Sunday, March 13, 2016

what would a current HIV or LGBT agenda look like?

People deservedly criticized Hillary Clinton for her false historical statement about Reagan and HIV/AIDS.  That referred to HIV issues of the 80s.  Below are some very quick topics I came up with about what current HIV and LGBT issues would be.  Any other suggestions?

The topics are listed in no particular order.

What would a 2016 HIV agenda look like
HIV Criminalization
Intersectionality, high rates of infection of African American gay, bi, and other men who have sex with men
Extortionist prices for pharmaceuticals  (and the reliance of the LGBT press on pharmaceutical ads)
Culture (gay by men, same gender loving, two spirit, transgender women ) vs just-the-facts Behavior (men who have sex with men)
(there must be an issue related to bio-women, but I can’t think of it, my blind spot)
Decriminalizing sex work
Harm reduction/decriminalization drug policy
Other ideas?
What would a 2016 lgbt agenda look like?
(all the HIV issues)
The invisibility of the non-coupled and how that related to poverty  A correction to the mono- and romanticist focus on same marriage of the last decade (As it costs more to live alone, poverty levels could be higher among the non-coupled)
Limitations of ENDA (exemptions for religious reasons, lack of protection against “gate-keeper” discrimination, its focus on individual actions)
Standardizing collection of Sexual Orientation/Gender Identity data including on the US census (this would allow comparisons of a company’s employees with census figures to show patterns of anti-LGBT discrimination)
Barring employers, landlords from using Facebook, internet searches in  hiring or renting decisions (this includes defending sexting )
Barring employers, landlords from considering tattoos and other body modification in hiring /renting decisions
Other ideas?

Wednesday, February 3, 2016

Lust, Men, and Meth: Book Review

A Gay Man’s Guide to Sex and Recovery by David Fawcett
By David Fawcett,
190 pages

Reviewed by Sean McShee

This book contributes to our understanding of meth addiction and sexual health among gay and bi men. Fawcett identifies internalized shame and isolation as social determinants that predispose some gay men to become meth addicts. A social determinant refers to conditions that a group shares. It pre-disposes members of that group to poor health outcomes.

Fawcett rejects “shaming”, “shunning”, or “demonizing” meth users. If internalized shame pre-disposes gay and bi men to all sorts of problems, continued shaming will only make matters worse. Shamed people may become more rigid in their behavior. Shame is counter-productive.

Fawcett describes the current social context as a “perfect storm” for the meth epidemic. The “culture wars”, lasting for almost 50 years consist largely of arguments about shame and resistance to that shame. Meth, more than any other drug, has a peculiar ability to fuse with sexual desire. This fusion occurs in the midst of epidemics of multiple sexually transmitted diseases. While treatments have made HIV a semi-manageable disease, the “HIV crisis” has now become the “HIV normal”. Guys in their 20s have lived their entire lives thinking of HIV as a semi-manageable disease. This “weather” pattern is ominous.

How psychoactive drugs work

Before delving into this book, here is a quick refresher on how all psychoactive drugs, from caffeine to heroin, work.

Brain cells communicate exchanging chemicals called neurotransmitters. This communication produces all of our perceptions, thoughts, feelings, memories, and actions. Some neurotransmitters stimulate; others relax. Some enhance mood. Still others disinhibit. We experience the exchange of neurotransmitters as changes in mood, thought, perception, or muscle movement.

Psychoactive drugs have the greatest effect in the reward system of the brain. We experience exchange of neurotransmitters in this part of the brain as pleasure or pain.

Psychoactive drugs have molecular structures similar enough to neurotransmitters to “fool” a brain cell into reacting as if it had just received an actual signal from another brain cell. That second brain cell then transmits its misidentified message to other brain cells. This misidentification of the psychoactive drug as a neurotransmitter causes the brain to reduce its production of that neurotransmitter. When the psychoactive drug wears off, the brain has less of that neurotransmitter available. This results in the opposite effect of the high. For example, severe lethargy and depression follows an energetic euphoric meth high, as the brain readjusts its chemical balance. Psychoactive drugs change brain chemistry. 

Part I The Perfect Storm

This part of this book concerns the effects of methamphetamine and the social determinants of methamphetamine addiction among gay and bi men. People at all stages of meth use and their significant others would find this section valuable, as would people interested in social issues within gay male communities.

Brain cells misidentify meth as dopamine. They then transmit that misidentified message throughout the reward system of the brain. On the physiological level, two brain cells communicate by misidentifying meth as dopamine. On the subjective level, we experience that misidentification as a sense of pleasure and well-being. If a large number of brain cells simultaneously misidentify meth as dopamine, we experience those misidentifications as a sense of euphoria and invincibility. Despite its similar molecular structure, meth differs from dopamine. While dopamine will be active for a short time, meth can last for up to twelve hours. This extended presence of meth throws the entire reward system off balance.

