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Examining public health nurses’ documentary practices: the impact of criminalizing HIV non-disclosure on inscription styles
Abstract
In Canada, there has been a rise in criminal HIV non-disclosure cases where public health records have been subpoenaed for use in police investigations and criminal court proceedings. In particular, public health nurses’ written counseling notes, originally collected for the purposes of creating a record of treatment and a plan of care, have been used as evidence against their clients. This article engages sociologically with this issue by analyzing whether and how this criminal law development has affected public health nurses’ reasoning and documentary practices in settings of HIV post-test counseling sessions. The paper argues that variations in nurses’ inscription styles result in part from considerations about the criminal law, which indicates the influence of ‘medico-legal’ relations that connect health care and the criminal justice system. Implications for nursing practice and the broader goals of HIV prevention are discussed. Data are drawn from interviews with thirty nurses working at four public health units in Ontario.
... ASO staff generally provide education and support services for PLWHA, which means that testifying or supplying case notes threatens the rapport and trust between ASO workers and PLWHA who seek out and utilize their services. [9,14] Given this development, it is important to remember that combatting the stigmatization and criminalization of PLWHA was central to AIDS activism in the 1980s and that AIDS Service Organizations (ASOs) emerged as part of this grassroots movement. [15] Over time, however, ASOs began to experience an increasing professionalization of their services and bureaucratization of their organizations, which critical scholars like Kinsman marked as a shift away from the volunteer and peer-based nature of early AIDS activism that created barriers for PLWHA to be involved in ASO management. ...
... Building on earlier research in Canada that found formally regulated professionals feel more compelled to document discussions about nondisclosure than do peer ASO staff, [9,14] our project examines: (1) whether this is replicable within our sample of Atlanta-based ASOs; and, (2) how understandings of health privacy legislation underpin ASO staff charting practices. ...
... Also in contrast to earlier fi ndings in Canada, our data showed no variation between professionalized and peer ASO staff in Georgia in terms of charting practices. [9,14] With only one professional participant reporting that criminalization changed how they do their work by encouraging them to be more cautious in terms of what they document, it does not appear that the professional obligations of regulatory bodies, such as the Georgia Board of Nursing or the Georgia Composite Board of Professional Counselors, Social Workers and Marriage and Family Therapists, affected the charting practices of professionalized ASO staff differently than non-regulated peer ASO staff. This fi nding can be explained by how participants interpreted the protections provided by HIPAA legislation. ...
Introduction: The growing professionalization of AIDS Service Organizations (ASO) and the criminalization of HIV nondisclosure have reshaped both ASO staff interactions with people living with HIV/AIDS (PLWHA) as well as ASO staff charting practices. Methods: Building on a recent national research project in Canada, we conducted semi-structured interviews in February-April 2017 with N=12 ASO staff in Atlanta, Georgia to investigate their charting practices in the context of HIV criminalization. Results: Our data showed no variation between professionalized and peer ASO staff in terms of charting practices, although the American participants reported being less protective about the content of their notes and less concerned about the risk their notes may pose in cases involving the criminal prosecution of an alleged HIV nondisclosure incident than was previously reported by their Canadian counterparts. In fact, we identified a false sense of security among American ASO staff stemming from their belief that the Health Insurance Portability and Accountability Act (HIPAA) would protect them from having to disclose their charting notes. Conclusions: We suggest that training and educational opportunities for both professionalized and peer ASO staff are needed to sensitize them to the implications of record-keeping on the prosecution of HIV nondisclosure.
... In particular, PHNs described the important task of establishing and maintaining counseling rapport as noticeably more challenging following discussion of criminalization (Sanders, 2013). They felt this undermined their ability to successfully discuss riskreduction strategies and obtain contact information for sex contacts (Sanders, 2015). PHNs also described organizational concerns about civil lawsuits against public health units in cases where patients were prosecuted for nondisclosure. ...
... They expressed concerns about being summonsed to testify against patients in court in nondisclosure cases (Sanders, 2014). These concerns led many PHNs to avoid discussing the limitations of confidentiality during counseling sessions while documenting information in patient case files that might be seen as superfluous to the plan of care but relevant to a court case in the event of an arrest for nondisclosure (Sanders, 2014(Sanders, , 2015. In short, the PHNs' reasoning and practices had become infiltrated by various extra-local concerns and personal experiences brought about by the criminalization of HIV nondisclosure. ...
