Shaming Prevention: Is PrEP a “Risky” Approach?

Commentary by Nina Brennan

Today is World AIDS Day. This morning, Michigan Public Radio reported a rising incidence of HIV diagnoses, with approximately 800 new cases per year. Complacent and/or apathetic attitudes which spanned the last decade appear to have placed HIV/AIDS awareness and prevention to the side; but advocates are urging public discussion about the pervasive rising incidence of diagnoses, indicating there is still a battle to be fought.

In mid-November, the New York Times published a spotlight on the controversial divisiveness between proponents of Truvada, an FDA-approved (2012) pre-exposure prophylactic (PrEP) which has been shown to significantly reduce the chance of contracting HIV, and one lone (or, at least, vocal) opponent: Michael Weinstein, president of the AIDS Healthcare Foundation.

In the article, Weinstein implied the push for Truvada is financially backed by “bareback porn” executives, and lambasted the drug as a “party drug.” He did not negate the effectiveness of the drug, however, and in fact, Truvada is prescribed to “at-risk” patients by the AIDS Healthcare Foundation. Yet, he implied the drug may serve as a false panacea: allowing for a deception of security which will undermine the importance of safe sex initiatives and condom culture. Proponents of Truvada counter that the use of condoms is markedly low in the clinical trial sample, and Truvada should be used for preventative health in lieu of total absence of protection – although, their use in conjunction is preferable. Additionally, there has been a long-standing stigma associated with HIV/AIDS, and some critics, including Daniel O’Neil, a physician and LGBT health advocate who wrote in the Huffington Post, argue that the opposition to PrEP is placing yet another layer of stigma on an already heavily stigmatized community:

“The ultimate concern is not that gay men would be unable to adhere faithfully to the daily dosing regimen and otherwise use PrEP as it was intended under a health provider’s care. Rather, it is a fear that some of us — for one reason or another — simply will not do so, and that some might indeed use Truvada as a ‘party drug,’ taken like candy before crystal meth binges or indiscriminate bareback sex parties. That said, it is clear that many responsible gay men already take PrEP because they are in a serodiscordant relationship or some other ‘high-risk’ situation, know the risks associated, agree to the regular checkups and lab work, and have made a conscious decision with their provider.” Indeed, the implications that Truvada is or will be used as a fail-safe in an effort to allow for risky sexual behavior reeks heavily of the same “slut-shaming” techniques, hurdles, and indictments women faced regarding their use of oral contraceptives, or other accusations of “improper” behavior which requires the HPV vaccine. In short, the assumptions that these preventative medications and vaccines are used as alternative to safe sex, that they are gateways to promiscuity, and the judgements about the people who use responsibly use them are dangerous and derogatory.

Weinstein alleged he is not the sole opponent of “over-prescription” of Truvada, but insists other high-ranking officials are scared into silence because of the economic control that Gilead, the manufacturer of Truvada, has on the non-profit AIDS organizations. While Michael Weinstein does appear to be the strongest opponent, his opposition to its use merits an interesting debate: Are researchers and activists favoring passive prevention methods? Michael Weinstein argued the reliance on Truvada negates decades of education and awareness, and the hard work to establish condom culture. Proponents argued that the condom culture which Weinstein is lauding, is clearly not as established as he thinks.

Full text references:

http://mobile.nytimes.com/2014/11/17/upshot/aids-group-wages-lonely-fight-against-pill-to-prevent-hiv.html?emc=edit_th_20141117&nl=todaysheadlines&nlid=23238478&_r=3&abt=0002&abg=0&referrer=

http://www.huffingtonpost.com/daniel-oneill/prep-yourself-making-better-sense-of-the-pre-exposure-prophylaxis-debate_b_5203299.html

Global Study which resulted in FDA approval: http://www.niaid.nih.gov/news/QA/Pages/iPrExQA.aspx

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Transgender Awareness after the Week

Commentary by Nina Brennan

Most people would argue that the momentum for LGBTQ equality has been gathering remarkable steam over the past few decades; same-sex marriage, of course, being one of the most forefront debates across the United States. Yet, LGBTQ advocates are also making strides in educating the public that there are many more significant issues which must be bolstered into the public conversation. Yes, marriage equality is extraordinarily important, but it is not the sole important talking point for LGBTQ equality.

