Geographies of gender and sexuality II: Charting scholarship on health

Abstract

Health has become a key focus for scholarship within the geographies of gender and sexualities. This progress report offers a schematic overview of the multiple ways in which the study of health (and especially disease and the lack of good health) has been studied in relation to such geographies. It explores the multiple ways in which an understanding of place has been operationalised, considers the potential importance still for large-scale quantitative studies, and highlights the importance of studies of health for broader debates and interests within the discipline. This progress report then concludes with some questions for future scholarship.

Keywords

epidemiology gender health place sexuality

I Introduction

The importance of research regarding the links between health, gender, and sexuality would appear to be both self-evident and vital. After all it is well understood that certain groups with same-sex desire are often at increased risk of various health-related concerns, including sexually transmitted infections especially among men – a topic that has remained relatively dominant in the field (Brown 1995, 1997; Brown and Di Feliciantonio 2022; Brown and Knopp 2010, 2014; Catungal et al., 2021, 2023; Kearns 2016; McKinnon et al., 2017; Myers 2010; Tucker 2020; Wilton 1996). Furthermore, it is understood that health concerns related closely to place-specific and yet complex, intersectional, and varied experiences of homoprejudice and gender-based violence and injustice remain a key set of challenges to overcome across the life-course (Datta 2016; Davies et al., 2018; Dyck 2003; Fluri and Piedalue 2017; Lewis 2009, 2014; Mkhize and Maharaj 2021; Sothern and Dyck, 2010; Sweet and Ortiz Escalante 2015). Equally, while as Johnston (2019) describes relatively much more work still needs to be conducted with trans people regarding their lives, scholarship is starting to explore the complex relationships between trans people and health, including in terms of healthcare access and transphobic experiences in healthcare spaces (Bauer et al., 2009) and far beyond (Todd 2021, 2023).

Yet while we can appreciate why we would want to draw connections between the study of gender and sexuality with that of health, the actual ways in which such connections have been considered by geographers and allied scholars show significant variety. The aim of this progress report is to explore and summarise some of the key yet different approaches taken in relation to the study of health and specifically in relation to instances of a lack of good health, via disease or forms of discrimination and inequality. Inevitably, therefore, a report focused on summarising some of the key different approaches taken by geographers remains an illustrative one in terms of the particular case studies or groups under study. Nevertheless, such a strategy hopefully proves useful to scholars who wish to understand some of the very different ways in which health has increasingly – and differentially – proved a driving imperative for geographies of gender and sexuality.

This report starts by exploring a key distinction within health scholarship, namely, that between medical geography and health geography. While the shift from medical geography towards health geography is well known within health scholarship, this progress report schematises how the shift has involved at least three interlinked approaches to the study of place in terms of gender and sexuality. It also considers how medical geography approaches may still have utility today, despite gender and sexualities scholars’ primary focus on health geography frameworks and qualitative approaches over the past 30 years. By drawing on two recent examples, this progress report then acknowledges how we must also appreciate how scholarship on health by those interested in gender and sexuality can also offer important wider contributions to geographical and allied scholarship by furthering broader academic interests and debates. To conclude, this progress report briefly offers some questions for future scholarship.

II Medical geography and health geography

A key distinction within geographical scholarship with regard to health that emerged in the 1990s was between what was known as medical geography and what was to become health geography. As Del Casino Jr.’s (2009) expert summary of this distinction outlined, medical geography, understood as one of the oldest sub-fields of geography, had focused on topics such as the study of disease in terms of distribution and spatial diffusion and was heavily quantitative and positivist in nature. Medical geography, and closely associated fields such as epidemiology, therefore, often drew on biomedical definitions of health and illness to chart and quantify disease burden and spread (ibid.; Tucker 2016). Health geography, meanwhile, as a sub-field that emerged in the 1990s, became positioned in part as a critique of medical geography approaches with a focus on cultural, social, and place-specific geographies of health (see, for example, Kearns 1993, 1995; Kearns and Gesler 1998). Specifically, a focus on place rather than space (and spatial diffusion models) can thus be seen to have also drawn on wider debates within geography occurring at the time on the importance of place vis-à-vis space and the significance of place in terms of meaning and social relations (Agnew 2011).¹ This, in turn, enabled a more concerted consideration of questions of power, forms of injustice, and inequalities rooted in particular places and their relationships to questions of health (Tucker 2016).

