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October 27, 2008

Resist "Lazy Structuralism": HIV Prevention as Case Study
By Trevor

If you've stepped foot in a feminist studies classroom in the past few years, you've undoubtedly come toe-to-toe with the famous "structuralism vs. postmodernism" debates that have clouded feminist and queer studies since the mid-90s. If you haven't, let me catch you up pretty quickly. Structuralists are -- generally speaking -- interested in the ways that societal institutions like race, class, gender, etc., "structure" people's lives. And when they say "structure," they generally mean: how do institutions shape / determine / give meaning to people's lives? So, if you're Black, you're disadvantaged in X, Y, and Z ways. And if you're white, you're advantaged in A, B, and C ways. Taken to its extreme, it can lead to a kind of institutional pre-determinism. This is of course a totally reductionist definition. But let's say it's a rough sketch.

On the other end of the table, you had postmodernists who rebuffed against this kind of "structural determinism" that came out of a Marxist tradition. Heavily influenced by so-called "queer theorists" who sought to deconstruct labels like "gay" and "lesbian," postmodern feminist theorists demanded a bit more complexity in the way that we described and understood the lives on individuals -- and basically argued that no one's life could be understood as the sum of their demographic variables. Just because you're ____, doesn't mean that _______. Taken to its extreme, postmodernism might lead to a viewpoint that every person's life is completely unique, and cannot (should not?) be lumped under any umbrella category with anyone else's life. It's all about agency, agency, agency! The hell with structure.

Now, I find myself constantly coming back to this debate. As a sociologist, I'm obviously interested in the way that social institutions give meaning to and shape people's lives. As an activist child of the queer 90s, I'm also deeply troubled by universalizing theories that eclipse the diversity of lived experience, where I think the real meat of the story is. So I'm constantly trying to sniff out some kind of middle ground -- some happy place where I can recognize that social structures provide the framework, while also allowing for individual choice (albeit under a constrained framework).

This debate has been slapping me square in the face lately in discussions on HIV Prevention in the US, which I'd like to argue been plagued by something I want to call "Lazy Structuralism" -- in the perverse form of epidemiological data on HIV transmission. We are time and time again presented with pie charts that informs us that a certain bloated percentage of new HIV infections is among a certain minority racial group. We are told, in this way, that race is a risk factor for HIV infection -- and that's about the end of the analysis usually. No meaty analysis of what cluster of mechanisms are approximated by or associated with the category of "race." Just pie charts.

I'm reminded here of my friend Michael Scarce's scathing critique of San Francisco's STOP AIDS Project's new attempts to quell HIV infections among younger MSM in SF by restricting their access to venues where older MSM frequent. This is based on "epi" data that indicates that a sizable chunk of new infections among younger MSM is the result of sexual contact with older MSM. Their solution: segregate the two populations. In a conversation on the Gay Men's Health Ning, Michael reminded us that:

More than likely, age does correlate in some way with risk. However, correlation is different than causation, and age of partner is one of the few questions asked by SAP in their data collection. But what are the deeper meanings and connections? What are the underlying social and cultural complexities? For example, older men in San Francisco tend to have dramatically higher incomes than those of younger men. It's quite possible a power differential corresponding with age is more relevant, such as money, housing, social status, employment, and so on. The difference between your analysis and that of SAP is this: Stripping these demographics of their cultural context alleviates researchers from the responsibility of having to consider how their work intersects and interacts with other social forces such as ageism and AIDS-phobia, as well as the great examples you give such as cognitive development, social psychology, racialized desires, and more.

In this way, what STOP AIDS is resorting to is what I'd like to term "Lazy Structuralism." They get this kind of "blocky," uncomplex data from public health, and try to use that totally decontextualized data to try and come up with an intervention. The result: a total fucking disaster. And of course it is. Because it's based on nearly meaningless data. What HIV epi data tells us is basically the outcomes sorted by a number of demographic variables. But it does nothing to tell us the causual mechanisms that are working behind the scenes to lead to those disparate outcomes. Obviously, skin color is not what's driving high infections among African-Americans. Things like access to housing, health care, racialized discrimination, and employment are the actual culprits -- obstacles that obviously may also be differently faced by Latino, white, or Asian-American queer men. Similarly, it's not the difference in age in and of itself that's driving the new infections among younger MSM, it's the differences in income, housing, etc. But epi data can't tell us that.

We need to be demanding an end to this kind of lazy, uncreative, and wholly uninspired thinking about the epidemic. It's not just misguided, in the face of rising disparities and new infections, it's patently unethical. It does representational violence to the lived experiences of queer men's lives, and threatens to divide and promote hostility within our communities. STOP AIDS' efforts are just one small example of this kind of thinking.