... Asking ourselves if our work met these criteria, both individually and collectively as a meta-analysis, we answered all questions in the affirmative, and then spoke to each criteria either in the methodology or discussion sections of this article. With respect to the issue of qualitative transferability, we similarly feel that the organizers that we have identified in this discussion do not supplant nor reiterate the detailed finding of our previous studies (see, for example, Bisaillon, 2012bBisaillon, , 2014Bisaillon & Ells, 2014;Sanders, 2014Sanders, , 2015 but rather add to and expand the scope of our earlier analyses. ...
Health sociologists interested in how macro state influences affect micro health care practices have much to gain from meta-ethnography research. In this article, we bring together insights from two separate empirical studies on state health care services involving HIV/AIDS as a way to speak to larger issues about the organization and production of medical expertise and governance in health care systems. We use Noblit and Hare’s meta-ethnography approach to bring these studies into conversation and identify six shared “organizers” of health care encounters. The organizers illustrate how state health interests operate across institutional contexts and impact the work of providers in seemingly unrelated health care settings. On the basis of this synthesis, we conclude that state interests both structure and create conflict in health care settings. We believe this perspective offers the potential to advance the goals of health sociology and the field of qualitative health research in general.
... Similarly, interviews with 30 public health nurses in Ontario revealed that the risk of subpoena of medical documentation for use in judicial trials influenced patient-provider discussions around the limits of confidentiality in the healthcare setting, with some providers withholding/limiting details about confidentiality to preserve therapeutic relationships [121]. Qualitative data drawn from the latter two studies also suggest that anticipation of possible subpoena of medical documents for use in trials may influence documentary practices within medical records, either to ensure adequate recall of clinical events, to signify professional standards are being upheld, or to maximize patient confidentiality [118,121,122]. ...
... Impact of criminal law on: Linkage and retention in HIV care Judging mothers: criminalization's creep into the health and social care of HIV-positive mothers (2014) [126]. Interviews conducted in Ontario with women in their 3rd trimester, and at 3 and 12 months postpartum.Discussing the Limits of Confidentiality:The Impact of Criminalizing HIV Nondisclosure on Public Health Nurses'Counselling Practices (2014)[122].Examining public health nurses' documentary practices: the impact of criminalizing HIV nondisclosure on inscription styles (2015)[123]. ...
Introduction:
In 2012, the Supreme Court of Canada ruled that people living with HIV (PLWH) must disclose their HIV status to sexual partners prior to sexual activity that poses a "realistic possibility" of HIV transmission for consent to sex to be valid. The Supreme Court deemed that the duty to disclose could be averted if a person living with HIV both uses a condom and has a low plasma HIV-1 RNA viral load during vaginal sex. This is one of the strictest legal standards criminalizing HIV non-disclosure worldwide and has resulted in a high rate of prosecutions of PLWH in Canada. Public health advocates argue that the overly broad use of the criminal law against PLWH undermines efforts to engage individuals in healthcare and complicates gendered barriers to linkage and retention in care experienced by women living with HIV (WLWH).
Methods:
We conducted a comprehensive review of peer-reviewed and non-peer-reviewed evidence published between 1998 and 2015 evaluating the impact of the criminalization of HIV non-disclosure on healthcare engagement of WLWH in Canada across key stages of the cascade of HIV care, specifically: HIV testing and diagnosis, linkage and retention in care, and adherence to antiretroviral therapy. Where available, evidence pertaining specifically to women was examined. Where these data were lacking, evidence relating to all PLWH in Canada or other international jurisdictions were included.
Results and discussion:
Evidence suggests that criminalization of HIV non-disclosure may create barriers to engagement and retention within the cascade of HIV care for PLWH in Canada, discouraging access to HIV testing for some people due to fears of legal implications following a positive diagnosis, and compromising linkage and retention in healthcare through concerns of exposure of confidential medical information. There is a lack of published empirical evidence focused specifically on women, which is a concern given the growing population of WLWH in Canada, among whom marginalized and vulnerable women are overrepresented.
Conclusions:
The threat of HIV non-disclosure prosecution combined with a heightened perception of surveillance may alter the environment within which women engage with healthcare services. Fully exploring the extent to which HIV criminalization represents a barrier to the healthcare engagement of WLWH is a public health priority.
