctors
all over the country tell stories of reckless behavior.  Rick Reich,  the 
AIDS-services coordinator for the Health District of Clark County,  Nevada, 
regularly counsels many couples in which one member is antibody-
positive. He sees one couple - the man is antibody-positive, his wife negative 
- who, without using condoms, average fifteen sexual encounters a week,   "with
no particular bias as to orifice," Reich says.  Another couple was sent  to him
two years ago, shortly after the birth of their child. Soon after the  baby was
born, the man, who had engaged in unspecified high-risk activity  several years
earlier, came down with persistent pneumonia proved to be a  simple case, but 
he tested positive.  His wife was tested and was positive;  the baby tested 
antibody-negative.  (It was unclear whether his wife had been  positive before 
the child's birth.) The couple continued to have unprotected  sex, knowing that
both of them were positive and that repeated exposure might  increase the 
chance that one or both of them would contract full-blown AIDS.   Last year the
woman decided that she wanted another child and became pregnant,  against the 
advice of physicians and health officials who warned her of the  serious 
probability that the child would be infected and die.  Everyone  concerned 
anxiously awaits the birth. This couple cannot be regarded as a  rarity. 
Preliminary findings at major hospitals in poor urban sections of the  New York
metropolitan area indicate a rate of seropositivity of two percent or  higher 
among pregnant women, and not all of them could have been ignorant of  their 
own antibody status prior to conception.

Such accounts challenge the claims that sexual conservatism has swept the  
country in response to AIDS.  In one study that is frequently cited, a  
behavioral psychologist interviewed 2,600 college students nationwide.   
Compared with students of twenty years ago, fewer approved of one-night stands 
(19 percent approved, as opposed to 48 percent in an earlier study).  That may 
well be what many men and women are saying.  But on any Saturday night in any  
city the bars are packed, and it is hard to believe that all these people are  
getting together to drink themselves under the table.

Optimists have cited the decline of certain sexually transmitted diseases, in  
particular syphilis and gonorrhea.  But it is a mistake to infer the potential 
for HIV transmission from incidence rates of these diseases, which differ in  
character and degree of transmissibility.  With syphilis and gonorrhea, the  
period of highest infectiousness occurs for several weeks after inital  
infection and then declines dramatically.  Someone with a syuphilitic lesion  
might cut back from four partners a month to two partners, and in skipping  sex
for two weeks be abstinent right through the phase of highest  infectiousness. 
Someone with HIV might similarly reduce his sexual activity  but would remain 
infectious before, during, and after a spell of abstinence. According to a 
growing number of AIDS authorities, the disease to watch  instead is hepatitis 
B, a viral liver ailment whose transmission patterns are  all but identical to 
those of AIDS:  it is transmitted through blood, semen,  and contaminated 
needles, and, like AIDS, is associated with a large pool of  asymptomatic 
carriers.  In the United States it is most common in gay men,  and can be 
passed from an infected mother to her newborn child.  Because the  incubation 
period for hepatitis B is only two to four months, the incidence of  recorded 
cases may be used as an index for the potential for ongoing  transmission of 
HIV.

In 1975 the Minnesota Department of Health began collecting data on all new  
reported cases of hepatitis B. From 1982 - the year in which the first case of 
AIDS was reported in the state - to the present, every six-month period has  
brought the same number of new clinical cases of hepatitis B in gay and  
bisexual men, although the same four-year period saw a 70 percent decline in  
the rate of syphilis.  A recent study at a San Francisco clinic similarly  
showed an overall decline of 70 percent in rectal gonorrhea from 1980 to 1985 -
but in a group studied at the same clinic during the same period the  
percentage of seropositivity for AIDS rose from 12 to 67 percent.

The studies suggest that although reduction of sexual activity affects the  
incidence of sexually transmitted bacterial diseases, it does not have an  
impact on the concurrent incidence of the viral infections hepatitis B and  
HIV.  Moreover, given the alarming accounts of hepatitis B and HIV contracted  
after a single encounter, it may well be that hepatitis and HIV are more  
readily transmissible than either gonorrhea or syphilis. (For gonorrhea the  
probability of transmission is about fifty-fifty in a single encounter with an 
infectious partner; for syphilis, even when a person still has a lesion, it is 
less than 20 percent.)  Studies of hospital workers stuck with contaminated  
needles while treating patients with hepatitis B and HIV have been used  to 
suggest that hepatitis is much more easily transmitted than HIV, but these  
studies cover only transmission by blood.  It appears that sexual transmission 
occurs as easily for HIV as it does for hepatitis B.  There are documented  
cases in which hepatitis B has been transmitted by oral sex alone from men to  
men.

Many people believe that they can cut in half their risk of exposure to AIDS  
by cutting in half the number of their partners.  This is probably not true  
for people with a great many partners.  Last September an article titled  
"Hepatitis B Virus Transmission Between Heterosexuals" was published by the  
JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION.  The authors studied patients at  
a sexually-transmitted-disease clinic and students at a large university, and  
were careful to exclude all risk factors for hepatitis B transmission except  
sexual activity. Their findings suggested that although risk of infection  
increased with sexual activity, it increased in a nonlinear way.  In fact,  
there appeared to be a quantum dynamic at work.  Among the students the  
prevalence of hepatitis B infection was 1.5 percent for those with fewer than  
three recent partners and 14 percent for those with three or more recent  
partners.  For the patients at the clinic the risk of exposure to hepatitis B  
was the same whether the number of lifetime partners was one to twenty-four or 
twenty-five to forty-nine - but for someone with fifty or more lifetime sexual 
partners the risk suddenly quadrupled.

Because the sexual transmission of hepatitis B and of AIDS are so similar, the 
implications of this study are especially discouraging.  And while hepatitis B 
kills only one percent of the 25,000 people who are reported as having  
contracted it each year, 30 percent of those who have contracted AIDS have  
died already and the number is continually being adjusted upward.

There are people who worry with seemingly little to worry about and people who 
don't worry who seemingly ought to.  Only rarely does one find people so  
worried that they have changed their behavior.  And these people - in  
particular, uninfected heterosexuals who have stopped having casual sex  
because of AIDS - very often deprecate themselves, describing themselves as  
hyponchondriacal, irrational, paranoid, or neurotic.  There is no question  
that AIDS provides a good excuse for men and women who were afraid to enter  
relationships anyway.  And people who worry obsessively about germs now feel  
vindicated.  But the number of people making real changes seems slight, even  
in places where information about AIDS is readily available.

Last summer the San Francisco AIDS Foundation conducted a telephone survey of  
400 randomly selected heterosexuals, 60 percent men and 40 percent women, one  
third minority, two thirds white.  The subjects were asked to evaluate, on a  
scale of one to ten, how much impact AIDS had had on their sexual behavior.   
The mean response was four. Thirty-three percent said that AIDS had had no  
impact; 35 percent gave responses from two to five.  Two thirds of  
respondents, then, rated the impact at five or below. Respondents were asked  
what types of people they believed to be at risk for getting AIDS.  In San  
Francisco, with the largest per capita rate of AIDS in the country at the  
time, only seven percent of those surveyed said that sexual partners of people 
in risk groups were at risk.

Respondents were asked whether they had considered taking the antibody test,  
which has received enormous publicity in San Francisco. Five percent had taken 
the test and 31 percent didn't know it existed.  Of those who knew of the test 
but hadn't taken it, 22 percent said they might, and 77 percent thought it  was
unlikely that they would.

This first statistic is perhaps the most interesting.  A growing number of  
sexually active heterosexuals, especially in cities with a substantial  
caseload of AIDS patients, are considering taking the test.  Most states have  
test sites, partly subsidized by the federal government, where the test is  
administered at no cost and sometimes anonymously.  (Health clinics usually  
charge between $80 and $100, and at a private physician's office the fee can  
be as high as $300.)  Perhaps straight men and women are willing to take the  
test because they are less concerned about confidentiality and civil-rights  
discrimination than are gays.  In the New York City metropolitan area, where  
by the most conservative estimates of the health commissioner 500,000 people  
are infected, it is not unusual to find in one office several people who have  
considered taking the test and one person who already has taken it.