Meth and sex “work” the reward system. Dopamine activates those brain cells that process erotic information, desires, activities, and fantasies. When brain cells communicate, they “lay down a path” between them. If these cells communicate frequently, the path becomes stronger to facilitate that pattern. These strengthened pathways allow us to perform familiar tasks by “going on auto-pilot”. Two activities done at the same time will cause brain cells to simultaneously communicate or fire. Meth and sex fuse (“what fires together, wires together”), a double whammy to the reward system. Fawcett argues that meth “hijacks” the reward system of the brain.

Fawcett accepts the concept of “process addictions” whereby rewarding activities in themselves can develop into addictions without the intake of any external psychoactive drugs. In each case, the reward system becomes disturbed. The presence of progression (becoming worse over time) and tolerance (needing a bigger hit over time) justifies labeling the problem as an addiction rather than a compulsion. Process addictions have generated controversy. Some people feel the label “addiction” should be restricted to pharmacological addiction. 

Fawcett argues that meth exploits key vulnerabilities among gay men. Some gay men lack confidence, feel worthless, isolated, or feel a sense of shame. Meth allows some guys to temporarily feel the opposite. Whether conscious or not, internalized heterosexist values lead many gay and bi men to unacknowledged, but felt shame. The extent of that shame influences the erotic lives of gay men in ways that remain hidden from consciousness. Meth has great appeal for these men. 

According to Fawcett, some gay and bi men reported that meth allowed them to experience feeling defiantly gay for the first time in their lives. For some gay men, their coming out process failed to deal with their internalized shame and isolation. Meth filled this hole in their life.

Exploring the Sexual Universe

The second part concerns how we structure and organize erotic attractions and relationships. This section would have value for many gay and bi men seeking to improve their understanding of erotic patterns. Fawcett asserts, “Our society has an overabundance of sexual images but also a simultaneous lack of deeper sexual understanding.”

The first part of the book focuses on the physiology of meth addiction, but we do not just experience meth or sex on a physiological level. We experience meth and sex on emotional, relational, and social levels as well. 

Fawcett distinguishes sexual orientation from sexual templates. Sexual orientation refers to the sex of the people that one finds attractive. In slang terms, we have a “type” to which we generally are attracted. In technical terms, we would have a sexual template. This template refers to the physical image and general erotic activities that a person finds attractive. People vary in how rigidly they adhere to their template. Relatively fixed by the time of puberty, this template structures our lifelong patterns of conscious and unconscious arousal. While people can add factors to their template, most people find eliminating factors from it extremely difficult.

Meth interacts with templates in strange ways. It shatters them. Most of us have “stuff“ buried beneath consciousness, ranging from internalized heterosexism to leather fantasies and beyond. Meth tends to cause that “stuff” to break out into consciousness but without conscious processing. Bringing this “stuff” out of sub-consciousness leads to better mental health, but only if someone had consciously processed it. This “stuff” has power and danger. If processed consciously, someone can challenge the reasons why it was buried. They can then integrate that “stuff” into consciousness. Without conscious processing, unintegrated “stuff” explodes into behavior in dangerous ways.

Restoring Your Life

The third part of the book concerns recovery. This section would be useful for someone with a significant other undergoing recovery, graduate students studying addiction, or addiction professionals. A recovering addict in early recovery would probably lack the concentration to read this book, however.

As gay male meth users in recovery have fused meth and sex, Fawcett stresses that recovery has to work these two tracks simultaneously. For the severely addicted, this entails abstinence from drugs and sex to allow healing to occur. The recovering addict has to learn new skills and acquire new tools to deal with the underlying feelings that drove the drug use. People can recover, but recovery requires resources.  

According to Fawcett, recovery has distinct stages in the recovery process. For the first two weeks without meth, the former user will experience intense cravings, depression, and paranoia. These tend to diminish relatively quickly.

The next 90 days will involve unlearning old cues and establishing new routines. In this period, the former user will have to become very aware of those environmental events that trigger a desire to use. These triggers can be sights, smells, sounds, people, neighborhoods, etc. The recovering addict has to learn how to avoid these triggers.  The brain will take 18 months to rewire the neural pathways. Eventually, the recovering addict can re-introduce sex into his life, but he can never re-introduce meth.

While this book focuses on meth addiction, Fawcett discusses ways of thinking about sex and relationships that many would find valuable. Other parts can generate community debate.   Below are some areas that could generate fruitful community debates and other areas that could use improvements.