Earlier this month, Private Chelsea Manning was, once again, thrust into the public dialogue when a New York Times editorial indicted Defense Secretary Chuck Hagel and other officials for denying her necessary medical treatment:
Clinical evaluations since have confirmed the need for care that includes hormone treatment, psychotherapy with someone qualified to treat gender dysphoria, and access to grooming standards for female prisoners — allowing her to grow longer hair, for example, to express her gender identity. A failure to follow this standard protocol for people with Private Manning’s medical condition can have a dire impact — creating a growing risk of serious depression, self-mutilation and suicide.

Full text: http://www.nytimes.com/2014/11/09/opinion/sunday/private-mannings-missing-medical-care.html?emc=eta1&_r=0

Not surprisingly, toward the end of National Transgender Awareness week (November 14-22), there have been multiple stories regarding transgender issues which reached the public realm. Another notable example – Michael Phelps’ alleged ex-girlfriend announced she was born intersex, and had her male birth organs removed. In a Facebook post, she wrote:
By the time I could walk and talk I made it clear I was a girl and dressed as one. In my early teens I was medically diagnosed and went on testosterone blockers, at 15, estrogen enhancers. My birth certificate was modified along with my name while I was a teenager, prior to any corrective surgery.

Full text: https://www.facebook.com/TaylorLianneChandler/posts/722682477808181

A common criticism of the news media storm regarding Taylor Chandler’s proclamation, is that it should not matter, and it should not be news. In lieu of belaboring perspectives about the necessity for public discourse, there is also another significant reason this story should be attended to. Again, she remarked “My birth certificate was modified along with my name while I was a teenager, prior to any corrective surgery.” Because she was born intersex, Taylor Chandler may not have been subject to the same requirements of those who were born with wholly improper genitalia, or perhaps she applied in a state which did not require invasive proof. The National Center for Transgender Equality has provided an interactive map which shows legislation regarding transgender issues across the United States. For example, the image below indicates the requirements for changing gender distinction on birth documents:

trans bc change

In Michigan, for example, a woman who is born with male genitalia will not be able to change her birth certificate to correct her gender without proof of sex reassignment surgery. Currently, even the definition of sex reassignment surgery is vague. For example, chondrolaryngoplasty, otherwise known as a trachea shave, is typically considered a gender reassignment surgery.

Upcoming legislation is particularly important. If we are to require transgender individuals to undergo invasive surgery in an effort to change their birth documentation to agree with their gender identity, we are dangerously suggesting identity is only a physical body distinction. And as Laverne Cox sternly implied to Katie Couric, no one should be forced to identify solely with what is underneath their clothing.

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Listening to Trans* Stories is the Way

Research Reviewed by Michael Tew

This review examines the conclusions of two studies about Trans* identity development. One is from a social work perspective and the other from communication studies. Both conclude that expression of the self is central to healthy identity development. True for most everyone but particularly important to Trans* people. Most importantly, both research projects are based on listening to authentic Trans* narratives.

Heidi Levitt and Maria Ippolito listened to the narratives of 17  Trans* people.  According to the participants in the study, the experience of being transgender entails (1) developing constructs to represent one’s gender authentically; (2) finding ways to communicate one’s gender to others and be seen; and, (3) balancing these needs with the need to survive under discriminatory political, social, and economic conditions

The themes that emerged in the analysis seemed to illustrate a core theme of trying to cultivate a multifaceted identity within a restrictive social gender paradigm, “much like trying to illustrate a vibrantly colored landscape when only black and white paints are available.” This finding highlights the importance of preserving Transgender clients’ sense of self-determination. Levitt and Ippolito identified three core experiences that led to participants’ understanding of and development of their identities as Trans* people: 1. From childhood treated like damaged goods: Pressure to be closeted about gender often led to self-hatred and isolation, all while under others’ scrutiny; 2 The power of language in fostering acceptance: In hearing other Transgender narratives, the possibilities for self-exploration and affirmation expand; and,  3. Identity formation is an ongoing process of balancing authenticity and necessity (e.g., safety, how much I can cope with, resources, legalities)

Audra K. Nuru listened to the narratives of 37 Trans* individuals who posted videos for the “It gets Better” project. The study identified the way conflicting personal and social identities are communicated in complex layers of expression. Nuru identified specific gaps in expression of Trans* identity and communication strategies commonly employed for crossing, filling, or negotiating those gaps. First, discrepancies between an individual’s self-view and the self as expressed when communicating with others are often negotiated by relegating certain dimensions of gender expression to private arenas and others to public arenas. Second, the gap between how people perceive the individual in different ways than the way the individual sees theirself  is frequently negotiated through relational disengagement and passing. Finally, incongruity in the way an individual enacts their identity and the expectations others have of gendered performances is often negotiated through label changing in reference to the self.  Based on these Trans* narratives, the study observes that difficulties in working through these gaps between a personal understanding of the self and the way the self is expressed in social contexts can result in relational dissatisfaction, relational strain, depression, or self-harm. The role of communication of the self, taken for granted by most, cannot be overstated in its effect on personal, interpersonal, and relational health.