In one such office, a law firm in Newark, a thirty-two-year-old attorney was 
working one afternoon when a friend, a partner in the firm who is known to 
sleep with many women, came in and sat down, white as a sheet. "Did you hear 
National Public Radio last night?" he asked. "The World Health Organization has
written off -- completely written OFF -- four central African countries because
the level of AIDS infection is so high."

Don't tell me about Africa," she said. "What are YOU doing?"

Like many well-educated professionals who are sexually active, the man had 
become an AIDS encyclopedia without changing his habits. He knew the 
public-health budgets of several nations around Lake Victoria, the 
seropositivity rate among newborns there, and the results of every study of 
hepatitis among gay men in New York during the early 1980s. He had started to 
worry about AIDS a year before and had become really worried after a discussion
with some old friends several months earlier.

"I don't usually discuss sex with other men," he said later," but somehow we 
got to talking about how many women we'd slept with in the part ten years. I 
went first and said, 'Oh, about three hundred,' thinking that was perfectly 
normal. I was appalled when the other men spoke up and the closest anyone else 
came to that number was about thirty. I didn't know I was an aberration.

"This advice 'Know your partner' is just ridiculous. The idea that, given the 
incubation period for the virus, you might have to think back seven or eight 
years -- that terrifies me. I don't know the people I slept with then. I 
started doing some geometric progressions and figured out that I'd been exposed
to tens of thousands of people.

"My fear is intellectual, though. It doesn't translate into my daily life. I 
have talked about AIDS with my current partner, whom I've seen for about two 
years. I have thought how wonderful it would be to know for sure you were 
antibody-negative and then be strictly monogamous with someone else who was and
who you could trust to be faithful. I guess they used to call that marriage. In
essence she and I do have a kind of pact. ["In essence" meant, it turned out, 
that he averaged one sexual encounter a week outside the relationship, often 
with one of the women he already knew.] She and I discussed the possibility of 
our both taking the test, and rejected it for the obvious reason: one of us 
might not be negative, which would immediately end the relationship right 
there.

"For me, knowing the results of the test would only be good if it told me I was
negative. I am very frightened of the social aspect of the disease. The 
curtailment of sex would be the least of my concerns. I am more moved by 
affection than by sex. What I couldn't stand to lose would be the sense of 
connection, other people's good opinion of me. I'm afraid if I found out I was 
positive, I wouldn't want to go on living. I just can't take rejection. In this
case ignorance is bliss, although you can't allow ignorance to create a danger 
for someone else. So I know what I have to do" use condoms. Have I done it? 
No." (For all that he knew about AIDS, he did not know that a person could be 
infectious and have no visible symptoms, or that condoms were recommended for 
oral as well and vaginal sex.)

His colleague in the office planned to take the antibody test. When she called 
her doctor's office for an appointment, the nurse said disgustedly, "You don't 
have AIDS. Don't worry about it." For two years the woman had dated a man who, 
she believes, was bisexual. Now she is planning to donate blood in order to 
ascertain her antibody status -- an option many people hesitate to pursue, 
because it takes much longer to learn results and cases of seropositivity are 
often reportable to state departments of health.

These two attorneys often work with a fifty-four-year-old insurance-claims 
investigator. He has already taken the antibody test. He got married in 1974, 
but in 1985 he and his wife separated for eight months, during which time he 
had a girl friend and occasionally engaged in swinger group sex, which he had 
practiced regularly throughout the sixties and early seventies. The man tested 
negative. "If I had tested positive, I wouldn't have known how to conduct 
myself around my children," he says. There is so much the doctors don't know 
about contagion. These swingers, they're mostly professionals, and they think 
the scene is safe. They're just kidding themselves."

The magazines in which swingers advertise their charms and through which they 
make contact with each other are now full of assurances that the people in the 
photographs are "squeaky clean." The presidents of several swinger clubs around
the country insist that swingers are more conscious of hygiene and disease than
the average crowd at any singles bar, and that they are pre-screened in a way 
that isn't possible at, for example, a disco. "Everyone who calls me asks about
AIDS," says the president of a 400-member club in Chicago. "I tell them I'm not
a doctor. I can't screen people physically, but I can psychologically. I ask 
someone who wants to apply about their family background. I check out the way 
they dress, their educational level, their profession, and the rest."

"No one has taken the blood test in the group," he says. "There has been no 
discussion of suing condoms. Definitely, there has been a greater tendency 
toward oral sex lately, and anal sex was eliminated without anyone having to 
mention a word. I would say about twenty percent of the men are bisexual and 
seventy-five percent of the women. I noticed that people have been avoiding the
bisexual men recently. Everyone is questioning their swing partners more 
carefully, but no one is overly concerned. In five years we have had no major 
health problems." Such claims notwithstanding, reported outbreaks of sexually 
transmitted diseases in swing clubs in Minnesota recently led to a CDC study. 
One hundred and thirty-four members (seventy-five men and fifty-nine women) of 
swing clubs in the Twin Cities volunteered to be tested for HIV. None of the 
men but two of the women were positive.

Many single men and women across the country describe a kind of radar that they
think they have for safe or clean partners. The word PICKY comes up a lot. 
These people say that they know just what questions to ask at a first 
encounter. Quite often the accounts that they give of their own amorous 
histories do not jibe with reports from close friends and ex-lovers, especially
concerning the number of partners the people reporting have had, which they 
underestimate. William Darrow, a research sociologist at the CDC, says, "If 
I've leaned one thing in twenty-five years of this work, it is that people's 
anecdotal accounts of their sexual experiences aren't worth much."

HOOKERS AND JOHNS: THE FEELING IS MUTUAL

AIDS is only beginning to suggest to heterosexuals a perception that is now 
sadly familiar to gay men: any new lover is a potential perpetrator. That fear 
finds its collective expression in the panic surrounding prostitutes. In every 
city, when AIDS is first perceived as a local problems that has come to stay, a
story about prostitutes makes headlines. This usually concerns an 
antibody-positive woman who persists in conducting business, or the issue of 
mandatory blood tests for all arrested prostitutes.

Since the first European epidemic of syphilis, in the sixteenth century, every 
major outbreak of venereal disease has precipitated intense concern about 
prostitutes and the need for regulation, usually for purposes of medical 
inspection. In the nineteenth century, as the horrors of congenital syphilis 
became better understood, the campaign against prostitutes acquired the urgency
of a drive to prevent infection of innocent wives and children. The degree of 
concern was appropriate: prostitutes were unquestionably the primary source of 
trouble.

Matters have never been as simple since, as is explained in WOMEN AND 
PROSTITUTION, by Vern and Bonnie Bullough, the deans respectively of the 
schools of natural and social sciences and nursing at the State University of 
New York at Buffalo. In the Bulloughs' account recent outbreaks of venereal 
disease have had less to do with prostitutes than with the sexual freedom of 
women, the abandonment of the use of condoms, and the knowledge that 
antibiotics usually mean a certain cure for most venereal diseases. One group 
that has continued to rely on condoms for prophylaxis is prostitutes. It is not
at all clear that a man is at greater risk having vaginal sex with a prostitute
while using a condom than he would be having vaginal or anal sex with a woman 
he picks up at a bar, without using a condom. It is almost as if the obsessive 
fear of prostitutes reflected a romantic wishfulness for an earlier time when 
the danger was as easily identified as the red-light district. In fact 
prostitutes who are not drug users may have at least as much to fear from their
customers as their customers do from them.