Areas for Debate: Sexual Addiction, Sexual Compulsion, Anhedonia, and Treatment Differences

The concept of “sexual addiction” will generate the most debate. Fawcett acknowledges that this position engenders controversy. I do not find compelling the argument that the label “addiction” best describes a type of compulsive sexual behavior. I would imagine it would generate a good deal of resistance and keep some people away from treatment. 

While the pharmacological addict can never again use the addictive substance, sex can be reintroduced to the recovering sex “addict”. This difference in treatment indicates a fundamental difference between pharmacological addiction and this process “addiction”. 

Process” addictions” can be considered a type of compulsive behavior involving the reward system. In a compulsive behavior, not involving the reward system, such as handwashing, the hand can never become clean enough. In a functioning reward system, rewarding activities lead to a sense of well-being and satiation, rather than a need for more. According to Fawcett, a key feature of sex addiction lies in its emphasis on anticipatory pleasure rather than orgasm. Compulsive sexual behavior never is good enough to produce satisfaction. 

Anhedonia, another disturbance of the reward system, may be involved. This condition refers to an inability to experience pleasure. Anhedonia frequently contributes to depression and self-medicating depression contributes to stimulant use. Compulsive sexual behavior may result from this pre-existing disturbance in the reward system, rather than a psychoactive drug.

Areas for Debate: Community vs clinical sample

Our knowledge of substance use suffers from a major knowledge deficit. Most of what we know about substance use comes from people in treatment programs, jails, and hospitals. We primarily know about this end-stage drug use. We do not know about drug users at earlier and less problematic stages. We have a knowledge deficit about the varied “careers” of drug users. An unknown number may never progress to addiction or may simply “mature out” of drug use. When people generalize from end-stage drug use to all drug users, they risk overstating the problem. This knowledge deficit should be acknowledged in all public discussions of drug use.

This knowledge would be particularly useful in answering the question:  How does addiction differ from people frequently doing what gives them pleasure? This question becomes particularly important for groups of people, such as gay and bi men, with a history of victimization by Puritanist ideology. Sensitivity to this history of victimization forms a key component of cultural competence for health issues for gay and bi men.

Possible Improvements:  Resources Needed

Fawcett states that people can recover from meth, but that recovery will take resources. He never mentions the amount of resources it will take. Addiction can leave people impoverished and homeless, but accessing services requires money. Emotional recovery requires time. This deserves a place in a book about addiction and recovery.

Possible Improvements:  Lack of a glossary

Fawcett introduces many scientific terms in the course of a book intended for a non-technical audience. As some people will encounter these terms for the first time in this book, it would have benefitted from a glossary.

Good books on public health issues work best when they generate debate.  They fail to work when people treat them as if they were sermons. This book should generate a good deal of debate about an important issue.

Full Disclosure:  I have known and worked with David Fawcett for over five years in various gay and bi men’s health organizations.

Friday, January 15, 2016

Feminist Evaluation and Research

Edited by Sharon Brisola, Denise Seigart, and Saumitra SenGupta (2014)
New York, The Guilford Press, 346 pp., $31.00  to $45 paperback Amazon (12/29/15) ISBN-13: 978-1462515202, ISBN-10: 1462515207

Reviewed by Sean Little
Words 1188
This book provides a useful introduction to the concepts and practice of feminist evaluation. According to Alkin’s and Christie’s evaluation tree with three branches (Method, Use, and Value), this approach lies firmly on the values branch (Evaluation Roots, 2004). It emphasizes the commitment to social justice as a core value. This emphasis introduces several additional problems. What constitutes social justice? Who gets to define it? Are we heading in the right direction? How will we know if we have achieved it? And can people “legitimately” disagree about what constitutes social justice? Another problem concerns those differences between the democratic political processes that rely on a presumption of equality, and the technocratic problems that rely on advanced training. This book did not really address these questions. Evaluators unfamiliar with feminist evaluation may find this book more valuable than others.

This book has three editors with different authors writing each chapter. Each author reiterates similar points, but with subtle differences. It has three sections:  1) Feminist Theory, Research, and Evaluation, 2) Feminist Evaluation in Practice, and 3) Feminist Research in Practice. While the first section consisted of theory, the last two sections focused on the actual practices of feminist evaluation and research.

In feminist thought, “gender” differs from “sex”. The World Health Organization defines gender as “the socially constructed roles, behavior, activities, and attributes that a particular society considers appropriate for men and women”. In contrast, “sex” refers to the anatomical and physiological aspects of male, female, and intersex bodies. Intersex refers to people with ambiguous genitals. Gender is social; sex is physical. Gender inequities refer to differences in status, wealth, security, health, and freedom between those people classified as male and those classified as female. Gender inequities occur individually, and structurally. Social norms, customs, and beliefs support and maintain gender inequities.