For geographers working on gender and sexuality at the time of and after this debate, scholarship started to engage with and critically interrogate work that had overlooked or side-lined the socially mediated nature of disease and lack of good health together with the agency of different communities in the face of health challenges. Here work also at times questioned how medical knowledge went about supposedly unproblematically categorising those under study and putting forward a-contextual, health-related interventions. Collectively, we can appreciate at least three overlapping ways in which geographers and allied scholars have undertaken such work via deep explorations of the relationship between particular places and a lack of good health via disease or forms of discrimination and inequality. Such work has focused overwhelmingly on qualitative methodologies.

First, place has been framed as an important way of understanding differential risk of disease and poor health. Drawing inspiration from geographers such as Craddock (2000) and Wallace et al. (1999) work here has considered how particular environments and the social, political, cultural, and economic factors which intersect with them may result in particular individuals finding themselves at greater or lesser risk of contracting or passing on disease. Especially with relation to the HIV/AIDS pandemic, scholarship has explored, for example, the reasons why groups such as female sex workers in an impoverished mining town in South Africa may find themselves at risk of infection, despite being aware of the virus and its implications (Campbell 2003). Scholarship here highlighted how information dissemination by itself (a backbone at the time to HIV prevention work and health policy by medical professionals) was insufficient to effectively address the intersecting place-based factors that lead to particular types of ‘risky behaviour’. Instead, it becomes necessary to appreciate how consideration of HIV risk may be mediated by other pressing contextual concerns, such as economic insecurity and severely regressive patriarchy (ibid.) (see also Parker et al. (2017) and Lewis (2015) for related intersectional and contextual factors regarding HIV risk and health promotion among gay and other men who have sex with men in sites such as New York and the small city-region of Halifax, Nova Scotia).²

Second, place has also been central for studies which explored how health crises can relate to and increase sexuality and gender-based discrimination and violence. For example, in relation to the COVID pandemic, scholarship has explored how lockdowns could impose on especially young people domestic arrangements that were unsafe (Ashby et al., 2022). Particularly for trans and non-binary people, the inability to escape unsupportive domestic environments for any length of time could result not only in repeated deadnaming, but also the very real threat of physical violence (ibid.), a problem made worse by the erasure of trans people in social and healthcare settings (Bauer et al., 2009; Namaste 2000; Todd 2021). In the former townships of Cape Town meanwhile, Tucker (2009) explored how HIV stigma can interface with and help perpetuate severe sexuality-based stigma. This work not only highlights another example as to how a health crisis can help perpetuate sexuality-based discrimination in particular places, but also how extreme sexuality-based discrimination may further complexify simplistic HIV information dissemination policy approaches as a supposedly ‘effective’ method of HIV prevention put forward by medical professionals. Furthermore, Kearns (2016) has described how sexuality-based discrimination and homophobic stereotypes were deeply imbricated in supposedly ‘objective’ epidemiological scientific modelling of the HIV/AIDS pandemic during the 1980s, and how such supposedly scientific writing impacted devastatingly on emergent gay communities in sites across the US. In a complementary manner, Brown and Knopp (2010) have considered how, during World War II Seattle, sexed, gendered, raced, and classed bodies were (re)produced in particular places by public health authorities concerned with curtailing venereal diseases which relied in large part on discriminatory imaginaries but nevertheless legitimated forms of governmentality to manage both individuals and populations (see also Brown and Knopp 2014).

