HIV, Sex and Sexualities in Asia and the Pacific:
Introduction
Larissa Sandy
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This special issue of Intersections examines responses to the human immunodeficiency virus (HIV) in Asia and the Pacific, with particular focus on stigmatised groups and marginalised populations that not only face a heightened vulnerability to HIV but are often blamed for HIV. The volume includes contributions from research work in low prevalence countries like Fiji and Tonga to countries with relatively high prevalence rates among sentinel groups (e.g. people who use drugs), for example, Indonesia. Nevertheless, the papers in this issue explore the need to go beyond numbers, simple surveillance data, behaviour change and communication (or BCC) strategies and prevention frameworks and challenge the notion contained within these of risk as 'disembodied acts': unprotected penetrative sex (per contact) in which a person engages as a de-linked individual.[1] Instead, the authors suggest the need to develop more anthropologically-grounded models of sexual cultures, practices and meanings able to take into account power relations and processes of social inclusion and exclusion and embodied practice. This special issue of Intersections grew out of my interest in HIV in Asia and the Pacific, the catalyst for which was my research with sex workers and people who use drugs and work on varied aid development projects in the region that focus on HIV.
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The first two papers in the volume, by Elke Mitchell and Karen McMillan examine a group considered particularly vulnerable to HIV in the Pacific: young people. The emerging HIV epidemics in the Pacific have increased attention paid to sexual practices, particularly among young people who often make up over fifty percent of the population in some Pacific Island countries. Their papers highlight how little we know about modern-day sexual cultures and practices of young people in Fiji and Tonga and demonstrate the need to both develop a deeper understanding of these, and carefully analyse young people's sexual networks to more adequately understand their vulnerability to HIV. Importantly, both papers argue against the uncritical adoption of existing theoretical frameworks and prevention programs and stress the need for an in-depth understanding of local cultures and practices to inform the development of more appropriate and culturally relevant frameworks and prevention programs.
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Mitchell's paper explores the phenomenon of transactional sex among female university students in Fiji. She begins by examining the available data on HIV in Fiji, focusing in particular on young women. She shows their heightened vulnerability to HIV, and highlights the roles that local sexual exchanges, gender order and existing inequalities play in increasing young women's vulnerability. By drawing on existing research on transactional sex among young female university students in Africa, Mitchell attempts to flesh out a framework for understanding transactional sex and considers possible factors that lead to the emergence of this form of monetised sexual exchange in Fiji. She argues that the importance of sexual transmission of the virus in Fiji means we need to widen the scope and examine differing sexual networks and their configurations—a point also relevant in the Asian context. Mitchell argues this is fundamental to understanding the dynamics of the transmission of and young women's particular vulnerabilities to HIV in Fiji, a theme continued by McMillan.
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McMillan's analysis of young people's condom use in Tonga draws upon interviews with young Tongan women and men aged 18 to 25 years old. She demonstrates the relatively high levels of HIV knowledge and awareness among young people; however, as McMillan argues, this knowledge is not readily translated into everyday practice. By exploring their experiences of using and not using condoms, McMillan unpacks how condom use is linked with social and sexual transgression, and demonstrates how HIV prevention programs ultimately fail to take account of young people's embodied relations with the world in which they live. As McMillan shows, young people in Tonga, much like young people elsewhere, clearly cannot cease to sustain relations with others. With these social relations comes commitments and obligations that extend beyond the individual, who is often the target of HIV prevention programs and key site for behavioural change strategies. Through her interview data, McMillan shows how HIV prevention programs and local practices do not fit together easily or harmoniously. She argues that paying attention to one can jeopardise attention to the others. She also demonstrates how her interlocutors clearly prioritise their concerns, commitments and obligations and shows the balance they attempt to bring about, which help form part of their identity and cultural and sexual practice. McMillan's work clearly demonstrates that HIV prevention programs need to consider not only how young people themselves make sense of condom use, but also their embodied relations and the local practices surrounding condom use.
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The following papers by Linda Ikeda and Jane Koerner and Seiichi Ichikawa look at the effects of surveillance and research data on two 'most-at-risk population groups', or MARPs in the latest revision to 'risk group' parlance, who are often the target of HIV surveillance, namely transgender women and men-who-have-sex-with-men or MSM.[2] In her paper, Ikeda examines the exclusion of male-to-female transgenders or mahuwahine in Hawai'i's HIV surveillance data and their further marginalisation through classificatory systems with which they do not identify. Ikeda describes the social, economic, political, cultural and medical marginalisation of transgender women in the US and Hawai'i and documents the substantial disparities in mortality and morbidity and living conditions resulting from their marginalisation and exclusion from society. Ikeda's analysis of transgender women within Hawai'i's HIV surveillance data reveals how sentinel surveillance systems are often predicated upon and perpetuate marginalisation, with this social exclusion an effect of lacking full sexual citizenship and inclusion in the body politic. She also draws attention to some of the behavioural and social and structural health risks attached to being a transgender woman in Hawai'i.
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Moving out of the Pacific, Koerner and Ichikawa write about the effects of the lack of HIV prevention efforts for men who have sex with men in Japan. Through a close examination of the available data on HIV, they document the steady increase in HIV prevalence among men who have sex with other men in the country, and, in the absence of government-led public health interventions, describe the emergence of collaborations between gay men's community groups and researchers. Their paper presents some early results from these collaborations and pilot research projects and considers the possibilities for future directions under a new government-funded research program. However, as Koerner and Ichikawa highlight, Japan still lacks a national response and approach, funding is insecure and research and prevention work remains patchy. They suggest the need to broaden the scope of prevention and research work to include a wider range of men who may not be involved with gay men's NGOs.
