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Article

HIV Law and Policy in the United States: A Tipping Point  

Scott Skinner-Thompson

The fight to effectively treat and stop the spread of the human immunodeficiency virus (HIV) has made meaningful progress both in the United States and globally. But within the United States that progress has been uneven across various demographic groups and geographic areas, and has plateaued. While scientific advances have led to the development of medicine capable of both treating and preventing HIV, law and policy dictate who will have ready access to these medicines and other prevention techniques, and who will not. Law and policy also play a crucial role in determining whether HIV will be stigmatized, discouraging people from being tested and treated, or will be identified for what it is—a preventable and treatable disease. To make further progress against HIV, the United States must address healthcare disparities, end the criminalization of HIV, and devote additional resources toward combatting HIV stigma and discrimination.

Article

HIV/AIDS Politics and Policy in South Asia  

Nayani Rajapaksha and Chrishantha Abeysena

Human immunodeficiency virus (HIV) is a major global public health issue. In 2019, an estimated 38 million people worldwide were living with HIV. Of these, 2–3 million HIV cases were estimated to be in the South Asia region. In South Asia, India has the largest population (1.366 billion), whereas the Maldives has the smallest (0.54 million) population. In line with global strategies, most of the countries adapt strategies to end HIV in 2030. The rights-based approach is a guiding principle of HIV policy in most countries. Integrated HIV testing and counseling services are implemented through facility-based and community-based services. The percentage of people who are on Anti-Retroviral Treatment among the diagnosed, is highest (81%) in Nepal. The Maldives and Sri Lanka achieved elimination of mother-to-child transmission of HIV in 2019. Coverage for preventive programs is low in all the countries. Condom usage is low in all the key population groups in the region except India, Nepal, and Sri Lanka. Sex education is integrated into the school curriculum in Nepal and Sri Lanka. Knowledge of HIV prevention among the young population is low in all the countries. India, Nepal, and Pakistan provide both needle and syringe programs and opioid substitution therapy. A high percentage of people who are injecting drug users (IDUs) have safe injecting practices in all the countries. The prevalence of HIV is low in all the countries, but concentrated epidemics continue in some countries. A higher prevalence of HIV is reported among IDUs in all the countries except Bhutan. The prevalence of HIV is also higher among transgender people in Nepal and Pakistan. Since 2010, a declining trend in new HIV infections has been observed in Bhutan, India, Nepal, and Sri Lanka, and an increasing trend has been observed in Afghanistan, Bangladesh, and Pakistan. Some South Asian countries have many punitive laws, while others have introduced legal protection for key populations. Sex work is criminalized in all the countries. In Bhutan, when men who have sex with men and IDUs seek health services, the health worker is obliged to report them to the police. Nepal became the first South Asian country to identify the existence of “sexual and gender minorities” in its constitution. There is a protective legal environment for homosexuality in Nepal. India also has several laws protecting homosexuals, transgender people, and IDUs, and laws against sexual harassment in the workplace. India has become the first South Asian country to implement special protective laws on HIV/AIDS. India has criminalized discrimination against people living with HIV/AIDS. The presence of stigma and discrimination is a major critical factor for the national approach to HIV prevention in all South Asian countries. Stigma and discrimination are observed in healthcare facilities, within families, in employment, and in educational institutions, and many countries have developed antidiscrimination policies in response. Throughout the region, poverty, low literacy, outbound migration, tourism, internal displacement, disasters, poor infrastructure of healthcare systems, population size, and social and cultural values have hampered the response to HIV.

