Sick again?: Gay men as a site of medicalization
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Sick again?: Gay men as a site of medicalization
- 1. SICK AGAIN?:MEDICALIZATION IN GAY MEN‘S HEALTH Sarah Chown Olivier Ferlatte MPH Student, Simon Fraser Community-Based Research Centre University PhD Student, Simon Fraser University Universities Without Walls Fellow November Gay Men’s Health Summit: Health & Sexual Rights 4, 2011
- 2. Overview Introduce medicalization Current context and examples of medicalization Internalizedhomophobia Prescribing healthy sex Pharmaceutical developments Tensions in medicalization Sexual rights Health equity
- 3. Defining medicalization Medicalization Process that uses medical knowledge and practice to regulate daily life Pharmaceuticalization Process that deems social, behavioural or bodily conditions as needing pharmaceutical treatment
- 4. Medicalizing Gay Men Homosexuality as a sin Homosexuality as a crime Homosexuality as an illness Diagnostic and Statistical Manual II International Classification of Diseases Psychology and psychiatry interventions Onset of HIV epidemic
- 5. Viagra Advertisements: Pride 2011
- 6. Current Context Medical interventions are increasingly visible: Prominence of PEP, PrEP, treatment as prevention in scientific literature and within the community without considering limitations/challenges Need to discuss the limitations of these approaches especially when they are coming at the detriment of social determinants and health promotion
- 7. Examples of medicalization Internalized homophobia* ‗Men who have sex with men‘ Prescribed idea of ‗healthy sex‘* Pharmaceutical developments: post and pre- exposure prophylaxis, treatment (as prevention)* Allocation of gay men‘s health funding
- 8. Examples of medicalization: Internalized homophobia ―feelings of inferiority, being evil, lacking self- worth and social value... guilt, shame, depression‖ (Aguinaldo 2008) Gay men‘s ―damaged psychologies‖ become a determinant of health (Aguinaldo 2008) individual becomes the site of intervention
- 9. Examples of medicalization: Prescribing healthy sex ‗Public health‘ prescription for healthy sex: Limit partners Use condoms consistently Test regularly Preventing HIV becomes an individual responsibility gaymen feel the need to showcase their ―good behaviour‖ by accepting all preventive measures (Verweij, 1999; Odets, 1997)
- 10. Pharmaceutical Examples of medicalization: Developments Pre-exposure prophylaxis Post-exposure prophylaxis Treatment (as prevention) Access to, and uptake of, these interventions are socially patterned: Knowledge, cost, adherence
- 11. Tensions in medicalization: Sexual rights What about pleasure?! Acknowledging the desire to have sex without a condom Sexual expression and sexual identities Sexual health information
- 12. ―…sexual health problems are systematically shaped by multiple forms of structural violence— institutionalized poverty, racism, ethnic discrimination, gender oppression, sexual stigma and oppression, age differentials, and related forms of social inequality—in ways that typically harm and negatively affect groups and populations already marginalized or oppressed.‖ (Parker 2007, p. 973)
- 13. Tensions in medicalization: Health equity Individual ability to adopt medical interventions shaped by systems of oppression ―Those who suffer because of [oppression]‖ are responsible to solve it, ―not those who create [it]‖ (Aguinaldo 2008, p. 93) Focusing only on individual interventions leaves systems of oppression that create inequity intact Inequitable outcomes beyond HIV can be
- 14. ―…How the field of public health approaches sexuality shapes society’s ability to realize sexual rights as part of a broader commitment to human dignity and worth.‖(Parker 2007, p. 973)
- 15. Conclusion There is a place for medical interventions: potential to both affirm and deny sexual rights and health equity Interlocking systems of oppression that pattern HIV rates, and access to medical interventions Moving forward with medicalization, need to consider: Operationalizeall sexual rights – not just to information! Gradients of access to existing individual level interventions Balance individual-level interventions with upstream interventions
- 17. THANK YOU!
