Men at Risk

Masculinity, Heterosexuality and HIV Prevention

Shari L. Dworkin

• Publisher: NYU Press
• Year: 2015
• ISBN:
  9781479896110
• Topic: Scienze sociali
• Subtopic: Studi di genere

Although the first AIDS cases were attributed to men having sex with men, over 70% of HIV infections worldwide are now estimated to occur through sex between women and men. In Men at Risk, Shari L. Dworkin argues that the centrality of heterosexual relationship dynamics to the transmission of HIV means that both women and men need to be taken into account in gender-specific HIV/AIDS prevention interventions. She looks at the “costs of masculinity” that shape men’s HIV risks, such as their initiation of sex and their increased status from sex with multiple partners. Engaging with the common paradigm in HIV research that portrays only women—and not heterosexually active men—as being “vulnerable” to HIV, Dworkin examines the gaps in public health knowledge that result in substandard treatment for HIV transmission and infection among heterosexual men both domestically and globally. She examines a vast array of structural factors that shape men’s HIV transmission risks and also focuses on a relatively new category of global health programs with men known as “gender-transformative” that seeks to move men in the direction of gender equality in the name of improved health. Dworkin makes suggestions for the next generation of gender-transformative health interventions by calling for masculinities-based and structurally driven HIV prevention programming. Thoroughly researched and theoretically grounded, Men at Risk presents a unique approach to HIV prevention at the intersection of sociological and public health research.

1

Masculinity and HIV/AIDS Prevention

Heterosexually Active Men as the “Forgotten Group”?

Although the first AIDS cases in the United States were attributed to men having sex with men, over 70% of HIV infections worldwide and nearly one out of three new infections in the United States are now estimated to occur through sex between women and men (CDC 2013a; UNAIDS 2012). Globally, while there is wide regional variation in the percentage of cases attributable to sex between women and men, one thing is clear: the proportion of women with HIV is rising in many regions of the world. In Asia, women are 30% of those living with HIV, and in sub-Saharan Africa, the percentage of adults living with HIV who are women is 60%. It is vital to note that increases in the proportion of women with HIV have occurred in a relatively short period of time; globally, in 1985, 30% of infected people were women, and this percentage now stands at approximately 50%.

Even in the United States, where the main group affected by HIV and AIDS is men who have sex with men (MSM), sex between women and men is now by far the main means of transmission for women and is the second most prevalent means of transmission for men. This is different from what HIV/AIDS transmission looked like in the past in the United States. In earlier stages of the epidemic in the United States, intravenous drug use (IDU) was the second most common means of transmission for men, and IDU was the main means of transmission for women. Among women diagnosed in the United States, sex with a man as the identified source of transmission more than tripled from 1985 to the present, and the Centers for Disease Control now regularly reports that 86% of cases of HIV among women are categorized as being from exposure to “high-risk heterosexual contact” (CDC 2013a). “Heterosexual sex” now accounts for 28% of all new infections in the United States; that is, one in five new HIV infections is among women who are infected through sex with a man, and approximately one in ten new infections is among men who are infected through heterosexual sex (CDC 2013a, 2012). Combined, these facts underscore that sexual behavior change not just among women but also among heterosexually active men will be key to controlling the HIV epidemic for both men and women. Unfortunately, this emphasis in HIV prevention has been sorely lacking, both domestically and globally.

Let’s examine the situation from another angle—first, globally. Approximately 30.7 million adults are living with HIV, and women constitute approximately 50% of the people living with HIV/AIDS globally. That is, of the 35.3 million people living with HIV (adults plus children), women constitute 17.7 million cases, children under fifteen years account for 3.3 million HIV cases, and adults are 32.1 million of the 35.3 million (UNAIDS 2012). Thus, if within the global pandemic, half of those who are infected are women, who is the other half? The other half is men, and globally, the large majority of cases are acquired through sex between women and men. However, the words “heterosexually active men” are not mentioned much in numerous national and key multilateral or bilateral agency reports. This is the case even in UNAIDS reports, and UNAIDS is the joint United Nations response to HIV and AIDS globally.

Discourses about “risk” and “vulnerability” that will be critically examined in this book circulate throughout numerous public arenas as a result of UNAIDS reports, and, interestingly, in the key surveillance slides, “women,” “children,” and “adults” are listed, but men are not. In fact, within the global surveillance slides at UNAIDS, men who have sex with men are often mentioned, but heterosexually active men and bisexually active men are not. Understandably, some men who have sex with men—or who have sex with both men and women—do not reveal this to others, and hence they may be difficult to identify or count. Additionally, homophobia and biphobia lead to a lack of recognition of men who have sex with men and men who have sex with women and men, leading to a lack of surveillance mechanisms being put in place in several countries to count such men (although 64 countries reported MSM as a surveillance category in 2010 and 104 countries reported MSM in 2012 [UNAIDS 2012]). Even though plenty of men worldwide have sex with both women and men (Dodge et al. 2012; Weinberg, Williams, & Pryor 1994), no country has a surveillance category for men who have sex with both women and men. Surveillance problems aside, however, currently, the large majority of HIV cases are said to be transmitted between a woman and a man. And yet, heterosexually active men in science-based prevention (“science-based” prevention efforts in this book refer to interventions funded by the National Institutes of Health and the Centers for Disease Control) efforts are often forgotten—both domestically and globally (except for international male circumcision efforts).