This study is unique because it addresses discursive processes – the ways messages about identity are continuously created through communication. Specifically, negotiating Transgender identity is a complicated, overlapping process that involves cycles of constructing, reshaping, and making sense of gender identity through communication. Trans* identities are not just products of communication, they are constituted by communication in the context of relationships and other social interactions.

Both of these studies are important for two reasons. First, this research comes from authentic narratives of Trans* people. These are not survey projects asking people to respond to categories of identity questions pre-determined by the researchers. They are the amplified voices of people speaking from their lived experiences. In other words, this is research that draws conclusions from Trans* people’s stories rather than fitting Trans* people’s experiences into foregone conclusions.  Second, this research is important to the extent that it should inform social workers, counselors, and psychologists about the complexity of Trans* identities and the multitude of ways gender identity is expressed. There is no one way of expressing the self as a gendered individual and attempts to fit a client’s identity into a box, no matter how progressively informed that box, the more likely that the client is not getting the help and support they need.

Levitt, H. & Ippolito, M. (2014) Being Transgender: The experience of Transgender identity development, Journal of Homosexuality, 61: 1727-1758

Nuru, K. (2014). Between layers: Understanding the communicative negotiation of conflicting identities amongst Transgender individuals. Communication Studies, 65: 281=297.

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“I Don’t Consider Myself an Activist”

Nina Brennan

On October 30, 2014, in an editorial to Bloomberg Businessweek, Apple CEO Tim Cook declared himself “proud to be gay.” Cook, a longtime advocate for LGBTQ equality policy, explained that while he has been open about his sexual orientation to friends and colleagues for years, he refrained from publicly announcing his preference due to his desire to maintain relative privacy – or at least as much privacy as the CEO of one of the largest corporations in the world can obtain. Recently, however, inspired by Martin Luther King Jr.’s call – “What are you doing for others?” – Cook recognized the impact of his declaration could extend to those who are struggling with identity. He wrote:

“I don’t consider myself an activist, but I realize how much I’ve benefited from the sacrifice of others. So if hearing that the CEO of Apple is gay can help someone struggling to come to terms with who he or she is, or bring comfort to anyone who feels alone, or inspire people to insist on their equality, then it’s worth the trade-off with my own privacy.”
Full text: http://buswk.co/1xeralU

His negation activism harkens to the 1993 Nike Air advertisement, in which Charles Barkley proclaimed: “I am not a role model,” implicitly urging parents to be more involved with their children, and urging children to view athletes with less idolatry.

Despite their claims, an undeniable facet of celebrity is the inherent public sphere, which begs, is Cook – as the first openly gay CEO of a Fortune 500 company – an activist by proxy? Whether his coming out on a national level is implicit activism, explicit activism, or not activism at all, it has sparked an important internet discussion: does it matter?

One Reddit user weighs in:
It shouldn’t be newsworthy, indeed, but considering that so many people including famous figures (CEOs, athletes, politicians), have been forced to hide their sexuality for pretty much all of history, it will continue to have some significance when a major CEO comes out. Hopefully, in some years, the expression “in the closet” may not even exist (/u//Nilas_T).
Full comments: http://bit.ly/10vxhr9

The effort for equality needs to exist publicly, so it can remain a public issue. Tim Cook – self-denied activist or not – has certainly bolstered the visibility of LGBTQ equality into the public sphere.

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Marriage Equality in the Sixth Circuit: Important Questions and Little Certainty

Michael Tew, Ph.D

In a packed courtroom of the U.S. Court of Appeals for the Sixth Circuit (and two overflow courtrooms with audio feed), three judges heard arguments about the rights of same sex couples in six cases from four states. August 6, 2014 was the most extensive day in the legal debate about Marriage Equality since the Supreme Court decision striking down Section 3 of DOMA in June of 2013. After a streak of 29 federal court victories for Same Sex marriage advocates, the outcome of these appeals is less clear. The court gave no indication of how it would rule or when it would rule but the decision seems to hinge on four specific questions.
Is there a fundamental right to marry for same sex couples?
Why should the court circumvent democratic process?
Is there a rational state interest in restricting marriage to opposite sex couples?
Does the court, at this level, have the ability to intervene?