- 18. PrEP and the iPrEx Study call for an independent threshold of efficacy for PrEP to be determined (Paxton, Hope and Jaff, 2007) No threshold was established Debate as to the 44% efficacy found in iPrEx interpretation of scientific studies, and the way findings are presented selectively to support or contest the use of a drug, results in a larger problem that contributes to pharmaceuticalizationBusfield (2006)
Notas del editor
- -need medicalization before there can be pharmaceuticalizatoin“conceptual phenomenon” used to understand the regulation of ‘deviant’ behaviour, stages of life such as pregnancy and ageing, and approaches to preventive medicine that regulate daily life (Verweig, 1992, p. 92). process by which parts of human life are increasingly being framed in the medical language of ‘health’ and ‘illness’ (Sadler et al., 2009; Verweij, 1999)
- -medicalization as a historical process-biopower?1869: first medical argument homosexuality is an illness, not a pathology-Benkert, a Hungarian physician, first argued homosexuality was “a medical pathology rather than a criminal offense” (Conrad, 2004, p. 32). (Conrad, 2004, p. 32)1940s:psychology and psychiatry to search for cures to homosexuality1950/60s: homosexuality listed as a sexual deviation in the Diagnostic and Statistical Manual (DSM II) and in the World Health Organization’s International Classification of Diseases (ICD) 1980s: onset of HIV ‘remedicalized’ homosexuality (Conrad 2004)
- *high road approach – but what about low road approaches?
- -presenting“feelings of inferiority, being evil, lacking self-worth and social value... guilt, shame, depression”-Gay people ‘become stuck with these irrational fears’ (I) and suffer from ‘a perceived need to conceal important aspects of self, and a fear of prejudicial events and rejection’ (J)-these feelings result from believing societal messages about gay men-outcomes associated with internalized homophobia includeself-defeating behaviors, and self-destructiveness’ (D).“…this health research locates ‘the problem’ and solution of gay oppression not on those who create this oppression, but on those who suffer because of it” (p. 93)
- -Public health capitalizes on gay men’s fear of HIV and uses it as an ‘entry point’ to prescribe for healthy sex-This prescription also homogenizes gay men and the sex they are having by assuming all gay men are putting themselves at risk of HIV and therefore needing to adopt these strategies 100% of the time-Gay men’s fear of HIV can be perpetuated by public health, and creates uncertainty amongst gay men about the possibility of having sex and being HIV-negative-Impossible“even [to] entertain the possibility of being gay and not infected” (Odets, 1997, p. 669)-in ManCount,13.6% of gay men in Vancouver believe they are somewhat to very likely to become HIV-positive in their lifetimes (Gilbert, 2011)-some individuals are more or less able to follow this prescription, because of systems of oppression including heterosexism and hegemonic masculinity, but also because of racism and capitalism, amongst others-starting to see organizations acknowledging more nuanced prevention strategies, but dominant societal views still position HIV prevention as an individual’s responsibility – just use condoms.
- -more individual level
- What about pleasure?! (Len concluded this in his presentation about abstracts at CAHR)-internalized homophobia-prescription for healthy sex is all about fear (not fun!), and it limits rights to a diversity of sexual expression -PrEP and TasP may remove fear for some gay guys – but not all gay guys may be able to afford/access/adhere to PrEP and TasP
- Medicalized interventions – no matter how great – are shaped by the same structural and systemic factors that lead to health inequities!!
- Medicine uses fear of HIV to regulate sexHowever, not all sex acts have HIV riskHomogenizes gay men by prescribing one vision of ‘how to have sex in an epidemic’Constructs sex as something subject to ‘the medical gaze’ rather than pleasurableHIV was a source of fear that medicine capitalized on to prescribe healthy sex (Impossible“even [to] entertain the possibility of being gay and not infected” (Odets, 1997, p. 669);13.6% of gay men in Vancouver believe they are somewhat to very likely to become HIV-positive in their lifetimes (Gilbert, 2011). , Preventing HIV becomes an individual responsibilitypreventive efforts commonly use blanket statements regarding the imperatives of condom use and testing, creating uncertainty amongst men – even those at no or low risk – about their health. This approach also encourages individual responsibility and creates a feeling that gay men feel the need to showcase their “good behaviour” by accepting all preventive measures (Verweij, 1999; Odets, 1997). “locates ‘the problem’ and solution of gay oppression not on those who create this oppression, but on those who suffer because of it” (Aguinaldo 2008, p. 93)
- The way public health constructs sexuality and sex MATTERS, since the dominant ways of thinking about sex are shaped dominantly by the media
- -As gay men’s health advocates, we need to ensure medicalized approaches to HIV do not take away from upstream approaches, do not reinforce individual responsibiliity to prevent HIV, and -What would sexual health information look like if we took sexual rights seriously? (A whole lot more sexy campaigns, I would guess)
- -even if there is a magic pill (that worked for everyone!), it would be a major challenge to make sure it could be distributed everywhere, that everyone had access to it, and are able to adhere to it as per the prescriptions