It is quite striking that heterosexually active men in the United States, particularly Black heterosexually active men—who are by far the most affected by HIV—have even been referred to by the National Association for the Advancement of Colored People (NAACP) and the National Action network (which works to serve Black communities in the United States) as “forgotten” by national and community-based HIV-prevention efforts (Raj et al. 2013). Nationally, it is true that the largest exposure category for the transmission of HIV is sex between men, but it is critical to look at regional variation concerning that trend. New surveillance data from the northeastern United States underscores that heterosexual transmission is the dominant mode of HIV acquisition for Black men (Raj & Bowleg 2012). Black men account for more than two-thirds of HIV cases that are classified as “heterosexual exposure” in the United States (Bowleg & Raj 2012). Shockingly, scrolling through the Centers for Disease Control (CDC) website in the United States reveals clear omissions concerning HIV risks among heterosexually active men. “Heterosexually active men” are not referenced under the “Who Is at Risk of HIV” section of the CDC website. Simultaneously, however, in 2010 on the CDC website, two authors ask in a short article whether there is a “generalized HIV epidemic” in various cities in America among Black MSM and Black heterosexuals (Dening & DiNenno 2010). Let me be clear: making mention of a possible “generalized epidemic” is a sign of a very serious epidemic—this is a term previously used to describe numerous developing countries experiencing an exacerbated HIV epidemic that has spread beyond sex workers, drug users, and men who have sex with men. If there is a near-generalized epidemic in parts of urban America “among Black MSM and Black heterosexuals,” how could heterosexually active men not even be explicitly mentioned as an “at-risk” group?

Similarly, the new National HIV/AIDS Policy (Office of National AIDS Strategy 2010) is next to completely silent on the need to focus on heterosexually active men. The rationale is that because of limited resources, scarce dollars are being put into working with those groups that have “the highest” need, and thus the focus is on MSM. All of the above tells us that prevention with heterosexually active men risks being forgotten. This is startling not only for men but also because sex between a woman and a man accounts for 90% of new infections for Black women, 86% of new infections for Latina women, and 74% of new infections for White women (CDC 2013e).

The global UNAIDS reports aren’t much better. Heterosexually active men are only mentioned in a few places in a several-hundred-page UNAIDS report where HIV/AIDS prevention is discussed. This is despite the fact that “unprotected heterosexual intercourse” is globally recognized as the “main mode” of HIV transmission in many countries around the world, including sub-Saharan Africa, the Caribbean, the Sudan, Papa New Guinea, most countries of Central Europe, and more. Despite this, it is the 2008 Global UNAIDS report that had the most material—only four paragraphs—that were dedicated specifically to prevention with heterosexually active men. Heterosexually active men are conflated with heterosexuality in that report (we do not know their sexual identities or the link between identities and practices because the surveillance mechanisms classify risks by behaviors, not identities). And, the 2012 version of the UNAIDS report no longer even includes a section from earlier reports on “tailored prevention for heterosexual men,” wherein UNAIDS authors overtly examine the lack of adequate prevention with heterosexually active men by underscoring that

while various prevention models have been developed to provide focused prevention support for men who have sex with men, few HIV prevention programmes have been specifically designed to take into account the values heterosexual men attach to sex, the pleasures they derive from it, and the social pressures associated with sex. A cardinal rule of HIV prevention is that programmes must be culturally relevant to the target population, but this maxim has not been rigorously followed among programmes that ostensibly aim to affect men’s behaviours. (UNAIDS 2008, 121)

As domestic and global HIV epidemics progress, discourses of “vulnerability” and “risk” tend to be used within the same unquestioned frameworks that link gender and sexuality in very particular ways, as will be explained throughout this book. If countries do recognize gender relations as central to the spread of the epidemic, science-based prevention programs largely conflate gender with women and focus on women. When programs are designed for women, these are conceptualized in terms of women needing interventions to protect them from gender inequality, from passive female sexual negotiations, and from the behaviors of male partners. But in this conceptualization of the gender order, heterosexually active men—who are very often also race and class marginalized—need . . . what? What kinds of programming do heterosexually active men need to prevent HIV? Are heterosexually active men considered in prevention programs in the science base (outside of biomedical male circumcision programs or pre- and post-exposure prophylaxis)? When HIV prevention programs are carried out with heterosexually active men in the science base, do these programs make much-needed connections among race, class, masculinities, and sexuality in order to intervene in men’s HIV risks? Are there structural domestic and global interventions for heterosexually active men designed to intervene in men’s HIV risks when we know that structural drivers shape not only women’s but also men’s HIV risks (see chapter 2 for in-depth coverage of this point)?

