Some Considerations on Sexuality and Gender in the Context of AIDS

Abstract

Gender has become a major conceptual tool for understanding the evolving HIV pandemic globally. As such, it has provided a powerful way to see the structure of relations between men and women as central to various epidemics, and added weight to our understanding of HIV infection as not simply an individual experience of disease. Yet, as a concept, gender has its blind spots. This paper argues that there are four issues central to our understanding of how the HIV pandemic moves and develops that are not necessarily best understood through an analysis that uses gender alone, namely: women's vulnerability, men's culpability, young people's sexual interests and marginalised sexual cultures. The paper proposes using sexuality as a framework for analysing these issues and seeks to utilise developments in critical sexuality research to add to gender as a way to increase the capacity to respond to the HIV/AIDS crisis.

Résumé

La sexo-spécificité est devenue un outil conceptuel majeur pour saisir l'évolution de la pandémie de SIDA. Elle a permis de comprendre que la structure des relations hommes–femmes est centrale dans les différentes épidémies et a étayé notre compréhension de l'infection à VIH comme une expérience de la maladie qui n'est pas simplement individuelle. La sexo-spécificité comme concept a pourtant ses lacunes. D'après cet article, quatre questions sont centrales pour savoir comment la pandémie de SIDA se développe, mais ne sont pas nécessairement mieux comprises avec une analyse utilisant seulement la sexo-spécificité. Ces questions sont: la vulnérabilité des femmes, la culpabilité des hommes, les intérêts sexuels des jeunes et les cultures sexuelles marginalisées. L'article propose d'utiliser la sexualité comme cadre pour les analyser et souhaite compléter la sexo-spécificité par les conclusions des recherches sur la sexualité en vue d'augmenter la capacité de réponse à la crise du VHI/SIDA.

Resumen

El género se ha convertido en una de las principales herramientas conceptuales para comprender la pandemia del VIH a nivel global. Como tal, ofrece una manera poderosa de ver la estructura de las relaciones entre hombres y mujeres como un factor central en varias epidemias y refuerza nuestra comprensión de la infección de VIH como algo más allá de la experiencia individual de la enfermedad. Sin embargo, como concepto, el género tiene su lado ciego. En este artı́culo se plantea que hay cuatro temas que son centrales a nuestra comprensión del movimiento y el desarrollo de la pandemia de VIH, los cuales no necesariamente se entienden mejor mediante un análisis que usa solamente el género. Ellos son: la vulnerabilidad de las mujeres, la culpabilidad de los hombres, los intereses sexuales de los jóvenes y las culturas sexuales marginadas. Se plantea usar la sexualidad como marco conceptual para analizar estos temas y pretende aumentar la capacidad de responder a la crisis del VIH/SIDA agregando al género las novedades en la investigación crı́tica sobre la sexualidad.

Key Words:

• gender roles and gender issues
• sexuality
• HIV/AIDS
• social theory

It might not sound surprising to say that gender and sexuality are different things. But those differences are more profound than is often realised and have consequences for how we understand the various HIV epidemics in the world. Gender, more that any other variable—or we could more usefully call it a social structure—dominates the pandemic.¹ The Oxford English Dictionary defines gender as: “[i]n mod. (esp. feminist) use, a euphemism for the sex of a human being, often intended to emphasize the social and cultural, as opposed to the biological, distinctions between the sexes”. In this sense, gender can sometimes be meant simply as referring to the characteristics of the division of the biological sexes into two distinct categories of persons with different attributes and/or capacities and (usually unequal) positions, rights and resources in society.

However, when we recognise that there is something very systematic about this division (and this inequality), that it runs too deeply in the history and culture of many societies to be accidental or cultural “choices”, we can regard gender as something more powerful. We can consider it as something that underpins the very organisation and systems of daily life in ways that seem “natural” and are not always obvious to us—it is as if life has always been thus. It is this organisational capacity and historical determinacy that can be termed social structure and, in this usage, gender is more akin to race/ethnicity or age/generation or social class/caste in acting as an organising principle: we move from the recognition of differences and division to the production of difference and the ordering of that division (and inequality). These two notions of gender—one as description of difference and division, the other as structuring principle—are important in understanding what is happening in the global HIV pandemic.

