It’s no secret that men have been having sex with men in numerous societies and cultures throughout history. Often, these men’s sexual desires and activity were regulated or prohibited by mainstream religious and legal rules. In 1869, Dr. Benkert, an Austro-Hungarian doctor and sexologist, introduced the term homosexual. This formalized the practice of studying homosexuality as a medical condition. As a result, same-sex sexual activity, and people who engaged in these acts, became subject to regulation by the field of medicine.

This history of homosexuality is a classic example of a conceptual phenomenon known as medicalization – that is, the process of defining certain aspects of human life in medical terms. While scholars agree that homosexuality itself has been successfully demedicalized in mainstream medical practice today, medical approaches remain a key component of the response to various aspects of gay men’s health, particularly in HIV. This blog reviews the concept of medicalization, discusses current examples of medical approaches to gay men’s health, and engages with critiques of some of these interventions.

Medicalization

Medicalization is a shift in the way individuals and society think about certain aspects of human life. As discussed above, medicalization occurs when some part of life, previously understood as a social behaviour or normal phase of life (such as ageing or pregnancy) gets framed as a medical problem that needs solving. The term ‘medicalization’ is often used critically to draw attention to the increasing power and authority health professionals and institutions have in people’s daily lives.

Historically, medicalization has been used broadly to consider the role of medical professionals. However, more recently, medicalization has taken the form of biomedical interventions. These interventions include increasing use of diagnostic and testing technology, and pharmaceutical treatments for an ever-growing list of conditions. Both forms of medicalization sometimes use the strategy of developing new diagnoses to detect and treat. While medical and pharmaceutical innovation play crucial roles in supporting health and wellbeing, the critical concept of medicalization questions the extent of the authority and power medical professionals hold in certain aspects of human life.

(Bio)Medical approaches to gay men’s health

The American Psychiatric Association (APA) added homosexuality to their authoritative classification system of mental pathologies in 1952. The World Health Organization followed suit and added homosexuality to the list of its mental illnesses in 1968. The inclusion of homosexuality as a medical condition gave professional legitimacy to medical practices of studying and ‘treating’ people who challenged cisgender, heterosexual norms. These professional bodies succeeded in framing homosexuality as an issue of medical concern.

Gay men were not the only people affected by these practices: lesbian women, trans*¹and intersex people were also subject to study and treatment. Most of these practices focused on ‘curing’ homosexuality, ‘correcting’ anatomical diversity, and enforcing gender norms. As a result of community-led activism, the APA was the first to delist homosexuality as a mental illness in 1973, and the WHO followed suit in 1990. During this time, professional bodies rescinded their support for practices purported to treat homosexuality. Conrad & Angell (2004) argue that homosexuality has been both successfully medicalized and successfully demedicalized in dominant western medical practice throughout the late 19th and 20th century.

‘Internalized homophobia’ (IH)² is another way of framing gay men’s health issues through a medical lens. IH can include feelings of insecurity, guilt, shame, depression, fear of one’s sexuality, rejection, and/or self-destructive behaviours (Aguinaldo, 2008). Interventions for IH, like other medical and pharmaceutical interventions, typically offer individuals a form of treatment that supports their health and wellbeing but does little to address structural issues that impact health. Aguinaldo (2008) argues that this approach to IH distracts from the social issues that contribute to the inequities gay men face, such as heterosexism and simultaneous forms of oppression.

HIV treatment and prevention efforts are also largely based on an individual intervention model and do little to address the social factors that drive HIV transmission. Adam (2011), Nguyen et al. (2011) and Giami & Perrey (2012), among others, argue that HIV prevention is increasingly reliant on medical and pharmaceutical innovation. They criticize these approaches because they are often developed and implemented without much consideration of impacts at the community level, and are often portrayed as quick solutions to complex problems. As a result, prevention strategies generated within communities may be overlooked or undervalued.

Treatment as prevention (TasP) and pre-exposure prophylaxis (PrEP) are two examples of pharmaceutical interventions whose place within gay and MSM communities have been hotly debated by gay advocates. In contrast, many jurisdictions have fought – and are continuing to fight – to ensure post-exposure prophylaxis (PEP), administered after exposure to HIV, is widely and freely available to gay men. Recently, PEP has been made available as part of a pilot project at six sites in downtown Vancouver, and is now covered in certain situations by BC Medical for gay and other MSM.³

Medical and pharmaceutical treatments are important; however, they are often not available to everyone. One concern around access is whether or not individuals know about these types of treatments and have adequate information about them and possible alternatives. Another concern is of course cost. For example, counseling which is used to treat IH, is not covered by provincial health care plans. It may be covered by private plans and is often offered by non-profit organizations; however, there is usually a limit to how much of these services people can access.

In British Columbia, HIV treatment is provided at no cost to people living with HIV. However, in most other places within and outside Canada, HIV treatment is not fully funded by government plans.

In the case of PrEP⁴, access is limited both by the fact it is not covered by provincial health care plans and is based on physicians’ willingness to prescribe Truvada for prevention purposes. Len Tooley, an HIV educator in Toronto, Ontario, recently shared his experience deciding to seek PrEP, and navigating the health system in order to receive this prescription. He addresses some of the major concerns that have surfaced about the use of PrEP and why it makes sense for him at this time.

Conclusion

Medicalization problematizes the unquestioned authority medical professionals are given to determine agendas for health, prevention efforts and research. Knowledge from gay men and community leaders in gay men’s health must be included in decision-making about gay men’s lives, and in developing policies, programs and research. In the first decades of the HIV epidemic, the work done by direct action gay and AIDS activists held the leadership of governments and companies alike accountable to the medical and social needs of gay men. Organizations, including AIDS Action Now, BC Persons with AIDS (now Positive Living BC), AIDS Vancouver and ACT UP NY, fought for improved research design and approval processes and for policies to recognize non-traditional families and reduce homophobic institutional practices. We should continue to advocate for both medical and social pathways that strengthen gay men’s health and wellbeing. To realize this goal, we must address the underlying factors that drive ongoing inequities in sex education, HIV prevention and treatment, and continue to support the work done by community organizations in promoting health, providing services and treatments, and advocating for social change.

Further information

• The biomedical and the social in HIV prevention (Barry Adam, 2011)
• Len Tooley on PrEP, Parts 1-3 (Jon McCullagh): http://positivelite.com/component/zoo/item/len-tooley-on-prep-part-one
• Continuing disparities in HIV treatment for Canadians (Canadian Treatment Access Council): http://ctac.ca/blog/?p=58
• Changing my mind on treatment as prevention (Bob Leahy): http://positivelite.com/component/zoo/item/changing-my-mind-on-treatment-as-prevention
• Rights Language and HIV Treatment (Cindy Patton)
• Sick again?: Gay men as a site of medicalization (Sarah Chown & Olivier Ferlatte)

^{1. Trans* is increasingly being used to recognize diversity within trans* communities. This term includes transgender, transsexual, genderqueer and other gender minorities who may not identify with binary gender categories.↩}

^{2. ‘Homophobia is killing us’: Heterosexism and gay men’s health↩}

^{3. PEP has long been available to people exposed to HIV in occupational settings or in cases of sexual assault. An 18-month pilot program was launched at six sites in downtown Vancouver to make PEP available for specific types of non-occupational exposures. More information about PEP is available at http://checkhimout.ca/PEP/.↩}

^{4. PrEP is currently available as an off-label prescription of Truvada, a drug used to treat HIV. PrEP reduces the possibility of HIV infection. It has been approved by the US Food and Drug Administration but has not been approved in Canada.↩}