Transformations in the Medicalization of Sex: HIV Prevention between Discipline and Biopolitics

Article excerpt

In recent years, there has been a radical change in perspective from within the field of HIV prevention. This change is marked by a dramatic increase in biomedicalized approaches that utilize mass testing, drugs and pharmaceutical products for chemoprevention and treatment, as well as the surgical technique of male circumcision. These therapies are used in replacement of or in combination with behavioral preventive methods. In this article, we review the nature and characteristics of these recent changes and critically analyze the types of social and cultural meanings regarding sexuality that are involved, beyond the assumed attempt to reduce HIV incidence. This article is based on the idea that HIV prevention, be it behavioral or biomedical, represents one of the major forms of medicalization of sexuality in the 20th century (Giami, 2011) and that current changes in preventative approaches also imply changes in sexual conduct and meanings and representations of sexuality that need to be carefully understood. It is also based on the idea that, beyond the recent dramatic changes, there is some continuity in the HIV prevention process. Whether these new HIV prevention strategies will contribute to the limitation and the reduction of the HIV incidence rate is not the topic of this article; it is not a public health evaluation article (Coates, Richter, & Caceres, 2008) or a critique of the new arrangements in HIV prevention (Dowsett & Couch, 2007), but an attempt at understanding current processes and changes in the medicalization of sexuality.

The medicalization of sexuality has already been the subject of numerous studies inspired by the concepts of Zola and Conrad (Bayer, 1989; Hausman, 1995; Hirschauer, 1997; Marshall, 2002). Here, medicalization is considered to be the definition of a problem in medical terms, the use of medical terminology to describe it, the adoption of a medical conceptual framework to understand the problem, and the use of medical interventions to treat it (Conrad, 1992; Zola, 1972). In more recent work, Conrad (2005) developed the concept of the "shifting engines of medicalization" to promote a better understanding of the process of change from behavioral and psychosocial medicalization of sexuality (Tiefer, 1996) to approaches based on the use of biomedical and surgical methods. Conrad (2005) demonstrated how "the availability of new pharmaceutical and potential genetic treatments are increasingly drivers for new medical categories" (p. 3). Considering the increasing recourse to biomedical products in the management of everyday life, Clarke, Fishman, Fosket, Mamo, and Shim (2003) went beyond the notion of a "shift" and developed the concept of "biomedicalization" to understand the structural changes occurring in the medicalization process. In Clarke et al.'s (2003) view, "IT]he scope of the biomedicalization process is thus much broader and includes conceptual and clinical expansions through the commodification of health, the elaboration of risk and surveillance, and innovative clinical applications of drugs, diagnostic tests, and treatment procedures" (p. 165). The concept of biomedicalization helps to better understand the passage from the medicalization of some conditions to the medicalization of health and ordinary lifestyles. It is not only the creation of new medical categories that is at stake here, but the radical transformation of everyday life. In this perspective, health--defined by the World Health Organization (WHO; 1946) as "a state of complete physical, mental and social well-being and not merely the absence of disease" (p. 1)--appears as socially, economically, and technologically produced, far from being a natural state.

However, this new approach developed in terms of biomedicalization did not include HIV prevention and treatment in the scope of its analysis and in the application of this concept (Clarke, Mamo, Fosket, Fishman, & Shim, 2010). One of the objectives of this article was to demonstrate how HIV prevention falls into the realm of both medicalization and biomedicalization and how these two perspectives impact on the organization of sexual conduct. …