Beyond abstinence: toward a different kind of yardstick.

Sex in Development: Science, Sexuality, and Morality in a Global Perspective. Edited by Vincanne Adams & Stacey Leigh Pigg. Durham, NC: Duke University Press, 2005, 360 pages. $23.95, softcover.

In January of 2003, Congress passed and President George W. Bush signed the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, also referred to as the President's Emergency Plan for AIDS Relief (PEPFAR). The law earmarks relief money for services to people with HIV and AIDS in fifteen countries in Africa, Asia, and the Caribbean.

As with most development policies advanced by the current Republican administration, PEPFAR included a number of ideological components that put a premium on morality rather than public health. PEPFAR extends the trend begun with the 1984 Mexico City Policy, better known as the "gag rule," which prevents foreign aid funds from being used to support services attached to comprehensive family planning programs.

PEPFAR specifically mandates controversial abstinence-until-marriage approaches to sex education, despite the fact that study after study has shown that comprehensive HIV prevention and sex education programs are far more effective than so-called "abstinence-only" approaches (Collins et al., 2002). According to Naina Kaur Dhingra, director of Public Policy Advocates for Youth, "abstinence-only" approaches prevent young people from gaining access to information about condoms, one of the most effective means of preventing HIV infection. The result is a culture of fear around condom use. Further, recent research suggests that marriage is no panacea: married women in Africa have been found to be at higher risk for HIV/AIDS than those who are not married. Unfortunately, such examples of misplaced focus are hardly new in the field of HIV/AIDS research (Murray & Paine, 1988).

An Anniversary and a Protest

The morality and ethics of AIDS policy have long been subjects of contested debate (Crimp, 2002; Warner, 1999), a debate that extends well into the realm of both local and international policy around sexuality and behavior. In this realm, interventions favoring sexual abstinence starkly contrast with evidence-based, less coercive harm reduction approaches to care and prevention (Siplon, 2002).

These debates were on people's minds as activists from five continents took to the streets during the 2006 United Nations General Assembly Special Session on HIV/AIDS. The meetings were held to commemorate the 25th anniversary of the AIDS pandemic. Thousands of protesters demonstrated outside the session to demand increased funding for treatment and comprehensive AIDS prevention. They expressed outrage and disappointment that 15 million people have died of AIDS since similar UN meetings in 2001, at which leaders made commitments to fight the pandemic.

In response to the ongoing politicization of the epidemic, activists demanded that world leaders implement science-based HIV prevention and universal access to HIV/AIDS treatment. Nearly two dozen activists from New York's Housing Works and ACT UP, including this author, chained themselves to each other and were arrested while delivering a letter to U.S. ambassador John Bolton's office denouncing the triumph of ideology over science in American AIDS policy (Reuters, 2006). Some compared the political manipulation of science under the current Bush administration to the Soviet distortions of science known as Lysenkoism.

Inside the United Nations headquarters, world leaders met to review progress on the 2001 commitments and to issue a declaration outlining goals for the coming years. Prominent AIDS activists from numerous countries spoke at a rally outside the meetings, highlighting the urgent need for vastly improved access to affordable HIV treatment and care. The World Health Organization estimates that only about one in six people who need HIV treatment currently have access. Accordingly, activists are demanding increased funding, policies that promote affordable generic drugs rather than big drug company profits, and training and support to increase the number of healthcare workers in areas with shortages.

Activists also focused on the need to implement science-based prevention strategies, including female and male condoms and harm reduction programs responsive to women, drug users, men who have sex with men, sex workers, and other vulnerable populations. They criticized governments for neglecting these groups, and accused the U.S. government of enacting highly politicized and ineffective prevention policies. According to Jodi Jacobson of the Center for Health and Gender Equity, the U.S. prohibits funding of proven public health strategies such as needle exchange, has dramatically increased funding for abstinence-until-marriage programs, and supports policies that foster discrimination against marginalized groups such as sex workers; in fact, current policy requires that foreign aid groups receiving U.S. funds must sign a pledge to oppose prostitution.

Science, Sex, and Morality

Many hoped that some 25 years into the AIDS pandemic, funders and development agencies would look further into the complexities of local circumstances and their related policy needs. Differing settings present profoundly specific contexts for care. For those with an interest in making sense of the uniqueness of a wide range of settings, practices, and struggles, there is no need to look any further than Sex in Development: Science, Sexuality, and Morality in a Global Perspective, a new volume of essays edited by anthropologists Vincanne Adams and Stacey Leigh Pigg.

The essays describe ways in which sexual practices have been politicized with the onset of AIDS as an international problem. "With the HIV/AIDS epidemic, sexual relations have suddenly come into the forefront," Adams and Leigh Pigg write in their introduction:

   No longer imagined indirectly through the proxy of fertility,
   sexuality has become scripted through the imperative
   of disease prevention and in some cases, remains
   attached to concerns about family planning. Discussions
   of who is having what sorts of sex with whom are routed
   through an ultimate concern with disease vectors, echoing
   an earlier era when venereal diseases were central
   to moral debates that linked health and national
   strength ... Yet compared with social hygiene campaigns
   of the late nineteenth and early twentieth centuries,
   today's focus on disease and sexuality is more explicit
   about sexual acts, pairings, and identities; more precise
   in its scientific elaboration of the physiological, even
   molecular, mechanisms of risk, more exacting and elaborate
   (p. 19).

