Sex and Other Sins: Public Morality, Public Health, and Funding PrEP

Guest Post by Nathan Emmerich

In the UK, a recent high-court decision[1] has reignited the debate about whether or not Pre-exposure Prophylaxis (PrEP) should be provided to those who are deemed to be at high-risk of contracting HIV.[2] Despite the fact that NHS England is now appealing,[3] it was a fairly innocuous decision: having suggested that they were barred from funding PrEP, the court ruled that it would be legal for the NHS to fund PrEP and that they should therefore consider doing so.3

What is less innocuous are debates about whether or not access to PrEP should be publicly funded at all. Whilst individuals report being able to buy a month’s supply online for around £45,[4] the annual cost of the drug to the NHS could be more than £4,000 per patient. Although this may seem a relatively exorbitant expense, it makes economic sense to provide PrEP; doing so could prove to be cheaper than providing treatment[5] to those who would otherwise become HIV positive.

Despite this sound economic rationale, the media, or certain sections of it, have predictably focused on one particular group who are candidates for the drug as they are at higher risk of contracting HIV: homosexuals. In particular, the debate has centred on promiscuous gay men or, to use the academic term, men who have sex with men. This includes individuals who regularly have sex with new partners, as well as those who engage in protected and unprotected group sex.

Perhaps as a result of this focus, the view that public funds should not be used for PrEP[6] seems fairly widespread. But while public acceptance has not yet been fully achieved, the Equality Act (2010)[7] means that it is illegal to discriminate against individuals on the basis of protected characteristics[8] such as sexual orientation.[9] We should, therefore, be concerned that arguments against funding PrEP might be motivated by some degree of homophobia.[10] If this charge is to be answered then we need to consider the arguments for and against the funding of PrEP in more detail.

There are, of course, plenty of other social groups that could benefit from PrEP, including some who are stigmatised, such as sex workers, and others who tend not to be, such as monogamous sero-discordant couples (i.e., a monogamous couple, one of whom is HIV positive and one of whom is not). However, reading the commentary on this issue would seem to indicate that the disinclination to fund PrEP is not applied equally. Thus, providing PrEP to hetero- or homo-sexual couples seems to attract support, but this is not extended to those whose sexual practices involve promiscuity.

As such, it would seem the opprobrium at work in this matter is primarily directed at non-monogamous ‘lifestyles’ and with sexuality playing a secondary role.

Homophobia has not, of course, gone away. Coupled with the continued stigmatisation of HIV/AIDS, this fact continues to have implications for the spread of HIV.[11] Many men are reluctant to get tested for HIV or engage with services that promote sexual health.

That being said, ideas about human relationships and traditional sexual practices have recently expanded. At least in the West, homosexuality is generally accepted or, at least, tolerated. Oddly enough, this is partially due to the influence of hetero-normativity: the cultural acceptability of homosexuality is, in no small part, due to the fact that homosexual relationships have increasingly been modelled on those of heterosexual couples, the most obvious example being campaigns to legalise (so called) ‘gay marriage.’

The reason that providing PrEP to monogamous sero-discordant couples is seen as an acceptable use of public funding is directly related to the context in which sex takes place. When it takes place within the confines of a monogamous relationship, moral concerns seem to become suspended. This does not necessarily mean that society approves of any and all sex that takes place within this socially sanctioned space, just that there is a cultural disinclination to address it directly.

Although sexual practices are becoming more diverse among the general population, they have not grown so diverse as to include promiscuity (taking multiple partners), sex work, and activities such as group sex: these activities remain subject to cultural disapproval and social stigma. As such, it seems that whether or not we think PrEP should be provided to those who would benefit from it is connected to public sexual morality, and that this may not simply be a matter of homophobia. Rather, concerns around PrEP seem to be predicated on fairly commonplace norms regarding monogamy and sexual morality.

Insofar as sex is seen as an essential facet of human relationships, the heteronormative institution of ‘marriage’ – or, at least, of a monogamous relationship between two people – continues to provide a strict normative context within which sex is not only seen as socially acceptable but is understood to find its proper expression. Whether ‘same-sex’ or ‘opposite-sex,’ it seems that monogamous couples have our moral endorsement and so giving PrEP to those whose lifestyle is understood to reflect this norm is subject to relatively unreserved approval.