... Of particular concern is that health records in Canada are subject to subpoena and can be used in court proceedings and police investigations (Sanders, 2015). The potential use of such records is worrisome considering the ongoing prohibition of the personal possession of a controlled substance, and the laying of manslaughter charges for those who provide drugs that result in an overdose death (Heighton, 2019;Hrymak, 2018). ...
As harm reduction programs and services proliferate, people who use drugs (PWUD) are increasingly subjected to surveillance through the collection of their personal information, systematic observation, and other means. The data generated from these practices are frequently repurposed across various institutional sites for clinical, evaluative, epidemiological, and administrative uses. Rationales provided for increased surveillance include the more effective provision of care, service optimization, risk stratification, and efficiency in resource allocation. With this in mind, our reflective essay draws on empirical analysis of work within harm reduction services and movements to reflect critically on the impacts and implications of surveillance expansion. While we argue that many surveillance practices are not inherently problematic or harmful, the unchecked expansion of surveillance under a banner of health and harm reduction may contribute to decreased uptake of services, rationing and conditionalities tied to service access, the potential deepening of health disparities amongst some PWUD, and an overlay of health and criminal-legal systems. In this context, surveillance relies on the enlistment of a range of therapeutic actors and reflects the permeable boundary between care and control. We thus call for a broader critical dialogue within harm reduction on the problems and potential impacts posed by surveillance in service settings, the end to data sharing of health information with law enforcement and other criminal legal actors, and deference to the stated need among PWUD for meaningful anonymity when accessing harm reduction and health services.
... Following the articulation by Mykhalovskiy and colleagues, a growing number of social-scientific studies in recent years have taken a broader view of healthwork in three key domains. The first is in the context of public health practices where family healthwork (Nichols et al. 2016), mental healthwork (Abraham et al. 2017), sexual healthwork (Fryer 2014), health seeking information (Harris et al. 2010;Lakoff 2015;Sanders 2015) and stroke prevention (Flogen 2014) constitute significant knowledge required by patients to take responsibility for their own health and well-being. The second revolves around healthcare services where patients make decisions about their healthcare and treatment choices based on the health information, especially in areas such as diabetes care (Arduser 2017; Lowndes 2012), breast cancer care (Goldenberg 2010;Sinding et al. 2010), women's prenatal care (Ion et al. 2020), women's preterm labor experiences (MacKinnon 2006), and patient-empowerment and health-related services (Bisaillon 2014;Veinot 2010). ...
Following the introduction of highly active antiretroviral therapy (HAART) in 1996, adherence was regarded by biomedical researchers as the only way to manage HIV effectively in everyday life. The sociological critique of this biomedical stance posits that the everyday management of HIV goes beyond the biomedical conception of adherence, as HIV-positive individuals undertake healthwork practices that form the basis of HIV management. Using symbolic interactionism and social context theory to ground the lived experience of healthwork, this paper explores the kinds of healthwork people living with HIV in Nigeria undertake. Drawing from 32 semi-structured interviews with HIV-positive individuals living in Nigeria, it was observed that healthwork is an individualized practice including spirituality, testing, counseling, adherence, concealment, dieting, and support-group participation. These practices are shaped by the sociocultural, economic, political, and structural factors in the Nigerian context. Meaningful healthwork practices were informed by the personal responses to HIV diagnosis, and such practices were tied to formal rules, local dynamics, and contextual issues that are shaped by structural and institutional factors. This paper contributes to sociological knowledge on HIV management by demonstrating the importance of context and meaning in the design of health interventions and programs connected with the lived experience of people living with HIV.
... The questions asked by Kristen are further complicated by the increasing climate of HIV criminalisation in Canada (CATIE n.d.). While Canadian law outlines specific conditions under which people living with HIV are obligated to disclose their HIV status before sexual encounters, a climate of surveillance has crept into public health and social service arenas blurring the lines and creating confusion regarding what disclosures are needed, by whom and in what circumstances (Greene et al. , 2017Sanders 2014Sanders , 2015. In a healthcare context, even if women living with HIV do not wish their HIV status to become known, and/or healthcare providers wish to avoid unwanted disclosure of a woman's HIV status, the legal obligation of people living with HIV to disclose to sexual partners, along with parental right to know about and consent to healthcare their child receives, creates conditions where the disclosure of HIV may occur. ...
