Opening up the debate about #PrEP

This year for World AIDS Day, the Wheeler Centre has kindly published a longform article I wrote about PrEP titled ‘The other blue pill’.

I wanted to resist taking a side in the debate ‘Is PrEP good or bad’ or ‘Should we fund PrEP’.  These are phoney debates: we toss around arguments for/against, even though PrEP is going to happen. 

What we’re really fighting over is different ways of framing the problem that lead in different program and policy directions.

As a piece of social science writing, I wanted to leave readers with a couple of different ways of thinking about how those debates are framed. Framing PrEP in terms of ‘who should pay’ and ‘who deserves access’ leads naturally to discussions about limiting access.

We know where that leads.  Victoria has a post-exposure prophylaxis (‘PEP’) program that was funded via block grants to hospitals rather than the PBS.  Funding hasn’t kept up with demand and the use of newer, more expensive drugs.

As a result, we have de facto rationing.  There is no incentive to promote PEP widely in the gay community, and awareness of PEP has remained stubbornly around 65% on the gay periodic surveys.  ‘Repeat presenters’ — people at high risk of HIV infection who we most want to target — report encountering ‘moral friction’ from hospital providers, with remarks like ‘It’s not the morning-after pill, you know!’  The Alfred Hospital has resumed its policy of refusing international students access to PEP — even though PEP isn’t funded by Medicare.

So my goal in the Note is to challenge the implicit logic that makes ‘But should we pay for that?’ a rhetorical question, answerable only in the negative.  I’m walking in the foot-steps of Gregory Tomso’s analysis of public health responses to barebacking:

In his essay “Violence and Metaphysics,” Jacques Derrida … writes of philosophy’s “unbreachable responsibility” to poses questions in such a way that “the hypocrisy of an answer” is not yet “fraudulently articulated within the very syntax of the question.” (p91)

Framing therefore involves symbolic violence: it poses the question in a way that closes off certain answers.  As Tomso notes, “there is also the violence that belongs to wanting to know something about another, the Other, who is not the self” (ibid).

So I didn’t want to argue my case via universalising discourses like human rights, the responsible subject, or ‘we all want the same things really’.

The article describes cultures of sexual adventurism among gay men as one of those laboratories for learning about challenges that face the broader community — such as the sustainability of monogamous relationships and the ethical negotiation of casual sex.

But it also flips the script a bit: instead of pathologising sexual adventurism, it uses major representative studies (HILDA and ASHR) to de-naturalise  heterosexual practices of monogamy and highlight the need for the ideas and practices queer culture is experimenting with.

And it points out the injustice of relying on social innovators experimenting on their own bodies and relationships without providing them with the basic resources needed to do this safely.

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how social change happens

In case the idea of ‘cultural laboratories’ sounds a bit weird, it reflects some thinking I’ve been doing on the side of (recently-concluded) project work with the ‘What Works and Why’ study led by Dr Graham Brown at the Australian Research Centre in Sex, Health and Society.

This thinking considers how social change happens if we understand society as a complex adaptive system: a ‘complex macroscopic collection’ of relatively ‘similar and partially connected micro-structures’ formed in order to adapt to the changing environment, and increase its chances of survival (Wikipedia).

In a 1999 paper, the European social theorist Klaus Eder set out to explain why ‘society learns, and yet the world is hard to change’.  If we can get a bunch of AFL footballers in the room and convince them that homophobia is bad (social learning), why is it so much harder to discourage homophobia as part of the culture of Aussie rules in society (social change)?

Eder suggests that we learn how to overcome social problems in small networks — but that only leads to social change when our discoveries get captured, remixed and amplified through higher-level processes, such media narratives, popular culture, government policy, etc.

In my example, this might occur via the AFL changing the rules to heavily penalise homophobic behaviour.  No doubt this would cause a fair amount of backlash, but that’s part of the amplification process.  The change might occur through public debate triggering similar learning processes and the dissemination of findings across a much wider range of ‘cells’ in the honeycomb fabric of society (clubs, schools, families, etc).

In an earlier post I argued that news coverage alone is pretty unlikely to achieve this, but feature journalism probably does, because it provides enough space to offer an alternative framework for understanding the issue, and it allows the mixture of research, argument and personal narratives.  We’ve become literate in science writing but the genre of social science writing can barely be said to exist, beyond the Gladwells and the Freakonomics of this world.

But even when social learning produces innovative strategies, the achievement of widespread social change is by no means guaranteed.  Different ways of having the debate, as I argue above, can stifle the change process.

We know that major social change tends to happen when learning bubbles up from a particularly innovative network during a ‘window of alignment’ among much larger social processes — such as a media crusade and a tidal swell of popular opinion and a change of government: moments that Kingdon called ‘policy windows’.  That’s why timing is such a crucial part of effectiveness in policy advocacy.

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trying to make social change happen

Having an account of ‘how social change happens’ is not the same as knowing ‘how to make social change happen’.  To be clear upfront, I don’t think there is a recipe you can follow that’s guaranteed to make social change happen.  But there are preconditions we can achieve to make it more likely.

