Dr Robert Pralat: “Until law is in line with medicine, scientific findings are going to continue to be perceived with suspicion”
“For about five years now we know that undetectable = untransmittable, people living with HIV who are on antiretroviral treatment who have an undetectable viral load (which is the vast majority of people living with HIV in the UK) cannot transmit HIV to their sexual partners. Many people still do not know that, but even if they do and it is a simple message, it can be hard to get your head around something which directly contradicts what you have been told for so long.”
Dr Robert Pralat is Leverhulme Trust Early Career Fellow in the Department of Sociology and a member of the Reproductive Sociology Research Group (ReproSoc). Dr Pralat’s work centres around sexuality, health, family and gender. His recent article, ‘Can HIV‐positive gay men become parents? How men living with HIV and HIV clinicians talk about the possibility of having children’ explores how ‘being undetectable’ affects gay men’s reproductive behaviours and the influence it has upon attitudes towards gay fatherhood.
Dr Robert Pralat talks to junior editor Laura Burland-O’Sullivan about his academic inspirations, the misconceptions surrounding LGBT+ and HIV+ parenthood and the importance of repeating the message ‘undetectable = untransmittable’.
What drew you to focus your academic work around the sociology of reproductive health?
Working on my dissertation as an undergraduate psychology student probably first sparked my interest in research. I went to university in Leeds and many of my friends were dancers at a prestigious school of contemporary dance and seeing some of the interactions around me made me fascinated by how working with one another in close physical proximity affected intimate relationships. Fast forward thirteen years my research now focusses on very different issues. My interest in intimacy has however remained. I followed my undergraduate degree with a masters in gender studies which I found academically enriching. Through gender studies I was introduced to sociology which became my ‘home’. Moving to the UK from Poland as a gay man in 2005, I was also baffled by how in the same year same sex couples in England gained the right to enter into civil partnerships and the right to jointly adopt. It seemed to me that the latter would take much more time to achieve. I was kind of fascinated by the cultural specificity. I became interested in both partnering and parenting as two forms of intimacy and that was the focus of my master’s dissertation. I was not sure if wanted to do a Ph.D. After four years and being in my early twenties, Leeds had become too small and I moved to London. I got a job at an independent research organisation. Here I worked on many different projects including work for the NHS and that is how I became more interested in health.
One of my favourite projects at the time was for a lovely charity called Body and Soul that helps children and families affected by HIV. We held focus group discussions in schools that uncovered many misconceptions about HIV, and I became really interested in that. I started a part time research job at UCL working on a large scale survey of attitudes among people living with HIV. Shortly after that I got a scholarship to do a Ph.D. at Cambridge which explored views about parenthood among people who formed same sex relationships. So, I put my interest in health and HIV on hold for a few years. But towards the end of my doctorate, quite accidentally, following a spontaneous conversation with a physician who became a colleague and a collaborator, I was able to bring the two interests together by looking at views about parenthood among gay men living with HIV. This is the main focus of my research now.
Are there any particular intellectual influences in the field that inspired you?
I have been teaching this week on HIV and the sociology of sexual health. I think the most inspiring research is the research that works well as an educational tool. Work that is engaging, eye-opening, myth busting and writing that conveys something very complicated in an accessible way without unnecessary jargon. Concepts that are powerful stay with you because the author is so good at explaining complex things very well. One recent example of such work is ‘Remaking a Life’ by Celeste Watkins-Hays about the experiences of women living with HIV. I was delighted that I could discuss this work with students who also found it very illuminating. Thinking about sociology and HIV, I love the work of Steven Epstein, which brings together two of my big interests: sexuality and medicine. It is a great example of scholarship that is empirically and theoretically rich and writing that has the highest level of clarity. Teaching in February, which is the UK’s LGBT+ History Month, is also an additional opportunity to include some history in sociology. I always find that the work of Jeffrey Weeks is helpful in doing that. My main research area is reproduction, and as someone with a background and interests in multiple subjects, I feel continually inspired by the fantastic interand multidisciplinary work that takes place in Cambridge which provides a great environment for really pushing disciplinary boundaries in this area and facilitates genuinely unconstrained intellectual curiosity.
Moving on to your own work. Despite undetectable HIV+ viral loads making it practically impossible to transmit HIV to a foetus, many men you interviewed believed it simply was not worth the risk. Do you feel that the transition of scientific evidence from the lab into the public social arena can mystify or distort what the scientific evidence actually tells us?
In the public consciousness since the 1980s conversations about HIV have been framed by the notion of risk. The risk of infection has been central to how we think and how we talk about HIV. Whether they are HIV positive or negative it is very common for people to overestimate the risk of HIV transmission. For about five years now we know that undetectable = untransmittable, people living with HIV who are on antiretroviral treatment and have an undetectable viral load (which is the vast majority of people living with HIV in the UK) cannot transmit HIV to their sexual partners. Many people still do not know that, but even if they do and it is a simple message, it can be hard to get your head around something which directly contradicts what you have been told for so long. Perception of risk is not just about information and knowledge but has so much to do with emotion. To a certain extent it is about repeating the message that U = U, similar to how there is constant need for communicating that kids raised by lesbian mothers and gay fathers are alright, they are not disadvantaged. It may sound like a broken record but it’s necessary because there are still people out there who just do not know. I think it also takes time for science to inform policy and for policy to accurately reflect science and until law is in line with medicine, scientific findings are going to continue to be perceived with suspicion.
In line with that, do you think there are any recent developments in the field of health or academia in general that are really important to this area of work?