Article

Transgender-Specific Policy: Gender Identity Inclusion in Public Accommodations  

Andrew R. Flores and Justin O'Neill

In the early 21st century the public debates about the inclusion of gender identity in public accommodations municipal ordinances and statewide and national laws represent another step in the ongoing struggle of the social movement seeking to advance the rights and liberties of lesbians, gay men, bisexual, transgender, and other queer (LGBTQ) people. Situating these current debates in the larger context of the LGBTQ movement connects this emergent issue to that broader struggle. The LGBTQ social movement and its counter-movement, often referred to as the Religious Right, have had numerous battles over social policy since the late 20th century. Importantly, movements and their counter-movements identify winning strategies and, at times, tactically innovate so as to effect a shift in current tactics in light of a failing strategy. Tactical innovation includes shifting policy debates, which has been a primary tactic of the counter-movement to LGBTQ rights. Transgender rights broadly and public accommodations policies specifically represent a tactical innovation in the ongoing development of LGBTQ rights in the United States. How has gender identity inclusion in public accommodations been addressed in politics, policy, and law? There are numerous dimensions of gender identity public accommodations policies as understood in social movements, American law, public policy and administration, public opinion, and sociology and social psychology. Public accommodations are a constant source of public contention. The legal landscape in constitutional, federal, state, and municipal approaches to these policies remains uncertain, and there are competing interpretations of law in whether gender identity protections are covered in existing federal statutes. The rhetoric of the policy debates in both state legislatures and initiative and referendum campaigns primarily focuses on the potential harms to women and girls brought about by men taking advantage of such laws to assault them in sex-segregated public facilities. An account of public opinion about these policies also shows that American adults are far more divided about transgender people using restrooms consistent with their current gender identity than other aspects of transgender rights such as employment nondiscrimination policies. Experimental interventions, such as in-depth conversations encouraging people to consider the day in the life of a transgender person, reduce transphobia and make people more resistant to arguments opposed to the inclusion of gender identity in public accommodations laws. Finally, some have questioned whether sex classifications are needed in public policy and how current nondiscrimination laws achieve their stated goals without such a system. Further development and inquiry absolutely are needed in all these areas.

Article

Public School Policies: Discrimination, Harassment, Bullying, and Accommodations  

Sean Cahill

Discrimination, harassment, and bullying against lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) youth are a major concern. Research shows that such victimization starts early, occurring in elementary schools. Given the central role social media play in the lives of youth, cyberbullying is an increasing concern. Victimization also takes the form of sexual harassment. Anti-LGBTQ victimization can cause youth to distance themselves from the school environment both physically and emotionally, skipping school or dropping out entirely. Fighting back against victimization and other factors, such as family rejection, homelessness, and survival crimes such as shoplifting, can cause LGBTQ youth to become involved with the juvenile justice system at higher rates than their heterosexual and cisgender peers. Research also shows that victimization correlates with greater behavioral health burden, including substance use disparities, suicidal ideation, depression, self-esteem, and social integration. LGBTQ youth are more likely to feel unsafe at school, get in a fight at school, and carry a weapon to school. Victimization also negatively correlates with academic performance, and hopes and aspirations for the future, such as plans to attend college. There is limited research on the disproportionate racial/ethnic impacts of these phenomena. A number of school-based programs and policies, and public policy interventions, have been initiated to ensure equal access to public education for LGBTQ youth. These include teacher and staff training, safe school programs, gay-straight alliances, and LGBT-focused schools. Policy interventions include nondiscrimination laws and regulations at the local and state level, interpretation of federal sex discrimination laws to encompass and prohibit some forms of anti-LGBT discrimination and harassment, and Congressional bills which would outlaw sexual orientation and gender identity discrimination in public schools. Some state and federal laws, such as parental rights provisions and abstinence-only laws, inhibit educators’ and administrators’ ability promote tolerance and acceptance of LGBT youth and promote sexual health and reduce HIV/sexually transmitted infection risk. There are a number of gaps in the research on LGBT-related school policies, including how to engender better parent–child communication about LGBT identity development and sexual health and how to measure sexual behavior in an increasingly nonbinary world.

Article

HIV/AIDS Politics and Policy in Sub-Saharan Africa  

Catherine van de Ruit

Sub-Saharan Africa has the world largest proportion of adults and children living with AIDS. To mitigate the multiple consequences of the epidemic, novel forms of governance arose as international organizations usurped the roles traditionally played by states; new funding streams emerged that led to asymmetries in biomedical resource allocation; and diverse partnerships among international agencies, nation-states, and local and international nongovernmental organizations emerged. Global health actors attempted to define AIDS policy and programming as an apolitical biomedical intervention. However, political dynamics were evident in the negotiations between international donors and African state bureaucracies in setting AIDS policy agendas and the contestations between African and international social movements and global health agencies over AIDS treatment drug prices and access to treatment interventions across the continent. During the first two decades of the African AIDS epidemic (1980–2005) the dominant approach to AIDS disease mitigation was the focus on AIDS prevention, and across sub-Saharan Africa standardized prevention interventions were introduced. These interventions were founded upon limited evidence and ultimately these programs failed to stem rates of new HIV infections. Social movements comprising coalitions of local and international activists and scientists brought extensive pressure on global health institutions and nation-states to reform their approach to AIDS and introduce antiretroviral therapy. Yet the path toward universal provision of antiretroviral treatment has been slow and politically contentious. By the second decade of the 21st century, antiretroviral therapy interventions together with AIDS prevention became the dominant policy approach. The introduction of these initiatives led to a significant decline in AIDS-related mortality and slowed rates of transmission. However, health disparities in treatment access remain, highlighting ongoing shortcomings in the political strategies of global health agencies and the public health bureaucracies of African states.