Mandatory testing of arraigned prostitutes has become a controversial issue for
health and law-enforcement officials. "Why should we use taxpayers' money for 
the test, which is expensive?" asks Robert Landreth, the chief of the vice an 
narcotics division of the Las Vegas police department. "we're just making it 
easier for these men. The woman will just take the papers and wave them in some
new customer's face to show she's negative, or was. Everybody should assume 
there's a risk. In Las Vegas most of the girls and their pimps are on hard 
drugs. Lots of them are bisexual. So are lots of the customers -- which makes 
me worry about the secretaries from Los Angeles who come up for the weekend and
decide they want to pay for their trip back by picking up a guy."

Dr. Joyce Wallace, the president of the Foundation for Research on Sexually 
Transmitted Disease, in New York, has recently undertaken a study of clients of
prostitutes. Of the 101 men in her study three have tested positive. One of the
three reported more than 2,200 sexual contacts, and after four interviews 
finally said that he had once been the receptive partner in anal sex. ("In my 
experience," she says, "many men will say they've had sex with a dog before 
they'll admit to having had sex with another man.") Another reported more than 
a thousand contacts and admitted to having had sex with a man "once, in an orgy
setting." Wallace is skeptical of the third man's claim to be free of risk 
factors other than frequent sex with prostitutes.

The real problem among prostitutes is IV-drug use. Wallace estimates that a man
has a fifty-fifty chance of exposure to the virus in an unprotected encounter 
with a prostitute who is an IV-drug user. And it is the addict who is most 
likely to forgo a condom for a few extra dollars. Last year Wallace studied 100
prostitutes who were former drug users. She found that if a woman had quit 
using drugs before 1977, there was a 16 percent chance she would test 
antibody-positive;
if she had quit from 1983 to 1985, there was a 64 percent chance. In a more 
recent study, of high-priced call girls, only one tested positive, and she was 
a former-IV drug user.

This second study seemed uncannily to answer the question of countless men who 
use prostitutes: If I pay enough, can I be sure she's safe? It is a question 
overheard frequently these days by a men's-locker-room attendant at a 
casino-hotel in Las Vegas. "The customers come for gambling and girls like they
always did," he says. "AIDS hasn't stopped them from coming, but man, you can 
tell they are afraid of the women. There is a lot of talk about finding 
'high-class' hookers, no matter what they cost, if they know they are clean. 
You know, I have one old customer who's been coming for years. He won't use our
plastic slippers anymore -- he brings his own -- and he won't use the whirlpool
and sauna, but he's still screwing around, saying he'll pay a hundred more if a
girl is clean. It is a kind of Russian roulette about AIDS. They're all 
screwing around, but if a man who even looks effeminate walks into the locker 
room, everybody tries to walk all the way around him."

The old stereotypes of johns -- husbands seeking relief once the family is big 
enough, traveling businessmen, people with sexual fetishes, servicemen, men 
eager to enjoy sexual practices supposedly objectionable to their wives -- are 
still valid. But prostitutes and brothel operators describe a new phenomenon: 
young professionals who don't want to take time away from their budding careers
to cultivate serious relationships but who want to let off some sexual tension 
once a week or so. Many of the young customers are precisely the same men who 
on other nights frequent yuppie singles bars. A thirty-four-year-old salesman 
who divides his time between Manhattan and Mexico City says, "I'd much rather 
pick up a woman in a bar than see a prostitute, but in a bar my average is one 
in ten. With a prostitute, if you have the money, you're on -- and you can look
like the devil that night."

In WOMEN AND PROSTITUTION the Bulloughs write that historically, when epidemics
of venereal disease occur, prostitutes' business may decline in hard-hit 
cities, but it usually picks up again when the first panic subsides, while 
remaining unaffected in other places. Reports around the country confirm that 
pattern in the midst of the AIDS epidemic. Business is still what it was in 
most cities.

Any reports of a drastic falloff in business come, unsurprisingly, from New 
York and San Francisco, and may or may not portend a recession in the trade 
elsewhere. The accounts by hookers there concerning their remaining customers 
suggest that many of the people most in need of information about AIDS are the 
last ones to get it.

Donna is a twenty-eight-year-old who lives in the San Francisco Bay area. She 
left prostitution for cosmetology last year, because she was afraid of AIDS and
because it had affected business, which she says had decreased by 90 percent 
from two years before. "I had always been careful and used condoms for 
intercourse," she says. "In 1983 I started using them for blow jobs and stopped
performing anal sex. I was nervous about some of the customers and tried to ask
them if they had every slept with another man, but many of them seemed ashamed 
by the question or would evade it. I just never felt like I knew.

"At the same time I was getting more careful, so were some of the customers. 
Even men who had been coming for five or six years just wanted a hand job. 
Well, the fee for a hand job is twenty dollars, as opposed to a hundred dollars
for intercourse. I tried telling a few customers there would still be a 
hundred-dollar minimum, but they said, 'No way." Sometimes a guy showed up who 
wanted to get laid but could only afford forty or fifty dollars. A year earlier
I would have sent them away, but I needed the money so badly I took it. The 
poorer customers were less aware of AIDS. Some didn't even know the problem 
existed."

Two years ago Donna worked with one other prostitute in a house in Berkeley, 
where, although she had dropped her rates, she watched the number of customers 
drop from an average of twenty-five a day to five. "Also, I used to get a lot 
of couples, three to four a night. Usually they had taken drugs and wanted a 
little excitement. That business dried up completely. From 1979 to 1983 I had 
averaged between five hundred and seven hundred dollars a day. Last year I was 
lucky to make a hundred a day. I never stopped worrying about getting AIDS; I 
really thought I was going to die from it. When the blood test became 
available, I took it. Negative."

Donna went to New York to see if business would be any better. The competition 
there was even worse, and she didn't earn her plane fare back to California. 
"When I got home, I knew I wanted out, and I quit on new Year's Eve. A lot of 
women would like to get out of the business but can't do anything else. They 
can't even support their pimps anymore, and they are getting their asses 
kicked. If a woman wants a piece of what action is left, she is going to have 
to give a lot more emotionally than many prostitutes like to do. Women have to 
be more heartful, more giving, they have to get interested in the man, really 
think about what they are doing. You practically have to kiss somebody's feet 
to get them to come back.

It is hard to imagine a place where AIDS might be a boon for prostitution, but 
it exists. In the Nevada desert, about sixty miles outside Las Vegas, Cadillacs
and pickup trucks are lined up every day outside the Chicken Ranch brothel 
while customers wait in the parlor, on red-and-gilt sofas covered with plastic.
The Chicken Ranch is one of the legendary whorehouses in Nye County, where 
prostitution is legal, as it is in all but five counties in Nevada. At the 
brothels women have regular weekly medical inspections and are tested for HIV 
once a month. The discovery that a woman is using drugs means immediate firing.

About a year ago Russ Reade, the owner of the Chicken Ranch, initiated a novel 
house rule: customers must use condoms for all sex acts. Prostitutes were soon 
calling from all over the country looking for a job. Needless to say, the idea 
didn't catch on a quickly with clients.

"It was the toughest business decision I ever made," says Reade, a former 
biology and sex-education teacher from California. "I walk fifteen to 
twenty-five customers out the door every week, usually a hardhat who says, 'I'd
rather die than use a rubber,' The customers who walk out are usually from 
lower socioeconomic groups, which just reflects the different level of 
educational awareness. It is like watching the money walk out. But in the past 
few months I've concluded that my business has started to increase since AIDS 
-- men feel safer here -- so it all balances out. Some customers want to see 
paper proof of a woman's recent antibody-test results. Now between twenty-five 
and thirty percent of the customers call beforehand and ask if there are 
condoms available or if they should bring their own. Another brothel in the 
area, The Cherry Patch, is considering following our example.

"More and more of the men are asking for just hand jobs. They want the girls to
do little dances for them or fantasy plays. They want to masturbate themselves 
watching a girl perform a show. I've had groups of men come in, and when one 
guy's turn comes up, he'll go in and give the girl and hundred and fifty 
dollars, saying, 'I don't want to do anything, but don't tell the other guys.' 
It is all AIDS, AIDS, AIDS."

