When Science Meets the Bedroom: 50 Shades of Pleasure and Prevention Bridging Session
Time:22.07.2014, 14:30 - 16:00
Chair:Sean Strub, United States
A panel of speakers reflected on the intersection of pleasure, power, prevention technologies and how this manifests in very different ways depending on the population, context and prevention options available. Presenters posed thought-provoking questions that illuminated how certain prevention options - PrEP, for example - can represent a welcomed and needed new prevention option for some populations and simultaneously shine the light on global inequities and policies that result in people who are already living with HIV not being able to access life-saving medicines. Are different populations' needs so divergent that they contradict each other? Numerous presenters and audience members advocated that rather than focusing on any one particular prevention technology we must continue to diversify and improve access to a wide variety of prevention tools to accommodate the very different ways pleasure and HIV prevention interact for different people.
Prevention science and sexual health
U. Davidovich, Netherlands
U. Davidovich took a retrospective look at how historical contexts have shaped and re-shaped the cultural, social, public health and relationship between condoms, pleasure, and HIV prevention with a emphasis on gay, bisexual and other men who have sex with men. At the beginning of the epidemic gay men actively adopted condoms which was exceptional given that they had traditionally been relegated to heterosexuals, and because of public health reluctance to condone them as a worthy strategy. Interestingly, levels of condom acceptability among heterosexual couples before the HIV/AIDS crisis were generally only around 20%. While rates of condom use among MSM may have declined from an astounding 80% down to 60-70% of people reporting consistent condom use with all sexual partners, the intense focus HIV prevention science has had on the 20-40% of people who are not consistent condom users highlights the dependence/preoccupation that arose from having so few prevention options available. In reality, studies have consistently shown that at at least 12% of men are effectively unable to have sex when using condoms because of loss of erection, however given the lack of alternative options their lived experiences could not be well addressed. As new options become available that are inherently more attractive (and actually usable) for certain men, Davidovich suggested that science could shift its attention to developing an understanding of how different prevention options meet different people's needs.
Community-based research evidence on risk behaviour and sexuality
G. Prestage, Australia
G. Prestage explored the value and importance of PrEP for gay men and addressed a number of common concerns/perceptions. He suggested that what has been missing from discussions about gay men's risk are issues of desire and sexual pleasure. He suggested that according to the data he's seen men who appear to take the most risk tend to be well-informed, self-accepting, well supported; most don't fit the victim profile, which doesn't make the easiest case for policy and program development.
Prestage's talk explored some of the moralizing and judgmental concerns that have been raised with respect to PrEP and PrEP implementation. He suggested that oft-cited concerns about gay men's ability or willingness to adhere to the PrEP regimen seems to be a double standard since research since the beginning of the epidemic has shown that 100% adherence to condom use is relatively rare.
Prestage posited that a great deal of the anxiety/antipathy towards PrEP is rooted in common prejudices stigmatizing gay men and portraying them as irresponsible risk-takers who, with access to PrEP, will abandon condoms altogether and turn into "rampaging whores," referring to the American-born "Truvada Whore
" cultural moment. This shift is somewhat perplexing, he suggested, as "condoms make it easier to be a slut and avoid infection too."
With respect to certain concerns that PrEP represents the biomedicalization o f HIV prevention, Prestage suggested that this need not be the case at all and challenged social science to consider how one of the social tasks that has accompanied the HIV epidemic has always been to counter the sexual repression that came with HIV. He posited that rather than rather than obsessing over the use of a new prevention option that has biomedical underpinnings, this could be an opportunity to revisit the social struggles around sexual liberation.
Prestage likened PrEP to early discussions about the birth control pill, noting that what it did was provide people with options, just as PrEP should. He then asserted that unless you believe people shouldn't be able to make their own kind of fun, letting people make decisions that are right for them shouldn't be a threat to anyone.
The presentation concluded with Prestage mentioning what he considered was the most significant and important question about the future viability of PrEP, namely the cost of the drug. He acknowledged that it was far too burdensome for many people and predicted that unless there is a concerted effort to make PrEP accessible and affordable a significant market for on-line purchase of generic tenofovir/emtricetabine (at a fraction of the price of brand name) would grow.
TUBS0305 Trans health and HIV prevention
C. Chung, United States
C. Chung shared a number of situations that reflected the ways in which sexual health and HIV prevention and treatment services have failed to adequately address the needs of trans women. A strong take-home message was that sexual pleasure is often a lesser priority compared to personal safety or the desire to have ones gender validated by sexual partners.
This state of affairs is only reinforced by dis-empowering environments, lack of trans-competent education and similarly trans-specific research data which reflect a general social disregard. Specific examples discussed included:
- Even in a resource-rich, high income city like San Francisco we still see evidence that treatment is not always a guarantee, either because of lack of competent services or because it's not a priority for trans women in their lives
- 95% of the trans women who are HIV positive already knew their status, however only 77% of those were linked to care within 3 months and of those who actually stayed in care and received treatment only around 40$ had achieved a suppressed viral load.