One is to keep the innovation bubbling away in those smaller networks — they are the cultural laboratories of change. If they dry out, you can’t just restart them at will when you need some good ideas in a hurry.

I saw this in action at the first national conference for the Australian Forum on Sexuality, Education and Health, with a panel featuring young queer educators talking about trigger warnings, activities for teaching affirmative consent, etc.  Some of the strategies sounded impractical to me, but practicality is not the point: experimental intensity is the point.

Second, we need a middle tier of project workers, researchers and policy advocates, who are paying attention above and below, identifying and validating good strategies from the laboratories and thinking about how to package them up, so there are policy options ready to go when those windows of opportunity appear.

Both of these suggestions depend on our health and welfare systems and the human services sector having enough resources flowing within them to support redundancy, which is essential for diversity.  Without that, you don’t get the multiple competing ideas that are essential for innovation.

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Mark McCormack interviewed by Dean Beck & Lauren Rosewarne

I finished high school in 1999. Homophobia was rife, and being gay I took it all personally.  In first year uni I came out as gay, and went back to my old school to coach Year 9 debaters.  Now, 14-15yo teenage boys are pretty awful.  But they quickly figured out my sexuality — the Onion headline ‘Newly Out Gay Man Overdoes It’ could have been written about me — and the gay jokes ceased.  Every now and again they’d slip up, blush and say ‘Sorry’.  Gay was no longer some abstract anti-ideal; it had been personalised.

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Promising forever

This is part two of a series beginning with What are you looking for?

Once I opened the wardrobe in the bedroom of a guy I was going out with, looking for towels, and I found a list: ‘What I am looking for in a partner’.  He’d been reading that awful, stupid book, The Secret, which told him to tell the universe what he wanted and this would ‘call it’ into being.  So he made a checklist of all the things he was looking for:  tall, white, professionally employed, et cetera; and the horrifying thing is, I was a pretty close match.  The relationship blew apart pretty soon after that, not because of my chagrin at being typecast, but because we were completely incompatible — sexually, emotionally and in our values around relationships.

Ever since then, if I even get a whiff of a ‘checklist’, I run a mile.  Guys post their list on their Manhunt profiles, or in chat, they’ll ask “what are you looking for” in the expectation that we’ll swap lists and tick off all the items we have in common.  It is desperately boring.  It’s a mercantilist take on human relationships, like a buyer and a vendor meeting in a marketplace and negotiating over an exchange of goods.  Guys who partner up on these terms often treat them as a contract, and cry foul when their partner turns out to have undisclosed interests or dimensions: “He didn’t tell me he wasn’t over his ex!” 

Most importantly, they’re operating on what I have called a logic of sameness, which assumes the most important predictor of a good relationship is matching — either literal similarity between the partners (‘pets who look like their owners’ syndrome; partners who could be twins) or close fit between your partner and your checklist.

The former is called homophily and it’s an incredibly reliable pattern in studies of dating and relationships: people tend to partner up with people who are similar on salient characteristics like class and religion.  The latter is an ego thing: it’s the belief that ‘I design my life, and I will design (ahead of time) the kind of partner I want, and I will choose a person who fits the bill, and we will have the kind of relationship that matters to me’.  I meet these guys in their thirties, bewildered by never having had a relationship longer than a few weeks or months (if that), saying in their profile “looking for the one”, painting themselves as the Last True Romantic.

In those brief, abortive relationships they never manage to ‘get outside their heads’, to see the person in front of them, to perceive them as a stranger — to have an encounter with the Other.  They can only see their checklist and keep measuring him up against it.  If you ask the Last True Romantic to set aside the checklist and play it as it goes, he’ll bridle, refusing to ‘lower his standards’.  And there’s the truth of it.  His ‘standards’ are a shield, there to protect him from the radical uncertainty of trying (and often failing) to live in relationship with an other.  He wants a Long Term Relationship instantly, skipping over the steady, day-to-day negotiation of differences.  He can’t manage the day-to-day, he can only manage Forever.

It’s a powerful desire, fundamentally egocentric, and it’s the same desire that drives the demand for gay marriage.  But that’s a topic for another post.

What are you looking for?

Every so often I post a Facebook update in a series I call “the Wisdom of Manhunt” (or Grindr).  They’re just quotes from people’s profiles on gay chat sites that made me LOL or WTF (and sometimes both in equal measure).  I love it when someone says something spiteful, e.g. ageist or racist, in such a way that it makes them sound incredibly foolish.

These posts always get a reaction from my friends — a mix of catty, hilarious remarks and thoughtful conversation on the issues involved. Someone recently said ‘hey, you should post these on your blog’.  It has been done before, with the infamous Douchebags of Grindr.  I admit to chuckling at first, but pretty soon the posts came to seem pretty douche-y themselves; there’s no moral high ground in the business of public humiliation.

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