Gender underpins most of the epidemiological models we use in describing HIV/AIDS. It is loosely used to describe the epidemics in Asia and Africa in particular and, as a consequence, enfolds others infected with, and affected by, HIV into its wake in a variety of binary oppositions or subsequent effects. By this is meant that one of the major ways of describing HIV/AIDS is to distinguish between infection rates among women and among men as a primary category of analysis. Indeed, this is important because women are becoming infected at faster rates than men in many countries and regions. That difference is to a certain extent due to biology (in part because women can become infected more easily during vaginal intercourse than men), but it is also due to structural causes, in particular women's almost universally unequal access to social and economic resources, which often leads to powerlessness, greater poverty and inequality, and their consequences (e.g. sexual violence, resorting to sex work for income, and so on). These deeper structural analyses of gender are crucial to understanding the growing pandemic.²

However, as a result of the focus on gender, other equally structural ways in which HIV is transmitted are often overshadowed. For example, young people in many places are most at risk. Even if young women are more at risk, young men in these places have enhanced HIV risk as well, so age/generation is having an effect as well as gender. Similarly, in many countries, the epidemic was and is still powerfully at work among gay and other homosexually active men (usually termed “men who have sex with men” or “MSM”); and the Central Asian republics are now experiencing rapid increases in HIV infection rates as a result of growing injecting drug use, increased sex work and a rapid rise in sexually transmitted infections (an important co-factor for HIV infection).

This paper argues that gender must take its place among these and other structural forces that underpin the growing HIV pandemic, such as inequality between developed and developing countries, poverty, mass migration and refugee movements, war, and social and cultural transitions brought on by globalisation. But the central argument of this paper is that sexuality—as a social structure too—is more neglected than many of these forces, in part because our ways of thinking about gender often subsume or obscure our thinking clearly about sexuality.

The primacy and logic of gender seems unquestionable. Of course, there are two biological sexes, male and female. Any exceptions to that merely prove the rule. Yet, the differences between the male and female human body are minimal in fact—two eyes, two ears, one mouth, a backbone, two legs, one heart, one brain and so on. True, there are differences: for example, the same fetal genital cells subdivide into two usually distinct kinds of genitalia, although those born intersexed are increasingly decrying biomedicine's attempts to squeeze them back into one or other of these two sexes. Indeed, many cultures, such as India, Indonesia, Tonga, the Philippines, Thailand, Australia, North America and Europe (and more) have both long-standing and recent technologically enhanced social forms in which the distinctness of the divide between male and female is smudged, reversed or transformed. Increasingly, these forms are being collected within the term transgender (although not without some argument as to the distinctly “Western” and, therefore, possible inappropriateness of the term). In other words, many cultures seem to have found and are finding ways to live with more than two sexes.

The psychosocial sex difference literature does measure minor differences, but in most of this research women and men are far more alike than different. Yet, whatever we have in common, it is our differences that dominate the discourse, so much so that we often fail to see more dramatic differences within a single sex. If we factor in behavioural traits, then the similarities between men and women in any culture are often outweighed by the differences to be found when comparing the same sex across cultures. For example, consider the oft commented-upon contrast between the reserved public behaviour of predominantly Anglo-Saxon societies and those derived from Latin cultures in sexual matters or in demonstrative emotional responses to events. The men and women within each culture are more alike in terms of behaviours and cultural traits than each sex is across cultures. We also know that so-called masculine and feminine traits and behaviours are variable and change over time and in different circumstances; they are not consistent across cultures and history. Take growing long hair as a simple example.