The next time you're at conference or community forum and hear someone repeat ad naseum that X percentage of new infections are among X population, raise your hand and ask them, "What's driving that disparity?" If they're honest, they'll probably tell you they don't know. If they're crafty, they'll speculate about a variety of factors that might be associated with the demographic variable at hand. But please: call them out on their willful ignorance in the face of increasing health outcome disparities. On their continued participation in institutions of research and prevention that refuse to fund innovative projects that seek to explore the causal mechanisms beyond sexual behavior, rather than the overly simplistic demographic outcomes. Because pie charts will not provide us with solutions, and we can't allow public health to continue its injustices against our communities by continuing to assault us with the Same. Old. Fucking. Data. It's tired. And it isn't working. And we're over it.

PERMALINK | Posted at 2:07 AM | Post a Comment (10)

10 Comments

Great post Trevor - passed it along to friends in Columbia's public health program!

Win | October 27, 2008 6:51 PM

Oh good! I hope some of them comment with their thoughts. I would imagine that there are sympathetic minds there...

Trevor Hoppe | October 27, 2008 8:12 PM

That's a ripper of a posting.

Just a quick question from a cultural studies person though: is that really what structuralism has come to mean in sociology? I'd be thrilled if it has, because it's much more intuitive than the linguistic meaning of structuralism. In my work on sexual racism I have used various different metaphors to capture the difference for a non-academic audience, like 'power imbalance vs power relation' or a concrete bridge vs. crowd-surfing. Interested to hear your thoughts?

Daniel Reeders | October 27, 2008 9:05 PM

Hey Daniel. Yes, the problem with these terms is their disciplinary meanings. I think many sociologists actually do refer more to the structuralism that you're referring to -- a kind of linguistic / social interactionist definition that actually refers to how the very structure of language and the social interactions in which language is constructed work to constrain / give meaning to our social worlds.

So you're right to question where my understanding here of "structuralism." I guess I'm referring as a movement away from relying on analyses of social institutions as our only way of understanding politics / society / lived experiences / whatever.

But perhaps that isn't quite what structuralism is... although I feel like in the context of political science I've heard others use that word to signify what I'm talking about. Perhaps I'm really referring to a kind of Marxist tradition...?

Well speaking of language! Hmph. You're right, though. I'm just not sure what a better word would be for what I'm referring to.

Trevor Hoppe | October 27, 2008 9:21 PM

This is super interesting, Trevor. It is a total departure from what my research is about, but is nonetheless interesting for it is curiously based on the structuralism-poststructuralism debate and the social-spatial dialectic that I am investigating. But before anything, I am of the view, and pitch-in if you think otherwise, post-modernism is generally associated with art, architecture and culture whereas post-structuralism is linked with literary theory, history and philosophy both however arguing for a counter discourse that seeks to challenge fixed/absolute meaning and monolith/power. From this standpoint, I completely agree and share with you my frustration with the deterministic and the supposed explanatory capacity of statistical correlations which in most cases isolate variables and discount the complexities of say the "lived" (as Lefebvre would argue).

Kush | October 27, 2008 9:30 PM

I think you're exactly right - there's a conflict between post-structuralist critique, in which power is mobile and distributed and power relations are subject to change, reversal and resistance, and the Marxist critique in which power is distributed along class lines and the whole structure is fairly permanent and unchangeable (except by the Revolution!). But is this what we think is happening in lazy public health usage of prevalence data? I think some of it arises from the unwillingness of public health decision-makers to 'get their hands dirty' by funding and engaging with research into gay male sexual and social practices. (Then again, if they're assuming these are just a male-male analogue of heterosexual practice, that really would qualify as a structuralist belief in the linguistic sense of the word... Trevor, I think the only conclusion I can reach here is that Daniel needs to go back to university and stop banging about on your blog!! :P)

Daniel Reeders | October 27, 2008 10:01 PM

We at STOP AIDS Project acknowledge and encourage a dialogue about how best to address GBT mens health, a topic which is of crucial importance to GBT men. We appreciate Michael Scarces participation in this dialogue and recognize the Gay Mens Health Summits role in fostering it. To be clear from the outset, Michael Scarce and STOP AIDS Project agree that segregating older men from younger men for the purposes of preventing the transmission of HIV is unquestionably wrong. Doing so would be against our values as an agency and as individuals who work in the field of GBT mens health. We wholeheartedly agree that constant vigilance is necessary to ensure the implementation of programs that are consistent with our personal, community, and agency values.