Third, place has been important to consider in attempts to address and overcome forms of stigma associated with disease and enable strategies at various scales to confront and navigate disease and poor health. Here, we can consider Michael Brown’s (1995) ground-breaking call to arms, which directly critiqued forms of scholarly inquiry that focused on ‘spatial science’ and epidemiological approaches to the study of HIV. As Brown points out, such as focus could side-lined community and individual agency to address the pandemic located in particular places (see also Brown 1997). Scholarship has therefore considered in depth the agentic abilities of communities to overcome stigma and the role of solidarity networks between groups such as gay men and lesbians to confront disease, together with their potential failures (see, for example, Catungal et al., 2021; Gieseking, 2020). Furthermore, recent scholarship has considered the strategies of individuals to minimise experiences of HIV stigma through migration to large capital cities, places that despite their rendering oftentimes as sites of homonormative exclusion may also offer the possibility of shared connection and inclusion (Di Feliciantonio, 2019). Equally we can consider scholarship on the body and forms of embodiment, for example, Moss and Dyck’s (2002) study of the particular challenges facing women with myalgic encephalomyelitis (ME) and rheumatoid arthritis (RA). This work not only outlines challenges facing women with chronic illness, but also the capacities of these women to exert their own strategies and multiple forms of resistance, reconfiguring physical and social spaces (see also Crooks and Chouinard 2006). For Dyck (2003), it is important to consider the implications of the diversity of ways in which women’s health and bodies are constructed, contested, and reproduced, and equally the diverse social and spatial strategies deployed by women to resist the devaluing of their position in society in relation to health. Echoing wider shifts away from medical geography towards health geography (Kearns 1993, 1995), such scholarship that highlights women’s agency with regard to health requires ‘talking to people, rather than about “dots on maps”…’ (Dyck 2003, 363 [emphasis in original]; see also Parr 2002).

Collectively, such work has allowed us to appreciate the need to consider how individuals and communities engage with risk and disease, how health crises may accentuate other forms of risk and vulnerability, and how individuals and communities respond to various forms of stigma associated with disease and lack of good health. Yet such work should not be taken as a signal that more quantitative and indeed perhaps more ‘traditionally’ medical geography approaches should necessarily in all cases be abandoned. Indeed Michael Brown, who can be seen to have initially helped lead the charge for those interested in gender and sexuality to critically interrogate medical geography in relation to HIV/AIDS and gay men, has distanced himself from any reading of his work which completely dismisses quantitative approaches (Brown 2009). As Brown explains, qualitative and ethnographic work by itself is unlikely to be used to leverage large-scale funding. And funding, especially that which originates from international and governmental agencies, it can be argued here, is more likely to be provided if policy and governance officials are persuaded by particular types of evidence rather than others. In other words, there remains a place for quantitative studies which align more closely to those of some of the core tenets of medical geography.

For example, work over the past decade and a half in relation to HIV/AIDS, by geographers and especially allied scholars, has provided information for policy and government officials on the relationship between marginalised communities and the pandemic at sites across the global South, where the brunt of the pandemic is still felt. While it has long been known that the pandemic remains a significant public health emergency in countries in regions such as sub-Saharan Africa, the impact of the pandemic on groups such as the epidemiological category ‘men who have sex with men’ (MSM) has historically been scant (Beyrer 2008). Indeed, despite what would become known as HIV/AIDS being first observed in West Africa in the early 1980s (Iliffe 2006), over 20 years later scholars were stating with a worrying degree of surprise that ‘Africans, like people from the rest of the world, apparently have significant experience with homosexual and heterosexual anal intercourse’ (Brody and Potterat, 2003, 434). Research by Arnold et al. (2013), Baral et al. (2009), Lane et al. (2011), and Tucker et al. (2013), among others, was therefore some of the first to explore via large-scale public health quantitative surveys HIV prevalence among MSM in the region and risk factors associated with an HIV positive status, together with factors associated with sexual risk taking such as sexuality-based discrimination. Along a parallel trajectory, Jobson et al. (2018) and Rwema et al. (2020), among others, have explored how trans women, who have also remained largely invisible in health policy in the region, are also at increased risk of HIV infection, and the reasons why. Collectively, this work was able to motivate to international funding agencies as to why HIV prevention, treatment, and care initiatives should be focused on groups such as MSM and trans women across countries in sub-Saharan Africa.