Is there a fundamental right to marry for same sex couples?
This is the central question that marks these cases as 14th amendment issues. The answer depends on how one views history. Attorneys representing the States, argued that, while opposite gender (referred to a traditional marriage by each of them) has deep cultural roots, it is too soon to say the same for same sex marriage. Michigan’s Aaron Lindstrom suggested there hasn’t been time for social science to examine such relationships and families. (That is not actually correct. See this credible study http://bit.ly/1oI0nfq). Judge Jeffery Sutton seemed to favor the view that states have the right to regulate marriage as they see fit. He took issue with Senior Judge Martha Craig Daughtrey’s assertive argument that Loving (1967) established marriage as a fundamental right. Further, Daughtrey pointed out that until the SCOTUS decision in Lawrence (2003) homosexuality was criminalized making any deeply rooted tradition impossible. Further, she reinforced MI Plaintiff attorney, Carole Stanyar’s argument that these cases “do not redefine marriage – they end the exclusion of same sex couples.”
Take Away: This is a critical determination. SCOTUS avoided a ruling on marriage as a fundamental right for same sex couples when it returned the Prop 8 case back to California. Windsor was not decided on that basis. Loving established the right to marry who one chooses as a fundamental right. Two circuit courts have already concluded that same sex couples are included in this right.

Why should the court circumvent democratic process?
Central to the arguments from Michigan, Ohio, and Kentucky (and clearly important to Sutton) was the issue of democratic process, through legislation and/or referenda. Attorneys for MI, OH, and KY asked the question of who gets to decide about same sex marriage. They each claimed that using the courts violates democratic principles and processes. Michigan attorney Lindstrom specifically argued that people are rationale deciders and the decisions made in anti-LGBT state referenda should stand until the people change their minds. Judge Sutton, during each argument, repeatedly asked questions that reflect and support this reasoning. He suggested that time will resolve the controversy democratically as the trajectory of state and Supreme court decisions favors the recognition of same sex marriage. It is on this question that Daughtrey was most pointed (and humorous). She asked OH attorney, Eric Murphy if he knew how long it took for women to gain the right to vote. He did not. The answer is 78 years. After which, due to lack of success in step by step “democratic processes”, the issue was decided by an amendment to the U.S. constitution. She and plaintiff’s attorneys all asserted that this is timeline is unacceptable and harmful to the plaintiffs and their families. Moreover, attorneys for all plaintiffs reminded the court that historically, questions of civil rights should not be decided by popular vote.
Take Away: First, the courts are part of the democratic process. They exist, in part, to ensure that the rights of minorities are not trampled by intolerant, tyrannical, or even uncomfortable majorities (read http://bit.ly/1u3Tt7T). The conflation of democracy with majoritarianism was a problematic theme in this hearing.

Is there a rational state interest in restricting marriage to opposite sex couples only?
The one word basis to the States’ (all of them response to this question – procreation. Leigh Gross Latherow, arguing to preserve Kentucky’s ban, was the most specific (and colorful) on this issue. A paraphrase: Opposite sex couples can and do procreate. Kentucky wants to promote procreation. Married couples procreate. People involved in “same sex behaviors” don’t procreate. So the state wants to regulate and encourage procreation through marriage. Same sex behaviors, then, aren’t part of marriage. When pressed by Judge Daughtrey about couples who are unable or choose not to procreate, Latherow answered that at least with opposite sex couples there was the possibility of unplanned pregnancy. Read here (http://reut.rs/1oJClB0) if you need more evidence of why this line of argument is absurd. Further, Joseph Whalen of Tennessee argued that, in the interests of promoting and preserving procreation, Tennessee did not intend to exclude same sex couples, it only chose to include opposite sex couples (capable of procreation). Both Sutton and Daughtrey were skeptical that any rational basis for exclusion was actually established.
Take Away: A procreation basis for rational interest has yet to be successful in any legal proceeding on marriage equality to date. Nothing offered in this hearing appeared to change that.

