Book Review

Culture and Sexual Risk: Anthropological perspectives on AIDS

N Engl J Med 1996; 334:1751-1752June 27, 1996

Article

Culture and Sexual Risk: Anthropological perspectives on AIDS
Edited by Han ten Brummelhuis and Gilbert Herdt. 355 pp. Langhorne, Pa., Gordon and Breach, 1995. $29. ISBN: 2-88449-131-7

This collection of essays takes a fresh look at the stories and the people at the heart of the AIDS epidemic. It extends beyond the normal boundaries of scientific discourse to find new and important insights, particularly about the meaning of sex roles and sexuality in their various cultural, political, and socioeconomic contexts. The message is that we need to expand our understanding of these issues if we are to influence the transmission and prevention of AIDS.

A major segment of the book deals with the changing role of the anthropologist and other social scientists in research on AIDS. The study of this disease has created a crisis in the discipline, forcing a rethinking of some of the core elements of theory and method. Anthropology has often been called on during the AIDS epidemic to capture data on “who does what with whom, and how often.” Much of this research has disregarded the paramount importance of seeing that high-risk sexual behavior is embedded in systems of culture and economic exchange. These types of studies are unlikely to end the AIDS epidemic, influence the treatment of sexually transmitted diseases, increase the use of condoms, or facilitate the broad socioeconomic change needed to reduce risks. Instead, a kind of scientific colonialization may be taking place, in which research models become tools of abuse and neglect rather than sources of comfort and care. What may be required, according to many of the authors, is a move from passive observation to active intervention. Anthropologists may need to take on the role of agents of cultural change — for example, by acting in culturally appropriate ways to get people to talk about sex to each other and not just to researchers.

The examples in the book's 16 essays, though often exotic in their settings, will assist the reader, irrespective of his or her local reality, to identify issues critical to the prevention and treatment of AIDS. They provide rare authoritative glimpses into the language and daily life experience of groups involved in high-risk sexual behavior around the world: from Thai sex workers to Brazilian teenagers to gay men in Sweden.

Many examples demonstrate and attempt to explain the gap between knowledge and action. For instance, knowledge of AIDS and AIDS prevention is widespread among Thai sex workers, but primary value is often given to the promise of a profitable relationship with a foreign client, particularly when AIDS is considered “far away,” not immediately visible, and connected to Buddhist ideas of retribution. In Thai culture, unwanted information may often be ignored, and there is a tendency among sex workers to trust their clients' judgment about the risk of infection, particularly when such pragmatism may allow an escape from poverty. Other examples show how seemingly contradictory behavior makes sense within a particular cultural milieu. For instance, although safer-sex strategies have been adopted by large segments of the gay and bisexual community, a majority of men in these groups continue to report occasional participation in the highest-risk sexual behavior, unprotected anal intercourse. Understanding more about the broader social and economic context in which men have sex with other men — how they live, meet, and couple — provides insights into these behavioral discrepancies.

In general, the examples clarify how the need to stem the spread of AIDS requires consideration of numerous cultural, economic, and psychosocial variables, and not just biomedical insights. As one of the authors notes, “The semiology of AIDS is as important as its biochemistry.”

Jeffrey Borkan, M.D., Ph.D.
Ben Gurion University of the Negev, Beer Sheva, Israel 88840