Describing the changes in business recently, Reade says, "It is clearer to me 
than ever before that men may think they see prostitutes for sex, but that 
isn't really the issue. They come for companionship."


BISEXUALS: IS HE OR ISN'T HE?

Each new study, it seems forces observers to discard one more supposition about
sexual practices in this country. Public-health official and private AIDS 
physicians around the country are struck by the presence of three different 
clinical subpopulations: Catholic priests; married gay men who do not want 
their spouses to know when they learn they are antibody-positive; and single, 
active bisexuals.

Health officials who deal with sexually transmitted diseases have long been 
aware of the frequency of homosexuality among Catholic priests. In the words of
one such official, "I and most of the public-health directors I've talked to 
about this subject estimate that in our communities at least a third of 
Catholic priests under forty-five are homosexuals, and most are sexually 
active. They almost always engage in anonymous encounters, the highest-risk sex
of all, and when they want help they don't come to clinics. I've met with 
priests in some of the strangest places." A county health department worker 
tells of going to a bathhouse to conduct syphilis testing and catching sight of
the priest who had given prenuptial counseling to him and his fiancee. "He was 
slapping on a towel when I walked in," the man says. "I pretended not to see 
him, and I think he did the same. Later I discussed it with my wife. To my 
surprise she didn't seem that upset. To her it seemed less like a violation of 
his vows than if he'd been having an affair with a woman in the parish. 
Bathhouse sex wasn't going to lead to a relationship." Even as the Church is 
toughening its stance on homosexuality, more and more priests are dying of 
AIDS. The official ticks off the most recent AIDS casualties that he has heard 
of among priests -- one in New York; two in San Francisco, two in his own city,
and a bishop in a nearby community; the obituary usually attributes the cause 
of death to some other illness, generally cancer. It seems only a matter of 
time before the situation will compel some acknowledgment from the Church of a 
reality it has chosen to ignore.

The potential role of bisexuals in heterosexual transmission of AIDS has been 
gravely underestimated. In the San Francisco AIDS Foundation survey of 400 
heterosexuals, seven percent of the women thought that their primary partner 
had had sex with another man within the past five years, and twelve percent of 
the men thought that their female partners had had sex with a gay or bisexual 
man within the past five years. In a separate survey of gay and bisexual men in
San Francisco, six percent of the respondents said that they had had sex with 
women within the past six month. In a study of 1,200 gay men in the Bay area, 
23 percent of the respondents reported that they had had sex with women within 
the past five years.

Some bisexual men fear that the disclosure of any history of past relationships
with men will turn a woman off. Perry is a forty-year-old masseur in Asheville,
N.C. Notorious among his friends as a man who sleeps around, he hardly sees 
himself that way. "I'm something of a maverick," he says." "I spend most of my 
time alone. What dating I do, I trust my judgment. I am extremely intuitive 
about people's wellness and their participation in their wellness process. I'm 
drawn to people who are in touch with their processes; I would intuit if 
someone had something as degenerative as the AIDS virus.

"I lived in San Francisco about eight years ago. I was in a place of 
questioning about my sexual identity. I had a gay experience for a while, 
working things out in my relationship with my father. Earlier in my sexual 
identity I had been tied up with my mother. During the past eight years my 
masculine identity has been coming out more. I don't think anyone meeting me 
now would know that experience had been part of my process.

"Whether I would tell a woman about my experience would depend on how much I 
trusted her. The fact that so much time has elapsed since I was in San 
Francisco makes me worry less. Besides, wellness is a process of being. I don't
buy into the Western-model germ theory that germs attack us. I am more 
attracted to the Eastern model, which has to do with a person's energy. Someone
may be AIDS-susceptible because of abuse of their basic wellness process. If 
you have a certain attitude, you draw things to you.

"The question of getting the antibody test flashed across my mind several month
ago. My intuitive reply to myself was, 'No I don't need to.' A year and a half 
ago I took a test for VD and was okay. I know that test is not specifically for
AIDS, but the results were in my consciousness. 

"One woman did bring up AIDS on a date. It was in her consciousness. I told her
my approach about germs. She has to deal with that." He did not mention his 
experience in San Francisco to her. "I would be very protective of myself 
before I gave that information to someone," he says.

Bisexuals have always been the big problem in tracing sexually transmitted 
diseases, according to Rick Reich, who spent several years working as a 
venereal-disease case investigator in Los Angeles before moving to Nevada. "In 
my experience," he says, "a certain kind of bisexual man is not immoral but 
amoral as regards sexual candor. He is less apt to fell the guilt or conflict 
that a gay man might going both ways." Dr. Marcus Conant, of the California 
AIDS Task Force, has also given a lot of thought to the potential role of 
bisexuals in the epidemic. He says, "If one point could be gotten across to the
ladies: just remember, a good-looking man is good-looking to EVERYBODY."

Of course, many bisexuals are frank, and a great many women -- more that is 
commonly realized -- are content with the knowledge that a lover may 
occasionally need another kind of satisfaction. Jill is a forty-year-old 
teacher in Little Rock, Arkansas. "I got married when I was eighteen," she 
says. "I found out after I divorced, twelve years later, that my husband was 
bisexual. I didn't have sex for seven years and just raised my child. Then I 
went back to school and made a nice friend in my class, who turned out to be 
gay. He invited me to the bars with some of his friends. I was petrified at the
possibility of socializing again, but thought, 'Well, I'm not ready to date 
again, but it would be fun to have a few beers. The gay bars would be a nice 
start. Nobody will bother me.' Boy was I wrong. I probably got propositioned 
more than the gay men I went with. I could have had three men every night."

At one of the bars she met John, who had been closeted until he was 
twenty-eight. They began to date. "it was an awakening for me. I had been a 
straight missionary-position type until I met John," Jill says. "I think 
bisexual men are more caring, tender, and they are not into a macho role that 
much. They know how to make love." She had a few affairs with other gay men she
met. John had a few more encounters. Last year he developed a rash and took the
antibody test. He tested negative. He had only a few encounters after the test 
before asking Jill to marry him. "I was really surprised by the reaction of our
gay friends, surprised how many of them said they wished they could get married
if they could meet the right person," Jill says. She and John have a pact that 
either one of them can have extramarital relations. John says that the fear of 
AIDS has prevented him from considering a fling. Jill says that she has no 
desire to be involved with anyone else.

"I have thought about taking the test," she says. " guess I figure that if John
has it, I have it. If I'm going to get it, I'm going to get it. I'm not afraid 
of death. Also, I would take the test if I hadn't had a hysterectomy -- I 
wouldn't risk getting pregnant and giving this to a baby. I am in hopes that 
John will start using condoms before we have to take the test.

"I'm afraid not too many of our friends practice safe sex. We have several 
friends with AIDS. A good friend of mine had sex with a woman yesterday -- and 
he is usually a basic bottom [the receptive partner in anal sex] with me. They 
didn't use condoms. even when I hear anything about AIDS on television, I feel 
like crying. I guess I now feel like the gay community is my community."

The painful dilemma of closet gays has already become a major theme of the 
epidemic. Less will be heard about another group, who might be described a 
closet straights. AIDS gives gay men a powerful motive to examine the sources 
and strength of their commitment to their sexual preference.