This paper describes findings from an institutional ethnography that arose out of the concerns of women living with HIV in Ontario, Canada, regarding the disclosure of their HIV status while accessing perinatal care. The enquiry traces the connections between women’s experiences of perinatal care, the activities of healthcare providers delivering such care and the ruling relations that organise women’s experiences and healthcare providers’ activities. Focusing on HIV disclosure as a concern expressed by women, the findings make visible the day-to-day, routinised practices of healthcare providers working in perinatal care for women living with HIV, as well as the ideological discourses of ‘fear of contagion’ and ‘AIDS hysteria’ that contributed to producing the kinds of care experiences that were articulated by women. Opportunities to strengthen perinatal care policies and practices for women living with HIV are discussed.
... They suggest how HIV criminalization can undermine effective HIV prevention by creating a public expectation for people with HIV to disclose to their sexual partners while, at the same time, making disclosure, at least for some people with HIV, a more risky and difficult thing to accomplish. Three articles by Sanders (2015); Dodds, Weait, Bourne, and Egede (2015); and French (2015) contribute to an emerging direction in the literature that explores the public health implications of HIV criminalization through a focus on public health, health care, and social service providers. Moving past the 'person with HIV/criminal law' dyad (Mykhalovskiy, 2011), these articles produce a more relational understanding of the public health implications of HIV prevention. ...
While public health remains the primary site of authority for preventing HIV transmission, recent shifts in the biopolitics of HIV have heightened tensions in the institutional and discursive relations through which the sexual lives of people living with HIV and broader HIV epidemics are regulated. Most notably, over the past decade, criminal justice responses to HIV have gained considerable traction. The growing use of the criminal law to regulate perceived HIV transmission risks has occasioned considerable controversy among people living with HIV, community-based AIDS organizations, health-care providers, public health authorities, prosecutors, judges, and the legal community. This article introduces a special section of Critical Public Health focused on the public health implications of HIV criminalization. The article reviews past and current work on the topic, situates the contributions made by the articles published in the special section, and outlines directions for future inquiry.
... The differences between our work and that undertaken earlier could be in part because key elements of criminal liability differ significantly between the UK and Canada. 5 Yet, in more recent research among HIV specialist nurses in Canada, Sanders (2015) reveals that changes to documentation practices in the light of criminalisation include a mixture of those who document more, and those who document less as a direct result of potential use of professionals' notes in criminal proceedings, similar to our findings. ...
We present qualitative research findings about how perceptions of criminal prosecutions for the transmission of HIV interact with the provision of high-quality HIV health and social care in England and Wales. Seven focus groups were undertaken with a total of 75 diverse professionals working in clinical and community-based services for people with HIV. Participants’ understanding of the law in this area was varied, with many knowing the basic requirements for a prosecution, yet lacking confidence in the best way to communicate key details with those using their service. Prosecutions for HIV transmission have influenced, and in some instances, disrupted the provision of HIV services, creating ambivalence and concern among many providers about their new role as providers of legal information. The way that participants approached the topic with service users was influenced by their personal views on individual and shared responsibility for health, their concerns about professional liability and their degree of trust in non-coercive health promotion approaches to managing public health. These findings reveal an underlying ambivalence among many providers about how they regard the interface between criminal law, coercion and public health. It is also apparent that in most HIV service environments, meaningful exploration of practical ethical issues is relatively rare. The data presented here will additionally be of use to managers and providers of HIV services in order that they can provide consistent and confident support and advice to people with HIV.
The use of the criminal law to punish those who transmit disease is a topical and controversial issue. To date, the law (and the related academic literature) has largely focused on HIV transmission. With contributions from leading practitioners and international scholars from a variety of disciplines, this volume explores the broader question of if and when it is appropriate to criminalise the transmission of contagion. The scope and application of the laws in jurisdictions such as Canada, the United Kingdom and Norway are considered, historical comparisons are examined, and options for the further development of the law are proposed.