Contrast this with the way heterosexually active women are framed within prevention programs and the way intervention programs are designed for women in the HIV pandemic. Analyses as to why women are at risk of HIV and AIDS both domestically and globally have been resoundingly clear: gender relations and gender inequality in particular have been identified as major “root causes” of what shapes and exacerbates the inception and course of the epidemic globally (Dworkin & Ehrhardt 2007; Gupta 1994, 2001, 2002; Gupta & Weiss 1993; Luke 2003; Kmietowicz 2004; UNAIDS 2008, 2012; Weiss & Gupta 1998). The above facts are said to be structural (e.g., lower levels of education and of access to the occupational structure, lower wages, lack of access to credit, lack of land ownership, property rights violations, food insecurity) but also have social and interpersonal dimensions (e.g., gendered power differentials, cultural devaluations of women, violence, trust, desire for closeness in relationships and in sex), and programs in HIV prevention therefore should work to “adequately address the contextual issues of heterosexual relationship dynamics” both domestically and globally (Logan, Cole, & Leukefield 2002, 873).

In the United States, the women most affected by HIV are Black women, whose rate of HIV infections is twenty times that of White women (CDC 2014). Black women’s HIV risks are shaped by many of the gendered dynamics listed above, but they are also impacted by unique experiences of racial inequality, residential segregation, poverty, unemployment, men’s incarceration histories, and a limited pool of available men (due to oppressive policing practices, poverty, incarceration). That is, in addition to the “gendered” factors mentioned above, the structural lack of availability of men can shape relationship dynamics, and research therefore finds that Black women are more likely to accept a lack of condom use and infidelity because of the desire to have and maintain a relationship with a male partner (Kline, Kline, & Okin 1992; McNair & Prather 2004; Newsome & Airhihenbuwa 2013).

Overall, then, while it seems abundantly clear at first glance that the centrality of “heterosexual relationship dynamics” means that both women and men need to be taken into account in science-based HIV/AIDS-prevention interventions, this has not historically been the case. That fact is the focus of this text. Why are women still the overwhelming focus of behavioral HIV-prevention interventions for “heterosexually active” adults in the science base, what has been the progression of (conceptual and empirical) work with heterosexually active men both domestically and globally, and what are the promises and limitations of past and current prevention programs with heterosexually active men? What should be done next? These are the main topics in this book.

Readers might still wonder, are heterosexually active men really even “vulnerable” to HIV? Does a discourse of vulnerability (with all of its attendant problems, which will be covered in chapter 2) that applies so easily to women and MSM even apply to heterosexually active men? And if so, does it apply to all heterosexually active men equally? How do we talk about heterosexually active men as vulnerable to HIV at the same time that we view men as race and class oppressed—and as participants in a gender order who may benefit from relationship power, male sexual entitlements, and other power differentials that shape women’s HIV risks (see chapters 2, 3, and 5)? What are the promises and limitations of HIV-prevention interventions that focus solely on gendered power and women’s empowerment to reduce women’s HIV/AIDS risks but do not focus on men at all (chapter 3)?

How should HIV/AIDS-prevention research proceed with a simultaneous understanding that women are disproportionately affected by the HIV/AIDS epidemic due to gender, race, and class inequalities and therefore require empowerment but that heterosexually active men and their health are also harmed by these factors (chapters 2–5)? How shall we as researchers and practitioners ensure that gender norms are viewed as playing a role in HIV transmission for heterosexually active men? Can this view occur alongside the view that recognizes that men are also harmed by structural inequalities such as racism, unemployment, heterosexism, oppressive policing practices, the prison system, migratory systems, processes of globalization, war, conflict, and more—and that these inequalities shape men’s HIV-risk behaviors (chapters 2, 3, and 4)? In rare cases where HIV-prevention programming actively attempts to wrestle with the many complex social forces that shape men’s HIV risks (globally), what is the result in terms of impacting gender relations, HIV risks, and violence (chapter 4)? Where programs do focus on gender relations as a root cause of HIV transmission, do men in prevention programs embrace global health programming trends that ask them to challenge gendered power relations in the name of improved health? Or do heterosexually active men resist such calls, viewing themselves as disempowered by race and class and equating calls for gender equality in health programs with a loss of masculine authority (chapter 4)?