More recently, and in the very different context of Monkeypox in the UK, Gavin Brown (2023) has also called for the need for greater spatial modelling and quantitative data to help explicate where those at risk live, where they travel so as to interact with each other, and where they access health services to better target services at those most in need. For Brown, geographers have a key role to play here, to better understand and help support health initiatives by charting and modelling the spatial and cultural dynamics and socio-sexual networks of gay and bisexual men. As such, we may wish to argue that in certain instances (and most clearly those where there exists limited large-scale information on marginalised communities), quantitative and epidemiological approaches may indeed still have vital utility (see also Rosenberg 2016).

In summary, this discussion has highlighted how very different approaches have been deployed by scholars interested in gender and sexuality at different moments regarding health. One body of scholarship, that emerged from the development of heath geography in the 1990s, has focused very much on understanding the overlapping relationships between place, human agency, discrimination, community responses to disease and poor health, and at times a critical interrogation of assumptions of medical science and policy. Another body of scholarship, centred around medical geography and epidemiology, while emerging from a far longer academic genealogy, was for a period viewed at best suspiciously by certain scholars working on gender and especially sexuality. Nevertheless, as this section has hopefully shown, if carefully implemented, there can remain utility to both bodies of scholarship in the present moment.

III Health scholarship as entryways to other geographical interests

Just as gender and sexuality scholarship on health was informed by wider shifts within geography in the 1990s regarding space and place, so too can we appreciate instances where scholarship on health in relation to gender and sexuality directly contributes to current wider interests and debates in the discipline. While many of the examples outlined in the previous section can be seen, in various key ways, to have done this too, presented here are two very recent examples, one in terms of giving space to alternative ways of knowing and one in terms of connections between subdisciplines.

In terms of the first example, scholarship by Brown and Di Feliciantonio (2022) has considered how elements of Foucauldian theorising, so central to much work on the geographies of gender and (especially) sexualities, can be augmented so as to allow us to consider the implications of new biomedical technologies more fully for groups such as gay men. While Foucault’s work has been especially important to understand the historical and contextual medicalisation and regulation of sexuality and associated biopolitical implications, Brown and Di Feliciantonio (2022) suggest that such theorising is insufficient on its own to understand the multifaceted ways in which new biomedical technologies function for individual bodies and communities who use them. Specifically, regarding the development of a daily regimen of Pre-Exposure Prophylaxis or ‘PrEP’³ that drastically reduces the risks of contracting HIV without the need for condoms, scholarship has considered how PrEP operates as an evolution of biopolitical regulation; as part of a ‘pharmacopower’ regime where the regulation, governance, and subjectification of the body is extended to the new pharmaceutical substances bodies ingest (Dean 2015; see also Preciado 2013). As a result, PrEP can be seen as part of a long line of neoliberal health interventions alongside other HIV medications (previously used to treat those with HIV, rather than prevent contracting HIV) where HIV care and responsibility remains devolved to the level of the individual (see, for example, Sandset 2019). For Brown and Di Feliciantonio (2022) however, PrEP can also be viewed as part of a wider socio-technical assemblage. Here focus shifts to encompass a study as to how new sexual cultures are developing because of PrEP and how PrEP therefore relates to questions of desire, pleasure and sex acts, the role of digital technologies (such as dating apps), and the reconfiguring of traditionally defined overtly visible ‘gay spaces’ or ‘gay villages’ to also include less visible suburban and private homes where these new sexual cultures may be emerging. Such work can be seen to add productively to other emergent scholarship on sexuality and assemblages such as that by Nash and Gorman-Murray (2017) together with broader work on assemblages thinking within geography.