It is also important to note that we have not launched any of the new programs from the study Michael cited and will not do so until we have satisfied concerns about their practical, epidemiological, and ethical appropriateness. Program ideas from this study have been discussed with focus groups and will be posted online for feedback before we move forward, and we invite you to participate in that process. We believe that we are acting cautiously and responsibly as we forge into new HIV prevention territory and welcome appropriate and healthy discourse about these issues as we move forward.

Having said that, we need to acknowledge that Michaels critique seems to be divided into two distinct halves, the first being the launch of an important community dialogue about the use and potential misuse of sexual network paradigms in HIV prevention, and the second an ad hominem attack on the agency and specifically-named current and former staff members. As it is illegal and inappropriate to discuss personnel matters, it is only to the first part of Michaels comments that we will respond, both to address some misunderstandings that seem to have unfortunately arisen, and to invite community members to join in the ensuing energetic and healthy discourse.

Like many of the readers here, STOP AIDS Project understands that new approaches to fostering GBT mens health and preventing the spread of HIV are needed. As most people can attest, attempting to try new things is much more difficult than resorting to the same set of tools over and over again. However, STOP AIDS Project as an organization and as a group of dedicated individuals is committed to taking on new challenges that improve GBT mens health outcomes. In doing so, we welcome community partners as we generate new ideas.

STOP AIDS has helped lead this pioneering effort to use sexual network approaches to address a simple fact: HIV prevention efforts that focus almost exclusively on getting men to wear condoms leave much to be desired not only in terms of decreasing the rate of new infections, but more importantly in terms of building community, addressing the underlying causes of stigma and isolation, and supporting the assets and resiliency factors that already exist in the GBT community. STOP AIDS Project recognizes that sexual decision-making is influenced by any number of individual psychosocial and behavioral factors like self-esteem, joy, lust, love, desire for intimacy, and substance use. Furthermore, our sexual decision-making is also influenced by macro-level factors like racism, homophobia, ageism, socioeconomic disparities, and HIV/AIDS stigma (to name a few). In our work we also take into account that our sexual decisions are also influenced to a large degree by who our partners are, and where we fit in a sexual network.

For example, if your partner barebacks more than you do, you are at much greater risk of being exposed to an STD or HIV than if he doesnt. In general then, barebacking with a new partner whose status you dont know in San Francisco carries a much higher risk than the same activity in, say, Boise, if only because the background prevalence of HIV is higher in San Francisco than it is in Boise. Similarly, for young GBT men (as well as young heterosexual women) one of the biggest risk factors is having unprotected sex with older partners. Why? The background prevalence of HIV is higher among older people. Does that mean that we shouldnt let men from Topeka move to San Francisco? Of course not. Does it mean that we should discourage young men from having partners who are older? Of course not. To take such a stance would be repugnant, and inconsistent with our personal and collective system of values. The stance we have taken is to confront these uncomfortable truths head-on and help men make informed, empowered decisions of their own.

The research project Michael references is part of the sexual networks approach we have begun to implement. This project focuses on disassortative mixing by self-reported sexual behavior, and not on demographic factors such as race, age, etc. We have had many conversationsboth internally and externallyabout maintaining an ethically appropriate balance between health and human rights concerns and we are determined to take thoughtful, measured steps to insure that any interventions we implement honor that balance.

These first steps in this new direction are formative and are helping us understand how sexual networks affect mens sexual decision-making and explore potential new programmatic ideas. Several months ago we started creating a program development guide, which will clearly articulate our process for the creation of any new interventions, including the ethical concerns Michael airs so passionately.

Phase One of this research project was to identify venues where self-reported HIV negative men who bareback often and self-reported HIV negative men who rarely or never bareback both meet their partners. In other words, we developed sexual behavioral indicators that focused not on average HIV-risk among patrons within a venue but on the "bimodal HIV-risk" -- where there were men with low HIV risk and men with high HIV risk meeting partners and making sexual choices in the same venue.

Phase Two involved conducting interviews with men from the venues identified in the first phase to assess factors in the venues themselves that might affect sexual decision making (For example, Two-for-One drink specials that, for some patrons, may lead to excessive drinking). We interviewed over 30 men (including employees of these venues, and other key stakeholders) and were able to solicit ideas from them about programs that would be specifically tailored to those venues. This part of the project allowed us to use qualitative data to help us understand the contextual factors related to sexual decision-making.

