Your choice

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I was born in 1981.
I’m now 33.
A lot has changed in those 33 years.

So I’m taking these at the moment.
PEP medication
For all the Matrix like excitement of taking a red pill and a blue pill, they’re actually fairly boring. Tales abound about how you’ll be laid out for weeks with symptoms akin to a persistent norovirus, or flu, or foul food poisoning. Alas, for me at least, they’re not even that exciting.

I get a bit nauseous the first few days. Then again, they give you anti-nausea pills, too. So I’m sorted.

I’m told they’re very powerful drugs but then, they tell me the mood stabilisers and antidepressants are also very powerful drugs. Frankly, unless I’m tripping balls within half an hour of swallowing them I have difficulty believing that claim.

They do clever and intricate things to do with DNA replication and integration. For all their apparent innocence, they are both absolute, undisputed marvels of 20th and 21st century biology, biotechnology, pharmacology and medical research.

They’re anti HIV pills.

I don’t even think I have HIV.


PEP, for those of you who don’t know, stands for Post Exposure Prophylaxis. They’re handed out after suspected HIV exposure and consist of standard anti HIV medication – the exact drugs vary depending on what other medication you’re taking and any pre-existing conditions. The idea is to slam the virus down before it takes hold, before it inserts itself into your own DNA and becomes a permanent resident within your immune system.

Treatments for HIV these days are, like I say, a marvel of modern medical research. HIV first came to attention around the time I was born; now, in my thirties, an individual living with HIV can generally expect a normal lifespan. There are exceptions, and there is variability in response; but from talking to most (heterosexual) people, the impression I get is that their perception of HIV is over fifteen years out of date. For many in the UK the tombstone adverts of the ’80s still loom large in their minds. Most, let’s be fair, never think of it at all.

HIV never went away. It just became old news, and old news is no news. But in the gay community, such as it is, it remains; a permanent resident. For gay men in London, if you’ve had unprotected sex with anyone at all whose status you’re unaware of, then you’re usually offered PEP. You’re presumed to have been exposed.


Sexual health counsellors are amazing.

OK, I only saw one, the one time, but she was amazing. Half her hair cropped tight, the other half waved wild, streaked green; torn jeans and flannel shirt and big, big boots.

She laughed lots.

“It’s your choice. You’re a smart guy; you know exactly the risks you’re taking. Even when you go out, get pissed, get high, you know the risks you will take. You keep on like this, you probably will get HIV.

“Your call”

Ever since 2008, my libido’s been fucked. And really, honestly, I don’t know why any more. Maybe the psychiatric meds. Maybe the depression. Maybe my own neurosis about sex, built up during the episode and now difficult to tear down again; am I any good, will they be disappointed, will they think I’m too fat, too thin, too boring, too kinky? Rejection hurts, it’s easier to say no. Or ensure no one ever even asks.

Unless I’m wasted.

When you’re wasted, everything’s easy, except thinking and talking and life. But pleasure, but desire, but lust… these things are easy. And when you’re wasted, who cares about the rest?

Fucking is easy when you’re wasted.

Lust is fierce when you’re wasted.

Who wants to use condoms, when you’re wasted?

I only have sex when I’m wasted.


Amongst gay men, there’s a degree of prejudice around barebacking (sex without a condom). To a degree, this is understandable; the safer sex message was naturally targeted intensely at our community, and of course there are those who remember the decimation of the ’80s. For a long while, the message was condoms or not at all. This prejudice is unfortunate, because gay guys – an increasing number of gay guys – bareback. We do it for many, often complex reasons. Often it’s just the one time; we’re drunk, we’re high. We always use condoms but we might slip up. Or maybe we’re with a partner and we both last tested negative. Or maybe we only fuck when high or otherwise disinhibited, meaning we never, or rarely, use protection. Or maybe, maybe just fuck it, because sex without condoms just feels better, and we’re fucking horny, and it’s fucking horny, fucking like that, cumming like that.