The criminalization of HIV nondisclosure is reshaping the landscape of support and care for people living with HIV/AIDS (PLWHA). Focusing on Canada, this article examines how criminalization is reshaping the relationships between frontline AIDS Service Organization (ASO) workers and their HIV-positive service users. Using data gleaned through semi-structured interviews with N = 62 frontline ASO staff members across Canada that were coded using thematic analysis, we describe how ASO workers are rethinking and altering their notetaking practices in light of fears about criminalization and how their charts may be used by legal actors. Specifically, we identified three main themes. First, awareness that their notes can be subpoenaed and used against their clients in criminal proceedings is leading ASO staff to keep less detailed records of their conversations with PLWHA, although there were variations by the type of position held. Participants with professional obligations (doctors, nurses, social workers) reported that they continue to keep more detailed charting records than other frontline ASO staff (peer counselors, educators, etc.). Second, participants acknowledged that criminalization threatens the trust dynamic in the therapeutic relationship and that by taking less detailed notes they risk the quality of care provided. Third, we found that evolving knowledge about risk and responsibility in light of criminalization is impacting the type of counsel ASO workers offer to PLWHA regarding how to document disclosure. The article concludes by reflecting on the challenges associated with navigating the “medico-legal borderland”, as ASO staff balance their commitments to serving PLWHA with the realities created by the harsh climate of criminalization. Greater political attention should be paid to the risks that criminalization poses to frontline HIV support work and efforts to support PLWHA, who already face significant stigma, without the additional stigma of the criminal label.
In 2012 the Supreme Court of Canada ruled that a person living with HIV must disclose their status before sex unless a condom is used, and they have a low or undetectable viral load, which is a measure of the amount of virus present in the bloodstream. This qualitative study examined the ruling’s impact on HIV/AIDS support services provision. Semi-structured interviews were conducted with 15 psycho-social support providers working with people living with HIV/AIDS, and then recorded and transcribed verbatim. Using inductive thematic analysis, researchers extracted the themes of knowledge of the ruling and role of service providers. Findings highlight uncertainty over the ruling and its application and service providers’ approaches to address the impacts of the ruling.
HIV criminalisation is a term that describes the criminal prosecution of persons in instances of HIV transmission, exposure and so-called non-disclosure of their HIV serostatus. In the United States (US), there have been over 500 reported instances of HIV criminalisation. Over the past decade, several negative consequences of HIV criminalisation have been identified, including its capacity to increase stigma and social injustice. In addition, scholars have built an evidence base demonstrating that HIV criminalisation has the potential to undermine HIV prevention and that it is thus harmful to public health. This article contributes to that evidence base by (1) combining Foucaultian studies of ‘governmentality’ with the sociology of ‘anomie’ to theorise the larger implications of HIV criminalisation for the institution of public health, and (2) presenting interviews with public health service providers working in Tennessee, USA. This state is an important site for studying the public health implications of HIV criminalisation because, between 2008 and 2012, it was reported to have led all American jurisdictions in prosecutions of HIV-specific criminal offences. Concentrating on discussions of post-test counselling, this article argues that a major system-level effect of HIV criminalisation is the propagation of an anomic affective climate, which makes it difficult to establish norms of HIV prevention.
We present qualitative research findings about how perceptions of criminal prosecutions for the transmission of HIV interact with the provision of high-quality HIV health and social care in England and Wales. Seven focus groups were undertaken with a total of 75 diverse professionals working in clinical and community-based services for people with HIV. Participants’ understanding of the law in this area was varied, with many knowing the basic requirements for a prosecution, yet lacking confidence in the best way to communicate key details with those using their service. Prosecutions for HIV transmission have influenced, and in some instances, disrupted the provision of HIV services, creating ambivalence and concern among many providers about their new role as providers of legal information. The way that participants approached the topic with service users was influenced by their personal views on individual and shared responsibility for health, their concerns about professional liability and their degree of trust in non-coercive health promotion approaches to managing public health. These findings reveal an underlying ambivalence among many providers about how they regard the interface between criminal law, coercion and public health. It is also apparent that in most HIV service environments, meaningful exploration of practical ethical issues is relatively rare. The data presented here will additionally be of use to managers and providers of HIV services in order that they can provide consistent and confident support and advice to people with HIV.