Until 1973 the American Psychiatric Association officially regarded 
homosexuality as a pathology. Soon after the APA abandoned that 
characterization, the concept of androgyny came into vogue -- the notion of a 
more fluid line between gay and straight orientation and the possibility of 
identifying male and female characteristics in both men and women. A new scale 
was suggested as a replacement for the Kinsey 0-6 scale (0 being completely 
heterosexual, 6 being completely homosexual, in fantasy, practice, and 
preference; almost no one was a 0 or a 6). The proposed alternative involved 
two separate measurements, first of a person's attraction to members of his or 
her own sex and then of that person's attraction to the opposite sex. One 
person might have a very low level of both and be contentedly celibate, while 
another person might be strongly inclined in both directions.
Even in the golden days of gay liberation, the seventies and early eighties, 
therapist reported significant numbers of patients practicing homosexuality who
wished to change their sexual orientation. In 1980 the APA's DIAGNOSTIC AND 
STATISTICAL MANUAL officially listed a diagnosis called ego-dystonic 
homosexuality. In Freudian terminology, behavior patterns that suit the ego are
called systonic and those that cause conflict are called sytonic.

The Masters and Johnson Institute, in St. Louis, Missouri, has been treating 
ego-dystonic homosexual patients since 1964.  Dr. William Masters reports that 
the number of inquiries about the program has jumped in the past eighteen 
months. Most of the patients participate in a sexual-readaptation program whose
final stages involve sex coaching with a female partner. Some need only 
intensive counseling sessions. "Frequently the men have convinced themselves 
that they are gay, been labeled gay at an early age by peers, or are late 
bloomers who have little sexual experience of any sort," Masters says. "But all
of them are less than charmed with their homosexual preferences and have really
secure reasons for change beyond fear of public opprobrium" He won't quantify 
the prevalence of ego-dystonic homosexuality beyond saying, "there's a lot of 
it out there, and it shows up in about fifteen percent of the gay men who come 
to the clinic for all different reaons."

Fears, questions, and misconceptions about AIDS come up frequently at the 
clinic in other therapy settings, which doesn't surprise Masters. "We have 
spent twenty-five years trying to disabuse people of their inhibitions about 
discussing sexuality, and apart from the fact that people are slightly more 
comfortable with the subject -- AIDS wouldn't have been mentioned out loud 
twenty-five years ago -- it is as if we made no mark at all. The response to 
AIDS has only underscored the depth of our frustrations here."

FATALLY MISINFORMED

The Government has often been accused of squeamishness regarding AIDS. If there
were one subject about which federal officials might be expected to overcome 
their reticence, it would be AIDS in the armed forces. Indeed, discussions of 
mandatory antibody screening of all military personnel began a year ago. Last 
year more than 400,000 prospective recruits were required to take the antibody 
test; 1.5 per thousand tested positive. Yet pre-induction screening would seem 
to be inadequate without regular mass screening on the bases, because many 
young men begin to engage in high-risk behavior only after they are in the Army
-- whether it be drug use, homosexuality, or seeing prostitutes.

In the past, efforts to regulate and inspect prostitutes have been initiated 
largely by the military, both here and in Europe. Venereal disease has always 
been an urgent concern for armies, being the primary reason for absenteeism. 
During successive wars the focus gradually shifted from regulation and 
examination of the prostitutes to education and inspection of the troops. "The 
chaplain said, 'Don't do it,'" Vern Bullough says. "Then the medic got up and 
said, 'Don't do it -- but if you do, here are a few tips.'" Men who remember 
their term in the Army in the Second World War insist that syphilis seemed no 
less a scourge than AIDS does now. It is now known that only a quarter of 
untreated syphilitics die, and many people die of natural causes without ever 
knowing they were infected, but these facts were not common knowledge then, and
prior to the introduction of penicillin a serviceman was indeed taking big 
chances when he went to a prostitute. Venereal disease was a major problem on 
bases everywhere, despite mandatory contact notification and an intensive 
education campaign. (A typical Army poster showed a harlot walking arm in arm 
with Hitler and Tojo under the caption "VD -- THE WORST OF THE THREE.")

With AIDS the issues extend to drug use and homosexuality, neither of which the
military much likes to address. The myth persists that hay men wouldn't be 
interested in joining the Army, when in fact the Army has traditionally 
provided a place for young gay men from small towns all over the country to 
make their first contacts.

A doctor who practices near the large Army base at Fort Bragg, North Carolina, 
believes that "cases are just incubating away out there." The reports of a few 
men stationed at the base support this impression. "When I came to Fort Bragg, 
almost two years ago, this place was a madhouse," says one young recruit. "IT 
was wild. Outside any bar on Bragg Boulevard the girls were lined up in cars, 
waving at you. There are fewer prostitutes around the base. Sure, some guys 
still see them, but if they've got the slightest little cold or stomach ache 
the next day, there are down at TMC [troop medical clinic] in about five 
minutes. That's what happened to my roommate, and he said, 'That's it for me.'"
There is still a lot of VD around here. Most men won't talk about it, though a 
few guys still think it is a status symbol. 'I've had it six times, mine almost
fell off' --
that sort of bragging, but it is changing.

"There is some talk of AIDS around the base. They might be giving the AIDS test
to everybody [he didn't know that some testing had already begun], and most 
people seem to think that is a good idea. There are some pamphlets about AIDS, 
but most guys say they'd like more specific information. Like, I know there is 
something about needles but I don't know what it is. They've got a bad drug 
problem here. I'd say about an eighth of the men are on hard drugs, and a lot 
more have tried it. They have been giving blood tests for drugs since I got 
here. You'd be surprised how many guys on drugs think they're going to take the
drug test but it won't show anything. They can somebody instantly for drugs. 
[[sic]]

"The problem is that everybody gets so bored. And there are no women. The 
message is, 'Get married or forget it.' You have to have some female company 
sometime. The situation creates a lot of homosexual behavior, which is the one 
subject nobody wants to talk about around here. They'll tell you about clap or 
prostitution, but nobody wants to talk about the gay stuff. What do they 
expect? Put four guys together sleeping in a tiny room, the very same guys you 
work with all day. It is too much for some people.

"I was on CQ [control of quarters] one night and a guy came running downstairs.
He was in tears, saying his roommates were in bed together. Let me tell you, 
those two were out the next morning."

Another serviceman confirms the drug problem on the base but thinks that people
know a fair amount about AIDS. "One guy in our area has it," he says. "The 
chaplain told us, and the reason the chaplain knew was because this guy was 
engaged and was afraid to tell his fiancee. But the chaplain wouldn't tell us 
his name, and I thought, 'That's nice, chaplain, that's real nice, but it 
sucks.' Because what if I keep shaking this character's hand repeatedly, not 
knowing who he is, and I catch it?"

Ignorance about AIDS has varying consequences. In the case of most people, it 
means treating those they suspect to be potential carriers rudely or worse. In 
the case of young servicemen, ignorance may lead to serious trouble. In the 
case of sexually active gay men, it is a tragedy -- as it is for poor black and
Hispanic youths, among whom there is a nationwide epidemic of venereal disease,
which is a certain cofactor in facilitating transmission of HIV. This in 
combination with the pervasive use of drugs among blacks and Hispanics ensures 
that the epidemic will hit them hardest next.

Medical professionals, to whom the majority of people turn for answers about 
AIDS, are themselves uninformed. A twenty-eight-year-old personnel director in 
Hoboken, New Jersey, says that she recently took the antibody test and was told
by her doctor that the negative results were meaningless. "You may have had sex
with someone five years ago and not manifest antibodies till five years from 
now," he told her. (It can take as long as a year to seroconvert, but not ten 
years.) A twenty-nine-year-old real-estate salesman in Pine Bluff, Arkansas, 
reports that his doctor talked him out of taking the test "because it would 
flip the technicians out." The doctor said he had talked another man out of 
taking the test that week, after making sure he wasn't gay. "He said he would 
have given him the test if the guy had been gay," the salesman says.

Sometimes ignorance about the disease, combined with irrational fears and, 
often, guilt about extramarital sexual activities, can lead people to develop 
psychosomatic symptoms of AIDS. Dr. Samuel E. Pegram, of Bowman-Gray School of 
Medicine, in Winston-Salem, claims that doctors are especially susceptible to 
this so-called AIDS-phobia. "Any of us who treat AIDS patients at one time of 
another come down with symptoms that look like AIDS," he says. "But beyond 
that, I have been amazed at the number of colleagues who never had anything to 
do with AIDS patients who felt perfectly well until they started thinking about
it."

