Abstract
It is somewhat shocking that almost 40 years into the global HIV/AIDS pandemic, Shari Dworkin’s book Men at Risk is among the first to call attention to the relative neglect of heterosexually active men in HIV prevention research, programming, and interventions. This clearly written, well-argued book is the culmination of over a decade of work by one of the field’s preeminent theoretical thinkers on gender and HIV prevention. The forgotten-ness of men, despite the fact that it takes two genders to tango in heterosexual epidemics, is reflected by the limited number of behavioral interventions exclusively targeted at heterosexually active men, and especially among those who are African American (chapter 1).
Dworkin accounts for this lack in two ways—outdated theories of gender underlying HIV prevention work, and tensions within feminism itself. Chapter 2 examines how second-wave feminist theories shaped HIV prevention thinking. It illustrates the powerful influence of Rubin’s (since updated) idea that women are “linked to a system of gender oppression within heterosexuality that was defined as the sex-gender system” (p. 20) and are therefore “categorically oppressed/vulnerable” in contrast to men who are seen as “categorically powerful/invulnerable” (p. 50). By not taking into account newer theoretical developments, such as intersectionality that recognizes overlapping racial, gendered, and economic systems of oppression, this thinking renders those most vulnerable to HIV/AIDS—marginalized men of color—invisible. A second reason for the neglect of men is the tension within feminism itself that Dworkin takes up in chapter 3. The chapter examines how theories about women’s categorical vulnerability then contribute to single gender programming aimed at empowering women. She shows how public health interventions often come bundled with multiple agendas, in this case attempting to tackle both gendered economic inequality (through micro-credit programs) and intimate partner violence (through anti-violence work with men). Both are seen as root causes of HIV vulnerability for women in many settings (p. 73). However, Dworkin highlights the limitations of single-gender programs, including women’s bearing the burden for change, and their dealing with back-lash from men who are excluded from programming (pp. 86–93).
Chapter 4 profiles a South African program “One Man Can,” “a masculinities and rights based gender transformative anti-violence and HIV prevention program” (p. 119). It works primarily with men to enact individual change, as well as create change-makers in communities when they return. After three very convincing chapters critiquing single gender programs, individual as opposed to structural programs, and programs that are not evaluated using randomized controlled trials (RCT), the reader is primed to read about an “exemplary” program embodying all the ideals described in previous chapters. Instead, we encounter an interesting and rich program that both historicizes and applies intersectionality to understandings of masculinity, but that nonetheless carries many of the issues previously raised. The men self-selected into the study, it was primarily a single-gender program, partners were not interviewed to see if change had really happened, and there was no “control” group. (This of course reveals the limitations of RCT for measuring transformational social change.) As a result, it was hard, at times, to suspend the theoretical critiques Dworkin advanced in previous chapters, in order to fully appreciate the outstanding work done by this organization.
Such a significant book on HIV prevention among heterosexual men would also have benefited from substantive engagement with circumcision for HIV prevention programs that were noted and then set aside, without explanation, throughout the book. They are the primary interventions for heterosexual men, are widespread in sub-Saharan Africa, and have been shown to be highly effective. Further, the fact that circumcision programs find benefits for men that do not necessarily spill over to their female partners, in part embodies the fears of feminist researchers who fear that “adding men” can be detrimental to women. For Dworkin, however, considering and including men is in fact “a feminist enterprise” (p. 9), and ignoring them ultimately costs not just men but also women.
Indeed, what is especially valuable about this book is its moving beyond problem description to suggesting crucial ways forward for the field in chapter 5. Dworkin calls for an updating of theories underlying HIV prevention research, programming, and interventions, to ensure they are attentive to relational and intersectional dimensions of gender (pp. 29, 87, 164, 171), and are inclusive of men, women, and others in HIV epidemics. She also highlights the urgent need for cross-collaboration among public health programming specialists and social scientists to prevent theoretical lags that can have severe consequences for heterosexual HIV epidemics. This important book is a must-read for scholars of HIV/AIDS, gender, social theory, public health, and policy.