The use of criminal-law powers to respond to people with HIV who place others at risk of HIV infection has emerged as a focal point of AIDS advocacy at global, national, and local levels. In the Canadian context, reform efforts that address the criminalization of HIV non-disclosure have been hampered by the absence of data on the contours, scale, and outcomes of criminalization. This article responds to that gap in knowledge with the first comprehensive analysis of the temporal trends, demographic patterns, and aggregate outcomes of Canadian criminal cases of HIV non-disclosure. The authors draw on insights into the role that rendering social phenomena in numerical terms plays for the governance of social life in order to make criminalization “visible” in ways that might contribute to activist responses. The article examines temporal trends, demographic patterns, and outcomes separately. In each instance, the pattern or trend identified is described, potential explanations for findings are offered, and an account is given of how the data have informed efforts to reform criminal law. Particular attention is paid to the following key findings: a sharp increase in criminal cases that began in 2004; the large proportion of recent criminal cases involving defendants who are heterosexual Black, African, and Caribbean men; and the high proportion of criminal cases resulting in conviction. The article closes with suggestions for future research.
How does the contemporary restructuring of health care affect nursing practice? Increasingly since the 1970s, and more intensively under recent reforms, Canadian health care is the focus of information-supported, professionally based management. In Managing to Nurse, Janet M. Rankin and Marie L. Campbell probe the operation of this new form of hospital and its effect management on nurses and nursing. Written from the nurse's perspective, this institutional ethnography discovers a major transformation in the nature of nursing and associated patient care: the work is now organized according to an accounting logic that embeds a cost-orientation into care-related activities. Rankin and Campbell illustrate how nurses adapt to this new reality just as they, themselves, perpetuate it - how they learn to recognize their adaptations as professionally correct and as an adequate basis for nursing judgement. Although Managing to Nurse may contradict contemporary beliefs about health care reform, the insiders' account that it provides is undeniable evidence that nurses' caring work is being undermined and patient care is being eroded, sometimes dangerously, by current health care agendas.
In Canada, there have been a growing number of criminal HIV nondisclosure cases where public health records have been subpoenaed to aid in police investigations and/or to be presented in court as evidence against HIV-positive persons. This has led some to suggest that nurses provide explicit warnings about the limits of confidentiality in relation to crimes related to HIV nondisclosure, while others maintain that a robust account of the limits of confidentiality will undermine the nurse-client relationship and the public health goals of reducing HIV/sexually transmitted infection transmission. This article engages with this issue by exploring whether and how public health nurses endeavor to control information about the limits of confidentiality at the outset of HIV posttest counseling. The data indicate variation in practices, as nurses pragmatically balance ethical and professional concerns; although some nurses intentionally withhold information about the risk of subpoena, others report talking to clients about confidentiality in ways that focus on the risk of harm associated with criminalization. The discussion argues that practice variation also illuminates medico-legal relations between health care and the criminal justice system. Data are drawn from qualitative interviews with 30 nurses working at four public health units in Ontario.
Bringing together papers written by Norman Fairclough over a 25 year period, Critical Discourse Analysis represents a comprehensive and important contribution to the development of this popular field.
This article contributes to the investigation of evidence-based medicine (EBM) as text-mediated relations of governance. Social critiques of EBM typically rely on a negative conception of power, such that EBM is considered to contain or limit the scope of medical practice. This article, by contrast, explores EBM as a productive relation, one that governs through medicine's `freedom' and opens up spaces of intervention. The article draws on an institutional ethnographic study of a research transfer initiative called informed - an evidence-based newsletter for family physicians. My investigation of the work practices of making informed underscores how texts are fundamental to the social organization of EBM. Through the example of informed, I locate reading as a central object of governance within EBM. I emphasize how the problematization of physicians as indifferent readers is linked with an effort to intervene in medical work through a new kind of text that clinically recontextualizes biomedical science.
Dans un numero thematique consacre au discours produit au-dela des frontieres professionnelles, c-a-d au discours impliquant des professionnels qui communiquent avec des individus issus d'autres professions ou avec des personnes non expertes, l'A. propose ici un article introductif dans lequel il presente quelques notions-cle liees a ce genre de communication : notamment, la recontextualisation, une strategie discursive consistant a recadrer le discours pour qu'il soit compris par des personnes issues d'un contexte different ; l'intertextualite, qui se refere a la reconstruction, la reformulation et la recontextualisation d'un meme sujet dans differentes situations de communication et entre differents locuteurs ; et la polyphonie, qui designe le melange de perspectives dans un meme texte a propos d'un meme sujet
This paper examines the problem of how institutions and the phenomena called formal or large-scale organization exist—the problem of the ontology of organizations and institutions. It addresses this problem using an approach that has been developed as part of a sociology exploring the social from women's standpoint, from which standpoint the extra-locality and objectification of these forms of organization are problematized. For the most part, sociology formulates the phenomena of organizations and institutions in lexical forms of organization, institution, information, communication and the like, which suppress the presence of subjects and the local practices that produce the extra-local and objective. This paper argues that texts (or documents) are essential to the objectification of organizations and institutions and to how they exist as such. It suggests that exploring how texts mediate, regulate and authorize people's activities expands the scope of ethnographic method beyond the limits of observation; texts are to be seen as they enter into people's local practices of wrking, drawing, reading, looking and so on. They must be examined as they coordinate people's activities.