I could go on listing similarities and differences or the lack of them. The point, however, is the dominance of the idea of “difference”, and the subordination of the notion of “similarity” in our way of understanding gender. The result is that we position gender, when understood as sex differences, in primary place in our analyses almost automatically, rather than critically. For example, the notion that women are poorer than men economically is often universally regarded as a distinct and defining gender difference; but there are many very rich women in the world and vastly more very poor men—gender may not be the only defining characteristic of poverty and unequal wealth distribution, and may mask other underlying structures of economic inequality.

This focus on gender as sex differences is the first of the major characteristics of gender that pervades our thinking about HIV/AIDS. It has been a very useful analysis to a point, but often is weakly used as a stand-in for the word “women”, i.e. what is happening for women in HIV/AIDS as a group, rather than what is producing differences between men and women's vulnerability to, and interconnected experience of, the pandemic. “Gender = women” analyses have offered a great deal of useful description about women's situation. They have rarely offered much analysis of how this situation is structured; and they often obscure the differences between women—for example, the greatly different lives of women in the North and in the South. They also usually tell us very little about men. This means we focus on the distinction between women and men first, before we focus on other distinctions to understand the epidemic, such as sexual orientation, age/generation, drug use, poverty, the sexual economy of sex work or the particular sexual culture of any given society.

But, surely, that is simply “sex” used as a variable; “gender” analysis is something else. True, one of the major conceptual dualisms that has dominated 20th century thinking is the “sex–gender distinction”, an idea not without its controversies (especially in feminist debate).³⁴⁵ This distinction, put simply, reinforces the idea that sex is nature, gender is nurture. We are born biologically sexed, but society en-genders us. Our bodies are raw material moulded into a range of culturally derived shapes, of which there are two major forms—women and men. We are “socialised” (to use one of social theory's less precise terms) into two forms of character and behaviour: feminine and masculine. In this formulation, gender magnifies sexual difference. Except it does not really work like that at all. It is far more complex, as recent work on gender from post-colonial feminism, from critical masculinity studies and post-structural sexuality theory continually shows.⁶⁷⁸⁹ Also, the increasingly vocal claims of transgender persons in many countries render any superficial and super-ordinate claims for a two-sex gender system as simplistic and inadequate, and even more so if we hold to the position that gender is a socially constructed distinction.

Many other forces are implicated in the production of lives and bodies, and little of the new and more complex theory on gender seems to find its way into HIV/AIDS discourse. The AIDS industry still relies on old understandings of the biological underpinnings of gender as a binary that fashioned the fascination with sexual and reproductive health throughout the twentieth century. This is the second key characteristic of gender: it is obsessed with human reproduction for its logic. All else is rendered as afterthought to the fact that, as a species, most of us can, and some of us occasionally do, conceive. Actually, we are remarkably infertile when you think of all the megazillions of ova and kilotrillions of sperm out there desperately seeking each other and mostly missing their mark. Have a think about how much sex is actually happening right this minute on this planet. Undoubtedly, most (but true, not all) of these sex acts happen with the only thought about conceiving children being to stop it happening!

Much of the legacy of this obsession with reproductive health has been inherited by HIV/AIDS from the twentieth century's efforts to improve reproductive health, limit the planet's soaring population growth, lower maternal and child mortality rates globally and, more recently, lower the burden of sexually transmitted disease. These are worthy causes and rightly have dominated the agendas of organisations and institutions like the World Health Organization (WHO), the United Nations Population Fund, the Population Council and many other national, international and bilateral agencies. Over the years, the academic research industry has developed models and instruments to monitor progress and investigate cause and effect in the reproductive health arena with some great successes (including in relation to infertility). In particular, the reproductive health of women has rightly and logically dominated this agenda. However, the precise challenge of HIV/AIDS has been in learning to think about sexual expression as it exists in, and is shaped by, culture and history precisely where that expression both does and does not intersect with human reproduction—because it is in these places that most of the patterns of viral transmission peculiar to HIV infection are to be found. Gaining new thinking on sexuality (not just sexual and reproductive health) has challenged existing paradigms and frameworks used in thinking about sex (including sexology and classical sex research too¹⁰¹¹), and it is within this challenge that this paper situates itself.