Article

Executives, Executive Politics, and the LGBTQ Community  

Mitchell Dylan Sellers

Executives in the United States influence politics and policies involving the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community. While this is more of a modern phenomenon, presidents and governors actively shape politics that directly influence the community. This allows executives to set the tone of discourse and the eventual result of LGBTQ politics. Most presidents in modern times shaped debate surrounding LGBTQ rights in a positive light, but President Trump’s tone and policies go against recent trends. Executives on every level of government can shape, and have shaped, LGBTQ politics using formal powers, such as executive orders, administrative orders, directives, memorandums, and councils. The various executive documents allow executives to directly set policy through orders or to provide guiding philosophy for how policy should operate. Councils and advisory boards inform executives by providing expertise that executives need to create sound policy. Executives rely on each of the policymaking tools to varying degrees, but all presidents and governors have the ability to use the powers. One often ignored way executives influence policy is by setting the agenda by “going public” to bring the issue to everyday citizens. Executives have shaped many policies that directly affect the LGBTQ community, but three policy areas deserve special focus: the ban on gay and transgender service members in the military, the HIV/AIDS epidemic, and nondiscrimination protections. In each of these cases, multiple executives have stepped in to shape policy and enforcement of regulations. In some cases, this is for the better. For instance, nondiscrimination policies came about in many states using gubernatorial executive orders. In other situations, executive action, or inaction, worked to the detriment of LGBTQ individuals, such as the failure of the Reagan administration to respond to the HIV/AIDS crisis. Executives have influenced policy and implementation of policies since the 1970s. This influence is likely to continue for decades to come, not just with these issues, but in many policy areas that affect the lives of LGBTQ individuals.

Article

The Special Role of Religion in LGBT-Related Attitudes  

Abigail Vegter and Donald P. Haider-Markel

Religious tradition and religiosity affect attitudes toward LGBT people, their rights, and their position within religious communities. There is significant variability within the American context concerning how religious traditions approach issues related to sexuality and gender identity, with monotheistic religions holding more conservative positions. These positions and the elites who hold them often influence the attitudes of their congregants, but not always, as some congregations diverge from the official positions of their denominations in terms of attitudes toward LGBT rights, religious leadership, and congregational membership. As the religious landscape is consistently changing in terms of attitudes toward sexual minorities, understanding the special role of religion in LGBT-related attitudes remains important and an area ripe for future scholarship.

Article

HIV/AIDS Politics and Policy in Eastern Europe and Central Asia  

Ulla Pape

Eastern Europe and Central Asia (EECA) is the only region in the world where annual HIV infection rates continue to grow. According to the Joint United Nations Program on HIV/AIDS (UNAIDS), in 2019 approximately 1.4 million people in the region were living with HIV. The main factors that have contributed to the spread of the epidemic over the past two decades include injecting drug use, the stigmatization and marginalization of vulnerable groups, the increasing spread of HIV into the general population, and the lack of evidence-based prevention and treatment programs necessary for controlling the epidemic. Limited access to life-saving antiretroviral treatment has intensified the impact of the epidemic in EECA and increased mortality rates among people living with HIV (PLWH). In the post-Soviet space, Russia is experiencing by far the biggest HIV/AIDS epidemic. This can be attributed largely to the government’s failure to introduce evidence-based prevention measures for vulnerable groups, e.g., harm reduction programs, which are recommended by international health organizations. Other countries in the region have been more pragmatic in their approach and introduced harm reductions programs on a broader scale. In Ukraine, the efforts to combat HIV, which led to an initial stabilization of the epidemic in 2012, have been endangered by the military conflict in the eastern part of the country and subsequent internal displacement, which has increased HIV vulnerability. In comparison with Russia and Ukraine, the countries of the South Caucasus and Central Asia are less affected by HIV. However, labor migration to Russia constitutes a persistent risk factor for HIV transmission from higher-prevalence Russia to lower-prevalence South Caucasus and Central Asia. Although initially the HIV/AIDS epidemic has been mainly driven by injecting drug use, it is also clearly linked to lesbian, gay, bisexual, and transgender (LGBT) politics and policies in EECA. Because of widespread stigmatization and marginalization, the spread of HIV within LGBT communities remains underreported and is barely visible in official HIV statistics. This makes it difficult for prevention programs to reach out to vulnerable groups. In all countries in the region, prevention efforts among LGBT communities remain inadequate and largely depend on local civil society organizations (CSOs), which lack the capacities to provide nationwide information campaigns and other prevention programs for the LGBT community. In addition, the work of CSOs that advocate for HIV prevention among LGBT groups is further undermined by repressive laws, e.g., the 2013 “gay propaganda law” in Russia, which has increased the stigmatization of LGBT people and has made prevention outreach more difficult. Research has contributed to our understanding of HIV vulnerability and its impact in EECA. Further research is needed, however, into the social and political factors that explain the persistent failure of regional decisionmakers to adequately address the growing HIV epidemic.

