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The category of “homosexuality” holds a very storied and complex place in the history of medicine, whereby the term itself was generated in the late nineteenth-century biomedical discourse in order to potentially liberate it from juridical categories of “sin” and “crime.” For this research paper in the Encyclopedia of Global Bioethics, the authors challenge this historical legacy by considering the contemporary clinical needs and contemporary ethical strains as related to lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI) persons in bioethics discourses. Over the course of special sections devoted to the terminological, biological, psychological, geographical, and political dimensions that complicate our precise appreciations of “homosexuality” as a bioethical category, this research paper suggests that a multidimensional, historically infused, and multiculturally mindful approach to homosexuality best informs the contemporaneous bioethicist.
Homosexuality, or same-sex affection, has been a long-standing feature of many cultures and many histories. While men or women who are attracted to individuals of the same sex can be called homosexuals, the term lesbian has traditionally exclusively referred to women who are attracted to other women. Individuals who are attracted to both men and women have historically been termed bisexual. In more recent history, individuals whose sexual attraction is limited by neither the traditional binary (cis-gender) types of male and female nor other categories of sex, gender, and gender identity have been termed pansexual. The term queer (historically a pejorative label for homosexuals and other gender/sexual nonnormative persons) has, in recent years, been reappropriated by lesbian, gay, bisexual, and transgender (LGBT) persons and others to denote a general self-identiﬁcation as either nonheterosexual or non-cis-gender.
For this research paper the authors challenge a historical legacy of “homosexuality” by considering the contemporary clinical needs and contemporary ethical strains of lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI) persons in bioethics discourses. Over the course of special sections devoted to the terminological, biological, psychological, geographical, and political dimensions that complicate our precise appreciations of “homosexuality” as a bioethical category, this research paper suggests that a multidimensional, historically infused, and multiculturally mindful approach to “homosexuality” best informs the contemporaneous bioethicist, especially on a global platform.
“Homosexuality” As Terminology
The term “homosexuality” dates from the late nineteenth century and bespeaks a terminological moment when same-sex affection expanded from juridical models of discourse to pathological ones.
Until the last decades of the nineteenth century, long-standing considerations of same-sex affection were almost universally appreciated as infractions – under the headings of sin or crime. Such critical interpretations of homosexuality as a punishable transgression remain today, although usually alongside contemporary and historical understandings of homosexuality as pathology. While select cultures historically (from the Ancient Greeks to some indigenous communities in North America and the Indian subcontinent) have found permissible, particular forms of same-sex affection and gender transgression, these tend to be isolated and proscribed according to other strict hierarchies of social class, age, and economics (Halperin 1989; Weeks 1981).
In the past several decades – inspired by diversity studies initiatives – scholars working in women, feminism, gender, queer, sexuality, and disability studies as well as historians of medicine have tended to describe the twentieth century as a period when the pathological concept of homosexuality made possible an understanding of same-sex affection as being attached to personhood, not merely behavior. French cultural critic Michel Foucault (1978) has called this a moment when there was a shift in the understanding of (homo)sexuality from mere action to personal identity – or, as he writes, from “temporary aberration” to “species” status. This is a shift from the performative question “What I did?” to the identity-based question “Who am I?” It is a historically and pathologically infused shift from evaluating gender and sexual-nonnormative persons from the perspectives of demonstrative difference to embodied (literal, somatic) difference. In charting these disproportions between public, private, somatic, and cultural appreciations of same-sex desiring persons, this research paper will consider the long-standing and enduring notions of how “homosexuality” is and has been understood and articulated globally within biomedical, bioethical, and sociopolitical discourses across geographies (Chauncey 1982). In short: How do science, medicine, religion, and regionalism serve as arbiters in the appreciation and estimation of “homosexuality” as a culturally and clinically constructed category?
“Homosexuality” As Personhood
Homosexuality or for that matter all sexualities are culturally speciﬁc forms of sexual personhood that presume particular conﬁgurations of sex, gender, and sexuality. In Euro-American cultural contexts, the experience of homosexuality maintains a distinctly ethical relation between the private self and one’s public persona. For example, the history of homosexuality in these cultural contexts is grounded in the medicalization of gender and sexuality or what Eve Sedgwick (1990) has referred to as the “epistemology of the closet.” According to this frame, the closet (or concealed homosexuality) is a culturally particular way of producing/not producing and knowing/not knowing about homosexuality (private homosexual desires and practices) as an aspect of an individual’s public persona (social identity). This “style of reasoning” about homosexuality requires that individuals maintain congruency between their private sexualized self and their public sexual and gender identities. When an individual’s private and public sexual and/or gender identities are incongruent, the ethics of this relation work by classifying the individual as abnormal. For instance, a male-identiﬁed homosexual who is anatomically and publicly male would be considered normal in this cultural frame. Alternatively, a heterosexual woman who socially identiﬁes as female, but who has intersexual characteristics, is typically classiﬁed as abnormal and may not be public about one’s intersexuality. Many scholars in gender studies and bioethics have analyzed the global racialization of abnormality and sex-testing surveillance among female athletes through testosterone-testing regimes in international competitive sports.
