Columbia University, Mailman School of Public Health, Division of Sociomedical Sciences, Center for Lesbian, Gay, Bisexual and Transgender Health, 600 West 168th Street, New York, NY, USA E-mail: im15{at}columbia.edu
In Smearing the Queer Michael Scarce (see extract pp.49899) shows how prejudice about homosexuality leads to biases in medical research and public health work. Scarce offers a critique that draws on the social constructionist method that views scientific evidence not as a representation of an underlying trutha rendering of the world as it isbut as a construction that reflects social structures, values, and the vicissitudes of social processes.1 The title's metaphor smearing, refers to two main areas of this exploration. Smearing recalls the medical examination of the gay person, as in the smearing of a preparation on a slide for microscopic examination, as well as the slander and vilification that can come as a result of such examination. The cover art by Linda Howard eerily conveys the biomedical reduction of the gay man's person by depicting his headless body being probed by 14 disembodied hands.
The book is an amalgam of styles and topics: a collection of essays, satire and even poetry through which Scarce explores how social prejudices are embedded in the health sciences' approach to gay men's health. He examines the definition of medical conditions, such as AIDS and Gay Bowel Syndrome; public health approaches to prevention of sexually transmitted diseases; the development of safe sex technologies, such as the female condom and microbicides; and screening for the prevention of anal cancer. In each of these areas, he shows how antigay and heterosexist biases result in limited, often damaging, understanding of gay men's health. The premise of this analysis is that widespread homophobia (negative attitudes toward gay men and lesbians) and heterosexism (a view that negates forms of sexuality, affection, or relationships that are not heterosexual) colour medical understanding of gay men's health.
In one elaborate analysis, Scarce chronicles the construction of a medical disorder labelled, Gay Bowel Syndrome, by Kazal et al. in 1976, and popularized one year later in an article by Sohn and Robilotti in the American Journal of Gastroenterology.2,3 The term refers to a variety of anorectal and enterological conditions, including, for example, amoebiasis, shigellosis and hepatitis, protocolitides, venereal disease and anal warts. The characterization of these conditions as a syndrome seems to have little or no biological or physiological rationale. Instead, researchers have been influenced by the observation that these conditions present in gay men, which, as a social category, imparted a special medical meaning to these otherwise common and distinct disorders and symptoms.
Such categorization, similar to the early categorization of AIDS as Gay Related Immune Disorder, is rife with social rather than medical meaning. It characterizes the gay man's body as inherently pathological, marking its perverse nature and menace to society for all to behold (p.22), and renders gay men, physiological foreigners and alienstropical, animalistic, primitive, and unsanitary (p.30). Scarce makes a convincing argument that the term's social meaning and impact lie outside medicine. Not surprisingly, this medical construct has become ammunition for repressive social forces that view homosexuality itself as a moral disorder. The term was adopted by the popular media, including major publications like Time Magazine and the Chicago Tribune, and has been used to vilify gay men, marking them for discrimination, and justifying the view that they are morally inferior. The term, and medical writings about it, provided antigay political groups with pseudo-scientific evidence for promoting discrimination against gay men. For example, when Cracker Barrel, a restaurant chain in the south of the US, barred gay men from employment, it cited their risk as carriers of enteric diseases as justification.
In a discussion of medical technologies Scarce shows how the same biases lead to neglect of gay men's health needs. His analysis of the development of safe sex technologies is particularly striking. It is another example of the overriding importance of values in public health, where heterosexism and sex-phobia directed medical conceptions of what are acceptable or desirable prevention techniques. It is striking to note that the US Government's Food and Drug Administration has never actually tested or approved the use of condoms for anal sex, in part because anal sex among men is still criminalized in many states. But it is not surprising in the context of the social analysis to discover that better prevention techniques, such as a barrier device for use by the receptive partner in anal intercourse similar to the female condom, or rectal microbicides that would allow condom-less anal intercourse, have not been developed for gay men. Even existing technologies, such as the female condom, which have been developed and marketed for use by women, have not been adopted or promoted for use by gay men even though there is evidence that they may be effective.
Scarce demands that health institutions develop technologies with gay men in mind. He goes far beyond familiar calls for cultural sensitivity and respect, advocating techniques that accommodate, even promote, safe but pleasurable anal intercourse among gay men. He demands that public health cater to gay men's desires for sex without barriers for no other reason than that it is self-affirming. Describing an anonymous sexual encounter in a poem he explains the desire for unsheathed intercourse, because I wanted to join him/enjoy him, join with him, /with nothing between us (p.83). His demand to accommodate gay men's sexual culture in the development of safe sex technologies is bold and unapologetic; it has a strong impact, demonstrating how wide the gap is between these demands and the social attitudes about sex and sexuality that guide public health efforts.
Scarce's work reveals a conflicted relationship between gay men and the health sciences. While offering a damning condemnation of public health, he also evidences respect for health science and the wish for greater attention to the health needs of gay men. When he describes how homophobia and heterosexism have led to the neglect of potentially life-saving research on and screening for anal cancer, for which gay men are at increased risk, he expresses a deep anger at medical researchers and urges more dedication to this health problem.
This difficult alliance between gay men and medical institutions conveys a plight similar to that of other groups e.g. ethnic/ racial minorities, women, people living in poverty, and residents of developing countries. Unfortunately, Scarce does not search sufficiently for connections between the health concerns of gay men and that of other disenfranchised groups. Members of disenfranchised groups share a dependence on health sciences and industries. Yet they remain cultural foreigners, and are often hurt because of bias and discrimination, or neglected because solutions to their problems promise little profit or scientific acclaim. For example, proper cost-effective treatment of human African trypanosomiasis is lacking in part because pharmaceutical companies have not identified it as a priority.4 The experience of HIV prevention among African Americans in the shadow of the Tuskegee experiments is another example, which is very relevant to gay men's experience.5 Such linkage by social analysts is important because it may promote collaboration among diverse groups, lead to necessary politicization of health problems, and increase gains for all. The legacy of ACT UP, a gay AIDS advocacy group that impacted AIDS research, treatment and prevention in diverse populations and throughout the world, is one promising example.
Scarce's analysis disappoints in several other ways. Despite his aim to release the discourse of gay men's health from the predominance of AIDS, the book strays only slightly to consider other sexual issues, and it continues a tradition of reducing gay men's health to sex-related concerns. It is ironic, and perhaps indicative of how insidious and subtle are social biases, that a book that correctly criticizes medical constructions as a reflection of a prejudicial view of the gay body, in turn portrays an image of the gay man that is so concordant with stigma. Absent from Scarce's portrait is a wide range of health concerns, and health biases, that affect gay men (and other sexual minorities). Among these concerns are the impact of prejudice and discrimination on mental health and suicide, violence, substance use, parenting and child care, health education, and health care access and utilization, as well as the salutogenic effects of community affiliation, spirituality, and personal resilience.6,7
Similarly narrow is the book's intellectual heritage. Scarce's work is informed by recent social critiques of the AIDS epidemic, including important work by Paula Treichler and Steven Epstein, but reliance on a broader foundation may have expanded the book's perspective. Missing are links with important critiques of biomedicine,811 public health,1214 and the impact of socioeconomic structures,15 and social stress on disease.1619 Also missing is a critical understanding of the book's subjectgay men'and a consideration of the variability therein.2022 These issues significantly limit the book's relevance to primarily sexual health concerns of a specific gay male culture. Nevertheless, Scarce's analysis provides an illuminating critical exploration that needs to continue as wider areas of lesbian, gay, bisexual and transgender health begin to be addressed in public health.
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