Article

U.S. Military Service and LGBT Policy  

Marissa Reilly, Elizabeth L. Hillman, and Elliot Koltnow

Examining the evolution of U.S military policy reveals how debates about the rights and opportunities of lesbian, gay, bisexual, and transgender (LGBT) people have been shaped by military personnel policies, federal laws, and cultural practices within military units. LGBT individuals have experienced U.S. military service through regulatory regimes that have often defined them as burdensome deviants and denied them civil rights enjoyed by other service members. LGBT people have served as volunteers and conscripts, openly and in the closet. Key periods of U.S. military history for LGBT service include World War II, the Cold War, as well as the Vietnam War era, the “Don’t Ask, Don’t Tell” (DADT) regime (1994–2010), and the post-DADT period (2011 and beyond). During these periods of time, the armed forces and the United States reassessed the regulation of the service of LGBT service members and implemented changes that affected the rights, opportunities, and safety of LGBT military personnel and potential recruits. Those changes traced a path from outright exclusion of open service by LGBT persons to exemption, under which LGBT persons may serve under certain conditions, which often included the threat of expulsion, punishment, and extra-legal violence. In the post-DADT period, inclusion, or open service by some, but not all, LGBT groups, was made legal and safer through changes in law and military regulations and training that protected against some types of gender-identity and sexual orientation discrimination. Because serving openly in the military is a sign of full citizenship in the United States as well as a means of achieving economic security, eliminating limits on LGBT military service has long been a focus of advocates for civil rights. Military service has been perceived as proving a citizen’s loyalty and patriotism as well as offering material and social advancement. With many LGBT people at greater risk of unemployment, homelessness, and premature death as a result of violence and social ostracism, military service has been an especially critical opportunity for political and economic advancement. Honoring this history and identifying existing trends can help the United States, other nations, and international organizations to adapt their policies in recognition of gender and sexual diversity. Even when excluded by formal policy, people have found ways to serve, sometimes at great personal risk. Although their labor is officially lauded as an asset, their contributions and needs have not been fully recognized or appreciated by the state they pledged to serve. As the nation’s largest employer and provider of structural resources, the U.S. military’s support of LGBT military personnel and veterans matters greatly to social equity for a still-vulnerable LGBT population.

Article

Marriage Equality Policy Diffusion  

Helma G. E. de Vries-Jordan

Marriage equality movements have been successful in achieving policy change in an increasing number of states. Hence, a growing body of scholarship has explored institutional and cultural factors that influence activists’ tactics and messaging and, in turn, contribute to marriage equality policy diffusion. Democracies with parliamentary, presidential, and semi-presidential systems, federal and unitary states with varying levels of centralization, and the presence or absence of constitutional anti-discrimination protections provide social movements with divergent political opportunity structures, contributing to dynamics in their tactical choices. In addition, the type of electoral system and party system, the presence of political parties that are movement allies, the use of conscience votes, the level of party discipline, the presence of out LGBT elected officials and straight political allies, and the degree of political will to enact policy change also impact activists’ strategic calculations. Finally, the use of personalized narratives in advocates’ messaging, the framing of marriage equality and LGBT rights as human rights norms, the adoption of family values frames to coopt opponents’ messaging, and the use of homonationalist versus homophobic discourses to justify policymaking decisions regarding same-sex marriage are explored. This article provides a comprehensive review of state-of-the-art research concerning all of the states that have legalized same-sex marriage as well as a detailed analysis of the mechanisms used to achieve policy change. After examining how different explanatory factors perform in accounting for the dynamics in marriage equality activism and policy convergence across a broad range of national contexts, new directions for future scholarship are suggested.