These are the main questions posed in this text, but there are others that are relevant. How, for example, shall prevention researchers simultaneously wrestle with the recognition that women’s social and structural empowerment is an important project in HIV/AIDS prevention—while also recognizing that masculinity, sex, and sexuality, defined according to constructs of “heterosexual identity,” tend to structure sex according to a hydraulic model of male desire, the predominance of penile-vaginal penetration, the centrality of male pleasure, and masculinity as bolstered by multiple partners (Flood 2003a, 2003b; Holland et al. 1994a, 1994b; Kimmel 1995; Vittelone 2000)? How exactly is HIV prevention to succeed when male condoms are overwhelmingly reported by men as decreasing pleasure and sensations (Choi, Rickman, & Catania 1994; Conley & Collins 2005; Khan et al. 2004) and when some feminist researchers have now pointed out that women increasingly report the same (Pulerwitz & Dworkin 2006; Higgins 2007; Higgins & Hirsch 2008)? On top of this, outside of biomedical solutions to HIV prevention (e.g., male circumcision, microbicide candidate products for anal and vaginal use, pre-exposure prophylaxis, or “PREP”), female condoms are “the only alternative to the male condom as a means of protection against both pregnancy and STDs,” and female condoms are not even adequately distributed or promoted in many countries while negative provider attitudes prevail and do not receive adequate intervention (Hoffman et al. 2004).

Throughout this book, it will be necessary for me to engage with the tensions between lines of work that focus on challenging oppressive gender relations in the name of HIV risk reduction and those lines of work that focus on masculinities and heterosexually active men to prevent HIV. I will pay special attention to the profoundly popular “vulnerability” paradigm in HIV research that portrays only women—and not heterosexually active men—as being “vulnerable” to HIV. I will critique this model and argue that it (vulnerable woman/invulnerable man) privileges gender analysis while omitting the unmarked category (men) and looks mainly at hegemonic definitions of masculinity while negating race and class marginalization. Ultimately, I will delve into how the current focus on “gendered” HIV-prevention interventions erases important drivers of HIV transmission—and therefore erases, marginalizes, or renders less fathomable or even unfathomable some important solutions to the HIV epidemic. Drawing on a “vulnerability” model, HIV prevention programs often seek to encourage women to employ more assertive sexual negotiations, but this model tends to ascribe men’s HIV infection to their participation in a system of gender oppression that privileges men and harms women. This negates the fact that some men are at much greater risk of HIV infection than others, that men are not only beneficiaries in a system of gender relations but also experience harm in it (Courtenay 2000a, 2000b, 2000c; Messner 1997), and that, if there are disjunctures between men’s sexual identity and sexual acts, this may shape their own and women’s HIV risks.

At the same time, this book will recognize that paying attention to the ways in which heterosexually active men are harmed through the gender order and in the HIV/AIDS epidemic is not some sort of antifeminist, relativistic, “equal-opportunity harm” argument, but rather that studying men and masculinity in the HIV/AIDS epidemic is, similar to studying men and masculinity in many other realms and disciplines, a feminist enterprise. It requires the ability to attend to hierarchies in an institutionally supported system of gender relations where men as a group benefit over and above women as a group and where women are disproportionately harmed (Connell 1987, 1995a; Messner 1997). But it also requires simultaneous examination of the “costs to masculinity”—recognition that both men and women are harmed when men adhere to narrow and restrictive definitions of manhood (Connell 1995a; Messner 1997).

It is important to recognize that studying men and masculinity in the HIV/AIDS epidemic also requires drawing on the critical insights of multiracial feminist studies, which have already pointed out that women are not a homogenous group and thus, men aren’t either (Baca-Zinn & Thornton Dill 1993; Cole 2009; Crenshaw 1991; Hill-Collins 1986, 1990; hooks 1984, 2000). These insights can press HIV researchers to then think about how some men disproportionately pay the health and inequality harms of the gender order—and how this affects both women’s and men’s health. Such thinking also requires that researchers consider the social and structural aspects of constraints on men’s behaviors, just as they do with women, and not essentialize individual “problematic” behaviors as being the cause of harm to men or to women. Thus, in addition to furthering the call to bolster the study of masculinity within the field of HIV/AIDS prevention, I will put forward multiracial feminist calls for intersectionality (the simultaneous intersection of gender, race, class, and sexuality: Baca-Zinn & Thornton Dill 1993; Crenshaw 1991; Hill-Collins 1986, 1990, 1999) that I consider to be urgent in the area of global and public health concerning matters related to men, women, HIV/AIDS transmission, and HIV/AIDS prevention (see chapters 2, 4, and 5).

Let me be clear: we are in the fourth decade of the epidemic in the United States, where the dynamics of gender, race, class, and sexuality relations intersect to produce sex between women and men as the larges...