Another prominent AIDS physician in the South recalls the case of one doctor 
who was about to get married. "He had worked near New York City in the late 
seventies, where he'd picked up a few girls in the shopping malls and gone to 
bed with them. Now he was convinced that he had AIDS. Nothing I could say made 
any difference, and he worked himself into such a state that one day he showed 
up in my office with skin lesions and a coated tongue. Now he absolutely knew 
he had AIDS and insisted that I give him the blood test. To put his mind at 
rest, I agreed. Well, almost unbelievably -- he must have had a slight cold or 
infection -- he tested in the positive range by a hair's breadth.

"He became hysterical. We gave him a second ELISA test and the more definitive 
test, the Western blot, both of which are routinely given for any positive 
result, and cultured his blood. Everything came back negative. Next morning he 
followed me around the hospital with a stack of articles about the incidence of
false negatives. Finally --
I'd seen this coming -- he told me he wouldn't get married until his fiancee 
took the blood test. She called, and I told her that under no circumstances 
should she give in to the pressure. They eventually got married and everything 
is fine, but that sort of hysteria is not unusual."


A CITY MOBILIZES
Until the Federal Government decides to oversee and coordinate AIDS information
campaigns everywhere, each community must take action in its own time and way. 
It falls to a few people in each city to wade through government-grant 
applications, CDC reports, and local demographic statistics; they must then 
decide where and how to begin presenting as a legitimate threat a disease that 
is still an abstraction to most people. The mobilization of a particular town 
or state often has less to do with the local incidence of AIDS than it does 
with the response of local public-health officials, the degree of unity and 
awareness among gay men, and local ethnic and religious traditions. Minnesota 
has only about 148 reported cases of AIDS, yet the state's education and 
prevention campaign promises to be a model for other public-health officials 
facing what might be called the second stage of the epidemic. 

Minnesotans, with their tradition of Scandinavian civic-mindedness, pride 
themselves on dealing with problems quickly, effectively, and unhysterically. 
"Our ethnic heritage makes us less volatile," says Dr. John Weiser, a family 
physician in Minneapolis and a member of the state health commissioner's task 
force on AIDS. Invoking the region's agricultural history, people talk of 
constructing floodgates, of digging firebreaks, of shutting the barn door 
before the horse gets out. AIDS educators try to take advantage of traditional 
community settings to get the message across. The Minnesota AIDS Project spent 
months trying to secure a booth at the state fair, which 500,000 Minnesotans 
visit each year. Members couldn't quite figure out why, finally, they were 
relegated to the horticultural building rather than assigned a place in the 
education building with other community groups. "Maybe they thought it was a 
kissing booth," says a member of the Project.

It was the kind of bureaucratic slight that could have caused a confrontation 
in San Francisco a couple of years ago, but the gay scene in Minneapolis is not
as politicized as it is in the Bay Area. In fact, AIDS has make it clear that 
there is a true gay community in just one city in America. Across the country 
openly gay men forming AIDS organizations in their communities say that their 
main problem is that most gay men are married and closeted or may not think of 
themselves as gay at all, despite occasional encounters in public washrooms, 
adult bookstores, or highway rest stops. In the Minneapolis area openly gay men
-- of whom there are approximately 6,000 along with approximately 100,000 
closeted gay men-- are  unusually well integrated into the general community. 
Minneapolis has had gay-rights legislation for nearly ten years; similar 
legislation did not pass in New York City until last year. Gay leaders invoke, 
again, the Scandinavian ethic: what you do is your own business --
just don't make a big deal of it.

The attitudes of Twin Cities residents toward AIDS are probably a good 
indicator of what thoughtful, well-informed people in America know about the 
disease. Last year the Minneapolis STAR AND TRIBUNE conducted an AIDS survey of
its readers. Nearly three quarters of the respondents agreed with the statement
that AIDS has spread so much that it is now a threat to the American public. 
Forty percent, however, thought the disease could be spread through kissing 
forty-seven percent thought that donating blood was a way to catch AIDS -- 
still the most common misconception. Yet despite holding these beliefs, 
approximately nine out of ten of the respondents said that they do not worry 
about getting AIDS themselves. The public's simultaneous perception and denial 
of risk undoes health officials.

"Now is the time to really move, if in ten years Minneapolis isn't to have the 
problem that San Francisco has," say Michael Osterholm, the state 
epidemiologist and one of the chief designers of the state's AIDS program. He 
emphasizes the importance of education but says that the paramount lesson that 
he has extracted from San Francisco's experience with AIDS is that education 
does not appear to be the decisive factor in producing changes in high-risk 
sexual behavior. He points to a study by the San Francisco psychologist Leon 
McKusic of gay men in San Fransciso, which began in 1983. At the start of the 
study the participants' level of education about safe sex was extremely high, 
and yet many well-informed men had made little of no change in their sex lives.
Of those who had, many were people who had a vivid memory of someone in the 
advanced stages of AIDS. "Education on disease prevention has never been enough
in and of itself," Osterholm says. "The issue is first finding a way to make 
people aware of their vulnerability."

Denial is rampant. Physicians and psychologists describe many men who have 
remained antibody-negative after several years of unrestrained sexual activity 
and have taken their good fortune to mean that they have some special 
resistance to the disease and can continue as before. It is difficult to foster
a sense of vulnerability in someone whose risk behavior is a compulsion. This 
is especially a problems with IV-drug users. Dan Cain, the executive director 
of Eden House, the city's best-known drug-rehabilitation program, believes that
drug addicts are going to be the biggest "crossover" in bringing AIDS to the 
general public in Minneapolis. He is one of many drug-abuse authorities 
nationwide who are concerned about cocaine users, many of whom are young 
professionals -- the last people one usually associates with shooting up. A 
recent survey by the National Institute of Drug Abuse revealed that 80 percent 
of all cocaine users have taken the drug intravenously.

At Eden House, Cain holds monthly seminars on AIDS and distributes 
health-department brochures on cleaning needles and safe sex. But he groans at 
accounts of halfway-house programs in San Francisco that distribute bleach to 
addicts to clean their needles. "Look," he says, "I'm happy to distribute 
pamphlets and have seminars, but I am here to get people OFF drugs. Most 
addicts don't know that in Minnesota you can buy needles over the counter; it 
doesn't become illegal till they are used for drugs. So am I supposed to tell 
people, Hey why not go down to the drugstore and pick up a bag? I just don't 
feel right doing that." 

Defining the line between education and promotion is similarly complicated for 
AIDS information on sex. Such efforts in Minneapolis, as everywhere else, are 
being partly shaped by events at the federal level. In the summer of 1985 the 
CDC invited applications for "innovative risk reduction" proposal grants. The 
proposals came flooding in. Innovative they were, but many were so sexually 
explicit that the CDC decided that taxpayers had to be involved in evaluating 
their suitability. The release of federal funds to any community for 
educational projects or materials was made contingent upon majority approval of
the materials by a panel of local advisers that reflected a cross section of 
the community. It was not to be dominated by gays.

Many studies from San Francisco and a recent report from the CDC suggest the 
impossibility of reaching all groups in a community with a single campaign. 
"For example, with Latinos, you try to reach family structures and health 
provides," says Holly Smith, the information director of the San Francisco AIDS
Foundation. "With blacks, you have to communicate through the churches, and 
with gays of course you need the bars." The Surgeon General has urged mandatory
sex education, which now exists in only New Jersey, Maryland, and the District 
of Columbia. Overnight, AIDS is supposed to force the hand of opponents of sex 
education. Yet even in San Francisco, where such a program is well established,
it has taken nearly two years for a pilot AIDS course plan to be distributed to
a sampling of city teachers. In most places the trick will be to warn children 
about AIDS without teaching them about sex.

