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Sex in the Village: Culture, Religion and HIV/AIDS in Thailand is an ambitious examination of HIV/AIDS treatment and prevention policies in Thailand. In this sociological treatise, Patchanee Malikhao addresses both global strategies as well as country-specific schemes, with particular attention to Buddhist and Christian faith-based community initiatives. Patchanee highlights the comparative aspects of her study of 'participatory communication-based HIV/AIDS campaigns' in differing religious contexts (p. 194), though her primary contribution arguably resides more in her analysis of underlying social patterns. Her main contention in this regard is that the particular instantiation of patriarchy in Thailand (with both socio-economic and religious antecedents) renders HIV intractable. She thus suggests that religious interventions alone are insufficient to address the AIDS epidemic and, further, successful HIV prevention and treatment will require a structural change in women's status in Thai society.
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Patchanee's most laudable impulse is to set contemporary Thai sexual practices and forms of social hierarchy in a globally-contextualised historical frame. Rather than follow common claims of the 'westernisation' of Thai society, Patchanee seeks to document the 'hybridization of the Thai political-economy' (p. 51). She argues that Thai sexuality is a cultural product, the result of 'the dynamic interaction of the socio-economic context with patriarchy (and female subordination) and the patriarchal Buddhist worldview amidst phases of historical globalization processes' (p. 10). To make this case, she provides a synopsis of major epochs of globalisation in Thai history, namely 'archaic globalisation' (before 1500s), 'proto-globalisation' (1600–1768), 'globalisation' (1768–1946), and 'contemporary globalisation' (1946–present). She traces how, for instance, during the globalisation period, older Thai norms of polygamy, male supremacy, and women as property converged with Victorian values of chastity (or premarital abstinence) and monogamy. This convergence of sexual norms and values—combined with the bureaucratisation of Buddhism that rendered certain forms of advancement available only to men—resulted in the rise of sex work, which has served to preserve the value of male sexual freedom alongside the emergent emphasis on female chastity before marriage.
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Following this historical thread, Patchanee parses contemporary sexual practices into those that converge and those that diverge with global trends, allowing her to show how paid commercial sex work has, in recent years, been surpassed by concordant simultaneous sexual partnerships with friends and other relations as the major risk for HIV transmission. Convergent (or globalised) forms of sexuality now include: an increased visibility of homosexuality; sex between adolescent males and girlfriends, rather than between males and sex workers; sexploitation of females and males from other countries; and premarital sex among adolescent females. Divergent (or localised) forms of sexuality include: the export of Thai sex workers; the sale of virginity; charity sex; sex work in karaoke bars, massage parlours, and other non-brothel locals; and internet mediated sex-related activities. By making clear that traditional Thai sexuality includes sex outside marriage, she shows the particular ways Thai social norms have come to valorise extramarital affairs, especially for men. In this way, she seeks to make norms of sexuality and related behaviour (including alcohol and prophylactic use) culturally decipherable, and thereby provide insight for corresponding HIV intervention strategies.
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Patchanee uses her historical frame, combined with qualitative research, to challenge certain aspects of the contemporary public health strategy. Patchanee seems to agree with the Ministry of Public Health (MOPH) report on HIV/AIDS (2001), which 'attributes the spread of AIDS to a lack of education, lack of employment opportunity, the centralised administration system, the not-up-to-date Thai legal system, and the Western world for introducing consumerism and materialism that shapes new values' (p. 93). Further, she seems to support the utilisation of mass-media and other communication-based prevention strategies. However, she contends, 'MOPH does not consider traditional cultural values as problematic, such as the double standard of sexuality among Thai males, inequality between genders and social classes, and the hybridised effect of problems such as casual sex without male responsibility and the turning to sex as a commodity by females who lose their virginity following casual sex' (p. 93). Therefore, 'as long as MOPH does not acknowledge that some Thai cultural values, such as hierarchy and hybridized sexual values, are part of the obstacles to HIV/AIDS prevention, not much success is to be expected' (p. 96, emphasis in original). It is a bold contention, a call for no less than a 'restructuring of a whole cultural system' (p. 95).
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The book is expertly organised. Patchanee succeeds in bringing an enormous breadth of material into a slim volume, utilising clear section headings, bulleted lists and flow charts to help readers navigate the world of HIV prevention strategies at local, national and global levels. However, while much is understandably truncated in such a tour, a bit more narrative structure might have helped the reader navigate through what at times feels like an onslaught of loosely connected facts and figures. Even in the ostensibly ethnographic chapters, as we move into descriptions of village life and individual religious leaders, the writing style remains 'information' oriented. We learn of vital statistics of contrasting Buddhist and Protestant villages—including the percentage of families who own basic appliances and the breakdown of occupation, type of housing and so forth—though without a clear connection of these basic life assessments to HIV transmission or other health-related practices. We hear tell of environmental pollution and negatively cast consumerist tendencies, without any psychological or practical insight into the local justification of such practices. We learn of project inception dates, organisational missions, and information dissemination techniques, but little of the lived interactions or meaning making in such engagements. For instance, Patcharee relates: 'A broadcasting tower with relaying megaphones stands in a few streets in moo [a Protestant village in her study]. Around 4pm the headman would broadcast news and information in the local dialect. He also relayed news and knowledge on HIV/AIDS prevention to the villagers' (pp. 129–130). We are left only to imagine how the headman did this, what exactly the messages were, and in fact whether or not we can trust that he actually performed the duties he reports. Furthermore, what was the reaction in the village to such announcements? How did what was said relate to villager understandings and priorities, if at all?
