This chapter asks a lot of tough questions: Is barebacking pathological? Is it correlated to personality disorder? Is it all about sex, sensationseeking, and pleasure? Or is it, as paradoxical as this may seem, actually an attempt to take care of oneself and to forge a deeper intimacy, closeness, and even spiritual communion?

Toby is a white, 35-year-old, HIV-negative gay man who came to see me because of depression and loneliness. A successful and ambitious architect, he worked exceptionally long hours to make partner in his firm. His last relationship ended during his final year of graduate school, after two years, and he had not had another partner in almost 10 years. Because of his intense focus on work, Toby had not taken the time to cultivate deep friendships. He did have a group of people with whom he would go to clubs to dance a few times a month.

In his 1997 book Sexual Ecology, Gabriel Rotello specifically discusses gay men’s sexual culture and barebacking from a systems or ecological perspective. Rotello posits that the problem with barebacking is not only that gay men who bareback fail to act individually in their own interests, but also that they fail to act collectively in the interests of gay men as a group. What Rotello is saying is that in addition to a specific act of sex without a condom potentially spreading HIV to a previously uninfected person, each act of condomless sex also helps break down community norms supporting condom use.

It is naive to assume that psychotherapy, even with the most sophisticated gay-affirmative therapist, could or even should prevent barebacking. Most mental health professionals today recognize that most people’s problems as well as potential resolutions are part of a larger interpersonal and social context.