Does the court, at this level, have the ability to intervene?
Judge Sutton seemed to question the latitude for the court’s decision based on an 11 word summary dismissal of a Minnesota same sex marriage case in 1972. In Baker v Nelson, the court dismissed the appeal “for want of a substantial federal question.” That meant that a lower court ruling that the Minnesota ban on same sex marriage was constitutional, would stand. The precedential nature of this ruling, cited as in all four state arguments, is subject to significant debate both in this hearing and otherwise (http://bit.ly/1AZf4At). Sutton questioned whether lower courts were bound by Baker while Daughtry, and plaintiff attorneys, argued for the application of developing doctrine and evolving legal theory and precedent.
Take Away: This was a legal/technical part of the oral arguments that was, perhaps, lost on many of the hundreds of spectators. It is important, though. The implication is that by rejecting an appeal 42 years ago, SCOTUS established a binding precedent that this Circuit Court would be the first to accept. Sutton’s commentary suggests he wants to hand this off to the Supreme Court sooner than later.

While we wait for a ruling from this hard to read panel, cases will appear before the Seventh Circuit Court on August 26th and before the 9th Circuit Court on September 8th.

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Born This Way? Sexual Science and the Invention of a Political Strategy

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Can Marriage Equality Result in Improved LGBT Health Outcomes?

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Michael A. Tew

Recent articles in the New England Journal of Medicine and the Journal for Nurse Practitioners consider the relationship between marriage and health. Each offers several good reasons why the answer to the basic question is yes but provide some caveats to qualify their assertions. Before getting to their arguments, however, the actual state of LGBT health as compared to the general health of the heterosexual population needs to be understood. Research has consistently demonstrated that LGBT populations experience more negative health related outcomes (mental and related physical health issues) as a result of stigma and discrimination. The National Alliance on Mental Illness reported on several studies that show wide disparities between heterosexual and LGBT reports of anxiety, depression, mood disorders, and substance abuse during an individual’s lifetime. These are NOT the result of simply being Lesbian, Gay, Bisexual, or Transgender. The disparity is the result of consistent and pervasive social, institutional, and familial discrimination. More profoundly consequential are the effects of actual or threatened physical violence, verbal violence, and internalized homophobia. An article in The Lancet (February 8, 2014) indicates that anti-LGBT polices and homophobia frequently prevent LGBT persons from even seeking health care at all. While the article used Russia and Nigeria as particularly troubling examples, evidence of similar problems in both Europe and the US were included.

Understanding that LGBT persons often experience health consequences specific to discrimination, it stands to reason that Marriage Equality, a significant step forward in confronting discrimination and stigma would help. In many ways, it does. Gilbert Gonzales writes, in the New England Journal of Medicine (April 10, 2014) that “Public health research has suggested … that legalizing same-sex marriage (among other policies expanding protections) contributes to better health for LGBT people.” His report cites data from Massachusetts and California that indicate same-sex marriage recognition was related to fewer mental health care visits and reduced psychological distress. Laura C. Hein (associate professor in the College of Nursing at the University of South Carolina) asserts, in the Journal for Nurse Practitioners (June, 2014), “Marriage is associated with multiple mental and physical health benefits, including benefits that support psychological health and access to health care through a spouse. Marriage also protects and promotes the health of the children of LGBT couples by providing the legal and health insurance protections that are granted automatically through marriage.” Both authors rightly frame Marriage Equality as a public health issue as well as a political and civil rights concern.

In the same issue of the Journal for Nurse Practitioners, however, Christopher M. Fisher (assistant professor in the College of Public Health at the University of Nebraska Medical Center and Director of the Midlands Sexual Health Research Collaborative) is less optimistic about the health improving value of marriage equality. He identifies other important sources of negative health outcomes for LGBT people such as structural stigma and institutional forms of discrimination that are not resolved by marriage equality. He writes, “Regardless of the legal status of same-sex marriage, stigma-related discrimination will persist for some time. Health care providers, including nurses, are among the many on the front lines who can provide a stigma-free environment and culturally competent care, which will be as important as marriage equality in eradicating health disparities for LGBT Americans.”

So there you have it. The evidence suggests that Marriage Equality will likely lead to better health outcomes for LGBT populations but that it is not the only answer to resolving health consequences resulting from stigma and discrimination. Therein lies a message about the Equality Movement and public policy at large. Marriage continues to be an important focus for advocacy but the movement for full equality is about much, much more.

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