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A similar set of questions arises in relation to the religious beliefs and practices in the communities studied. Patchanee seems to adhere to a particular interpretation of Buddhist scripture, going so far as to say that 'no one in this village, not even Phra Akhom [the head Buddhist monk leading the HIV project under investigation], understood it correctly' (p. 143). It is implied that a constellation of particular teachings and internalised understandings form the heart of true Buddhism, and thus she can relate how:
Most of the people I interviewed hardly knew the meaning of the Sila Five or the Five Precepts of Buddhism even though their religiousness score was higher than 90 percent. This is because such a religious scale measures the frequency of their visit to the temple and their involvement in religious activities, not how they understand their own religion. No villagers could explain the core of their religion, in spite of identifying themselves as Buddhist. (pp. 124–25).
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This preconceived definition of religiousness obfuscates a richer appreciation of the views and priorities of the villagers who comprise the participatory schemes in question. They are instead seen by and large only as 'trapped in the patriarchal system that shapes the Buddhist worldview of the Thais since the archaic globalisation' (p.144).
What is interesting is that Patchanee may inadvertently be creating a hierarchy in which she, the social scientist, can distinguish right from wrong, while those under investigation are blind or otherwise duped. Is she simply creating a hierarchy between sociologist and villager, parallel to the hierarchy between men and women that she critiques? This is a problem that plagues almost all participatory action research, and, in the spirit of solidarity, is worth exploring more deeply here.
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Importantly, Patchanee effectively distinguishes between differing health-communication strategies, which all too often remain completely opaque in global health studies. In her review of global AIDS intervention and policy platforms (Chapter 4), she includes structural change strategies as well as behaviour change strategies. She provides a good overview of the chronology of HIV prevention strategies in Thailand—including the negative branding of HIV-positive people, the fallout of such campaigns, the trending of positive messaging, and the rise of community-based approaches beginning with the 1997 economic crisis. She goes on to differentiate social marketing techniques (including classic health information dissemination and forms of health messaging), media advocacy and participatory-based health communication advocacy (for which she is careful to distinguish Freirian participatory action from the more programmatic UNESCO approaches).
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To further delineate these approaches, she describes two different development paradigms, locating social marketing and media advocacy within the 'modernisation paradigm' and participatory-based approaches in the 'multiplicity paradigm.' In this categorisation, all behaviour change strategies are relegated to quantifiable outcomes that fail to take structures into account, while, in contrast, participatory practices in the so called multiplicity paradigm take a more holistic frame. By extension, taking a holistic view seems presumed necessarily to rescue participatory communication processes from the problematic top-down procedures that characterise 'modernisation' development operations.
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As mentioned, Patchanee advocates for sweeping social change; however, the suggested interventions for such change indicate a possible blind spot in her work. So on one hand, Patchanee described the oppressive force of social hierarchy, suggesting how women's social position and structurally supported behavioural norms puts women at risk for HIV and hampers HIV prevention and treatment in the population at large. Women were historically taken as property, and they have continued to be imagined as less-than men by the religious system and in the socio-political realm as well. Is it not a similar move for a researcher to take as 'wrong' the perspective and practices of rural people, of uneducated people, or of people with simply different ways of being? When Patchanee suggests, along with one of her simpatico informants, that major media reforms are necessary to educate people and to provide them with wholesome inputs (p. 150), who is supposed to know best what those curricula and various inputs should be?
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Thai society is hierarchical along many axes, beyond the axis of patriarchy that Patchanee illustrates for us. For example, most social groupings come to have a leader, determined by gender, age, class, geography, ethnicity, education and so forth. How is participatory health communication to engage in such a web? Where are the proper loci for breaking down hierarchy and where are they to be utilised?
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If we instead take the holistic frame as a starting point for investigating engagement practices and the goals of social change, Patchanee's study opens ample avenues for further study. In the conclusion of Sex and the Village, Patchanee lays out a series of recommendations for researchers, policy makers and civil society leaders. These can be taken further. Research is needed to understand how the various forms of hierarchy are embodied in the creation of policy, as well as in the implementation and evaluation of interventions. In addition, Patchanee and other researchers can reflect more on their roles in these hierarchies, as researchers, as educated women and men, and so forth. Patchanee's historical framing of patriarchy and 'hybridised' forms of sexuality in Thai society pushes us now to explore hybridised forms of community engagement, and to envision creatively what Thai feminism might look like in the complicated webs of social stratification.
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