There is unfortunately still a lot of stigma. Effective HIV treatment can only improve people’s quality of life to an extent. On one hand, it is fantastic that now thanks to treatment HIV can play a really small role in people’s lives. On the other hand, it turns HIV from an issue of public concern to an issue of private matter and that does not necessarily help to eradicate stigma. I think it is great that ‘It’s a Sin’ has proven so popular as it has generated so many conversations and provided many opportunities to raise awareness of how much things have changed and how much the reality of living with HIV has changed.
When I was reading your work, I wondered if the heterosexual narrative that presents women to be the main drivers of wanting children resulted in a presumption that men do not want to have children. Do you feel this could have contributed to a lack of scientific focus on HIV+ male gay couples becoming parents?
This is part of it but then again there is also some truth to that narrative. Colleagues who work on egg freezing often find that the most common reason why women decide to freeze their eggs is because they are unable to find a stable committed relationship with a man who wants to commit to having children with them. So statistically it is probably true that in heterosexual relationships women are more likely to drive the desire for having children. They are probably not more likely to want to have children, but more likely to appreciate that the ability to do so is time dependant. As a sociologist I feel the need to emphasise the role of cultural expectations. Women may be more likely to initiate conversations on parenthood or be quicker in turning desires into intentions or feel more responsible for materialising parenting desires. There are multiple social prompts to make them do so. The perception that men, gay men in particular, are less likely to want to have children is probably one result of that.
Another article of yours, “Parenthood as intended: Reproductive responsibility, moral judgements and having children ‘by accident’’’, addressed ‘parenthood by accident’ and how that is a largely heterosexual experience. Do you feel that this contributes to HIV+ LGBT+ individuals feeling more responsible about the dangers of transmission to an unborn child than HIV+ heterosexual individuals would as they are unable to invoke the ‘by accident’ argument to avoid moral judgement about their reproductive behaviour?
That is a good question! There is often a sense of heightened responsibility when for whatever reason you are made to feel that you do not deserve to have children or that you should not become a parent. I suppose there are parallels here between being queer and living with HIV. We can think of different minoritised and stigmatised categories of people. If you do fall into one or more of these categories and do want to have children, you are likely to feel some added pressure to prove people wrong and show that you can be a good parent and that you are a responsible citizen. One way in which this can manifest is through more planning and a more intentional approach to parenthood that creates a sense that you are well prepared, that everything is well thought through. This can also be amplified by neoliberal middle-class expectations that over time have raised the threshold for what are considered as the necessary conditions for having children. These are ever more difficult to achieve for an increasing proportion of people. There is an interesting interaction between advantage and disadvantage in perpetuating notions of responsibility.
In your article “Can HIV‐positive gay men become parents? How men living with HIV and HIV clinicians talk about the possibility of having children”, you noted that most of the interviewees identified as gay, not bisexual. Do you think a bisexual or transgender/nonbinary focussed or racially specific study around attitudes towards HIV+ parenthood would be beneficial to the conversation?
Absolutely, I think it is so important. In our research we sought to recruit both gay and bisexual men, but we did not recruit enough bisexual men to be able to represent their perspectives in a meaningful way. We recruited patients through clinics which rely on the behavioural category of men who have sex with men. In some ways it’s more of an inclusive category but in other ways it may also contribute to bisexual erasure. I spoke with healthcare professionals who could not think of bisexual men amongst their patients and they would sometimes use the terms ‘men who have sex with men’ and gay interchangeably. But many men do identify as bisexual and research on LGBT+ parenthood has been very slow in capturing bisexual experiences and I think it is very important to really address this massive gap. Likewise, for the perspectives of people who are trans and nonbinary, we still know so little about those perspectives. There is now a better way of asking about gender identity in the context of sexual health. I think it will become easier for researchers working in this area to successfully recruit people who are trans and nonbinary. There is more information now and it is easier for trans and nonbinary people to be counted in the first place, which is fundamental to them having their voices heard. For sexual health research conducted through clinics there needs to be ways of recording the ways in which people identify to find them and to give them the opportunity to share their experiences and views. I hope that in the near future more and more work will be done to capture some of the underrepresented perspectives. I suppose the issue of race and ethnicity is very similar. For different reasons minoritised voices are often underrepresented in studies both on reproductive and sexual health and on LGBT+ parenthood. Again, I hope much more work will be done to address these gaps. In retrospect, I would have done some of my own research differently to better incorporate more perspectives that could have enabled me to represent them in a way that is more meaningful.
Finally, do you have any advice for young scholars in these weird times?
Yes, these are weird times that we are living through. Well, in many ways academia at the moment may seem like something that is not going through the best time. There is a lot of gloom around particularly the precarious nature of a lot of academic employment. Yet there are not many industries where people are not struggling right now. Doing a job that involves research and teaching continues to be a great way of combining two fascinating things. It is important to be aware of the challenges early career scholars face, it tends to be quite a complicated and long journey for people to progress in their careers. At the same time, if you are passionate about a particular topic, if there is something that you would genuinely like to spend lot of time thinking about, you are in a good position to overcome some of the obstacles. With my background in different disciplines and moving in and out of academia and following different directions sort of accidentally, I think it is important to be open to whatever opportunities emerge in front of you. Sometimes what seems like an undesirable outcome or a less attractive opportunity may ultimately take you somewhere where you discover new passions and interests and you develop a career working on topics that you would not have thought of before. Some of the unpredictability can be quite exciting as you don’t really know where research will take you. It might be good advice to follow your instinct and just be open to new experiences. Working in academia you need to be prepared for constant rejections. But some of them can be blessings in disguise.