Consider the following thought experiments. Imagine a drug that could be taken to significantly lessen the risk that a smoker would develop lung cancer, or a drug that would lessen the risk of ‘at risk’ individuals developing diabetes. In such cases would we be inclined to refuse public funds for such drugs merely because such individuals could lessen their risks even more by giving up smoking, or by losing weight and eating a healthy or, at least, healthier diet?

There is, certainly, something regrettable about having to spend public money on a drug that offsets risks generated by an individual’s own behaviour. Nevertheless, from an epidemiological – and therefore public health – perspective, the notion that an individual makes a choice about whether or not to smoke, or to have a bad diet, is too simplistic, even when we place the issue of addiction to one side. Thus, even when smoking cessation programmes are available and even when nutritional advice is within easy reach (as it increasingly is), plenty of people still smoke and consume a less than healthy diet.

Smoking and bad diets are correlated with a variety of demographic factors, and our choices are always made within particular cultural and socio-political contexts. Even so, some have questioned if the NHS should be funding stomach-stapling operations for those who are overweight, or if smokers and non-smokers can expect to receive the same level of treatment and care.

There may be reasonable disagreement about those specific cases. But few, I think, would be inclined to refuse funding for the kinds of prophylactic drugs I have imagined. Whilst this indicates that public norms regarding sex and sexuality do seem to be playing a role in arguments about funding PrEP, the points I have made suggest something about changes to the way health is currently being framed.

As others[12] have[13] noted,[14] the idea of ‘health’ and ‘wellbeing’[15] have recently taken on a moral hue and contemporary norms are such that smoking and obesity are increasingly understood as reflecting the moral failings of individuals. The implication is that a healthy lifestyle can be seen as the moral equivalent of monogamy, whilst smoking or an unhealthy diet can be understood as being subject to the kinds of implicit moral judgements that are commonly applied to promiscuity.

The fact that we would fund drugs that lower the risk of developing lung cancer or diabetes does not mean that the smokers or those who are overweight are not currently subject to any form of moral judgment or social stigma. For example, in 2014, a Devon Care Commissioning Group considered denying surgery[16] to smokers and those who were morbidly obese. Subject to severe criticism, the plan was never implemented, and so it would seem that if health is taking on distinctively moral connotations it is, as yet, of a different order to the kinds of moral judgments at play in matters of sex, sexuality, and funding for PrEP.

Whilst it is inevitable that our society promulgates such moral norms, they should be considered critically before being allowed to structure the way in which medicine is practiced, and public health initiatives are organised. If we do not, and we allow the creation of a morally judgemental health service, we risk inflicting greater levels of harm, both in the population in general and among those who are already subject to social stigma. Not only that, but in many cases, it would mean incurring greater economic costs for the sake of some moral principles that, whilst commonly espoused, may not actually be as widely held as one might think.

It is important to ensure that both our public services and healthcare organisations are free from unwarranted biases or questionable moral judgements (although this should not stop individuals from understanding their own behaviour in moral terms). According to this view, it is not the sex, but the risk taking that we should be concerned with.

There are many ways to lower the risk of sex with multiple partners. It can, of course, mean using condoms or other barrier methods or significant engagement with healthcare services such that they can take on significant import from the perspective of a group’s culture.[17] It can also mean undergoing regular testing (as is the case for many of those who work within the pornography industry), or it could mean relying on fluid bonding and the high levels of trust involved in intimate human relationships, including polyamorous relationships.

Nevertheless, accidents can happen and mistakes will be made, and people should not be penalised for that by the health system. Given the fact that it would be impossible for any health service to distinguish between those who are at fault and those who are not – something one might compare to odious and invidious notions of the deserving and undeserving poor – it is better to provide a service on a non-judgemental basis.

This does not mean we should abandon the endeavour to lead morally good lives or cease to encourage others to do so. Whatever they may be, our sexual proclivities do not absolve us of any individual responsibility we might have to ensure we protect both ourselves and our sexual partners from the negative consequences of our actions. At the end of the day, it is not the sex we have that is morally significant, but the way we act whilst having it: practicing safe(r) sex should be understood as a personal moral imperative.