In this cultural frame, the arrangement and relation of different aspects of sexual personhood – the body, individual psyche and emotional and intellectual attributes of the person (private self), subjectivities, and public persona (e) – are particular to speciﬁc places and historical moments. This means that when homosexuality emerges in different cultures globally, a properly global bioethics must determine how homosexuality is produced as a qualitatively different object of knowledge as it is translated into pre-existing sex/gender systems. In many societies like Brazil, Indonesia, Melanesia, Thailand, and South Africa, it is normal that public gender and sexual identities have no necessary relation to private anatomies or sexual desires and practices. Godfrey Lienhardt’s classic study of personhood among the Dinka of South Sudan reminds us that “the real difﬁculties of translation [of culturally particular forms of personhood] arise when we ask (and we may ask mistakenly, for the question presupposes particular kinds of answer) for a description of private self that acts and is acted upon, and where that action is located”(Lienhardt 1985, p. 146). This means that a range of culturally speciﬁc social processes – such as economic exchange, the division of public and private aspects of the self, and religious practices – inﬂuence how sexual personhood is produced by individuals and how homosexuality is experienced cross-culturally.
“Homosexuality” And Cultural Specificity In Global Bioethics
Understanding the cultural speciﬁcity of sexual personhood is necessary to the successful design and implementation of biomedical and global health research and interventions. However, this speciﬁcity is typically overlooked or presumes a Euro-American model of sexual personhood. In the context of South Africa, black gay-identiﬁed men are classiﬁed as men who have sex with men (MSM) by global health researchers. However, across South African society, many families, friends, and “straight” male sexual partners (who are also classiﬁed as MSM) of gay men classify gay men as women – sometimes the gay men do so themselves. This produces contexts of HIV vulnerability around feminized, gay-identiﬁed men in their private sexual relationships, which include alarming rates of sexual violence. Thus, global health experts classify them as men without understanding how their experiences of feminization, womanhood, and sexual violence in their everyday lives signiﬁcantly mediate their risk of HIV infection. When these experts use epidemiological models to distribute biomedical HIV prevention technologies, such as pre-exposure prophylaxis, or PrEP, their models do not account for these risks since they do not take the culturally variation in homosexuality into account. In this way, global health experts may, paradoxically, contribute to contexts of HIV vulnerability among these men by making ﬂawed risk calculations that result in health resource disparities. Therein lies a bioethical dilemma – how should global health experts approach homosexuality in contexts where there are multiple cultural ﬁelds that produce complex forms of sexual personhood? In this example, one could argue that it is preferable to afﬁrm the agency of gay men to self-identify as men; thus they should be classiﬁed as men. However, such an afﬁrmation is ethically problematic because it ignores the context of vulnerability within which these gay men exist. Their experience of homosexuality is a conﬁguration of sexual personhood where they self-identity as male, yet they regularly experience feminization through gender (not sex) reclassiﬁcation of their public persona through pre-existing cultural conventions of gender and sexual identiﬁcation.
These complex forms of sexual personhood are produced by the coexistence of more than one paradigm of sexual and gender identities in any society at a given historical moment. However, much scholarship on homosexuality has been inﬂuenced by theories of paradigmatic rupture that presuppose the supersession and invalidation of the preceding order. As Heather Love (2011) has argued, existing scholarship on (homo)sexuality has been heavily inﬂuenced by Gayle Rubin’s now-classic work Thinking Sex (1984), in which she calls for an “autonomous theory and politics speciﬁc to sexuality.” The predominant inﬂuence of this aspect of Rubin’s work on the study of homosexuality cross-culturally has been that the gender dynamics of pre-existing sex/gender systems are typically overlooked in health-related research and interventions among LGBTQ populations globally. This is problematic because many of these populations are signiﬁcantly inﬂuenced by gender dynamics. This is due to the way in which Thinking Sex and other scholarships rest implicitly on ﬂawed Foucauldian analyses of paradigmatic rupture with regard to the historical transition between gender and sexuality paradigms during modernity.
This transition is what Rubin calls “kinshipbased” gender systems and “modern” systems of sexuality. Conversely, Eve Sedgwick argues:
Issues of homo/heterosexual deﬁnition are structured, not by the supersession of one model and the consequent withering away of another, but instead by the relations enabled by the un-rationalized coexistence of different models during the times that they do coexist. (Sedgwick 1990, p. 47)
This means that the analysis of homosexuality in global bioethics is incomplete without also determining how pre-existing models of kinship-based gender relations inﬂuence the historical emergence of homosexuality, changing the cultural meanings, experiences, and phenomena of sexuality in everyday life. Taking into account the cultural speciﬁcity of homosexuality would have a signiﬁcant bearing on the way that biomedical clinical research, medical care, and public health surveillance and interventions should be designed and implemented among LGBTQ-identiﬁed and other gender nonconforming groups. This is particularly an issue if bioethicists wish to address the upstream social determinants of health in a way that addresses the sociocultural variability in the way that gender, sex, and sexuality are interrelated through culturally particular conﬁgurations of sexual personhood.