Turning around to that vast, varied swathe and saying, “what’s wrong with condoms” – well we’ve been doing that for decades, and still we have HIV, inserted into our lives. It’s as absurd as telling people to ‘just say no’ to drugs. It’s tone deaf, idealistic to the point of idiocy, and presumes a perfect, predictable world. Sorry sugar – the world isn’t like that. People aren’t like that.

The messages of moral superiority, ‘just say no’, that barebacking is stupid, hurts. It hurts the individuals who do it, and it hurts the community it’s supposedly aimed at protecting. It results in the people who bareback  – for whatever reason – not talking about it, not understanding the options now available, picking up hearsay and horror stories about the medications available. It plays a part in fuelling anti HIV prejudice, which is still all to prevalent not only in the wider world but in our community. You’d think that we of all people would understand that this never solves anything; that communication is better than silence, understanding better than judgement.

Your call.

Now, I am finally awake

Plans that either come to naught

Or half a page of scribbled lines

– Pink Floyd, ‘Time’

You, but on a really good day

– Advertising slogan for Berocca vitamin drink

“Do you ever make plans?”

This seems a curious question from the psychiatrist. I assume he’s making a suggestion – maybe if I made more plans to do stuff, I’d feel less listless, less detached from life. Less like a spectator, bored by the spectacle.

“I do, sometimes. Nothing ever comes of it. All sorts of projects; I get a bit into them then nothing happens. I just forget about them, leave them to one side”

“Hmm”, he hmms.

It’s true, and it’s always frustrated me. I can never maintain focus long enough to see any of my projects through. It’s not just projects – those bursts of energy; after I quit Leeds uni (the first time), I spent about a month with a pristine bedroom, polished surfaces, reading voraciously about world religions and Buckminster Fuller (this is entirely reasonable; world religions are fascinating and it’s a good bit of cultural knowledge to have – and Buckminster Fuller was just an all round brilliant guy). Got into Timothy Leary and devoured the experience vaults on Erowid.

“It makes sense”, Emily commented recently, when I told her. “I’ve often felt quite jealous of the way you can seem so connected to the world”

It made it hard to believe I’d ever been really depressed. I was just being daft, dramatic. I carried on thinking that way about my depression until I was at least 24 – which is to say, almost 10 years since it first clearly emerged. Joy can delude as sure as despair. But the world just makes sense, you see? You just need to stop worrying, and let it all fall into place.

Around my 30th. My birthday’s in January and London was brisk and, in my mind, sunny. I’d just got a Kindle – present from brother #1 – and every now and then I’d see another with one. “Aren’t they great?!” I’d enthuse to them, shockingly unbritish. Spend a few minutes singing their praises with a complete stranger. And a sale in Habitat! Christ only knows how much I spent, but I don’t think I’ve ever been quite so delighted by homeware.

That stunning few weeks, a handful of years ago – looking gorgeous and feeling free. New clothes, new look, new body (seriously, I looked smoking). Fierce kissing and fucking; finally I’ve got this whole thing figured out.

(an aside – Clive Wearing’s diary, tragically timestamped, each erased line declaring ‘Now, I am finally awake‘)

And more recent – tellingly, just before my most recent fall; the grace was singing in me. All my neuroticism evaporated, the happy realisation that I’m fine, just me, myself. No need to worry about other’s opinions, other’s lives are not yardsticks with which to judge your own. Happy. Spring in my step and spring in the air, blossom, me blossoming out. Lab book filled with extraneous scribbles and commentary, flourishes. It all fell into place.


I compared all this, you see, to the ferocity of paroxetine. The hypomania induced by paroxetine was more probably mania – mania without grandiosity or delusion, but with a brilliant, blinding, childish energy; impatient, white water energy, all song and dance and singing and dancing, through the streets, cigarettes and cream. Bliss over every hair on my flesh, fluttering through every cell in my body. Bliss… bliss falling asleep, bliss upon waking. Bliss unlike any other. And compared to that – compared to that, everything else faded, everything else fades. Drugs, sex. Love. Nothing compares.