A core theme of the volume is the use of science to veil moral discourses aimed at control of sexual deviance. Here, notions of what is natural, normal, and appropriate are manipulated within highly ideological approaches to development, which echo bygone eras of colonial control.

Sex and Development is divided into three sections. Part one, "The Production of New Subjectivities," includes reports on the sexual revolution in Russia, family planning in Greece, and sex education programs in Uganda. Part two, "The Creation of Normativities as a Biological Project," includes reports on sexual autonomy in Papua, Indonesia, prostitution in India, and moral regimes versus traditional pleasures in Tibet. Part three, "Contestations of Liberal Humanism Forged in Sexual Identity Politics," includes reports on the politics of AIDS in West Africa and India.

The book's highlights include the introduction by the editors and the report on competing discourses of sexuality in Uganda by Shanti Parkh. Here, Parkh describes how age-old methods of sexual initiation are threatened by new technologies of sex education, including television and public health campaigns.

The same themes unfold again and again from essay to essay. Development programs turn local communities into sites of contention as differing interest groups seek to establish criteria for what is natural and what is deviant, what is moral and what is culturally appropriate. The dance between development dollars and sexual practices takes place in a profoundly imbalanced public arena, as parties struggle over competing discourses, intentions, meanings, and unintended consequences. All the while, "Targeted groups are portrayed by experts and elites as either ignorant or, more benignly, as objects of pity when they are presented as voicing reasoning about their sexual and reproductive bodies that is non-science based," the editors explain (p. 41). Here, "the idiom of rationality and the project of education often become vehicles through which class or racial distinctions are marked," (p. 41). Inevitably, the discourse of scientific facts, "can readily function as a tool for carving out social superiority," (p. 41). And the pattern repeats itself over and over again across a range of sexual and reproductive health programs.

Yet the struggle for autonomy and self-determination to defend culturally specific meanings remains imperative. Garcia Marquez (1982) addressed the difficulty of finding words or a framework to understand and make sense of "otherness" in his 1982 Nobel Lecture: "It is only natural that they insist on measuring us with the yardstick that they use for themselves, forgetting that the ravages of life are not the same for all ..." The struggles for autonomy described in Sex in Development echo the dilemma described by Marquez when he said, "The interpretation of our reality through patterns not our own, serves only to make us ever more unknown, ever less free, ever more solitary."

To ground their research, the authors and editors cite Carole Vance's studies of sexual anthropology, Allan Brandt's studies of sexually transmitted diseases, and Michel Foucault's studies of sexuality and social control. Yet it often feels as if they fail to add new revelations to this conversation, instead borrowing from the same often opaque, often dense language to describe how systems of surveillance, patterns of control, and regimes of regulation repeat themselves anew from continent to continent. The patterns of development and coercion described herein feel exhaustingly familiar.

For many, the story of sexuality and difference is a story of social control of desire and the mechanisms that compel people to list, quantify, and confess to any number of the most basic human acts. Parkh begins her report by quoting Foucault, explaining, "These sites radiated discourses aimed at sex, intensifying people's awareness of it as a constant danger, and this in turn, created a further incentive to talk about it" (p. 125). In many respects, this quote says it all. After a generation of structuralism and permutations of GLBT and queer studies, the study of sexuality still lives under this shadow, struggling to find its own voice.

References

Collins, C., Alagiri, P., & Summers, T. (2002, March). Abstinence-only vs. Comprehensive Sex Education: What are the Arguments? What is the Evidence? Progressive Health Partners, AIDS Policy Research Center, and the Center for AIDS Prevention Studies. AIDS Research Institute, University of California at San Francisco Policy Monograph Series. Available at: http:// ari.ucsf.edu/pdf/abstinence.pdf.

Crimp, D. (2002). Melancholia and moralism. Essays on AIDS and queer politics. Cambridge, MA: MIT Press.

Marquez, G. (1982). The Solitude of Latin America (translation). Nobel Lecture, December 8, 1982. Available at: http://nobelprize.org/ nobel_prizes/literature/laureates/1982/marquez-lecture-e.html. Accessed July 24, 2006.

Murray, S. O. & Paine, K. W. (1988). Medical policy without scientific evidence: The promiscuity paradigm of AIDS. California Sociologist, 11, 13-54.

Reuters. (2006, May 31). AIDS drug cost protest in NY leads to 21 arrests. Available at: http://www.alertnet.org/thenews/newsdesk/ N31349827.htm. Accessed June 1, 2006.

Siplon, P. (2002). AIDS and the policy struggle in the United States. Washington, DC: Georgetown University Press.

Warner, M. (1999). The trouble with normal. Sex, politics, and the ethics of queer life. New York: Free Press.

Reviewed by Benjamin Shepard, Department of Social Work, California State University at Long Beach, 250 Bellflower, Long Beach, CA 90840. E-mail: [e-mail]