The perception prevails across the country that gays -- either because they are
of a different sensibility or because they are at higher risk, depending on 
whom you talk to -- can take, need or deserve more sexually explicit materials.
Those trying to distribute AIDS educational materials in Minneapolis agree that
closet gays will resist messages directed specifically at homosexuals. And the 
heterosexual population is to be educated but not alarmed. So a gay newspaper 
might carry a steamy ad of a nude man stepping into an oversized condom and 
pulling it up the way a woman might slip into a dress. With the large 
population of closet cases in mind, the Minnesota AIDS Project has developed a 
series of ads featuring good-looking athletes -- a cyclist, a mountain climber,
a skater --
wearing safety gear, with the caption "PLAY IT SAFE." These and other ads for 
the general public suggest, "Choose partners you can trust and practice safe 
sex."

The Minnesota AIDS Project is currently trying to persuade the city's 
metropolitan transit authority to accept two bus ads that contain the word 
CONDOM. "You can see the situation the AIDS has put public-health officials 
in," Michael Osterholm says. "Do we say 'Use condoms?' Do we say, 'Here's how 
you put on the condom. This is the shaft ...'" ? Besides, while condoms are 
important, they are not fail-safe. They are only going to slow the epidemic 
down, they are not going to stop it. Someone may avoid exposure for two years 
and then be infected two years from now. Anyone who is sexually active runs the
risk of being exposed to the virus sooner or later. The issue is multiple 
partners, though nobody wants to hear that, and as for anyone who says it too 
often, it is 'Shoot the messenger.'"

Skeptical about the impact of broad-based education campaigns alone, Osterholm 
became convinced last year that the most effective strategy to employ against 
AIDS would be to zero in on the most sexually active individuals in risk 
groups, and the blood-test sites seemed the place to do it. Most important were
people who tested antibody-positive. "It is probably more important to reach 
one positive individual than ten who are negative," he says. The best bet 
seemed to be to counsel antibody-positive people and then to encourage them to 
notify as many of their sexual partners as they can remember, or to offer to 
perform that service for them. Such a program has been in place for about half 
a year. If a person opts to have the Minnesota Department of Health notify his 
or her contacts, the record of their names is destroyed within six months after
they have been notified of the risk of exposure and advised to take the 
antibody test.

The effectiveness of the program has mitigated the initial concerns of some gay
leaders about potential breaches of confidence. Osterholm maintains that the 
state Public Health Service has been notifying contacts in syphilis cases for 
nearly a century and has an excellent record of not releasing data. He also 
point out that of the 11,000 Minnesotans tested in the first year, the majority
chose to go to their private physicians rather than to the test sites, and 
physicians must report any antibody-positive person by name to the Department 
of Health.

The number of people being tested in Minneapolis rose sharply after an incident
last spring. WCCO-TV, in the Twin Cities, co-produced a documentary about 
Fabian Bridges, a man with AIDS who, it emerged in the show, continued after 
his diagnosis to have sex and sometimes solicited it. The morning after the 
show was shown at a local town meeting, Caroline Lowe, a reporter for WCCO, 
received a phone call from a man named Stan Borrman, who said that he was a 
former male prostitute and that he was calling to ask that the station look 
into the prostitution agency he'd worked for, whose owner, he suspected, was 
infected with AIDS and had men working for him who were antibody-positive. Lowe
asked Borrman his own antibody status. It was positive. In fact, he had ARC or 
AIDS-related-complex, which often leads to AIDS. (Because the greatest amount 
of virus can be cultured from ARC patients, they are believed to be the most 
infectious.) He had had more than a thousand partners in the three and a half 
years since he had become ill, and didn't know how much earlier than that he 
had become infected. Borrman, an alcoholic and drug addict, practiced safe sex 
with customers when he was "sober" but couldn't remember what he did when he 
wasn't Finally he'd decided he couldn't go on, confronted his boss, and quit.

Borrman told Lowe that most of his customers had been suburban married men. He 
agreed to do an on-air interview, partly in hopes that clients would recognize 
him and go in to have antibody testing. The interview produced all kinds of 
frantic calls, including one from a woman who had once seen Borrman with her 
husband. Her husband had told her that Borrman was a new employee. Borrman 
entered a chemical-dependency treatment clinic. He told the reporter that 
throughout his years of seeking treatment he'd been amazed at how many 
customers' faces he had recognized among the counselors, doctors, and 
officials. Several times he urged Lowe to take the antibody test herself. "You 
can never know about your husband," he said.


FEAR AND DESIRE

Intimate freedoms are at stake. The gay community's experience with AIDS has 
already produced two equally unsatisfying redefinitions of sexual liberation. 
Last August the NEW YORK NATIVE, a gay newspaper, published an article titled 
"High Risk Sex as Existential Choice," by R. William Wedin, Ph.D. Wedin set 
forth the story of Sam, a young man whose physician had refused to treat him 
any longer, dismissing him as suicidal because he had decided to continue 
having anal sex with his longtime lover, though both he and his partner had 
been promiscuous as recently as four years earlier and neither had yet taken 
the test. Acknowledging that there may well be a suicidal element, among 
others, in the sorts of health-jeopardizing behavior that people continue to 
engage in, Wedin concluded by asserting that for many men like Sam, choosing to
persist in high-risk sex while being aware of the potential consequences may be
"a statement of selfhood ... a song for the soul." Writing on the occasion of 
Sam's death, Wedin reflected that such men may be "tragic heroes all.... Not 
because they covet death or see in it a masochistic 'high,' but because, after 
sober study and thought, they arrive at that moment which, according to 
Aristotle, can only be described as one of 'are.' When they realize that they, 
if only they, must risk even their own annihilation in order to BE. To be as 
well as exist. To be whomever they choose to be...."

Dr. Marcus Conant offered a radically different view in a letter to the San 
Francisco BAY AREA REPORTER, a gay newspaper. His message was simple: If you 
don't want to catch AIDS, don't expose yourself to the virus. Given the fact 
that safe sex is not always possible -- condoms break or leak, straights want 
to procreate sometimes -- a person to whom AIDS is the primary concern has two 
choices. He can find a partner with the same antibody status as his own and 
practice safe sex as much as possible, or he can be celibate, and hope that a 
cure or vaccine appears soon. It was advice he had offered before: "Take up 
mountain climbing, write the great American novel, just give it up."

The newspaper responded to the letter by publishing an editorial called "Get 
Thee to a Nunnery," which began, "Dr. Stangelove is back...." The celibacy 
question provoked yet another round of debate in the gay community at large. 
Certain AIDS activists suggested that people so inclined to promote celibacy 
might have "separate grief issues" they weren't acknowledging and might fear 
intimacy as a result of having lost so many loved ones.

The questions Wedin and Conant pose, now writ large for the gay community, will
eventually become meaningful to heterosexuals. In fact, sides are already being
taken in the discussion about straights and AIDS. In a PLAYBOY editorial last 
year, the editors responded to advice that the sex expert Dr. Helen Singer 
Kaplan had offered to single women in a magazine article "Remember, no casual 
sex ever again." The editors wrote, "It's a good idea to forget about anonymous
sex, but how far do we have to go?....When two people meet for the first time 
and spend an intense, nerve-tingling day and a half together, with no intention
of buying a house, having children or taking a mortgage on a condo, is that 
casual sex?" In other words, weight the risk against the anticipated pleasure. 
But considerations are seldom so clear. In the face of AIDS, the impulses 
toward promiscuity and celibacy coexist in many women and men, and the tugs of 
attraction and fear, desire and mistrust, come into play simultaneously.

For great numbers of people, even for many of those who worry about AIDS, the 
prospect of an orgasm in ten minutes eclipses any thought of the next twenty 
years of their lives. The notion of "safe sex," or, perhaps more accurately, 
"safer sex," looks like their brightest hope, and the more specific information
they can get, the better. Much of it is likely to come from the increasing 
number of people with a commercial interest in the promotion of safe sex.