In the first chapter, Sharon Brisola identifies eight key feminist evaluation principles. First, knowledge depends upon the culture, society, and time in which it emerges. Second, knowledge has an explicit or implicit purpose. Third, evaluation is an inherently political activity. Fourth, all methods, institutions, and practices are socially constructed. Fifth, multiple ways of knowing exist, but people value some ways more than others. Political choice, frequently unstated, drives this prioritizing of some ways of knowing. Sixth, gender inequity, race, class, and culture, all interpenetrate. While one can extract information about one of these elements, that information will be, regardless of its utility in some contexts, incomplete without examining the other elements. Seventh, gender inequity exists at the systematic and structural levels. Eighth, evaluators have an ethical obligation to act to reduce oppression.

Brisola rejects the belief that feminist evaluation should only focus on women. Instead, it focuses on power dynamics and the resulting social and gender inequities. She argues that men can be practitioners and subjects of feminist evaluation.

According to Brisola, feminist theories examine four major areas: 1) the inequities linked to gender, 2) the ending of oppression, 3) the interests, concerns, and perspectives of women, and 4) the critiques of male bias in practice and theory.

Feminist evaluation can align with other evaluation approaches to produce blended approaches:  feminist empiricism, standpoint feminism, feminist post-modernism, and a variety of critical theory feminisms (post-colonial, black, Chicana, race, queer, and lesbian). Feminist empiricism uses positivist methodologies to examine feminist issues. Standpoint feminism assumes that where we sit at the proverbial table determines where we stand politically. Feminist theory, a critical theory itself, can align with other critical theories. These blended critical theories can be based on ace, sexuality, gender identity, or colonial status to form new critical theories. 

Brisola argues that feminist evaluation challenges epistemology (how and what we know), ontology (what constitutes “reality”), and methodology (what are tools are used to extract “knowledge” from “reality”). Despite these challenges, feminist evaluation can align with other approaches such as stakeholder, democratic, fourth generation, participatory, empowerment, emancipatory, transformative, and developmental evaluation.

In the second chapter, Sandra Mathison distinguishes between evaluation and research. Evaluation always involves both facts and values, but research does not require a consideration of value, other than methodological rigor. Evaluation also differs from research in its context specificity. Evaluation always refers to a particular evaluand in a particular context, but research involves the production of generalized knowledge. 

Mathison identified several common strands among feminist researchers:  1) the relational nature of the encounter between the evaluator, and the people associated with the evaluand; 2) the context of the evaluator’s life and its effect on the evaluator’s practice; 3) a focus on experience and complex questions of power; and 4) the inequity of gender.

This book introduces feminist evaluation to readers, but it has several drawbacks relating to its social justice focus.

The authors fail to clarify what they mean by social justice, or how to adjudicate competing definitions of it. Social justice can be a meaningful motivating force, but it can also be a vague platitude to which people with serious disagreement can “agree”. For example, everyone wants “peace” in the Middle East but people disagree, sometimes violently, as to what that means. People socially construct the concept of “justice”, but that construction lacks a guarantee of consensus. Can people disagree about what constitutes “social justice” without serving the interests of maintaining oppression? Theories advocating a social justice focus should address this issue. 

The authors emphasize the social justice commitment in feminist evaluation and research. They fail, however, to acknowledge the conflicts of interest in the material practice of evaluation and the relative powerlessness of the evaluator. This material practice involves the economic transaction between a knowledge worker and an organization with large enough amounts of capital (power) to fund an evaluation. When an independent consultant bids on a contact, this economic transaction becomes visible. When an employee has the role of evaluator, this economic transaction has been built into the hiring process, performance reviews, organizational culture, and communications from management. The funder of the evaluation determines the scope of the evaluation, not the knowledge worker.  

If an organization has the capital (power) to hire an evaluator, it may well have some vested interest in power dynamics, conscious or not. Some organizations may have worked through this issue, but it is na├»ve to think all have done so. I find it odd that social justice approaches to evaluation do not include this conflict of interest in their theory, as it is implicit in their understanding of power dynamics. None of the authors in this book addressed this issue. 

One of the articles examined a feminist evaluation of three sites in pre-Civil War Syria. An al-Qaeda front group now controls one of those sites. Any empowerment or social justice in that site has presumably ceased. Evaluators have minimal power compared to the US Congress, let alone an armed group of religious fanatics.  Theories that emphasize social justice should address the limitations of evaluator power.

While this book has it flaws, it does illuminate feminist evaluation. It also unintentionally points out the limitations of thinking that knowledge workers can drive social change.

The review first appeared in the 2016 Winter Edition of the Newsletter of the Southeast Evaluation Association.