The legacy of this obsession with reproductive health is one of the great discursive engines driving HIV/AIDS thinking, one rarely questioned or assessed for its aptness, biases or misapplication. It colours our thinking on women's vulnerability to HIV—one of the great theorems of HIV/AIDS—and it supports the spurious bifurcation of women into, on the one hand, sources of infection (usually sex workers) and, on the other, innocent victims (usually wives), a view not unseen in current HIV/AIDS discourse even if the “innocent/guilty victims” phrase is now regarded as beyond the pale. This way of thinking about women and sex was once famously described by Australian feminist Anne Summers as “damned whores and God's police”;¹² and arises surprisingly often—if in less stark terms—when the situation of married women in Africa, for example, is framed in discussions of the so-called “heterosexual” epidemics there.¹³

Furthermore, this obsession with reproductive health also shapes much of our focus on young people—in this case, the theorem of the unwanted or teenage pregnancy as abjection lurks darkly. This obsession also grounds our understanding of historically greater prevalence of AIDS among men in a theorem of perpetration; so much so that the Joint United Nations Programme on HIV/AIDS (UNAIDS) entitled its 2000–2001 World AIDS Campaign: “Men make a difference” to try and shift the prevailing understandings of how men are vulnerable to HIV/AIDS. Finally, this reproductive health focus of gender glues the marginalisation of sex workers and gay and other homosexually active men back into the theorem of deviance, for when relations between men and women in regard to sex are the focus of attention, they are assumed to be “normal” because they are normative (i.e. more frequent and widespread, the statistical average) and other sexual interests or forms of sexual expression become “un-norms”, non-normative and therefore not “normal”.

Gender in this framework does us great disservice in its failure to conceptualise sexuality. Even in the most sophisticated analyses of gender, sexuality is often reduced to a component of gender.¹⁴ Indeed, sexuality is often subsumed within the emotional and relational domain of gendered families and culturally prevailing forms of heterosexuality. As a consequence, for example, sexuality becomes a small part of human reproduction in our sex education programmes, rather than being about pleasure or desire. It is reduced to a mechanism (or vector) in demography's reproductive health and global population concerns—women get pregnant or contract disease through sex. It is a necessary evil in many religions, but these mostly draw on concerns with lineage and inheritance for their reasoning and, as such, are largely about controlling women's fertility and ensuring that men's heirs are actually theirs. In all of these ways, human sexuality is reduced to the acts and arrangements of the relations between men and women and their reproductive proclivities and potential, particularly the “heteronormative” (meaning the prevailing Western notion of opposite-sex, monogamous, sexually reproductive—i.e. vaginal intercourse alone—married relationships).

Well, maybe it should not.

There are other ways to understand sexuality as a structure of ideas, an array of discourses and sensations, as the embodiment of pleasures and the forming of sex object choices, and the endless unfolding of categories of desire. There might be ways to understand HIV/AIDS more usefully were we to configure it as an “epidemic of people who have sex”¹⁵—that is, as a problem of human sexuality, not just as a problem of reproductive health.

What would happen were we to consider seriously that:

•	HIV/AIDS is actually an epidemic of desire;
•	in many places HIV is transmitted in sex acts occurring outside the ambit of the heteronormative and its reproductive imperative, e.g. driven by transactional sex work, or men having sex outside marriage whether tacitly approved of or not, or anal intercourse between women and men;
•	institutions produce sexuality regimes, which construct sex as a currency that moulds desire to its own purposes (e.g. sex as punishment in prisons), revealing again how malleable desire actually is;16
•	the sexual economies 16 of our cultures underpin patterns of HIV transmission (“sexual economies” means the organisational forces and resources supporting, for example, sex work in brothels or sex tourism, or the long-standing traditions of sex between men that occurs in certain environments or cultures171819);
•	certain sexual cultures in circumstances of poverty produce particular patterns of vulnerability to HIV, e.g. sex work undertaken by street children in many countries and by the (transgender) Hijra in South Asia;
•	unknown rates of HIV transmission occur in sex acts between men around the world, most of them not within “gay” discourses or sub-cultures, and are so varied that to categorise these men simply as “men” too or as part of a singular masculine sexuality is specious;
•	in many countries, injecting drug use has a deep and complex connection to sex lives, for example, in sex work or in relation to recreational sexual activity—this is what is meant by the phrase the “feel of steel”, a recognition that there is something about injecting as an act that registers a form of desire (indeed, the word “penetrated” is used by some injectors) over and above its being just another mode of drug administration.20

This is not to argue that gender has no place in our understanding of HIV/AIDS; it is to argue for a more sophisticated understanding of how gender works and how it connects with other forces that structure social and sexual life. For example, the epidemics in many African countries were for a very long time thought to be heterosexually driven, with (female) sex workers regarded as the group most likely to be the engine of transmission. A good gender analysis notes that there are men involved here, namely the sex workers' clients and partners, and that those men's sexual interests need to be investigated and understood better as contributing to the epidemic as well. Moreover, understanding the cultures that produce such patterns of men's sexual interests might be useful in understanding these men's particular vulnerability to HIV infection. Recent work has confirmed that men having sex with men, and anal sex between men and women, may have been neglected epidemiologically in assessing how the virus is moving in many of these same African countries, and may be produced by cultural traditions and social forces other than traditional heterosexual gender relations alone.²¹

Furthermore, sub-cultures of men who have sex with men in some countries may be at enhanced risk of HIV infection for reasons different from those affecting gay men in the West. For example, “Kothis” are men, mostly young effeminate men, who have sex with other men, usually older and married, sometimes for money, and who are found in most South Asian cultures. They are not transgender or “gay” men, but regard themselves as a distinct South Asian cultural form of men who have sex with men. Their vulnerability to HIV cannot be reduced to their being men per se, but is largely due to being sexually active with male partners of women at high risk, for their partners also have sex with female sex workers and girlfriends. A simplistic gender-driven “men as perpetrators” theorem can only deal with the Kothis' specific vulnerability to HIV infection by declaring them “un-men”.²²

Yet, the disproportionately higher rates of HIV infection in the US among African American women would seem a primary gender difference in understanding the US epidemic. But, surely, race as a social structure must be factored into any real understanding of this enhanced risk, as African American men are also disproportionately infected. The compounding factors of injecting drug use and social inequality must also play a role. However, recent work on men of colour on the “down low” (i.e. engaging in sex with other men, but not regarding themselves as “gay”) reveals long-standing, but changing cultures of sex between men, often married men, that could also be driving part of the US epidemic, and which will have consequences for the men involved as well as their women partners.²³ This is not just a simple epidemic related to gender as difference or division alone, but to intersecting patterns of human sexual expression and other complex social forces.

Were we to analyse our various and varying epidemics in terms of sexuality or sexual cultures like these, we might develop a quite different vision of how the virus moves, what speeds or slows its transmission, and what shapes its patterns in particular places. We might understand transmission differently as something other than individual volition (or someone's “fault”); something fuelled in and structured by cultures of desire, such as sex tourism, gay communities, sex work (as an industry), institutional and obligational sex in prisons or colleges, and even sex between women (a recent case of HIV transmission between two lesbians requires some fast re-thinking about the risk attached to sex between women²⁴). We might also look toward explanations that acknowledge the hierarchies in sexuality that privilege certain forms of sexual activity and interests, and marginalise others; that de-legitimise desires in some cultures regarded as acceptable elsewhere. We might then reckon with the fact that HIV transmission occurs relationally in historically structured sexual economies, within various patterns of having sex, or seeking sex partners, or placing sex within a range of meanings different from commitment or love, as non-reproductive, as pleasure, as privilege, as power, or even submission.