Setting such a high bar for hypomania, it’s no wonder I didn’t catch all these other moments. Or casually dismissed them, only accepting that SSRIs  pushed me into a very, very mild state.

Turns out my very, very mild state is actually just a state.

I keep taking the pills.

 

 

The promise of lust

Partial list of side effects from citalopram information sheet I don’t know exactly when it shifted, and I definitely don’t know why. I tend to put a definite cut off around 2008, since the 2008-09 episode was so profound, lasted so long, and smothered me; like sleep, under morphine.

At first I blamed the drugs. That was comforting and easy, because after all a side effect of SSRIs is loss of libido. It also held out the promise that once I was off the drugs, I’d be up and running again. I was willing to put up with a flatlining sex drive for a while, for the relief the antidepressants gave me. They were only temporary, after all.

And then I came off the drugs, and I looked forward to the promise of torrential lust. Being young and gay in London with no strong desire for sex is… frustrating. I wanted that part of my life back. So I waited, and I waited, and it never came.

Oh sure, I could get drunk and horny. But that’s missing the point, isn’t it? Drunken lust is clumsy, grasping and loose. Temporary, and soon forgotten. Being young and gay in London with no strong desire for sex is more than a little alienating.

I still blamed the drugs, or maybe I blamed the depression, or both. Blamed some kind of permanent rewiring of the circuits of sexual desire. Maybe they’d burned out? Maybe they’d atrophied? We live in a culture saturated by sex – gay subcultures especially are sodden with it. But for all that, we seem to have little real regard for it. For most of us, sex is important, beyond hedonism and lust and beyond even passion. It’s important for contact, for happiness. For relationships and belonging and feeling a broad and deep range of emotion, sensation.

And I wasn’t getting any.


“Loss of libido” is thrown away in the patient information sheet which details side effects of SSRIs, alongside “failure to reach / maintain an erection (in men)”* and “Anorgasmia (failure to reach orgasm)”. I guess in the grand scheme of things, these aren’t profoundly worrying side effects – the other drug I’m on, lamotrigine, lists Stevens-Johnson syndrome (a potentially fatal loss of skin) and disseminated intravascular coagulation (DIC, AKA Death Is Coming) as it’s potential side effects. Yes, I’d rather have no sex drive and shit orgasms than die horribly from my skin sloughing from my body. Still. Hardly a fair comparison.

Sex is important. And when you’re prone to depression, not having a full – or any – sex life, and thus no romantic life, is dangerous. It denies you a source of pleasure, emotional soil in which to grip your roots to the world. “Protective factors”, in the dry but honest language of a psychiatric consultation. The fewer roots you have the more likely you are to wither. The easier it becomes to simply take the hand you’ve been dealt, and fold.

Sex is important. I really, really don’t think the wider psychiatric community appreciate just how important it is, largely oblivious to how antidepressants can deeply wound a life.


Of course, I’m human, and humans excel at making simple things complicated. Maybe the depression led to a plummeting libido. Maybe SSRIs turned down too many switches inside my head. But people are more complicated than just brains. After so long without a shag, the whole issue takes a life of it’s own, entwining with sexual confidence and body confidence, until it becomes impossible to know if you’re not having sex because you don’t want to, or because you’re afraid to.

I hope this problem is nice and simple and neurological. I hope my bottomed out libido can be blamed on a zapped out reward pathway, or a scrambled endocrine system, or anything other than high level psychology. Because if it’s up to psychology, I really can’t see it being resolved any time soon. Sex is important. Without it I don’t meet guys, I don’t date. I must be the only gay man in London who has never met anyone off Grindr. Seriously. My last online hookup was in 2008. This. Is getting. Tiring.


“Would you be open to a mood stabiliser?” The psychiatrist asks.

I’ve been rumbled. They want to take the hypomania from me.

“Which one?” I ask. They know I study neuroscience. It’s in the file. An awful lot is in the file.