In terms of the second example, we can also see how questions related to health can also speak to geopolitical concerns within geography. By reviewing US foreign policy from the end of the Cold War to the present, Kearns and Tucker (2023) argue that the US has been engaged in a form of ‘unipolar colonialism’ with regard to its HIV funding, most directly through the US President’s Emergency Plan for AIDS Relief (PEPFAR) – the largest single country health intervention in history prior to COVID. As they argue, via PEPFAR, the US has intervened in states it defines as failing their citizens, bypassing national governments and rearranging social and economic relations based on a particular subset of American national values. While there already exist a body of work which has explored health (and HIV in particular) in relation to geopolitics (see, for example, Elbe 2005; Ingram 2005), Kearns and Tucker (2023) extend such work to consider how a particular subset of US national values, defined in large part by the Christian right, was able to effectively downplay the importance of human rights for those at risk of infection. Such as strategy has directly and negatively impacted PEPFAR’s work for groups such as sex workers and gay men. For female sex workers, especially during the early years of PEPFAR that were heavily shaped by right-wing religious groups in the US, PEPFAR was explicitly barred by Congress from distributing funds that could be spent by any organisation that did not ‘explicitly oppose prostitution’. Ignoring overwhelming evidence at the time (including that of the World Health Organisation) that addressing HIV among female sex workers required empathy and the avoidance of discrimination, the US moved away from science towards what Kearns and Tucker see as a particular rendering of religious beliefs as its guiding principle for disbursement of PEPFAR funds (ibid.). In Uganda today – a country that remains a key recipient of US and other foreign aid – the religious right in the country has spent over a decade successfully getting codified into law life sentences for gay male sex and the death penalty for ‘aggravated homosexuality’ (which includes one partner having HIV – irrespective of any form of prophylaxis being used). Left open to consider is how a health programme such as PEPFAR, with its own religious history and relative sidestepping of the importance of human rights-based agendas, may have helped inform the situation facing gay groups in Uganda today. Such work may be seen to add to that which has critically engaged with the geopolitical power of the US, its ‘logics’, and the harms that can result (see, for example, Gregory 2004; Puar 2007).

IV Conclusion – Some questions for future scholarship

The aim of this progress report has been to provide a broad overview of the ways in which geographers and allied scholars interested in gender and sexuality have engaged in remarkably different ways with questions of health and, in the main, factors related to a lack of good health. As mentioned in the introduction, the examples that have been provided here to help tell a story of these different approaches remain partial and it would be remiss not to acknowledge that the application and configuration of other case examples may lead to other stories of the histories and current applications of health research related to gender and sexuality. Nevertheless, the very fact that there can exist different stories to tell is also an indication of the richness of work that now exists. Yet an acknowledgement of such richness also allows for the posing of two further questions, briefly outlined here.

First, an element that connects all the above highlighted scholarship is the differential health experiences for groups due to forms of and varying levels of discrimination and inequality requiring particular differentiated responses. A question to consider for future scholarship may be the degree to which there may be utility in exploring more forcibly topics that remain important for geographical health scholarship more broadly. While, as outlined above, there do exist examples of such work, there may remain many other health concerns that so far have received relatively little attention from a gender and sexuality perspective. For example, burgeoning work on non-communicable diseases, often tied to a lack of food and nutrition security, while of emerging key importance in scholarly and policy arenas could be more directly considered in terms of pre-existing forms of gender and sexuality-based discrimination and inequality.

Second, left to consider is the degree to which there is utility in exploring and framing health concerns related to gender and sexuality in relation to North/South divides. We may wish to appreciate the potential importance of such divides both in terms of different experiences of individuals and groups across these divides and in terms of the potential connections and shared experiences or forms of solidarity across these divides. While effort has been made in this progress report to include scholarship that has engaged with the global South, it does remain the case that most work on gender and (especially) sexuality by geographers remains rooted in the global North. The same can be said to apply for such scholarship on health.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Andrew Tucker

Notes

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