Phase Three, which has just begun, identifies an appropriate program based on the information produced in the first two phases. In this case, appropriate includes how effective, ethical, and practical an idea is, how the patrons are likely to respond to it, and an assessment of possible indirect consequences. To date, we have held six focus groups to get input on intervention ideas and are poised to launch an online survey as well.

We state categorically that we are not focused on separating individuals by ageor separating them at all, for that matter. In trying to understand how men pick their sexual partners we have noted that men often do make selections based on age, which is related to both existing assumptions in the community about age and serostatus, and unfortunately to the ubiquitous ageism that permeates mainstream gay cultures conflation of youth, beauty, and sexual desirability. These are not dynamics that we are interested in judging, supporting, or manipulating; they are simply findings in our work.

In point of fact, we have discussed how to facilitate an enhanced sense of community and intergenerational social support by designing interventions that bring men of all ages together. We have found in our interviews that there is great interest in this type of support and we are attempting to be responsive to a clearly articulated community need. We have, and will continue to discuss how to make it easier for younger and older gay men to share their experiences from their generational perspective. Further, we believe that intergenerational dialogue is an important and critical component of a healthy community. We are exploring how to do so in the context of several programs that we are hoping to implement.

For those unfamiliar with our work, we want to assure you that our process has been, and will continue to be, inherently community-based. We are deeply committed to making sure that all of our programs respect the human rights for which we all have fought so many years. As an agency we pride ourselves on building partnerships and on going beyond service provision to empowering and organizing communities.

We are open to new ideas, intellectual rigor, and robust dialogue. Please feel free to write or call if you dont understand something were doing. Will all of us agree? No although from the blogs we've read thus far, we probably agree much, much more than we disagree. We can all strive to understand each other, find common areas of collaboration, and find out how we can best work to assure that gay, bi, and trans men can make new HIV infections something to look back on as part of building a healthier community.

Kyriell M. Noon
Executive Director
STOP AIDS Project
knoon@stopaids.org

Kyriell Noon | October 30, 2008 12:01 AM

We used to call this the numbers game when I taught the subject... everyone wants to get ahold of the disease and say "it's ours." African-American leaders desperately want to say HIV is ours so they can quickly dissociate themselves from the gays... the gays are happy to say "it's not ours," though the gay advocates are trying to fervently point to rising rates in MSM.

Blah, blah, blah, blah.

How about this for a unified theory of prevention: condoms save lives... everyone's life. :-) Targeting doesn't matter, and demographic information equates t olittle more than statistical noise that is descriptive rather than predictive (or prescriptive) in nature.

To ask why AFrican-Americans are seeing increases is not simply to ask "what are the factors driving the disease," but "what are the factors behind poverty, educational gaps, and lack of opportunity." The question becomes broader, and then you have to include questions of prisons... and teenage motherhood... and public health as a whole.

It's much easier just to say "you're black? get tested" rather than "wear a condom."

In the end, because of everything else in people's lives, we know that we'll be far more likely to get someone tested than to get someone to wear a condom.

How sick is that?

PS Trevor... I am in DESPERATE need of a resource... I'm working on a paper (I'm trying to get my first publication under my belt before I apply to grad school) on the public health implications of STI treatment without testing (and thus without any requirement to report). I'm gathering data from my employer... but I was wondering if you knew of anything out there...

Specifically, I want to make an argument that it's not just a scientific question of creating resistant bacteria but is laden with a host of other, as yet unanswered, questions (including potentially leading to sexual irresponsibility).

QueerCincinnati | October 31, 2008 3:59 AM

Are you referring to partner packs? Because that's certainly something I would support... but honestly I'm not really sure what kind of literature you're referring to here.

I mean, let's be real: "wear a condom" was rammed down gay men's throats and we see how well that's working. So I'm not convinced that we need to revert back to a unified, universal effort to promote condom use. I think it's too little, too late. People have already found ways to mitigate risk in the absence of condoms. The problem -- I think -- is that strategies for doing so may work in certain contexts, but utterly fail in others (e.g. serosorting in San Francisco where testing rates are high, versus serosorting in Detroit where testing rates are relatively low).

Trevor Hoppe | October 31, 2008 1:08 PM

While I can't speak to the particular case (HIV prevention) that you deal with here, on a more theoretical level, you should check out Pierre Bourdieu. His concepts of habitus, field, and social capital form a great theoretical foundation for studying the intersection of the individual and the institution and bridging the gap between structuralism (which he seems to view as reducing the individual to a mere support for structures) and an appreciation for the wealth of diversity in lived experiences (while not going so far as to suggest that our choices as individuals are limitless or even all that extensive).

Chris Coombs | January 8, 2009 1:36 PM


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