“Lamotrigine”

I’ve heard of it, but beyond it being a mood stabiliser I know nothing. I don’t want the sluggishness that can come with some psychiatric meds (paroxetine destroyed me with sleep; and I’ve seen the effects of olanzapine – an antipsychotic – second hand). Will it place a final nail in the coffin of my libido? I’m wary. I want to know it’s mode of action, I want to know if…

“Like I say; I think the SSRIs work because they make me slightly hypomanic. If you take that away… What’s left?”

He reassures me; “just a trial”

It’s ultimately up to me. Naturally I go online and look up the mode of action (voltage gated sodium channel blocker, calcium channel blocker, glutamate modulator). I look up personal experiences.

Rise in libido.

Not everyone, not all the time. And sometimes the reverse – maybe it could be the final nail in the coffin. And sometimes the rise is due to activation of mania, sometimes fades after a few weeks. Still. It hangs there, glowing on my iPad screen. The promise of lust. Rise in libido.

I say yes.

I take the pill.


*Seriously, this is how it’s phrased. I love the fact they felt the need to specify.

Mirtazapine, intense as in

Peaches! It's a visual metaphor, maybe.So last week I asked for my prescription to be changed.

I’ve been on citalopram for about a year now – it’s is a common-or-garden antidepressant which has a very similar cellular action to Prozac – they’re both what you may or may not know as ‘selective serotonin reuptake inhibitors’ (SSRIs). I won’t go into the nuances of SSRI treatment here, save to say they work to an extent, and for some people more than others. I’m fortunate – citalopram seems to work very, very well with me. So why change?

Side effects.

The side effects of SSRIs are usually not too bad – the worst I’ve ever had, or seen anyone have, is an immense tiredness, which can be enough to lead people to quit. But the tiredness I experience on citalopram isn’t anything troubling to me; I need an afternoon nap and that’s pretty much it. Given how profound and dangerous the depths of my depression can be, a few piddling side effects really aren’t worth worrying over, not in the heat of the moment (or, rather, the depths of the dark).

After a while tho, when all is sunny and well, what had been niggling side effects take on a change in character; specifically, the rock-bottom libido I’ve lived with for a few years now, notwithstanding alcohol inebriation. SSRIs are known to sometimes muck about with sex drive, and after mirtazapine was brought to my attention I thought it worth a punt.

Even so, I don’t have great hopes for this ‘working’; that is, delivering some miraculous return of my sex drive. Libido is complicated and impacted by a whole range of factors, from depression itself to past sexual and romantic history, confidence, self-perception, all the way up to culture and subculture, and perception of one’s own role within that wider context. Even if my predicament was initially brought on by a simple chemically-induced neurobiological change, it will be far from simple now. Brains are complex, and people even more so. Still, this is low hanging fruit (fnar), and you have to make a start somewhere – this is a start, of a kind.

And what a kind! My GP looked surprised at my request, pointing out that mirtazapine is usually prescribed for more anxious-depressive types, those filled with a worrying energy. The drug, he explained, can have quite profound sedative effects. Take at night. You might have difficulty waking. Dreams may come.

Dreams did come, and they’re still coming, though I’m told they’ll eventually, probably, fade. Some claustrophobic, some vertiginous, some icy and frightening, all suffocating, intense. Intense as in seeming profound, only to tatter away with a moments thought. Intense as in teenage crush, primal and primary, confusing. Intense as in shrooms, hilarious because, hilarious because hilarious, because. Haunting, and like ocean waves dragging you down as you wake, as you surface, only thrashing and gasping and drowning again into dreaming, and again, and again into dreaming.

The first day, my eyes opened and I got up, I drank strong coffee and more strong coffee but never really awoke, napped for hours before exhausted went to bed, another twelve hours, awoke to dreaming, awoke to dreaming, awoke.

The second day – strange and a world full of echoes and space, but more awake. I think I’m lucky – the tiredness fading fast and swift now, even if the dreams still boil away at night; while waking is still a confused surfacing it’s getting easier. During the day I can write, read, I can even talk and think, and it’s been less than a week. That’s some quick neuroadaptation!

Maybe I’ll even get my libido back.testosterone