The pharmaceuticalization of sexual risk: Vaccine development and the new politics of cancer prevention
Introduction
Two sets of preventive "cancer vaccines" are currently on the medical marketplace: vaccines targeting the hepatitis B virus (HBV) to prevent a common form of liver cancer and vaccines targeting human papillomavirus (HPV) to prevent cervical and other HPV-related cancers. These interventions targeting the HBV and HPV viruses constitute part of a body of scientific work in recent decades that has established causal connections between various infectious agents-which are transmissible person-to-person, including through sexual contact-and the subsequent onset of specific cancers. Several additional viruses that can be transmitted sexually and are causally linked to cancer, but that so far are not preventable by vaccines, include hepatitis C, human herpesvirus type 8, human T-cell lymphotrophic virus type 1, and Epstein-Barr virus. Together with HBV and HPV, research on these viruses references an expanding approach to apprehending cancer that focuses attention simultaneously "inward" toward the molecular level of the agents causally linked to cancers and "outward" toward the worlds of sexual practices, cultures, and identities that may be causally connected to the risk of infection. This new way of conceiving of cancer as linked to sexual transmitted infections (commonly termed STIs) straddles the conventional explanatory divide between biological/endogenous and social/environmental causes of cancer, shaping both knowledge about cancer and approaches to cancer prevention.
By juxtaposing the cases of HBV and HPV and their preventive vaccines, we seek to analyze how this new way of knowing and doing cancer prevention contributes to what sociologists term "pharmaceuticalization" (Abraham, 2010a, Abraham, 2010b, Busfield, 2006, Conrad, 2005, Williams et al., 2011) and anthropologists describe as a "pharmaceuticalization of public health" (Biehl, 2006, Biehl, 2008, Petryna, 2006, Whitemarsh, 2008) while simultaneously "sexualizing" the field of cancer prevention. Pharmaceuticalization refers to biomedical processes by which social, behavioral, or bodily conditions are defined and deemed to be in need of treatment with pharmaceuticals (Abraham, 2010a). In examining the global, political dimensions of health and illness, pharmaceuticalization reveals the ways various institutions, including the pharmaceutical industry, NGOs, and state and local actors, cooperate or collide to transform the right to health into the right to treatment (including prevention) with pharmaceuticals (Biehl, 2006). This pharmaceuticalization of public health variously produces and reflects an uneven distribution of not only pharmaceutical drugs and devices, but also health and illness among and within groups and regions. We conceptually conjoin pharmaceuticalization with processes of sexualization to understand how ideas about sexual transmission, sexual practices, and sexual cultures are implicated in and constitutive of (or, at times, in tension with) pharmaceuticalization and specifically, how these promote health first through individualized risk prevention and later as a population health strategy.
To draw out these dynamics, we analyze the sociotechnical trajectories of HBV and HPV vaccines segmented into three moments: from the time that viral causes are identified and thus a new knowledge of cancer is asserted, to vaccine implementation as a new way of doing cancer prevention, and to the stage of expanded vaccine distribution. At each stage, we examine the ways sexual and scientific meanings and categories are constituted, and once seemingly settled, incorporated into organizational and clinical practices. We analyze the interactive dynamics of biomedicine, including its political-economic context, key players, sexual risk production, invisibilities produced, and other preventive strategies offered. We conclude by asking whether vaccination is indicative of larger biomedical shifts in which the right to health has become the right to biomedical prevention (Biehl, 2006, Dumit, 2012).
We argue that these two cases follow paths similar to those of pharmaceuticals more generally: They produce risk as well as risk markets, and offer treatments that resemble not so much the vaccine markets of the early twentieth-century as the pharmaceutical markets of the twenty-first century. In these cases, individual risk, not disease, becomes the object of intervention and the terms upon which immunization practices are deployed. Yet we found that the marketing success of these vaccines, to some degree, hinges on the suppression, management, or "taming" of sexual dynamics related to that risk. In particular, individualized sexual risk becomes at least partly desexualized first by the redescription of that risk under the banner of cancer prevention and then through a range of pharmaceutical company, biomedical, and policy practices that follow. While much distinguishes the cases of HBV and HPV, the comparison demonstrates how the situationally contingent production of risky subjects and risky bodies depends not only on the specificities of viruses, diseases, and vaccine development but also on the broader biomedical, political-economic, and discursive frames within which sexualities are understood.
Section snippets
Theory and methods: analyzing pharmaceuticalization and sexualization processes
We conceptualize viral agents with cancer causing properties as nodes in a network of molecular biomaterials, sociocultural discourses, and material practices. We situate these in the context of processes of biomedicalization to capture biomedical, institutional, and knowledge-making processes following a post-WWII expansion of medicine that includes shifts from the "clinical gaze" to a "molecular gaze" (Clarke et al., 2010, Rose, 2007), shifts from illness to health as the object of biomedical
Background: vaccines and the knowing and doing of cancer prevention
There is a long history of scientific inquiry into causes of disease at the molecular and sub-molecular levels. This "inward" attention to apprehending disease includes a shift from identifying the biomolecular agent-such as a virus-as an actor in the etiology of disease to a new way of knowing and intervening in disease itself. Once viruses (as well as bacteria, fungi, protozoa, etc.) were identified and understood as external pathogens, hypotheses emerged about social conditions and behaviors
Findings: the sexual politics of cancer prevention
Table 1 summarizes the argument that follows, outlining key events, knowledge, and actors in the sociotechnical pathways of HBV and HPV to capture processes of pharmaceuticalization as they intersect with, produce, and efface sexual meanings, practices, and communities.
Discussion: sex, vaccines, and the pharmaceuticalization of cancer prevention
HBV and HPV vary significantly in the specifics of the viral infections, as well as in their cancer association, transmission routes, and emphasis on sexual lives and practices. Yet we found that what emerges from a comparison of their socio-technical trajectories are instances of rigorous attempts to tame and displace sexual concerns. With vaccines, a focus on common sexually transmitted infections with uncertain pathways is deemphasized in favor of a focus on cancer prevention and individual
Acknowledgments
The authors would like to thank Susan Bell, Anne Figert, Anne Pollock, João Biehl, Keith Wailoo, Angela Creager, Jennifer Reich, Kelly Joyce and audiences at conferences for their extremely helpful engagements with many of the ideas presented here. We also thank Stefan Timmermans and the anonymous reviewers of Social Science & Medicine. We are most grateful to the strong graduate research assistance provided by Gemma Mangioni, Alka Menon, and Joseph Guisti at Northwestern University and Jesus
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