I attended my first Pride in 1979, when I was seven years old. In preparation for the march, I made signs with my mom and her partner (now her wife; they got married in 2015 after 37 years together). Their signs were long, lofty, and political. The sign I made was inspired by a button I had seen on St. Patrick’s Day. It read: “Kiss me, I’m gay.”
My mom asked me if I wanted to switch signs with her — was that really the sign I wanted to carry myself? I had no idea why she was asking me this; my sign was better, so of course that was the one I wanted to carry. I admit that my seven-year-old self was almost embarrassingly straight; but to me, carrying the sign wasn’t an identity statement. It was an affiliative statement. I was claiming my place as part of this community, embracing its joy and its pain and its liberation and its struggle as my own. People kissed me all day (and they always asked first).
Almost forty years later, I have devoted the majority of my professional life to the care of the LGBTQ community in all its diversity. Most recently, I have been a staunch advocate for access to pre-exposure prophylaxis (PrEP), the daily pill that reduces risk of HIV infection by over 90 percent. I advocate for PrEP not only because it prevents new HIV infections, but also because it redefines the narrative around gay sexuality that emerged in the HIV era.
In spite of the tremendous gains that we have seen in LGBTQ liberation in the past decades, many still experience the threat of HIV infection as an ever-present shadow over their sexual lives. In our research with the Hunter HIV/AIDS Research Team, we have found that between 25 percent and 39 percent of HIV-negative gay men say they think about HIV all or most of the time in their daily lives, and between 29 percent and 46 percent say they think about HIV all or most of the time while they are having sex. This omnipresent burden of HIV is an underrecognized psychological tragedy of the epidemic.
But even less recognized is the way the threat of HIV infection has operated as a type of social control. Consciously or unconsciously, the constant threat of illness is presented to members of the LGBTQ community as the “cost” of their sexual expression and liberation. In other words, our society will tolerate your having “that kind” of sex, as long as you always remember you can die from it.
These words may seem harsh, but I believe they are critical to understanding the dynamics that have impeded PrEP rollout, including reluctance on the part of healthcare providers and systems to fully embrace it as a prevention strategy. PrEP provides relief from the burden of HIV threat, and many people report that taking PrEP allows them to fully experience intimacy and joy in sexuality without anxiety or fear. But lifting this burden also lifts social control over sexuality. In one of the first PrEP trainings I conducted for providers, one doctor said to me: “But wait — if we give this medication to gay men, they can have as much sex as they want and they won’t get HIV.” Concerns about making PrEP more widely available arise, in part, from discomfort with the notion of gay sex without a cost.
The fight for PrEP availability and accessibility, then, is at its core a fight for sex positivity and true sexual liberation. Sex that’s free from the threat of HIV is not merely a side benefit of PrEP: It is a central good in itself. Ensuring access to PrEP is a statement that we — as a society, as a public health community — will not use the threat of illness as a tool for social or behavioral control over sexual expression.
At the same time, our society is facing another, parallel debate over health, sexuality, and social control. On June 1, the Trump administration, through the Department of Health and Human Services (HHS), proposed a new rule for the Title X program, the Public Health Service Act that funds family planning services in the United States. If adopted, this new “gag rule” will prohibit providers in Title X–funded settings from giving abortion referrals or even mentioning abortion as an option in their counseling of pregnant patients.
The new Trump rule would also remove a current regulation that requires Title X–funded settings to provide access to “medically approved” family planning services. The removal of this regulation will allow Title X funding for settings that offer only “natural” family planning methods (i.e., fertility awareness, also called the rhythm method) to patients seeking contraceptive services.
Fertility awareness can be an effective contraceptive method, but only if the individual using it abstains from sex for about fourteen days out of every month — that’s almost half the year. As such, when offered to the exclusion of other methods, natural family planning specifically restricts individuals’ ability to choose when and whether to have sex, unless they want to live with the constant threat of unintended pregnancy.
Social control over sexuality is, in fact, the explicit goal of restricting access to reproductive health services. Consider this quote from a 2011 interview with Sandy Rios, director of governmental affairs for the American Family Association, which supports the new gag rule: “Why in the world would you encourage your daughters, and your granddaughters…to have unrestricted, unlimited sex anytime, anywhere, and that, somehow if you prevent pregnancy, that somehow you’ve helped them.” Just as the doctor at my PrEP training was afraid to give people the opportunity to have sex without fear of HIV infection, Rios is concerned that if we give people access to reproductive health services, they can have as much sex as they want and they won’t get pregnant.
If you care about access to PrEP — if you believe deeply in the sexual liberation it can facilitate — then you should care about access to birth control and abortion as well. Denying full access to reproductive health services, like denying access to PrEP, exerts social control over sexual expression by associating it with a threat (of HIV, of pregnancy) even though we have the biomedical means to alleviate that threat. And similar to the fight for PrEP access, these restrictions will fall hardest on people of color, who comprise more than half of all patients in Title X–funded health centers.
Stopping these proposed changes to Title X is an emergency. If the new regulations go into effect, more than 4,000 Title X health centers will be barred from providing comprehensive reproductive care to their more than 4 million patients. To help, you can learn more about the issue; post comments to HHS during the open comment period; tell your representatives how much you care about this issue; or give money to advocacy organizations that are fighting for reproductive justice.
The LGBTQ community has been my community since I was a child, and my affiliation remains strong in part because of our community’s passionate commitment to sexual freedom in all its diversity. I will be marching in this year’s Pride parade with my husband and my son, holding banners for my mother and her wife (whose marching days are behind them, but whose advocacy still burns bright). I hope you will stand with us in the fight for reproductive justice, which is part of sexual liberation for us all.
Dr. Sarit Golub is a professor of psychology at Hunter College and the Graduate Center of City University of New York. She directs the Hunter HIV/AIDS Research Team (HART), which conducts interdisciplinary, community-based research.