- During iPrex study there was an effort to recruit trans women into he studies but most dropped out because they didn't feel like the providers or researchers were affirming who they are, and instead that they were being treated as MSM - a very common situation in clinical research
Perspectives on prevention from the International Community of Women Living with HIV
J. Whitbread, Canada
J. Whitbread opened by acknowledging that as a woman living with HIV she was very aware that science has helped with her cause for pleasure in the bedroom, and has likely made for a more robust sex life for many women living with HIV.
That said, the technologies and options available to date are not without their faults, and when it comes to biomedical interventions and technologies they have done little to challenge some of the gender disparities that occur in the bedroom which can be the deciding factor as to whether a certain option are used. Condoms use, for instance, is not always possible for women. Further, many of the safer sex technologies that have been created through scientific/commercial research are not necessarily practical for many queer sexual configurations, such as for queer women or differently gendered bodies.
Whitbread concluded her presentation by posing some questions intended to provoke discussion around PrEP given that, to her, conversations about PrEP were being pushed. She felt that PrEP is not talked about very much among the networks of women in which she was involved, and recounted experiences of speaking to other HIV positive women who did not know what PrEP was. Upon explaining the technology a common response was that it didn't make sense that this would even be considered given the challenges they faced as HIV positive women accessing life-saving treatment.due to limited access this technology only impacts a small portion of people in the world: white, gay men in the North.
Sexual and reproductive rights of women
S. Mthembu, South Africa
S. Mthembu opened by acknowledging that women are entitled to sexual and reproductive health (SRH) and rights, and that this is an obligation of the state. She reflected that discussing pleasure within this context is rare and noted that often in SRH programs there is an almost exclusive focus on reproductive as opposed to sexual rights, reflecting the fact that women, by and large, are viewed more as reproductive beings than as sexual beings. Further when sexuality is addressed it is often solely focused on the potential negative consequences of sex such as STIs, unwanted pregnancy, and HIV. Despite being the "other side of the same coin," pleasure is rarely if ever part of the conversation.
Mthembu reflected an overall feeling that regardless of pleasure, many scientific inventions such as condoms were inherently difficult to use because of the challenges in negotiating condom use. With respect to female condoms, she proposed that a technology meant to be used by a woman on her own body - which may be seen by the other gender as a commodity that she herself does not own - may be even more difficult than negotiating male condoms. In other words a woman saying "I have a condom" is also saying "I own my own body," which could create a problem in the bedroom for her.
With respect to non-condom based technologies Mthembu pointed out a number of serious drawbacks, highlighting how addressing women's sexual health and pleasure in a piecemeal fashion (technology by technology) results in women being left behind. Research on microbicides - often spoken of like a magic bullet that you can use without anyone knowing as many as 8 hours before sex - is progressing at a very slow pace, which is a reflection of a lack of investment in the field and a general sense that women with HIV have been excluded from research. Other technologies also have their own downfalls: HPV vaccines may result in a partial reduction in risk of HIV transmission, but this doesn't matter much when someone's socioeconomic status dictates whether they get it. Depo-provera, on the other hand, is provided widely but is known to interfere with the vaginal environment and could actually increase women's risk of contracting STIs and HIV.
Mthembu concluded by saying that if condoms haven't been the solution for women in the past three decades, they alone will never be the solution. She advocated for the inclusion of safe contraceptives and STI treatment as part of HIV prevention, and that nurses and doctors much take this to hard and start actually looking into women's vaginas rather than automatically treating them with antibiotics for STIs at any mention of vaginal discomfort.
Questions, Answer and Audience Discussion
- A lively and engaged discussion ensued, largely regarding PrEP and its place in the scheme of prevention moving forward. Common concerns such as long-term side effects (which can be confused with short-term tolerability) and cost of the medication and campaigns promoting the option were raised. Others responded by saying that costs could potentially be subverted by acquiring the medication through means like internet purchases. Long-term side effects are a concern which is why clinical monitoring and consistent care are important. A PrEP user emphasized that suggesting PrEP is a 'lifestyle drug' and statements characterizing PrEP as giving a "toxic medication" to "healthy" people distorts from the reality that people who are expected to take PrEP are in fact at very high risk of becoming HIV positive, and are thus not far away from having to not only take Truvada but other HIV medications for the rest of their lives, while PrEP use can be stopped.
- There was general agreement that many more options are required to address the diverse contexts of pleasure and risk among different groups of people.
- An audience member raised the issue of chidren's sexuality, reminding everyone that children want to know about pleasure, how to engage in their sexuality safely, and that abstinence-only education does not answer their questions. Important to acknowledge that we are all sexual beings and remove the taboos from sexual pleasure.