'Risk' has become one of the defining cultural characteristics of Western society at the end of the twentieth century. As in other areas of life, 'risk' has become central to discourses related to individual health; that is, risk has become a common construct around which health in Western society is described, organised, and practised, both personally and professionally. The purpose of this paper is to explore the notion of a 'phenomenology of risk' by considering the results of a preliminary study undertaken to explore the themes which emerge in women's accounts of their own individual risks for breast cancer. A second purpose is to move towards situating the phenomenology of risk within the social and political context within which individual experience occurs. To that end, this study was framed theoretically within the emerging social science literature which examines the broader social and political meanings and implications of health risk discourses. This paper demonstrates that by embodying prevailing discourses on health risks in general, and on breast cancer risk in particular, the women in this study have embodied a political rationality, which, among other things, reconstitutes them as autonomous, responsible 'entrepreneurial subjects'. The phenomenological and political implications of the findings of this study are considered.
Objectives:
We explored associations between awareness of New Jersey's HIV exposure law and the HIV-related attitudes, beliefs, and sexual and seropositive status disclosure behaviors of HIV-positive persons.
Methods:
A statewide convenience sample (n = 479) completed anonymous written surveys during 2010. We recruited participants through networks of community-based organizations in the state's 9 health sectors. The survey assessed participants' awareness of New Jersey's HIV exposure law, their sexual and serostatus disclosure behavior in the past year, and their HIV-related attitudes and beliefs. We compared responses of participants who were and were not aware of the law through univariate analyses.
Results:
Fifty-one percent of participants knew about the HIV exposure law. This awareness was not associated with increased sexual abstinence, condom use with most recent partner, or seropositive status disclosure. Contrary to hypotheses, persons who were unaware of the law experienced greater stigma and were less comfortable with positive serostatus disclosure.
Conclusions:
Criminializing nondisclosure of HIV serostatus does not reduce sexual risk behavior. Although the laws do not appear to increase stigma, they are also not likely to reduce HIV transmission.
This report contributes to the development of an evidence-informed approach to using the criminal law to address the risk of the sexual transmission of HIV in the province of Ontario, Canada. In recent years, the application of criminal law powers to circumstances of HIV exposure in sexual relations has emerged as a key HIV-related policy issue. In Ontario, people living with HIV/AIDS (PHAs), AIDS Service Organizations (ASOs), human rights advocates and others have raised concerns about the expansive use of the criminal law in addressing HIV-related sexual offences. They have raised questions about fairness in the application of the criminal law and about its negative consequences for PHAs and established public health and community-based HIV prevention strategies. This report is rooted in these concerns. It responds to them in two ways. First, it explores various forms of evidence relevant to a thorough policy consideration of the use of the criminal law in circumstances of sexual exposure to HIV. Second, it proposes policy options for addressing the problems posed by the criminalization of HIV non-disclosure in Ontario.This report emphasizes that uncertainty in the criminal law formulation of the obligation to disclose HIV-positive status is foundational to current problems in the use of the criminal law to regulate the risk of the sexual transmission of HIV in Ontario. It further emphasizes policy issues and problems arising at the nexus of science and criminal justice, in particular, those posed by the inconsistent use of complex scientific research by courts in deciding cases of alleged HIV non-disclosure. Finally, the report underscores that the criminalization of HIV non-disclosure hinders established HIV prevention efforts and contributes to HIV-related stigma.The report recommends that the Ontario Ministry of the Attorney General establish a consultation process to inform the development of policy and a practice memorandum regarding cases involving allegations of non-disclosure of sexually transmitted infections, including HIV.