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Ikeda's and Koerner and Ichikawa's papers highlight the importance of working with community groups and organisations. Koerner and Ichikawa argue that this has been instrumental in the response to rising HIV prevalence among men and also to producing programs, materials and spaces sensitive to men's needs. Ikeda reveals how we can learn from mahuwahine who, when counted, report a relatively low HIV prevalence rate. She suggests this indicates the presence of protective factors connected to community and cultural values and further, the inclusion of transgender women can result in programs specific to and respectful of their needs and wants.
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The last three papers focus on labour, in particular sexual and domestic labour, arguably seen as traditionally 'feminine' forms of labour. In her paper, Hilary Gorman examines the lives of young female street-based sex workers in Surabaya, Indonesia. She draws on data from in-depth interviews and direct observations to provide a case-study analysis of the conditions under which they provide sexual services. Picking up on the themes raised by Ikeda, Gorman's analysis of structural violence reveals how poverty, physical and sexual violence, police harassment, trauma, high maternal morbidity and mortality and STI rates—due in part to poor access to medical services, including reproductive and sexual health services—suffered by this group of women has been naturalised and normalised, rendering them as 'expendable non-persons'.[3] By examining existing gender ideologies and the sexual status quo, Gorman poignantly analyses the effects of gender ideologies and norms, defined through state ideologies and practices and public, social moralities that demand sexual services but condemn the women who provide these services as deviants, or immoral 'bad' women, which, as she argues places them at particular risk.
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Keeping the focus on Indonesia, Theresa Devasahayam continues with the examination of inegalitarian societies and unequal economic orders, and argues that such unequal social and structural conditions place women at an increased risk of contracting HIV. Her paper is based on data collected during direct observations of Indonesia's pre-departure orientation program for migrant labourers and interviews with key project staff. Devasahayam's analysis of programmatic content reveals how the program provides little protection for migrant labourers, and, almost wholly focussed on individual behaviour change, it does little to consider circumstances in which women often find themselves at risk, which are often not of their own choosing. She also suggests the program downplays and indeed ignores the social and structural factors impacting upon migrant women that shape their choices and actions, and argues, as have others, for debunking the 'misidentification of what are often for women the real risks of infection: monogamy, heterosexuality, trust and love'.[4] Even if migrant women remain monogamous, as Devasahayam shows, they are not in a position to expect and ask for the same of their male partners who remain at home (and whose 'wandering' behaviour is indeed socially sanctioned and culturally accepted). On their return, monogamous wives do not know whether their husbands have HIV or not, or nor do they have the capacity to negotiate condom use. Her paper demonstrates how HIV prevention programs often highlight the individuality of risk and the agency available to individuals, leading to the over-investment in the individual with an approach to prevention predicated on 'just say no'. Indeed, this exaggerates women's agency, and highlights the paradox they face: women are less likely to use condoms in stable relationships for a range of reasons and, while they remain faithful, they are unable to compel faithfulness in their partners.[5] As Devasahyam demonstrates, women's conditions of existence place them at risk and the pre-departure HIV prevention program obscures these social relations and ignores the social and structural factors that increase migrant women's vulnerability to HIV before, during and after migration.
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Devasahayam, Gorman and Ikeda analyse the social and structural factors increasing vulnerability to HIV: social and structural inequalities, the conditions of existence for stigmatised groups and women from low socio-economic backgrounds, the experiences and processes of stigmatisation and marginalisation and the dominant gender and sexual order. The processes and experiences of structural violence shape the stories recounted in these three papers: the inequalities of power involving global capitalism, class, bureaucracy, gender, sexuality, age, and stratified and post-authoritarian societies increase a person's vulnerability to HIV, which as their papers demonstrate, prevention programs and surveillance frameworks fail to adequately address.[6]
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The final paper, by Elena Jeffreys and Roberta Perkins, looks at women's transnational and domestic migration for sex work in Australia. Drawing on data from the Australian component of a larger research project on Chinese sex-worker transnational labour migration, they document little differences between the use of HIV and STI prevention measures by Chinese and other sex workers in Australia, which clearly indicates the on-going need for specialised services. Contrary to popular perceptions, Jeffreys and Perkins show how Chinese sex workers' migration experiences do not fit that of the trafficking or slavery model, arguing instead that their experiences be understood through labour and migration frameworks. However, they highlight serious issues that may place Chinese sex workers at increased risk, including the criminalisation of sex work in certain states, lack of access to justice and police protection. These issues warrant further attention, and as a follow up to this study, there is a clear need to document the attitudes of the authorities and clients, and gain an in-depth understanding of their attitudes and practices toward migrant and other sex workers in Australia.
Endnotes
[1] M. Clatts, 'Disembodied acts: on the perverse use of sexual categories in the study of high-risk behavior,' in Culture and Sexual Risk: Anthropological Perspectives, ed. H. ten Brummelhuis and G. Herdt, New York: Gordon and Breach, 1994, pp. 241–56.
[2] In most research and public discussion, transgender women and men who have sex with men are often conflated, with male-to-female transgenders considered 'MSM' regardless of how they identify, and this is an issue which Ikeda examines in more depth.
[3] N. Scheper-Hughes, 'Dangerous and endangered youth: social structures and determinants of violence,' in Annals of the New York Academy of Sciences, vol. 1036, no. 1 (2004): 13–46.
[4] L. Hammar, 'Sex industries and sexual networking in Papua New Guinea: public health risks and implications,' in Pacific Health Dialog, vol. 5 no. 1 (1998):47–53.
[5] J. Hamblin and E. Reid, Women, the HIV Epidemic and Human Rights: A Tragic Imperative, HIV Development Program Issues Paper No. 8. New York: United Nations Development Program, 1991.
[6] P. Farmer, Pathologies of Power: Health, Human Rights and the New War on the Poor, Berkeley: University of California Press, 2005.
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