These culturally particular conﬁgurations of homosexuality also give rise to speciﬁc socially constituted forms of stigmatization. Erving Goffman’s classic work deﬁned stigmatization as “an attribute that is signiﬁcantly discrediting .. . an undesirable difference” and that the person thus stigmatized carries a “spoiled identity” (Goffman 1963, p. 3). Richard Parker and Peter Aggleton (2003) have demonstrated how stigmatization of groups deemed to be “sexually deviant,” such as homosexuals and other LGBT populations, have created bioethical dilemmas in the context of the HIV and AIDS pandemics. They point out that stigma works systemically as part of culturally particular logics and society-speciﬁc forms of social relations. This means that stigmatization of homosexuality will have a particular history that is intimately related to how sexual personhood is constituted among the various cultural groups in every society.
Although stigmatization of homosexuality creates contexts of vulnerability to biomedical risk and violence around LGBTQ-identiﬁed persons, David Halperin and Valerie Traub (2010), along with numerous other sexuality studies scholars, have explored the issue of reclaiming shame. They do so with the aim of asserting the power and possibility of the role that stigmatization has played in the historical response of lesbian and gay cultures to biomedical disasters like HIV. Speciﬁcally, the essays in this text remind readers that the mobilization of shame in LGBTQ health politics has historically been proven to be a powerful and shrewd political strategy. Likewise, Michael Warner argues:
[T]he difﬁcult question is not: how do we get rid of sexual shame? The answer to that one will inevitably be: get rid of sex. The question, rather, is this: what will we do with our shame? (Warner 1999, p. 3)
These renegotiations and reconceptualization about the role of shame in LGBT health politics are perhaps best demonstrated by Steven Epstein’s study of the role of AIDS activists and biomedical experts in creating what he refers to as scientiﬁc “credibility.” He ethnographically explores the contributions of both activists and HIV scientists while not privileging either perspective. The study ultimately highlights the role of shame in AIDS and LGBT activist social movements’ protests and how this dramatically inﬂuenced the constitution of scientiﬁc knowledge about HIV and AIDS and the development of antiretrovirals early on in the pandemic’s history (Epstein 1996).
“Homosexuality” In Contemporary Global Bioethics
In contemporary global bioethics discourse, homosexuality serves as a central topic of discussion and debate on numerous fronts. Some of these topics include healthcare access and equitable treatment for LGBT patients; social stigma surrounding homosexuality in various cultural and religious contexts; legal and job protections for LGBT citizens, couples, and families; HIV/AIDS prevention, treatment, and risk management in MSM populations; the obfuscation of some disenfranchised members of the LGBT community (queer women and transgender persons, in particular) in contrast to the greater attention to MSM populations; and the mobility and migration of LGBT/queer culture and persons across national and cultural divides, especially in a present age of sociopolitical and socioeconomic globalization (Wahlert and Fiester 2012).
Like other categories of marginalized personhood – based on class, gender, ethnicity, disability, and political (dis)enfranchisement – homosexuality makes itself known in global bioethics discussions insofar as it addresses tenets of cultural competency, cultural diversity, and social justice. For instance, a number of LGBT and intersex-speciﬁc bioethical topics arise. These include issues as diverse as reproductive ethics for same-sex partners; the cultural complexity of ethical analyses concerning post and pre-exposure prophylaxis (particularly in socioeconomic contexts as diverse as the United States and South Africa where HIV-positive persons are still not guaranteed access to lifesaving antiretroviral, a subject leading AIDS scholar Cindy Patton addresses in her work); discriminatory nomenclature regarding trans health issues within the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association for mental disorders; pediatric ethics-inspired interventions for trans and intersex children; as well as gender testing in competitive sports (Patton and Kim 2012). In all of these domains, culturally distinct forms of personhood need to be critically mediated in terms of how a global form of bioethical analysis can be most mindful of LGBTQI health access, LGBTQI health disparities, and LGBTQI-invested interventions that are best designed, evaluated, and implemented.
For this research paper on “homosexuality,” the authors have scrutinized and challenged the historical legacy of “homosexuality” by considering the contemporary clinical needs and contemporary ethical strains of lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI) persons in bioethics discourses. Over the course of special sections devoted to the terminological, biological, psychological, geographical, and political dimensions that complicate our precise appreciations of “homosexuality” as a bioethical category, this research paper suggests that a multidimensional, historically infused, and multicultural mindful approach to “homosexuality” best informs the contemporaneous bioethicist, especially on a global platform.
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