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Spotlight Center on HIV Prevention Today

Opinion

PrEP and Pleasure: We Need More Holistic Sexual Health Conversations

April 6, 2017

Preston Mitchum

Preston Mitchum (Credit: John Nelson)

I have concluded that I hate condoms: the smell, the feel, the removal of pleasure. Hate them.

I understand that not wearing them -- and not forcing sexual partners to wear them -- could expose me to a greater likelihood of sexually transmitted infections (STIs) (with the exception of HIV, as I am now on pre-exposure prophylaxis [PrEP]). But, I have enough sexual health knowledge to understand the informed decision I am making. That's the beauty of holistic sexual health and informed consent: understanding potential risks from actions, but being invested in one's body enough to realize that bodily autonomy and integrity also matter.

With the insistent, and oftentimes unnecessarily forceful, mantras of "always wear condoms" emanating from the entire public health sphere, it begs the question: if many individuals are educated on the risks and consequences of condomless sex, why is it still so prevalent in various communities?

People are tired of hearing that's what sex is: a risk, something of which to be afraid. Rarely, do we ever discuss the benefits of sexual exploration, climaxing and understanding what's best for our bodies. The hyper-focus on condoms runs the risk of ignoring an important personal and public health conversation: many people don't use condoms because they want to feel more pleasure.

Working in public health, I am grateful for those who understand how their body derives pleasure. It is this gratitude that forces me to stay focused on ensuring that people have informed consent to make the best decisions for their personal sexual health practices.

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What matters to me is not that condoms are being forced down people's throats, so to speak, but that people understand that condoms are but one (and not the only) tool in a holistic sexual health toolbox. And I'm speaking about male condoms specifically -- because we rarely think about other barrier methods, despite the long-underrated promise of the female condom.

Rejection of condoms does not mean one must stop engaging in sexual intercourse -- and it certainly does not mean that our sexual health practices are immoral or deviant. On the contrary, it can mean that we have been bold enough to explore our bodies' needs and desires, exercise our bodily autonomy and decide what is best. Medical professionals must understand this or will continuously fail at meeting patients' needs.


The Power of Holistic Sexual Health Conversations

It's time that patients, providers, pharmaceutical companies and the public health community have honest and difficult conversations about condoms, PrEP and bodily pleasure.

PrEP is a once-a-day prescription that people can take to drastically reduce chances of acquiring HIV. There are currently many campaigns marketing PrEP in the United States, and many of those focus on black and Latinx gay/bisexual men, in particular.

If followed correctly, PrEP is nearly 100% effective. The very few cases of reported HIV transmission are primarily due to non-adherence to daily dosing or exposure to drug-resistant HIV.

Holistic sexual health conversations and empowering messages not only lead to more ownership over one's body; they also contribute to better PrEP adherence. Recent studies show that when counselors framed PrEP as part of a healthy sex life, new PrEP clients were significantly more likely to have high levels of adherence to the medication (which presumably also better prevents HIV acquisition).

As a newer PrEP user, my disdain of condoms prevention has made recent doctor's visits interesting. The other week, during a routine check-up with my doctor, she asked, "Are you remembering to wear condoms?" "Sometimes," I replied.

Naturally this led to a reminder that "PrEP is only showing effectiveness toward HIV, not STI prevention."

I was aware of every fact that she repeatedly mentioned. What I did not understand, however, was why she thought I cared: I am not reckless, and I don't think that my life doesn't hold value. I voluntarily decided to take PrEP because I understood what my body enjoyed and that was one way of owning what was within my bodily control.

I paused and finally asked, "If we know that condoms are an effective tool in preventing HIV and other STIs and people didn't wear them prior to PrEP, as a community, why do we now think people will suddenly wear them?"

I am not a nebulous being with no understanding of how biology -- and by extension, my body -- works. Nor am I saying that people should not wear condoms because they are on PrEP.

I'm saying that many people don't wear them anyway, regardless of HIV/STI risk, so having doctors repeatedly reminding their patients to wear them during every sexual encounter is counterproductive (though effectively mandated in public health guidelines).

Holistic sexual health is critical to an individual's overall health outcomes. Ideally, a provider would ask about sexual partners not in order to instruct patients to have less sex (or fewer partners), but in order to inform us about several available prevention options. A provider would not hyper-focus on condoms as the sole solution to HIV and STI prevention, but would inquire about patients' individual needs and desires to determine what else might work for each client. Providers using a holistic sexual health framework do not apply a "one size fits all" model to patient's desires -- they learn about the patient and incorporate what is most appropriate, not merely formulaic.

We are not a business deal. We are not our monthly check-ups and appointments. We are our joys, our beliefs, our freakiness and our celebration and expression. It is imperative that we discuss the benefits of sex as much as, if not more, than the risks and consequences that can flow therefrom. Holistic sexual health isn't necessarily about eliminating risk; it's about providing people with enough options and choices to mitigate the risk.

Preston Mitchum is a Washington, D.C.-based writer, activist and policy nerd. He is a regular contributor to The Root and theGrio and has written for The Atlantic, Think Progress, OUT Magazine, Ebony.com, and the Huffington Post. Follow him on Twitter to see just how much he appreciates intersectionality.


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