Using criminal law powers to respond to people living with HIV (PHAs) who expose sexual partners to HIV or transmit the virus to them is a prominent global HIV public policy issue. While there are widespread concerns about the public health impact of HIV-related criminalization, the social science literature on the topic is limited. This article responds to that gap in knowledge by reporting on the results of qualitative research conducted with service providers and PHAs in Canada. The article draws on a studies in the social organization of knowledge perspective and insights from critical criminology and work on the "medico-legal borderland." It investigates the role played by the legal concept of "significant risk" in coordinating criminal law governance and its interface with public health and HIV prevention. In doing so, the article emphasizes that exploring the public health impact of criminalization must move past the criminal law--PHA dyad to address broader social and institutional processes relevant to HIV prevention. Drawing on individual and focus group interviews, this article explores how criminal law governance shapes the activities of providers engaged in HIV prevention counseling, conceptualized as a complex of activities linking clinicians, public health officials, front-line counselors, PHAs, and others. It emphasizes three key findings: (1) the concept of significant risk poses serious problems to risk communication in HIV counseling and contributes to contradictory advice about disclosure obligations; (2) criminalization discourages PHAs' openness about HIV non-disclosure in counseling relationships; and (3) the recontextualization of public health interpretations of significant risk in criminal proceedings can intensify criminalization.
In England and Wales, criminal prosecutions for recklessly causing serious bodily harm by transmitting HIV have occurred since 2003. Understanding how people respond to the application of criminal law, will help to determine the likely impact of prosecution. As part of a wider qualitative study on unprotected anal intercourse amongst homosexually active men with diagnosed HIV in England and Wales, 42 respondents were asked about their awareness of criminal prosecutions for the sexual transmission of HIV, and how (if at all) they had adapted their sexual behaviour as a result. Findings demonstrate considerable confusion regarding the law and suggest that misunderstandings could lead people with HIV to wrongly believe that how they act, and what they do or do not say, is legitimated by law. Although criminalisation prompted some respondents to take steps to reduce sexual transmission of HIV, others moderated their behaviour in ways likely to have adverse effects, or reported no change. The aim of the criminal justice system is to carry out justice, not to improve public health. The question addressed in this paper is whether desirable public health outcomes may be outweighed by undesirable ones when the criminal law is applied to a population-level epidemic.
Description from publisher website at: http://www.rhmjournal.org.uk/
In 1998, the Supreme Court of Canada ruled that a person living with HIV could be found guilty of aggravated assault if he or she did not disclose his or her HIV-positive status and exposed another person to a "significant risk" of HIV transmission. The notorious case--R. v. Cuerrier--involved an HIV-positive man and two women with whom he had intimate relationships involving unprotected intercourse. At the time the ruling, which imposed full legal responsibility for HIV prevention on people living with HIV/AIDS, raised many questions. Ten years later, many of those questions remain unanswered. In addition, a host of new issues have been added to the debate.
younger than 14 years (at which time the AAP recommends full disclosure for all patients, with a preference for earlier disclosure as appropriate), full disclosure of the diagnosis may not be necessary for meaningful assent. Rather, it may be necessary only that the child and family be engaged in an established disclosure process. Such a process requires that the clinician or researcher obtaining assent be familiar with the child’s development and progress through the disclosure algorithm. In addition, the language to be used in the assent process should be discussed and agreed on in advance with the family. At age 14 years, most children ordinarily are able to understand the implications of an HIV diagnosis and are ready for full disclosure. Wider debate and consensus building about assent and disclosure are needed among agencies that sponsor pediatric HIV research in the United States and internationally. Financial Disclosures: None reported. Funding/Support: This Commentary was supported in part by Cancer Center Support Core Grant P30 CA21765 from the US Public Health Service and by the American Lebanese Syrian Associated Charities (ALSAC). Role of the Sponsors: The Cancer Center Support Grant and ALSAC fund St Jude’s infrastructure but had no role in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; or the preparation, review, or approval of the manuscript. Additional Contributions: We thank Patricia Flynn, MD (Department of Infectious Diseases, St Jude Children’s Research Hospital), for information about the staged disclosure process at St Jude and for her critique of the manuscript. We also thank Sharon Naron, MPA, ELS (Department of Scientific Editing, St Jude Children’s Research Hospital), for editing and review of the manuscript. No compensation was received by those named herein. REFERENCES
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