The age-old binary relationship between the top and the bottom is as simple as it is complex. In any sexual encounter, gay, straight or otherwise, one person typically assumes the dominant role while the other takes on a submissive role. And while the “give and receive” of actions and pleasures may ebb and flow during intercourse, many people generally prefer one role or another. But while tops and bottoms are equal, their differing roles do come with different health issues and responsibilities that every gay and bisexual man should be well informed about, regardless of sexual position.
Preface: All STIs are bad for your health. However, they are not all created equally. In general, condoms do protect against STIs that are spread through body fluids (semen, blood and anal or vaginal fluids). STIs that spread through skin-to-skin contact (Herpes, HPV) can still spread with condom use, especially if either partner has any open sores or lesions. In terms of focus and clarity, this discussion will singularly focus on HIV rather than other STIs.
The Top
Definition: The insertive partner in same-sex anal sex with cisgender gay men (men whose bodies align with their identification as men) or transgener gay men, or vaginal sex with pre-op or non-op transgender gay men.
Synonyms: The Knob; Handy Man; The Unit; Tarzan; The Muscle
Overview: There is nothing like a good top. However, there is a general misconception that there are little to no health risks associated with topping, but a good top knows that he has to think about his sexual health and safety just like any bottom out there. In fact, the top’s sexual health is probably the most important, as his status is what could place the bottom at risk for HIV transmission.
(Popular Myth: A guy who exclusively tops will never get HIV.)
Risk: A guy who is topping is generally at a lesser risk for HIV than the guy who is bottoming, but both topping and bottoming during unprotected anal sex is considered high-risk behavior. When a condom isn’t used, HIV can enter through the opening of the penis through small cuts, abrasions or open sores. Having another STI can further increase your risk for transmission. Research also suggests that uncircumcised tops are at a higher risk for HIV infection than those who are circumcised. Either way, topping doesn’t protect you from HIV.
Responsibility: When topping, it is arguably more important to know your HIV status. If you are HIV-positive and not on treatment, you may have a high viral load that places your sexual partner at higher risk for transmission. If your partner is HIV-positive, you are still at risk but that risk is reduced, especially if he is on treatment and undetectable. A condom or PrEP are your best options for protection, because it places you in control of protecting your partner and protecting yourself. For a top who is HIV-positive, maintaining an undetectable viral load through consistent use of antiretroviral medication and consistent medical care is the best method of protecting himself from transmitting the virus.
The Bottom
Definition: The receptive partner in same-sex anal sex for cisgender gay men or transgender gay men, or vaginal sex with transgender gay men.
Synonyms: The Hole; Jane; Power Bottom; The Brains
Tops may get the glory, but bottoms make the world go round. To be a good bottom a guy has to know what works for his body, how to maintain a healthy and hygienic rear end, and how to navigate his sexual health without compromising his pleasure. Quite simply, tops have it easy when it comes to gay sex because being a good bottom is no easy job.
(Popular myth: If an HIV-positive guy is always the bottom, he will never transmit the virus.)
Risk: Simply put, a gay man who bottoms is more at risk for HIV. The sensitive lining of the anus is more susceptible to cuts and abrasions during sex. These cuts and abrasions allow for HIV that is present in the top’s cum or pre-cum to come into contact with the bottom’s bloodstream.
Responsibility: When bottoming, you should always inquire about your partner’s HIV status since your position places you more at-risk for transmission. Regardless of his answer, your best option for protection is the use of Truvada as PrEP, because it places you in control of your own health regardless of his status or condom use. As a bottom, you can negotiate condom use, but your partner is the one who wears the rubber. If you bottom and do not wear condoms 100 percent of the time, the use of PrEP will afford you with the certainty of protection. Once again, a bottom who is HIV-positive can protect himself from transmitting by consistently taking their HIV medication and staying in care.
The Perfect Top/Bottom Dynamic
If you are a gay man, you may have a position preference, but chances are you will change it up every now and then. Whether you are a guy who prefers to top or just a big ‘ole bottom, make sure you know the ins and outs of both roles so that you can be pleasing to your partner while protecting yourself. If you do so, then it won’t matter if the top is on bottom, the bottom is on top, or if both of you are tangled sideways because you both with be equal, and equally protected.
