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«by Annette-Carina van der Zaag A Thesis Submitted to the University of London for the Degree of Doctor of Philosophy Department of Sociology ...»

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The Promise of Vaginal Microbicides

Configurations of Women’s Empowerment in a Time of HIV

by

Annette-Carina van der Zaag

A Thesis Submitted to the University of London for the Degree of

Doctor of Philosophy

Department of Sociology

Goldsmiths College

University of London

Abstract

The Promise of Vaginal Microbicides

configurations of women's empowerment in a time of HIV

In this thesis I offer a feminist theorisation of the development of vaginal microbicides:

female initiated HIV prevention methods (vaginal gels, films, sponges and rings) developed explicitly to empower women in the HIV pandemic. They are currently being tested within clinical trials which have produced mixed results and are on-going.

In this thesis I reflect on the development of vaginal microbicides as a biomedical intervention that promises a transformation of gender dynamics voiced in terms of women’s empowerment as well as a material protection against the HIV virus. I approach the development of vaginal microbicides as a feminist-biomedical process constitutive of the microbicide/woman they investigate and advocate. As such, I aim to contribute to theoretical debates surrounding female-initiated HIV prevention by suggesting a different set of theoretical tools in order to capture the various modes of enactment at stake.

To this end I set out a performative approach to the body and scientific development, through Donna Haraway’s ‘cyborg myth’ and Karen Barad’s ‘agential realism’. Building on the arguments of various Science and Technology Studies scholars such as Bruno Latour, Annemarie Mol and Nelly Oudshoorn, I conduct a textual analysis of clinical trial reports, advocacy documents and various journal articles based on social science studies. I argue that biomedical process tends to constrain what I understand as the microbicide’s ‘material-semiotic potential’ and the configuration of its potential user. Moreover, the trials themselves operate with a conception of power, and of the trial, that does not allow them to consider biomedical investment as itself constitutive of women’s vulnerability. Ultimately, the thesis presents and critiques what happens to feminist ideals in the trials, and concludes that despite those ideals, and despite the ethical concerns with women’s vulnerability within the trials, the pursuit of the promise of microbicides has not engaged with the full complexity at stake.

Declaration by Candidate I hereby declare that this thesis is my own work and effort and that it has not been submitted anywhere for any award. Where other sources of information have been used,

–  –  –

First and foremost I am grateful to my supervisors Marsha Rosengarten and Vikki Bell for their continuing inspiration, academic guidance and emotional support, without which this project would not have been possible.

I am indebted to everybody with whom I have been able to share my thoughts and who have contributed to this project through conversation and critique. I would like to thank Monica Greco and Celia Lury for the thorough reading of my work and the pointed critique during my upgrade from MPhil to PhD which shaped and moulded this project in a positive and constructive way. I would like to thank Lori Heise for her willingness to discuss my project and provide further information when needed. I would like to thank Kimberly Keith for her support and much appreciated proof reading skills. Finally, I am grateful to the HIV project reading group members Ulla McKnight, Richard Boulton and Agata Pacho for the many HIV and PhD process related conversations.

Furthermore, I would like to thank Bert van der Zaag, Peter van der Zaag, Carla Elmont, Melissa Fink and David Drew. You have supported me, each in your own way, throughout the years of this project. I could not have done this without you.

Finally, I am grateful to my mother Carlita Elmont, whose strength and persistence has never ceased to be an inspiration for seeing this through. I started my process of writing this thesis as you started your process of healing from cancer. We always said a time would come within which we could look back and reflect, in health. Writing these acknowledgements reminds me of where we are, now, in this moment.

Chapter 1. Introduction

In this thesis I seek to offer a feminist theorisation of the development of vaginal microbicides. Vaginal microbicides are topical pharmaceutical compounds (applied to the surface of the body in contrast to a systemic intervention such as an oral pill) that have been tested in clinical trials since the early 1990s in a variety of forms; creams, gels, films, sponges or rings, which women can apply vaginally to protect themselves against HIV infection. (GCM 2009a) Vaginal microbicides are developed, explicitly, as female-initiated HIV prevention. In light of the increasing feminisation of the HIV pandemic, the development of vaginal microbicides carries the promise of women’s empowerment.

I aim to contribute to feminist critiques of materiality by focusing on the microbicide as a biomedical intervention that incorporates both ideals of women’s empowerment and a material protection of the female body against the HIV virus. As such, the microbicide as an object invites new ways of thinking women’s bodies in explicitly sexualised ways at the very centre of power relations and the possibility of their transformation. Furthermore, in this thesis I aim to contribute to theoretical debates surrounding female-initiated HIV prevention, by shedding light on the intimate relations between the body, feminist theory and biomedicine which characterise the field of microbicides.





In this thesis I will compose a critical intervention into the theoretical or conceptual HIV debates concerning women’s empowerment within the biomedical development of female-initiated HIV prevention.1 I will reflect on the fact that the campaign for microbicides has been voiced as an explicit feminist campaign, largely fuelled by an understanding of gender dynamics that speaks in terms of women’s empowerment, and aims – beyond the fact of HIV prevention as it were - to transform gender and sexual power relations.