Condom sales have reportedly risen in the past two years, although 
manufacturers will do anything not to acknowledge the role of gay men in their 
sales and are clearly determined to avoid association with homosexuality. 
Increases have been observed in the sale of spermicidally lubricated condoms, 
such as the Sheik Elite and the Ramses Extra, produced by Schmid Laboratories. 
There are only a few such products on the market; other manufacturers are 
assessing the potential impact of the Supreme Court's decision to let stand a 
judgement by a New Jersey court, which awarded over $4 million to a couple who 
claimed that nonoxynol-9 had caused birth defects in their baby daughter. The 
issue of product liability will remain a major problem in combating AIDS, less 
in relation to prophylactic products than to vaccine and drug development.

One official of a pharmaceutical company that recently ceased distributing a 
line of condoms questions the reports of a boom in condom sales because of 
AIDS. "We never realized a penny on the product," he says, pointing out that 
most of the publicized sales figures come from the condom industry. 
Fluctuations in sales may be due to the removal of IUDs from the American 
market, homosexuals' fearing AIDS, or women -- most of them married -- reaching
an age when discontinuing the Pill is recommended. Still, most industry experts
might say that the company got out of the business too soon, claiming that AIDS
has done for condoms what herpes never managed to do. "We can't look like we're
gloating over the situation," says a senior vice president of marketing for one
manufacturer. "Besides, even though STDs [sexually transmitted diseases] are 
certainly one reasonable substrategy in marketing condoms, if we go that route 
and a cure is found in one year, where are we going to be?" Advertisements for 
one line, LifeStyles, refer specifically to AIDS and picture a distraught 
woman. It remains to be seen whether the grim text ("I enjoy sex, but I'm not 
ready to die for it") will attract or repel consumers, and how significant the 
increase in condom sales will be.

To gather information for marketing purposes, various manufacturers have held 
round-table discussions with women about condoms. Participants' concerns are 
predictable: they worry that men will prefer that they put on the condoms but 
that they won't be able to do it deftly or that a man they're dating will lost 
interest if they insist on condoms. Men's feelings range from not minding 
condoms at all to actually preferring no sex to sex with them. In the San 
Francisco AIDS Foundation survey of heterosexuals, people were asked to rate 
different sexual activities on a scale of 1 to 10. The group as a whole rated 
vaginal sex with a condom at 4.9, oral sex at 6, vaginal sex without a condom 
at 9.2.

Many prostitutes learn to put a condom on with their mouths and take it off 
without a man even knowing. The ability to use condoms skillfully, safely, and 
spontaneously will soon become important to many more people. One of the big 
problems with educational materials about sex and AIDS is that they tell people
what not to do -- don't exchange bodily fluids -- but fail to suggest what they
can do instead. Inspiration must supplement education, and it appears to be on 
the way, coming from unexpected quarters.

"Some education is going to have to reach the level of pornography or your are 
going to be missing enormous numbers of people who are definitely at risk," 
says Jim Mitchell, one half of Mitchell Brothers, the country's best known 
adult-film producers. The Mitchells have recently released BEHIND THE GREEN 
DOOR: THE SEQUEL, the first safe-sex porno film. Last summer it was the 
number-one adult-film home-video seller in the country.

Throughout the film plastic gloves are squeaking, vibrators humming, spermicide
flowing. One critic suggested that the film was about as titillating as 
open-heart surgery. "It got a GREAT review in SCREW," Mitchell says curtly. "It
is a start." He acknowledges that because the film was designed as model for 
other pornographers, the education message may be too strong. The brothers' 
next venture into "latex sex" films, he says, will be "a lot more molten." 
Mitchell is quick to admit that he and his brother pursued the safe-sex angle 
in part because they didn't want to face lawsuits one day from start claiming 
to have contracted AIDS while working on a Mitchell Brothers film.

The star of BEHIND THE GREEN DOOR: THE SEQUEL, twenty-four-year-old Elisa 
Florez, whose stage name was Missy Manners, has attracted more attention than 
the film itself. (Since Judith Martin, the "Miss Manners" columnist, filed a 
cease-and-desist order, Florez has gone by the name Missy.) The daughter of a 
prominent Republican, she is a former staff member of the Republican National 
Committee, Senate page, and staff member for Senator Orrin Hatch. Florez, who 
was featured in last month's issue of PLAYBOY, may become the pinup girl of the
epidemic. "We don't usually do porno stars," says PLAYBOY's photo editor, Gary 
Cole. "But she came in wearing this angora sweater with pearls all over it, 
handing out her little safe-sex kits, and everybody just about fell over. She 
is the furthest thing from a porn queen." The PLAYBOY feature focuses on 
Florez's background rather than her safe-sex message. "We wanted to be careful 
not to be seen as endorsing something," Cole says. "Besides, the message seems 
to be that the only safe activity left is talking dirty on the phone." (Cole 
may have the kit; he hasn't seen the movie.)

Florez has spent months promoting the film and the safe-sex message. "The 
government just isn't about to do it," she says. "I remember sitting in on 
Senate hearings a few years ago where funding was cut for Planned Parenthood 
because some senators objected to the explicitness of the sex-educations films 
for teenagers. Well, we're out to reach people who are promiscuous, have 
multiple partners, and still want to live their fantasies. It's a dirty job -- 
dirty enough for pornographers."

Florez concedes that safe sex hasn't caught on in the pornographic-film 
industry yet and says she knows of many gay actors who are still making 
straight-sex films, bisexual films, and gay film. During the filming of BEHIND 
THE GREEN DOOR, she says, she was "terrified of possible exposure" and insisted
that each of her partners wear two condoms in case one broke. "First I put the 
nonoxynol-9 on the man, then a condom, then more nonoxynol-9, then a condom," 
she says. "In fact, a lot of men say they like the sensation of two condoms 
better than one. More friction."

Speaking before women's groups, Florez dispenses information approved by the 
San Francisco AIDS Foundation and other groups that sponsor safe-sex education.
"Never use oil-based products, like Vaseline Intensive Care, Crisco, or baby 
oil, with a latex condom, because it makes the latex porous and nullifies the 
worth of the condom against the virus." In every group, she says, one woman 
invariably raises her hand and timidly asked, "Ohhh, Missy, how do you 
negotiate safe sex with your partner?" "I just say, 'Negotiate, bullshit. If 
you take off your panties, you take out a condom.'"

Her next project is to see that every buyer of the BEHIND THE GREEN DOOR video 
also receives a complimentary Missy Safe-Sex Kit, which includes a pair of 
latex gloves, a packet of nonoxynot-9, several types of condoms, and a "dental 
dam" -- a six-by-six-inch square of thin latex, to be spread over the vaginal 
area during oral sex -- plain and chocolate flavored.

Strange days -- and night -- lie ahead. It is true that there are still only 
about 1,100 cases of heterosexually transmitted AIDS. But it is also true that 
there were fewer than a hundred three years ago. The same numbers can be used 
to make a case for worrying or not worrying. Whatever happens, people will 
never get enough of tales of the epidemic, any more than they will tales of 
American slavery or of Nazis and their captives: the subject is subliminally 
pornographic, at once appalling and erotic. There is a certain excitement in 
having a legitimate reason -- even a responsibility -- to discuss in public 
what nice people have never discussed.

As the incidence of AIDS continues to rise, so will panic. But if fears, 
federal funds, and education alone are sufficient to alter people's most 
private habits, it will be for the first time ever. The changes that people at 
risk have been willing to make have not been sufficient. The impact of 
television could make a critical difference, especially if health officials and
advertisers coordinate their efforts. Much is being asked of condoms, with all 
their frailties. It could be months but will probably be years before 
transmission of the virus is fully understood. It can't hurt to think of the 
virus as having an intelligence, and a commitment to survival that exceeds that
of many people.

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