Article

Sex Reclassification for Trans and Gender-Nonconforming People: From the Medicalized Body to the Privatized Self  

Ido Katri

Sex reclassification is a core issue of gender nonconforming legal engagements. Access to proper identification documents for trans and nonbinary people relates to lower levels of exposure to anti-trans violence, discrimination, and suicidality. In the first decades of the 21st century, the majority of global jurisdictions have seen some kind of reform with respect to sex reclassification. Nonbinary classifications, such as the X marker, are also becoming available for those who wish not to be classified as either M or F. Across the globe, five major policy streams can be found: total ban on reclassification, that is, having no law or policy in place that allows for reclassification; reproduction-related prerequisite, that is, requiring applicants to undergo sterilization or genital-related surgery; other medical intervention-based schemes, that is, requiring applicants to provide proof that they have modified their body using some kind of gender-related medical technology; corroboration requirements, that is, requiring that a third party, usually a medical professional, corroborates the identity of the applicant; and the emerging “gold standard,” gender self-determination, that is, laws and policies requiring only an expression of a desire or need to be reclassified. These streams of policy provide varying levels of access to proper identification documents and place different burdens on applicants, some requiring bodily modifications while others rely on autonomous will. Yet all these policies still demand an alignment between the internal truth of the body and external facts, resonating with the logic of birth assignment of sex itself—that is, the idea that the allocation of differentiated legal status of M or F reflects an immutable truth about legal subjects. Current laws and policies fail to address harms caused to gender nonconforming people by state mechanisms themselves. They only provide remedies ex post facto. In the early 21st century, all countries assign a differentiated legal status of either M or F at birth based solely, in almost all cases, on external genitals of newborns. This differentiated legal status is recorded on the birth certificate and becomes a part of one’s legal identity for life. This allocation of status reflects the idea that external genitals of newborns are proof of their owners’ future roles as men or women, that is, an idea that there is a pre-legal alignment between certain bodily configurations, social role, and gender performance. This mundane administrative mechanism not only justifies different treatment for men and women but also marks trans and nonbinary people as others. In order to better address the harm caused by systems of gendered distribution of resources and opportunities, there is a need to go beyond sex reclassification to question birth assignment itself.

Article

LGBT Military Service Policies in the United States  

Andrew Goodhart and Jami K. Taylor

For most of its history, the U.S. military has maintained a policy of exclusion toward lesbian, gay, bisexual, and transgender (LGBT) people serving in uniform. The justifications for these exclusions have included the view that being homosexual or transgender is a psychological disorder, that it undermines military morale and effectiveness, and a fear that LGBT people would be vulnerable to foreign espionage. Explicit policies banning consensual homosexual sex—and excluding from service those who engage in it—date to the period between World Wars I and II, but de facto efforts at exclusion have existed since the early days of the republic. Regulations governing homosexuals in the military came under pressure in the 1970s and 1980s as societal views toward lesbian, gay, and bisexual (LGB) people changed, and those LGB service members discharged under the policy increasingly challenged their treatment in court. (Public pressure to change regulations governing transgender people in the military arose mostly in the 2000s, though litigation efforts date to the 1970s.) In addition to general shifts in public and legal opinion, the debate over LGB people serving in the U.S. military was affected by the experience of foreign militaries that allow LGB people to serve. United States law began to loosen formal restrictions on LBG people serving in uniform with the passage of “Don’t Ask, Don’t Tell” (DADT) in 1994, but it still required LGB people to serve in secret. Changing public perceptions of LGB people and problems implementing the ban galvanized support for eliminating such restrictions. In 2010, President Obama signed legislation repealing DADT and removing all restrictions on LGB people serving in the military. However, transgender people do not enjoy the same rights. The Trump administration has revised Obama-era rules on transgender service members to enable greater exclusion. The issue is being contested in the courts and appears ripe for further political and legal dispute.