I understand the idea of a microbicide to have generated a complex object that is aimed at protecting women against the HIV virus by engaging their specific physiological vulnerability while intervening into the power relations that place women at risk of HIV infection, through its specific incorporation into women’s sexual practices. However, this idea has come to be enacted and articulated through biomedicine and consequently it has materialised into various microbicide candidates through the various scientific mechanisms that make up the biomedical field. Although this engagement with biomedicine has generated the promise for the materialisation of an efficacious microbicide, I will argue that biomedical process – its practices and imaginaries - functions as an interference into the complexity the microbicide gathers and the imaginative potential this object wields.

After nearly 30 years of microbicide testing, there still is no effective microbicide to As for instance Amy Kaler’s work on women’s empowerment and the female condom (Kaler 2001, 2004) date. Although the field is marked by a certain failure, it has managed to persist. I will argue that the field’s various biomedical mechanisms, that might very well aid its persistence, have eroded what I understand as the microbicide’s ‘material-semiotic potential’ and the configuration of its potential user and as such the microbicide’s transformative potential. Ultimately, the thesis presents and critiques the consequences of materialising feminist ideals through biomedical process and the clinical trials specifically, and concludes that despite those ideals, and despite the ethical concerns with women’s vulnerability within the trials, the pursuit of the promise of microbicides has not engaged with the full complexity at stake. I will argue that in order to engage the various modes of enactment at stake in the field of microbicides, in all their ethical complexity and transformative potential, a different way of thinking the field is pertinent, an analytical toolkit, or certain imaginary, attuned to the complex relationality this field generates.

Empowerment a vehicle of inclusion

In order to contextualise what I shall propose is a highly innovative material achievement of feminist theorising in the form of research into topical vaginal microbicide, it is useful to set out how an alliance between feminism and biomedicine came to be forged and how this alliance construed an intricate relation between the concept of women’s empowerment and biomedical intervention, fundamental to the field of microbicides. To do so I will give a brief overview of a cluster of documents published in the late 1980s and early 1990s that I understand to have set the scene for the microbicide to emerge as an intervention specifically aimed at women’s vulnerability.

The development of vaginal microbicides is closely tied to the increasing feminisation of the HIV pandemic and the perceived need of women’s empowerment herein. According to UNAIDS statistics, worldwide there are around 33.3 million people living with HIV (UNAIDS 2010: 7), of which women and girls make up more than half (UNAIDS 2010: 10). Globally, the number of women living with HIV has been on the rise since the early 1990s. This increase is more prominent in some parts of the world than others. For instance, in SubSaharan Africa young women are eight times more likely to be HIV positive than men their age (UNIADS 2010: 10). Since the early 1990s feminists in women’s health started advocating for a HIV prevention option specifically focused at women’s needs and specific vulnerability.

This inclusion of women’s needs is rooted in the conception that women are subject to a lack of power in their gendered lives across many societies and that this distribution of power fuels their vulnerability to HIV infection. This is a mainstream discourse in the global field of HIV prevention now. However, women were not always a visible risk group within the global field of HIV prevention.

To exemplify, on the 12th of June 1988 at the fourth International Conference on AIDS in Stockholm Jonathan M. Mann, the director of the World Health Organisation’s Global Programme on AIDS, presented a talk entitled “The Global Picture of AIDS”. This talk was an effort to look back on the pandemic’s brief history and set out a trajectory for the years ahead. Significantly, at that time, women as a group vulnerable to HIV infection were virtually invisible in the HIV/AIDS pandemic. To the extent that women were included, they were included as transmitters of virus, as prostitutes and mothers transmitting the virus to their clients and children. It was only at the beginning of the 1990s, that women became recognised as a vulnerable group at high risk of HIV infection and could slowly come to be included in global health discourse on HIV prevention. I suggest that the concept of ‘empowerment’ functioned as a vehicle for women’s inclusion into global HIV prevention discourse.

In the early 1990s, coinciding with the time women entered global HIV discourse, two large scale events, namely the International Conference on Population and Development in Cairo in 1994 and the Fourth World Conference on Women in Beijing in 1995, set the stage for the intimate relation between women’s health and women’s empowerment.

Women’s empowerment became a central issue in Cairo as for instance the report on this conference states that “[t]he empowerment of women and the improvement of their political, social, economic and health status are highly important ends in themselves. We further believe that human development cannot be sustained unless women are guaranteed equal rights and equal status with men.” (United Nations Population Information Network and UN Population Fund 1994: paragraph 7). Furthermore, during this time women’s health was a main feature at the World Conference on Women: “Women have the right to the enjoyment of the highest attainable standard of physical and mental health (...) Women’s health involves their emotional, social and physical well-being and is determined by the social, political and economic context of their lives, as well as by biology.” (UN 1995: 39) In other words, the concept of women’s empowerment started entering the sphere of global health.

During this time, the idea of a vaginal microbicide came to the fore. I will contextualise the emergence of microbicide development efforts more specifically, by briefly exploring three main documents provided by the World Health Organisation in the early 1990s. Firstly, a report of the meeting on research priorities relating to women and HIV/AIDS held in Geneva, November 1990; secondly, the 1992 Global AIDS Strategy; and thirdly Women and AIDS: Agenda for Action which was drafted in 1994.

From the very beginning of women’s inclusion in WHO’s engagement with the HIV pandemic, empowerment increasingly emerged as a central theme. In the 1990 meeting, a

discourse on women’s empowerment surfaced as the transformation of those socioeconomic circumstances hindering risk-reducing behaviour, as it explicates:



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