We also need to factor in shifting social forces that situate sex in different fields of action (such as rape in war, sexual adventures on vacation, relational disruptions to families during refugee migration, and as a result of rapid urbanisation in the developing world transforming traditional types of partnering and family life). Each of these offers an example (and there are many others) of HIV vulnerability—and therefore transmission possibilities—that is superior to that offered by the simplistic and quite misleading terms we often glibly use, such as the “heterosexual” epidemic, to describe most if not all infections that occur during sex between men and women. As Carol Jenkins, noted anthropologist with extensive experience in HIV/AIDS work in Asia and the Pacific, has long argued—to call any transmission of HIV that might occur during the gang rape of a woman “heterosexual” misunderstands that the men infected during such an event will most likely be infected by the semen of the other men (should it be classified as “homosexual” transmission, then?), even if any woman's infection during such an event might be described as such (Carol Jenkins, personal communication).

A classic example of the easy slips gender analyses alone facilitate concerns the sexual interests of young people. Cross-cultural research continually shows diverse and diversifying sexual cultures among young people.²⁵²⁶²⁷ In some cultures, sexual activity starts young, is distinctly age-banded and certainly non-reproductive in its focus and practice. Young people are remarkably enterprising in pursuing their sexual interests, whether adults see such interests as premature, unfortunate or disturbing. Global youth culture has repositioned young people with a legitimacy of erotic concerns and possibilities. How might we better understand HIV epidemics among young people were we to configure them as constructed within emerging and globalising sexual cultures and not just concerning issues of the distinction between young men and women and their reproductive health?

Meanwhile, of late, men sexually interested in other men are found to exist in cultures where their existence and HIV vulnerability have been denied for the two decades of the pandemic. Those who have worked with male homoerotic subcultures since the beginning of the pandemic are not at all surprised really, that we are discovering homoerotic traditions in, for example, Zimbabwe, despite President Mugabe's highly politicised insistence that such things are decadent Western practices. We still see Asian leaders posturing refusal to acknowledge their long-standing cultures of same-sex activity, while the number of presentations on male-to-male sexual activity in that region has grown exponentially over the last three of the international AIDS conferences. If the consequences were not so tragic, we could shake our heads at the many Islamic countries that deny centuries of artistic and literary tradition that glorified love between men,²⁸ as they face growing epidemics in countries like Indonesia, Malaysia, Nigeria and many Central Asian republics.²⁹ Religion is clearly not adequate protection from a virus.

Meanwhile, the hypocrisy of the Christian churches knows no bounds, and political leaders play along with right-wing morality agendas. This is mostly because they fear that sexuality will finally be recognised as fluid, mutable and incomprehensible within that simplistic binary of heterosexual or homosexual—as something that will not lend itself so readily to political and moralistic control. Sexual interests can and do take many different forms, over time, in different places, during a lifetime, at certain moments (as Alfred Kinsey et al. revealed over 50 years ago³⁰³¹). This is well known, researched and documented in human experience. Gender analyses alone cannot account for the remarkable variability in sexual expression and desire, and these denials seriously hamper our efforts to stop this pandemic.

We also compound our bewilderment at the sexual nature of the HIV pandemic, not just with these sex and gender confusions, but also by thinking of sex as just “behaviour”. The reduction of sexual activity to behaviours is one of the sad and sorry reifications in HIV/AIDS research. By far, the vast majority of non-biomedical research on HIV/AIDS has been behavioural research, usually by survey methods, counting people's sex acts, partners, preferences, places, times and reasons for sex, and assessing levels of risk for HIV infection. Scanning the scientific journals and the abstracts for the huge global and regional AIDS conferences reveals the dominance of seeing sex largely as behaviours. However, the notion of behaviours denudes sex of all meaning and pleasure. It neglects, as a result, how meaning and pleasure rely on context, how context exemplifies culture, and how culture is structured by history and discourse. When we drive our understanding of the epidemic by behaviours alone, we fail to comprehend that many of the social determinants of behaviour lie beyond the conscious apprehension of immediate acts and volitions, i.e. sexual behaviours are socially embedded practices.³² If we fail to understand the determinants of HIV risk and vulnerability as profoundly social—and by social is meant relational, contextual, cultural, political, economic, historical, symbolic and discursive—we fail to understand best how to intervene.

Also, in such behavioural surveys, we are often concerned more with the sex of the sexual partner than the meaning of sex without a condom or an understanding of which circumstances within a sexual economy structure risk as, say, pleasure or intimacy, or social membership or an act of self-actualisation. Research undertaken in the mid-1990s among young people in seven developing countries, commissioned by the then WHO Global Programme on AIDS and completed by UNAIDS, revealed the importance of changing sexual meanings, sexual cultures and sexual identities in the patterns of sexual activity, forms of partnering, and meanings of sexual safety for young people within rapidly changing cultures.³³ This is more complex than—even if it involves—gender relations. And it is no different for adults.

Calls to move our thinking toward seeing gender more structurally—what is sometimes referred to as “gender power” or, better, the “gender order”—are heading in the right direction, but there is a strong tendency for this formulation to lead back to the “women's vulnerability” and “men's perpetration” theorems again. We actually need to scale up other structural conceptualisations, such as sexuality, to carry analytical capacity in parallel. This is also true of those other powerful social structures: race–ethnicity, age–generation, economic inequality (whether class or caste based), and the political and cultural shifts being caused by globalisation. The challenge I would like to see us take up is to test our underlying assumptions before we deploy gender a priori to understand HIV/AIDS, to stop and think before we say “heterosexual” epidemics or “women's vulnerability”, or lump all men together in some singular notion of men's sexual irresponsibility, or when we abridge complex categories of sexual expression in that ubiquitous, yet hopelessly opaque acronym “MSM”.

It must be clear to all by now that as the epidemics continue to grow exponentially, our modelling to date is inadequate. Gender is only offering part of the analyses needed. This is not an anti-gender standpoint, but rather a call for the recognition of the important contribution of gender as one conceptual framework in HIV/AIDS, which needs to be combined with the theoretical strengths and critical capacities of other analyses, particularly of sexuality as a field to study, to amplify our understanding of how HIV is pursuing its trajectory through the population of this planet. We might need seriously to register that much of social life is structured sexually.³⁴ Then, sexuality—as a critical field of research, theory and analysis—might provide some much-needed new answers.

The implications for the fight against HIV/AIDS of such a shift are important ones. Secrecy about human sexuality is one crucial way to hide those aspects of desire that are not approved, and render them vulnerable to persecution. But that secrecy will not protect people against HIV. Denial of sexual practices and the cultures that are built from them will simply exacerbate the epidemic. In any country, confronting the reality of the complex sexual lives of its citizens is bound to be difficult, and none has found this easy in relation to HIV/AIDS. But the history of this pandemic teaches us that eventually every country will have to do this; not just in relation to sexuality but also in relation to drug use, sex work, young people's sexual interests, and assumptions about the heteronormative that obscure great variation in sexual practice between women and men. The price of not confronting this reality, of not implementing good sex education programmes that are realistic about sexuality, of not offering truthful public health education campaigns about HIV and sex, drugs and risk, of not providing condoms (and injection equipment), and of not doing so in ways and places that reflect the realities of sexual cultures (e.g. prisons and schools—to name just two) will continue to be counted in lives lost to AIDS.

Acknowledgements

This is a revised version of a paper originally written for an invited oral presentation in the Bridging Session on Gender and Sexual Difference at the XIV International AIDS Conference, Barcelona, July 2002.